    [Senate Hearing 112-337]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 112-337

                                                            Senate Hearings

                                     Before the Committee on Appropriations

    _______________________________________________________________________

                                                      Departments of Labor,

                                                 Health and Human Services,

                                                 and Education, and Related

                                                    Agencies Appropriations

                                                           Fiscal Year 2012

                                              112th CONGRESS, FIRST SESSION

                                                                    S. 1599

            DEPARTMENT OF EDUCATION
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
            DEPARTMENT OF LABOR
            NONDEPARTMENTAL WITNESSES
            SOCIAL SECURITY ADMINISTRATION

                                                            S. Hrg. 112-337

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2012

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

                                    HEARINGS

                                    before a

                              SUBCOMMITTEE OF THE

                COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                          ONE HUNDRED TWELFTH CONGRESS

                                 FIRST SESSION

                                       on

                                    S. 1599

     AN ACT MAKING APPROPRIATIONS FOR THE DEPARTMENTS OF LABOR, HEALTH AND
    HUMAN SERVICES, AND EDUCATION, AND RELATED AGENCIES FOR THE FISCAL YEAR
               ENDING SEPTEMBER 30, 2012, AND FOR OTHER PURPOSES

                                   __________

                            Department of Education
                    Department of Health and Human Services
                              Department of Labor
                           Nondepartmental Witnesses
                         Social Security Administration

                                   __________

             Printed for the use of the Committee on Appropriations

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            committee.action?chamber=senate&committee=appropriations

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                          COMMITTEE ON APPROPRIATIONS

                       DANIEL K. INOUYE, Hawaii, Chairman
    PATRICK J. LEAHY, Vermont            THAD COCHRAN, Mississippi, Ranking
    TOM HARKIN, Iowa                     MITCH MCCONNELL, Kentucky
    BARBARA A. MIKULSKI, Maryland        RICHARD C. SHELBY, Alabama
    HERB KOHL, Wisconsin                 KAY BAILEY HUTCHISON, Texas
    PATTY MURRAY, Washington             LAMAR ALEXANDER, Tennessee
    DIANNE FEINSTEIN, California         SUSAN COLLINS, Maine
    RICHARD J. DURBIN, Illinois          LISA MURKOWSKI, Alaska
    TIM JOHNSON, South Dakota            LINDSEY GRAHAM, South Carolina
    MARY L. LANDRIEU, Louisiana          MARK KIRK, Illinois
    JACK REED, Rhode Island              DANIEL COATS, Indiana
    FRANK R. LAUTENBERG, New Jersey      ROY BLUNT, Missouri
    BEN NELSON, Nebraska                 JERRY MORAN, Kansas
    MARK PRYOR, Arkansas                 JOHN HOEVEN, North Dakota
    JON TESTER, Montana                  RON JOHNSON, Wisconsin
    SHERROD BROWN, Ohio
                        Charles J. Houy, Staff Director
                      Bruce Evans, Minority Staff Director
                                     ------

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

                           TOM HARKIN, Iowa, Chairman
    DANIEL K. INOUYE, Hawaii             RICHARD C. SHELBY, Alabama
    HERB KOHL, Wisconsin                 THAD COCHRAN, Mississippi
    PATTY MURRAY, Washington             KAY BAILEY HUTCHISON, Texas
    MARY L. LANDRIEU, Louisiana          LAMAR ALEXANDER, Tennessee
    RICHARD J. DURBIN, Illinois          RON JOHNSON, Wisconsin
    JACK REED, Rhode Island              MARK KIRK, Illinois
    MARK PRYOR, Arkansas                 LINDSEY GRAHAM, South Carolina
    BARBARA A. MIKULSKI, Maryland        JERRY MORAN, Kansas
    SHERROD BROWN, Ohio

                               Professional Staff

                                  Erik Fatemi
                                  Mark Laisch
                                Adrienne Hallett
                                 Lisa Bernhardt
                                Michael Gentile
                              Alison Perkins-Cohen
                          Laura A. Friedel (Minority)
                         Sara Love Rawlings (Minority)
                          Jennifer Castagna (Minority)

                             Administrative Support

                                  Teri Curtin

                                C O N T E N T S

                                  ----------

                            Wednesday, March 9, 2011

                                                                       Page

    Social Security Administration...................................     1

                           Wednesday, March 30, 2011

    Department of Health and Human Services..........................    73

                             Wednesday, May 4, 2011

    Department of Labor: Office of the Secretary.....................   145

                            Wednesday, May 11, 2011

    Department of Health and Human Services: National Institutes of
      Health.........................................................   215

                            Wednesday, July 27, 2011

    Department of Education..........................................   411

    Departmental Witnesses...........................................   495
    Nondepartmental Witnesses........................................   489

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2012

                                  ----------

                            WEDNESDAY, MARCH 9, 2011

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

                         SOCIAL SECURITY ADMINISTRATION

    STATEMENT OF MICHAEL J. ASTRUE, COMMISSIONER

                    opening statement of senator tom harkin

        Senator Harkin. The Subcommittee on Labor, Health and Human
    Services, and Education, and Related Agencies will now come to
    order.
        Our topic today is administrative funding for the Social
    Security Administration. Normally, this time of the year, we'd
    be talking about the President's budget request for the
    upcoming year. However, since this is not a normal year, we're
    also here to discuss funding for the rest of fiscal year 2011.
        Today's hearing is very timely. Three weeks ago, the House
    passed a spending bill for the rest of this year that cuts $102
    billion from the President's request. The Senate majority has
    offered an alternative that meets the House halfway, cuts $51
    billion.
        I believe the Senate plan represents a reasonable approach.
    But, that's just my own opinion, my own views on this, to
    reduce the deficit while protecting programs that help meet the
    basic needs of the most vulnerable Americans: seniors,
    children, those living in poverty, people with disabilities.
        And we're here to discuss one of the most important
    programs. And that's Social Security. Created in 1935, Social
    Security is the centerpiece of America's social safety net,
    providing insurance against poverty from old age, the loss of a
    spouse, or a debilitating disability. Today, 58 million
    Americans receive Social Security benefits. Eight million will
    file, this year. Social Security field offices will receive 45
    million visitors. And Social Security's 1-800-number will take
    67 million calls this year.
        Because of the economic downturn and the aging population,
    in the last few years the number of Americans turning to Social
    Security and filing for retirement and disability benefits has
    increased significantly. You know, as the economy goes down and
    unemployment goes up, and it's harder and harder for people at
    or near the age of 62, they can't find work; they take early
    retirement because they just can't find jobs. So, the number of
    people applying has gone up. Also, people who may have had a
    minor disability--they've tried to overcome it and work, but
    now they're out of work and they simply can't find a job--they
    file for disability. So, that's why we've got a huge increase
    in an economic downturn.
        While the backlogs still persist, the administrative
    funding, so far, has largely kept pace with this increased
    demand. This, for one thing, has allowed Social Security to
    significantly step up its program integrity activities. Social
    Security Administration periodically conducts reviews to
    determine if beneficiaries are still eligible under the--both
    the income and disability guidelines.
        Since 2007, the Social Security Administration has
    increased the number of continuing disability reviews by over
    50 percent, and redeterminations of nonmedical eligibility, by
    over 140 percent. Combined, these activities save taxpayers--
    save taxpayers--an average of about $8 in future Social
    Security, Medicare, and Medicaid benefits for every $1 spent in
    administrative funding. So, we spend $1, we save $8.
        Today, however, adequate funding for the Social Security
    Administration to properly administer these programs is at
    risk. The House continuing resolution H.R. 1 would cut
    administrative funding for SSA by $125 million below last
    year's level--fiscal year 2010 level--even though, as I pointed
    out, their workloads on disability claims, hearings, retirement
    claims, are staying at record high levels.
        Under the House plan, the SSA, the Social Security
    Administration, would have to cut its staff by 3,500 by the end
    of the year, and may ultimately have to resort to furloughs. As
    a result, millions of Americans filing disability claims this
    year will have to wait much longer for benefits. Everyone will
    have to wait. You probably won't get online, and you probably
    won't get your phone call answered right away--and the program
    integrity efforts, the one I just mentioned, about making sure
    that we save money by making sure that people that are on
    disability or filing claims are still eligible--so, delaying
    these isn't just bad for the economy, but it's devastating for
    the individuals, on both sides.
        The Senate majority plan would provide, on net, $600
    million more for the Social Security Administration's
    administrative expenses. This is less than the President's
    request, but it will keep the offices open and allow the agency
    to meet its most basic service commitments to the American
    public and prevent its backlog of work from growing any bigger
    than it is today.
        So, that's what this hearing is about. We need to know what
    the impact will be on the Social Security Administration, on
    their ability to respond to the huge workload, and the effect
    it will have on recipients and people who rely upon their
    disability or their supplemental security income (SSI) or their
    old-age survivors' benefits. So, that's why we're having this
    hearing today. We need to know what this means.
        So, I look forward to hearing the testimony from our
    distinguished panels on this matter. But, first, I yield to
    Senator Shelby for any opening remarks.

                     statement of senator richard c. shelby

        Senator Shelby. Thank you, Mr. Chairman.
        Thank you for calling this hearing to examine the fiscal
    year 2012 Social Security Administration's budget request. I
    look forward, as you do, to hearing the panels' testimony and
    their views on this critical program.
        The greatest obstacle to our Nation's fiscal stability is
    ignoring our increasing entitlement obligations. Simply put,
    there is no way to control our debt without getting serious
    about entitlement reform. And, while we can argue about how to
    reform Social Security, we cannot argue about whether it should
    be reformed. It's a question of when.
        In 2010, for the first time in the history of the Social
    Security Program, the system paid out more in benefits than it
    received in payroll taxes. This is a critical threshold that
    was not expected to be reached until at least 2016. Social
    Security is now at the tipping point, the first step of a long,
    slow march to insolvency if we don't do something about it.
        According to the Social Security Board of Trustees, the
    Social Security Trust Fund surplus will be completely exhausted
    by 2040. At that juncture, Social Security will have to rely
    solely on revenue from the payroll tax, which will not be
    sufficient to pay all the promised benefits.
        There are currently 50 million Social Security
    beneficiaries, and their numbers are increasing faster than the
    number of taxpayers. The number of workers per retiree has
    fallen from 42 to 1 in 1940 to about 3 to 1 today. Social
    Security is unbalanced because contributions are insufficient
    to provide the promised benefits. In a sense, it's a classic
    Ponzi scheme, with new contributions used to pay off earlier
    investors.
        I think we must also recognize that the Social Security
    Disability Insurance (SSDI) Program contributes more than its
    share to Social Security's looming insolvency. During the
    economic recession, the unemployment rates soared, as did
    applications to the SSDI program. The number of individuals
    receiving SSDI benefits has jumped more than 10 percent in the
    last two recessionary years. The increase will accelerate the
    exhaustion of the SSDI reserves by 2018, and was recently
    described by the Congressional Budget Office (CBO) as ``not
    financially sustainable.''
        And, while the SSDI program faces the same fundamental
    issue as the retirement program--that is, there are fewer
    workers to pay for an ever-increasing population receiving
    benefits--its questionable structure adds complexity. What was
    supposed to be a narrowly tailored program to help individuals
    who could no longer work grew into a gigantic budgetary burden
    that looks more like an unemployment program, to some people.
        What makes the problems worse is that, unlike the Federal
    Unemployment Program, there is no time limit for how long an
    individual can receive SSDI. But, more significantly, among
    those receiving SSDI benefits, the incentive to return to work
    is very low. In fact, revealing one's ability to go back to the
    workforce could result in permanent loss of SSDI benefits. The
    strong work disincentives under the SSDI results in workers
    never seeking gainful employment, at the risk of losing future
    benefits. Clearly, Congress must face the potential fiscal
    collapse of the Social Security system in the future.
        However, today's hearing focuses on the near-term issues
    facing the program and the only aspects of the $817 billion
    fiscal year 2012 budget the Appropriations Committee has
    control over, $12.5 billion that funds administration costs and
    the Office of the Inspector General.
        The fiscal year 2012 budget requests an additional $1
    billion over the fiscal year 2010 budget to reduce the daunting
    744,130 disability claims and 722,872 hearings case backlog. On
    top of the significant backlog, the processing time for
    disability claims is 112 days, and the wait time for a Social
    Security appeal hearing is 371 days.
        Interestingly, two-thirds of those who appeal a Social
    Security decision win their case on appeal. And, while I
    understand the disability process is complex, it's also highly
    subjective. With an appeal-over rate so high, why are so many
    people winning on appeal. Instead, shouldn't they win at the
    beginning?
        As the Social Security Administration continues to tackle
    the backlogs in their caseload, I think it's important that
    funding to pursue continuing disability reviews remains strong.
    SSDI benefits are not, and should not be, benefits for life.
    Only those who continue to qualify for benefits should receive
    them.
        We need, I believe, to ensure that fraud and abuse of the
    system are rooted out. Those who take advantage of the system
    ruin it for those who are genuinely in need. In a program where
    there are no fines and virtually no prosecution for those who
    attempt to fraudulently collect benefits, we need to examine
    ways to stop fraudulent applicants.
        The administration of Social Security, while only a small
    percentage of the entire system, is a vital component to the
    success and the fiscal stability of the overall program. This,
    however, does not mean that it can operate without stringent
    oversight from this subcommittee. We need to ensure that that
    money is being spent wisely and in the best interest of the
    U.S. taxpayer.
        Mr. Chairman, I look forward to working with you on this
    panel, and look forward to the hearing.
        Senator Harkin. Thank you very much, Senator Shelby.
        I'd like to just ask my colleagues if they have some short
    remarks they'd like to make.
        Senator Mikulski.

                    statement of senator barbara a. mikulski

        Senator Mikulski. Thank you very much, Mr. Chairman. My
    remarks will be brief.
        I joined the Labor-HHS Subcommittee at the start of this
    Congress, and I'm delighted to be here. As both the chair and
    the ranking on the Commerce, Justice, Science Subcommittee,
    Senator Shelby and I are used to talking to rocket scientists,
    Federal Bureau of Investigation agents, and those in the
    Commerce Department who advance the trade for the United
    States. But, whether you're a rocket scientist or whether
    you're a janitor, Social Security is your program. This is the
    one program that the entire United States Government effects.
    So, whether you were a Nobel Prize winner, whether you are the
    cop protecting the lab where they work, or whether you're the
    person who cleans up that lab when everybody goes home, Social
    Security is your program.
        I'm very proud of the fact that Social Security is
    headquartered in my State. Thousands of people work there every
    day to make sure that this benefit is a guaranteed benefit, not
    a guaranteed gamble for those who want to privatize it, but
    they guarantee also that the checks will be delivered on time,
    to the right person, with the right actuarial assignment or
    payment given to it. I'm very proud of them.
        And, quite frankly, Mr. Chairman, I'm deeply troubled about
    where we are on the cuts to Social Security, the contemptuous
    attack on Social Security as a benefit, and then the even overt
    hostile attack on Social Security employees. They're on the
    front line every day--some in harm's way, when a disgruntled
    person shows up off their meds--but, they're there every day,
    every way, serving the people of the United States of America,
    and we have to make sure they have the right pay, the right
    resources, and the right respect.
        Senator Harkin. Thank you, Senator Mikulski.
        Senator Reed.
        Senator Reed. No, thank you.

                 introduction of commissioner michael j. astrue

        Senator Harkin. Well, thank you all very much.
        We'll start with our first panel.
        Michael J. Astrue serves as a Commissioner of the United
    States Social Security Administration. He was sworn in on
    February 12, 2007. Prior to joining Social Security, the
    Commissioner served as counsel to the Social Security
    Commission, general counsel and Department of Health and Human
    Services, and as an associate counsel to the President, in both
    the Reagan and George Bush, Sr., administrations. He's a
    graduate of Yale University and Harvard Law School.
        Mr. Astrue, welcome to the subcommittee. Your testimony
    will be made a part of the record in its entirety. And, if you
    could sum it up in several minutes or so, we'd be most
    appreciative.
        Commissioner Astrue. Great.
        Senator Harkin. Thank you.

                     summary statement of michael j. astrue

        Commissioner Astrue. Chairman Harkin, Ranking Member
    Shelby, and members of the subcommittee, thank you for this
    opportunity to discuss the important work of the Social
    Security Administration.
        For a number of years, going back to the 1990s, we did not
    receive full funding, and service deteriorated. When I became
    commissioner in 2007, I promised improvements. And Congress has
    supported those improvements. With necessary investments,
    greater productivity, and new initiatives, we have reversed the
    trend of declining service and increasing backlogs.
        Our top priority remains eliminating the hearings backlog.
    And we've made significant progress 4 years in a row. We have
    decided over one-half a million of the oldest, most complex
    cases, some as old as 1,400 days. We have cut the waiting time
    for a hearing decision, from nearly 18 months in August 2008 to
    exactly 1 year in February 2011.
        We have made the most progress in some of our most
    backlogged offices. For example, our Atlanta downtown office
    had an average waiting time of 1,020 days in August 2007. We
    have slashed that time by 70 percent. The average waiting there
    is now 297 days.
        Without your continued support, however, we will not meet
    our commitment to eliminate this backlog by 2013. Our staff and
    our State disability determination services (DDS) partners kept
    our pending level of claims well below our fiscal year 2010
    projected level, while achieving the highest level of accuracy
    in over a decade, even as they faced furloughs and a huge
    influx of claims, due in part to the economic downturn.
        In fiscal year 2010, callers to our national 800 number had
    the shortest waiting time and lowest busy rates since we began
    tracking these measures, nearly a decade ago. We reduced the
    average waiting time in our field offices. We have increased
    our important program integrity work, which is improving
    payment accuracy in the Supplemental Security Income Program.
        Every $1 we spend on continuing disability reviews yields
    $10 in lifetime program savings. Every $1 spent on SSI
    redeterminations yields more than $7. To do this complex work,
    we need an adequate number of well-trained employees.
        Since 2007, our dedicated employees have averaged nearly a
    4-percent annual increase in productivity, which is fueled by
    hard work, better business processes, and smart investments in
    information technology. Few, if any, organizations can boast
    productivity gains of this magnitude.
        The fiscal year 2012 President's budget request of $12.5
    billion is what we need to reduce our remaining backlogs and to
    increase our deficit-reducing program integrity work. But,
    achieving that performance depends on receiving the President's
    budget request in fiscal year 2011.
        Because of the uncertainty of our budget and the length of
    the continuing resolution, I've already had to make choices
    that will begin to erode service. I cut back on hiring, last
    July, and have continued to scale back on hiring and other
    areas. We now expect a net loss of 3,500 Federal and State
    employees this fiscal year. Most of these employees work in
    offices across the Nation, and they will not leave those
    offices uniformly. Some offices are already understaffed. Our
    employees continue to serve the public as best they can, but
    they are disappointed about the prospect of watching what we
    have worked so hard to achieve potentially slip away.
        I regret that we may not be able to keep our commitments to
    the American people because we do not have the necessary
    support to move forward. Millions of people we serve cannot
    afford to wait. People with disabilities lose their homes,
    medical coverage, and dignity. That outcome does not serve
    Americans or the economy well.
        In addition to other cuts we've made, we are discontinuing
    service at over 300 remote sites and are considering field
    office consolidations. We will not open eight needed hearing
    offices, and we will not be able to staff the new Jackson,
    Tennessee, Teleservice Center this year and maybe not next year
    or in future years. We're suspending printing and mailing of
    annual earnings statements, which will save about $70 million
    annually.
        If you look at what we have accomplished in just 4 years,
    you'll see that we are a good investment. With adequate and
    timely resources and the superb efforts of our employees, we
    deliver on our promises. Nevertheless, we cannot eliminate our
    disability backlogs, provide accurate and responsible service,
    and meet our stewardship duties, unless Congress provides us
    with the resources to do the job. Suddenly reduced funding
    halfway through the fiscal year could eliminate most of the
    progress that we have made.
        I'm happy to answer any questions that you may have.

                               prepared statement

        Senator Harkin. Mr. Astrue, thank you very much for a very
    concise statement. I know you have a longer statement, which I
    went over the other evening, and it will be made a part of the
    record, as I said, in its entirety.
        I thank you for----
        Commissioner Astrue. Thank you, Mr. Chairman.
        Senator Harkin [continuing]. Summing it up.
        [The statement follows:]
                    Prepared Statement of Michael J. Astrue
        Chairman Harkin, Ranking Member Shelby, and Members of the
    Subcommittee: Thank you for the opportunity to discuss the President's
    fiscal year 2012 budget request for the Social Security Administration.
        For over 75 years, Social Security has touched the lives of
    virtually every American, whether it is after the loss of a loved one,
    at the onset of disability, or during the transition from work to
    retirement. Our programs provide a safety net for the public and
    contribute to the increased financial security for the elderly and
    disabled. Each month, we pay more than $60 billion in benefits to
    almost 60 million beneficiaries. These benefits not only provide a
    lifeline to our beneficiaries and their families, but also are vital to
    the Nation's economy.
        Americans request a staggering amount of service from our agency.
    We respond to their needs through a network of 1,500 offices that
    provide service to local communities across the country. Nearly all of
    our employees work in these local offices where they do a wide range of
    work including issuing Social Security cards, handling applications for
    benefits, maintaining workers' earnings records and the accuracy of our
    benefit records, deciding appeals, answering our 800 number, and
    assisting with Medicare.
        In fiscal year 2010 we:
      --Completed 4.7 million retirement and survivors claims;
      --Completed 3.2 million initial disability claims;
      --Served 45.4 million field office visitors;
      --Completed over 67 million transactions over the telephone;
      --Verified over 1 billion Social Security numbers;
      --Issued 17.2 million new and replacement Social Security cards;
      --Conducted 325,000 full medical continuing disability reviews (CDRs)
            and 312,000 work CDRs;
      --Completed 2.5 million Supplemental Security Income (SSI) non-
            disability redeterminations;
      --Paid $1.4 billion in attorney fees;
      --Completed 738,000 hearings;
      --Defended 12,000 new Federal court cases;
      --Facilitated over 1,500 data exchanges with Federal, State, local
            and foreign government entities as well as some private sector
            companies;
      --Oversaw approximately 5.6 million representative payees;
      --Completed 240 million earnings items for crediting to workers'
            earnings records; and
      --Mailed out 152 million Social Security statements.
        We have a long-standing and well-deserved reputation as a ``can-
    do'' agency. Despite years of underfunding, our hard-working and
    dedicated employees have done their utmost to maintain the level of
    service that the American people expect and deserve. We have been
    innovative and proactive in adopting strategies to allow us to meet the
    challenges we face. To the extent resources allowed, we have hired and
    trained staff to handle our increased workloads, and we have used
    technology to complement our traditional work processes and make them
    more efficient.
        In retrospect, our remarkable successes planted the seeds for many
    of our current challenges. Congress, confident that those successes
    coupled with our ``can do'' attitude meant that we could always find
    ways to adapt, appropriated less than the President requested each year
    from 1992-2007. At the same time, requests for our core services rose
    as the population grew and baby boomers aged, passing through their
    most disability-prone years before retiring. Even with this new and
    unavoidable demand, we managed to maintain our high service levels for
    some time.
        Inevitably, though, we could no longer hold out. Unprecedented
    workloads combined with declining budgets damaged our service delivery.
    We could not keep up even with a long string of employee productivity
    increases. Throughout most of the past decade, the amount of program
    integrity work our employees could keep up with while handling other
    priority work dropped dramatically, even though we know that program
    integrity work saves the taxpayer about $10 for each dollar spent. The
    time claimants waited for disability hearings rose to an average of
    800-900 days in many cities, and some claimants waited as long as 1,400
    days. Waiting times for in-person and telephone service increased, as
    did the public's and Congress's frustration with us.
                             recent accomplishments
        In the last 3 years, we have demonstrated the nexus between
    adequate funding and our ability to deliver--the Congress increased our
    funding, and we made real and measurable progress. We reversed many
    negative trends, most notably with the hearings backlog, and
    significantly improved service and stewardship efforts. We made these
    improvements even though we have had to absorb huge unexpected
    increases in workloads due to the worst economic downturn since the
    Great Depression.
        When I became Commissioner, the Congress made it clear that I had
    to reduce the amount of time it takes a claimant to receive a hearing
    decision. I recognized their concerns and committed to eliminating the
    hearings backlog. Although we have many pressing workloads, we have
    never wavered from this top priority, demonstrating what it means to be
    a results-driven organization.
        With your help, we attacked the backlog and made incredible
    progress in the last 4 years. We have cut the national average time
    claimants wait for a hearing decision by one-third, from an all-time
    high of nearly 18 months in August 2008 to exactly 1 year in February
    2011. We have made the most progress in offices that had the largest
    backlogs. For example, the Atlanta offices had some of the longest wait
    times in the country. In the summer of 2007, the Atlanta Downtown
    office had an average waiting time of 1,020 days, and the Atlanta North
    office averaged about 900 days. By January 2011, we reduced the wait in
    the Atlanta Downtown office to 297 days, a 70 percent reduction, and to
    307 days in the Atlanta North office, a two-thirds reduction.
        During this time, we focused on the most urgent part of the
    backlog--the oldest, most complex cases. In 2007, we had claimants who
    waited for a hearing decision for as long as a staggering 1,400 days.
    Since 2007, we have decided over a half million of the oldest cases. By
    the end of fiscal year 2010, we had virtually no cases pending for more
    than 825 days. This year we are focusing on the cases that are 775 days
    or older, and through January 2011, we have decided over 60 percent of
    these cases.
        We expect that once we eliminate the backlog, we will be able to
    decide hearings in an average of 270 days. In 2007, 50 percent of the
    pending hearing requests were older than 270 days. Today, about 30
    percent of our cases are over 270 days, and that percentage continues
    to drop.
        Another indicator of our progress is the number of our
    administrative law judges (ALJ) who are on pace to meet our
    productivity expectation to decide between 500-700 cases each year.
    When we established the expectation in late 2007, only 47 percent of
    the ALJs were achieving it. By the end of fiscal year 2010, 74 percent
    of the ALJs met the expectation.
        We have made considerable progress, despite the significant
    increase in disability claims. More disability applications result in
    more appeals. Last year, we received nearly 100,000 more hearing
    requests than we received in fiscal year 2009. This trend of increasing
    claims has continued. In our highest month for hearing requests last
    year, we received approximately 73,800 requests. This year, that number
    rose to a record monthly high of about 82,000.
        In fiscal year 2010, we handled more than 3,161,000 initial
    disability claims--a record number that is 300,000 more than the year
    before. Even with this huge increase in determinations, we could not
    keep up with the number of disability claims we received. The number of
    pending initial disability cases rose to over 842,000. We have begun
    working this number down, and as of February 2011, we have reduced the
    pending claims to 774,000.
        The State disability determination services (DDS), the State
    agencies that make initial disability decisions for us, are not
    sacrificing quality to gain productivity. The DDSs have steadily
    increased the accuracy of their decisions since fiscal year 2007. In
    fiscal year 2010, the DDSs achieved an accuracy rate of 98.1 percent,
    the highest level in over a decade.
        These accomplishments are particularly remarkable considering the
    unjustifiable--because we fully fund this work--furloughs of disability
    determination services employees in many States.
        To help States with mounting disability claims, we created Extended
    Service Teams (EST) modeled after our successful National Hearing
    Centers. The ESTs are located in State DDSs that have a history of good
    quality and high productivity. These centralized DDS teams are helping
    us reduce the initial claims backlog as we electronically shift claims
    to them from the hardest hit DDSs. We have also expanded our Federal
    capacity to decide disability claims. We currently have 12 Federal
    units that assist those DDSs most adversely affected by the increase in
    initial claims.
        Identifying and paying eligible claimants early in the disability
    process clearly benefits those with severe disabilities and helps our
    backlog reduction efforts. In fiscal year 2010, we used our fast-track
    initiatives, Compassionate Allowances and Quick Disability
    Determinations, to issue favorable disability determinations to over
    100,000 disability claimants within 20 days of filing. We implemented
    these initiatives while maintaining a very high accuracy rate.
        In fiscal year 2011, we implemented a new regulation to allow
    disability examiners to make fully favorable determinations for
    claimants with the most severe disabilities without consulting a
    medical professional. This change allows us to decide claims even
    faster.
        Last year, more than 45 million people, a record number, visited
    our field offices across the Nation. Despite the increased number of
    visitors, we reduced wait times in our field offices more than 10
    percent from fiscal year 2009.
        We completed more than 67 million transactions over the telephone--
    another record number. Callers to our national 800-teleservice centers
    had the shortest wait time and lowest busy signal rates since we began
    measuring these services over a decade ago. In the last 2 years, we cut
    our busy rate by more than half, from 10 percent in fiscal year 2008 to
    4.6 percent in fiscal year 2010. We also reduced the time spent waiting
    for an agent by over 37 percent, from 326 seconds in fiscal year 2008
    to 203 seconds in fiscal year 2010.
        Our online applications have been indispensible in helping us keep
    up with the enormous growth in retirement claims. For that reason, we
    made it easier to file disability claims online. In January 2010, we
    released a streamlined disability report, which we use to collect
    information about a claimant's disability. This user-friendly report
    allows a claimant to complete an application more quickly and improves
    the quality of the information we receive.
        We continue to expand and improve our online offerings. In March
    2010, we introduced an online Medicare-only application. In July 2010,
    we introduced our Life Expectancy calculator, which helps people decide
    when to start collecting retirement benefits. In December 2010, we
    launched a Spanish version of the Retirement Estimator--the first non-
    English interactive online application in the Federal Government. We
    have the three best electronic services in the Federal Government, as
    measured by the University of Michigan public satisfaction survey. Our
    Spanish-language retirement estimator is on track to become the fourth.
    These easy-to-use online tools encouraged 37 percent of retirees and 27
    percent of disability claimants to file online in fiscal year 2010.
        We have increased our program integrity work, which saves taxpayers
    dollars. In fiscal year 2010, we completed over 700,000 more SSI
    nondisability redeterminations than in fiscal year 2009. Completing
    more of this important stewardship work, helps us increase the payment
    accuracy in the SSI program.
        Our employees deserve the credit for these successes. From fiscal
    year 2007 to fiscal year 2010, their productivity increased by an
    astounding average of nearly 4 percent per year. I am privileged to
    lead a workforce dedicated to the highest standards of public service.
    Despite the pressures that increased workloads bring, our employees
    understand how important our mission is, voting us one of the top ten
    best places to work in the Federal Government for the third consecutive
    year.

        We are proud of the hard-earned progress we have made over the past
    3 years. However, demographics, rising workloads, and heightened fiscal
    austerity will threaten our recent achievements and make further
    progress at this level unlikely.
                       effects of continuing resolutions
        We understand the economic reality that is driving budget
    decisions. I have looked for and found ways to cut back. We have
    trimmed non-essential travel, training, and even systems enhancements.
    By far the largest part of our budget funds payroll. Eighty percent of
    our employees work in local offices across the Nation. I have even cut
    this critical area--the people we all depend on to get the work done--
    by freezing hiring and offering early out.
        Beyond payroll costs, most of our remaining costs are mandatory
    expenses to maintain our operations. For example, we must pay rent and
    maintenance on the 1,500 facilities we occupy; we must pay postage on
    more than 390 million notices we send annually; we must pay for medical
    and vocational evidence and expertise; and we must pay for armed guards
    in our offices to protect our employees and the public. Unfortunately,
    these guards are particularly vital now given the increase in threats
    against our employees.
        A theoretically level-funded continuing resolution does not
    consider that our costs do not remain flat--we have to absorb mandatory
    cost increases with last year's funding level. In addition, the $350
    million Recovery Act funding we used in fiscal year 2010 to handle
    claims was not included in our continuing resolution level. Between
    having to cover mandatory cost increases and not having Recovery Act
    funding, we are operating at a significant loss over last year.
        In this modern era, we are completely dependent on information
    technology. Not only do we need stable and robust systems to handle our
    day-to-day work, technology makes us more efficient. Unfortunately,
    under a continuing resolution, our information technology (IT) funds
    are severely constrained. Many of our investments in technology to
    improve our productivity have been curtailed. If the continuing
    resolution reduces our funding further, or the funding reduction
    continues into future years, our ability to continue keeping our
    technology environment operating smoothly will be threatened.
        Our technology to this point has enabled us to implement work
    processes that are less costly, more accurate, and require fewer
    employees to accomplish the same amount of work. Without our current
    investments, we would not have been able to keep pace with the recent
    increases in claims. We would not have realized the increases in
    productivity that have enabled us to serve the public as we have. IT
    investments are critical if we are to continue to improve productivity
    and achieve our performance targets. We must maintain and invest in
    technology.
        Because of the uncertainty of our budget and the length of the
    continuing resolution, I have had to make choices that will begin to
    erode service. Our employees continue to churn out work, but they are
    disappointed and are becoming demoralized about the prospect of
    watching what they have worked so hard to achieve slip away. I regret
    that we may not be able to keep our commitments to the American people
    because we do not have the necessary funding to continue moving
    forward.
        Our employees come face-to-face with the public every day, and they
    are acutely aware of how the public will suffer. As I mentioned
    earlier, there is a direct nexus between our funding and our service
    level. We want to prepare you for what a deep cut would mean. Our
    backlogs will skyrocket, and people will wait considerably longer to
    receive decisions. As our backlogs grow, it will become more difficult,
    expensive, and time-consuming for us to eliminate them. Waiting times
    in field offices and on our 800-number will increase dramatically. Deep
    cuts will cause billions of dollars of payment errors that will take
    years to address, hardly a wise use of taxpayers' dollars. Even if we
    have specific funding for program integrity work, we need the people to
    do that work plus all of their other fundamental responsibilities.
        A full-year continuing resolution will require us to put on the
    brakes, reversing the tremendous progress we have made in the last few
    years. Common sense dictates that we need enough skilled employees to
    handle mounting workloads. A continued hiring freeze means we will lose
    about 2,500 Federal employees and 1,000 DDS State employees this year.
    Our field employees will not leave the agency uniformly. Attrition is
    random, leaving some offices seriously understaffed.
        While we regret the resulting loss in service, we have tried to
    prepare for the continuing resolution. In July, we instituted a full
    hiring freeze for all headquarters and regional office staff, and then
    we further restricted hiring to allow only those components critical to
    the backlog reduction effort to replace staffing losses. Under a
    continuing resolution, we will continue--and likely expand--the hiring
    freeze. We will reduce or eliminate, overtime, which our front line
    employees depend on to keep up with their work.
        We have decided not to open eight needed hearing offices, and we
    will not have staff to open our new Jackson, Tennessee Teleservice
    Center this year, and perhaps not even next year. We are discontinuing
    service in over 300 remote service sites throughout the United States.
    Most of these sites are ``contact stations'' housed in locations like
    libraries, senior centers, or other facilities where a Social Security
    employee travels, typically once or twice a month, to take applications
    for Social Security cards or benefits, as well as answer questions. We
    have also begun looking at field office consolidation where that
    decision makes fiscal sense.
        Each year we send Social Security Statements to non-beneficiaries
    who are over age 25. These annual Statements cost us approximately $70
    million each year to print and mail. In order to conserve funds, we
    will suspend the current contract and stop sending out these
    Statements. Individuals contemplating retirement can get real-time
    information about the amount of their benefits on our highly regarded
    Retirement Estimator, available on-line at www.socialsecurity.gov.
    Field offices may also provide Statement data. After we negotiate a new
    contract, we will send Statements only to people age 60 and over and
    people under age 60 upon request. We also are working on making the
    Statements available online.
                  ongoing funding--fiscal years 2011 and 2012
        The President's fiscal year 2012 budget request includes $12.522
    billion for our fiscal year 2012 LAE account. This level of funding
    will allow us to maintain staffing in our front-line components, fund
    ongoing activities, and cover our inflationary increases. It will allow
    us to reduce our hearings and initial disability claims backlogs and to
    continue to reverse the decline in our program integrity work. Our
    fiscal year 2012 request is a very modest increase from our fiscal year
    2011 request; the increase of $143 million is primarily to fund
    additional program integrity efforts.
        However, this level of funding will be sufficient to meet these
    goals only if we receive the full amount that the President requested
    for fiscal year 2011. While full funding of the President's budget
    request will allow us to build on the tremendous progress we achieved
    over the past few years, it will not allow us to keep up with some of
    the important, statutorily mandated, and less visible work we do, such
    as representative payee accountings and benefit recomputations.
        Even with full funding, we will not have sufficient resources to do
    all that you and America expects us to do. Accordingly, we will use our
    fiscal year 2011 and 2012 funding to focus on our three priorities.
      --Continuing to reduce the disability backlogs;
      --Improving service to the public; and
      --Saving taxpayer dollars.
        We will continue to operate very efficiently, holding
    administrative costs in fiscal year 2012 to just 1.6 percent of benefit
    payments.
                  continuing to reduce the disability backlogs
        Hearings Backlog.--Eliminating the hearings backlog continues to be
    our number one priority, and we have made real and measurable progress
    in reducing both the number of pending hearings and the amount of time
    a claimant must wait for a hearing decision.
        In fiscal year 2012, with full funding of both the fiscal year 2011
    and 2012 President's budget requests, we will continue our progress
    toward our goal of eliminating the hearings backlog in 2013. Resources
    permitting, we plan to hire an additional 130 ALJs in late fiscal year
    2011--particularly if hearing requests remain so high--to ensure that
    we can meet our commitment to eliminate the hearings backlog by the end
    of fiscal year 2013. We expect to complete a record number of
    hearings--over 800,000 in fiscal years 2011 and 2012, which is more
    than double the number we handled 10 years ago.
        We continue to focus on eliminating our oldest cases. In fiscal
    year 2011, we are targeting the 106,715 cases that will be 775 days or
    older by the end of the year. In fiscal year 2012, we will lower our
    threshold to 725 days.
        While we have made significant progress, people still wait too
    long. That wait has very real implications--many people with
    disabilities lose their homes, medical coverage, and dignity while
    waiting for a decision on a hearing. We want to maintain our momentum
    and eventually restore an appropriate level of service. Without the
    President's budget, it is highly likely that we will miss our goal of
    eliminating our hearings backlog in 2013. If that happens, gains that
    we have achieved in prior years will vanish.

        Initial Claims Backlog.--We remain committed to returning our
    initial disability claims pending to its pre-recession level by 2014.
    However, in order to meet this commitment, we will need sustained,
    adequate funding.
        Another significant obstacle to tackling this backlog is the
    decisions by a number of States to furlough federally paid State
    employees who make our disability determinations. To address that
    problem, in July 2010, we submitted a legislative proposal to Congress
    that would prohibit States, without our prior authorization, from
    reducing the number of State personnel who make disability
    determinations for Social Security. I look forward to working with you
    on this important issue.
        If we receive full funding, we estimate we will complete 3,409,000
    disability claims in fiscal year 2011, and 3,268,000 in fiscal year
    2012. We have several initiatives planned and underway to help us
    achieve our goal.
        We are dedicated to fast-tracking disability claims that obviously
    meet our disability standards and to providing decisions within 20 days
    of filing. With the effective use of screening tools, expanded
    technology, and electronic services, we have increased our ability to
    identify and quickly complete cases that we are likely to approve. We
    continue to refine our methods for identifying these cases so we can
    increase the number of fast-tracked claims while maintaining accuracy.
    We plan to increase the number of fast-tracked claims to 5.5 percent of
    all new claims filed in fiscal year 2012.

                        improving service to the public
        The availability of online services is vital to good and efficient
    public service. Increasingly, the public expects to have the option to
    conduct business over the Internet at their convenience and at their
    own pace. Even though our employees continue to review online benefit
    applications and contact applicants to resolve questions or
    discrepancies, these online services reduce the average time our
    employees spend completing claims, giving them additional time to
    address more complex issues.
        We plan to continue to expand and improve our online services. We
    plan to implement a new, even more secure authentication process to
    provide a safe environment for people who are interested in conducting
    additional business with us online. This protocol will be the gateway
    to allow the public to access their personal information online. We are
    also working on an initiative that may provide access to a variety of
    personalized online services, such as verifying earnings history,
    receiving notices, and requesting certain routine actions.
        Investing in online services is critical for providing better and
    more efficient service to the public. We will only be able to meet our
    budget commitments if we continue to see growth in our online
    applications. In fiscal year 2011, we plan to implement a shorter
    online application for cases in which a claimant alleges a
    Compassionate Allowance condition. In fiscal year 2012, we expect that
    50 percent of all retirement applications and 38 percent of all
    disability applications will be filed online.
        Because calling our 800-number continues to be the option the
    public chooses most frequently to access our services, we are committed
    to improving our telephone service. In fiscal year 2010, we awarded a
    contract to replace our 800-number telecommunications infrastructure.
    The new system will include state-of-the-art features such as providing
    immediate telephone assistance to people who visit our website. It will
    also allow us to redesign our call flow to eliminate lengthy navigation
    menus that are frustrating to the public. We plan to implement these
    and other enhancements in fiscal year 2011 and fiscal year 2012.
        We also recognize the importance of improving our field office
    service. Despite a record number of visitors, we reduced wait times in
    our field offices for those without an appointment from 23.3 minutes in
    fiscal year 2009 to 20.7 minutes in fiscal year 2010. We will continue
    improving our field office service in fiscal year 2011 with Social
    Security Television (SSTV). SSTV broadcasts to our reception areas
    information about our programs and services, such as what documents
    visitors need to apply for benefits or to request a Social Security
    card. It saves the public and our staff time.
        We are improving field office telephone service by continuing to
    replace obsolete telephone systems in all of our field offices. Nearly
    70 percent of our field offices have the new system, and we are on
    schedule to complete the rollout in 2012, although abrupt budget cuts
    may slow that rollout. The new system reduces operating costs and
    replaces increasingly unreliable outdated telephone systems. It also
    will allow us to improve both service and efficiency. For example, with
    the new system, we will be able to implement a Dynamic Forward-On-Busy
    feature, which will offer field office callers who would otherwise get
    a busy signal the option of being transferred to our 800-number during
    non-peak times.
        Video service can provide an efficient and innovative way to
    provide Social Security services to the public. For example, we
    negotiated an agreement with the Walter Reed Army Medical Center to
    install onsite video service delivery equipment that connects
    hospitalized military service members with Social Security claims
    representatives to apply for disability benefits. Video service allows
    our offices to link together to provide help to busy or understaffed
    offices. With adequate funding, we can continue to expand our use of
    video services to reach our customers in remote sites such as American
    Indian Tribal centers, local community centers, senior centers,
    hospitals, and homeless shelters, and end the inefficiency of traveling
    to remote sites on a regular basis.
                            saving taxpayer dollars
        We continue to find better ways to conduct our business. We are
    committed to minimizing improper payments and protecting program
    dollars from waste, fraud, and abuse. We pay over $60 billion in
    benefits each month and have a duty to protect taxpayer dollars. We
    invested $758 million toward our program integrity efforts in fiscal
    year 2010, and our budgets propose to invest even more in fiscal years
    2011 and 2012.
        We have many stewardship activities that are critical to helping us
    prevent and detect improper payments. These include our program
    integrity reviews, our initiatives to reduce improper payments, and our
    joint Cooperative Disability Investigations effort with our OIG.
        We have two types of program integrity reviews for which we receive
    special funding: CDRs, which are periodic reevaluations to determine if
    beneficiaries are still disabled, and SSI redeterminations, which are
    periodic reviews of non-medical factors of SSI eligibility, such as
    income and resources. We estimate that every dollar spent on CDRs
    yields at least $10 in lifetime program savings. Every dollar spent on
    SSI redeterminations yields more than $7 in program savings over 10
    years, including savings accruing to Medicaid.
        For many years, we had to cut back on these reviews due to
    inadequate funding. However, with your support, we have been able to
    increase the number of program integrity reviews we complete, saving
    billions of program dollars. In fiscal year 2012, we plan to conduct
    592,000 full medical CDRs, up from the 360,000 we plan to conduct this
    fiscal year. We also plan to conduct 2.6 million redeterminations, up
    from an estimated 2.4 million in fiscal year 2011.
        The fiscal year 2012 President's budget includes a legislative
    proposal to require employers to report wages quarterly. Increasing the
    frequency of wage reporting would improve program integrity for a range
    of programs by generating more timely information for retrospective
    checking and quality control.

        We have several initiatives underway to reduce improper payments.
    In fiscal year 2009, over 99 percent of all OASDI payments were free of
    payment error. Our SSI payment accuracy is improving, but it is still
    not acceptable. In fiscal year 2009, 91.6 percent of all SSI payments
    were free of overpayments, while 98.4 percent of all SSI payments were
    free of underpayments.
        To help improve our SSI accuracy rate, we have developed several
    program initiatives that are both cost-effective and prevent or
    minimize improper payments. These include:
      --Access to Financial Institutions (AFI).--In 2004, we began piloting
            AFI, which runs data matches with financial institutions that
            allow us to quickly and easily identify assets of SSI
            applicants and recipients that exceed the statutory limits. In
            November 2007, we expanded AFI to California. Currently, 25
            States use AFI, and we expect to complete our rollout by the
            end of fiscal year 2011. Once we have fully implemented AFI, we
            project roughly $900 million in lifetime program savings for
            each year that we use the fully implemented process. We are
            working with other agencies to see if they would benefit from
            this initiative.
      --Telephone Wage Reporting.--Wages earned by SSI recipients can
            affect their payment amounts. We do not always receive reports
            of income timely; in fact, this is a major cause of SSI
            improper payments. Using our SSI Telephone Wage Reporting
            System (SSITWR), recipients can call a dedicated toll-free
            number to report their wages via a voice recognition system. In
            fiscal year 2010, we received over 331,000 calls to our SSITWR.
            These reports generally require no additional evidence, which
            saves time in our field offices. Wages reported using this
            method are 92.2 percent accurate, compared to the 75.5 percent
            dollar accuracy of wages reported through traditional means.
            Based on the positive results of electronic reporting in the
            SSI program, we are planning to expand telephone wage reporting
            to Social Security disability beneficiaries.
        With adequate funding, we plan to continue to modernize our
    information technology infrastructure. If our systems are down, we
    cannot function. We must continue to provide service that is more
    efficient, continually refresh our technology before it becomes
    obsolete, and ensure that we can continue to protect our data from
    security threats.
        We will expand our use of Health Information Technology (HIT). This
    promising technology has reduced the amount of time it takes for us to
    obtain medical records, which in turn decreases the time it takes to
    complete a disability claim. In fiscal year 2010, we funded
    technological support for a number of healthcare providers to send us
    medical records electronically.
             disability work incentives simplification pilot (wisp)
        The fiscal year 2010 President's budget request proposes a 5-year
    reauthorization of our section 234 demonstration authority for the DI
    program, which would allow us to test program innovations. One such
    innovation is the WISP program, which would provide beneficiaries with
    a simple set of work rules and would no longer terminate benefits based
    solely on earnings. Many DI beneficiaries want to return to work but
    they do not attempt to because they are worried about losing monthly
    benefits and health insurance if their work attempt fails.
    Additionally, the current work incentive rules are complex and can
    sometimes result in large overpayments.
        WISP is intended to address these concerns by replacing complex
    rules with a clear, simple, unified process that is both easier to
    understand and easier to administer. Work would no longer be a reason
    for terminating DI benefits. We would continue to pay cash benefits for
    any month in which earnings were below our established threshold, but
    would suspend benefits for any month in which earnings were above the
    threshold. A beneficiary would maintain an attachment to DI and
    Medicare as long as the disabling impairment continues.
        Testing WISP under rigorous evaluation protocols would allow us to
    analyze the effects of these changes on the behavior of beneficiaries
    and potential applicants across the country.
                                   conclusion
        I am proud that we have significantly improved the service we
    deliver to the American people. Without the additional funding Congress
    provided to us since fiscal year 2008, Americans would wait
    significantly longer to receive decisions on their claims, speak to a
    representative in our field offices or on the phone, and have their
    cases heard by an ALJ.
        While we hope that the worst of the economic downturn is behind us,
    unemployment is predicted to remain high. Since high unemployment rates
    usually result in more benefit applications, we expect the number of
    new claims, particularly for disability, will continue to remain high.
    These additional claims will ultimately result in more hearing
    requests.
        We have made great progress for the American public, but it will be
    jeopardized without full funding of the President's fiscal year 2011
    and 2012 budget requests of $12.379 billion and $12.522 billion,
    respectively. The American people are still struggling through the
    economic crisis. We cannot allow our services to deteriorate. A
    reduction in our funding at this time would reverse the progress we
    have made over the last few years. Millions of deserving Americans
    count on us, and we need your continued support to provide the service
    they expect and deserve.

                   ADMINISTRATIVE FUNDING FOR SOCIAL SECURITY

        Senator Harkin. So, we'll begin a round of 5-minute
    questions.
        First, I just want to reiterate, for everyone here, we're
    here today to discuss administrative funding for Social
    Security. Issues concerning the solvency of the program are not
    in the purview of this subcommittee. I will be limiting my
    questions to the very important topic at hand that will impact
    millions of Americans this year, and I ask my fellow
    subcommittee members to do the same. Debates on solvency and
    what needs to be done to ``fix'' Social Security stuff,
    that's--as I said, that's not in the purview of this
    subcommittee. What's in the purview is the funding for the
    administration of the program, and how that program operates
    with that funding.

                           ANNUAL EARNINGS STATEMENTS

        So, Commissioner Astrue, just a couple things. One, you
    said you're suspending printing and mailing of the annual
    earning statements. Is this the statement that people get every
    year that says, ``Here's how much you have put in and here's
    what you can expect to get''----
        Commissioner Astrue. Yes.
        Senator Harkin [continuing].``When you retire''?
        Commissioner Astrue. Yes, it is, Mr. Chairman.
        Senator Harkin. One of the things that, when Social
    Security started doing this--I don't know how long ago Social
    Security started doing this, but----
        Commissioner Astrue. We started doing this, on a pilot
    basis, when I was with the agency the last time. So, it would
    be more or less around 1987----
        Senator Harkin. Somewhere in there.
        Commissioner Astrue. Mr. Chairman.
        Senator Harkin. Since then, what's happened--correct me if
    I'm wrong--is that people get these statements and they then
    have a better idea if they need to save more or put more in
    some other retirement account or something, because they'll
    know what their Social Security is going to be. And now they're
    not going to have that information?
        Commissioner Astrue. Well, they will substantially have
    that information in a different form, Mr. Chairman. So, one of
    the things that we have done on my watch is that almost all
    Americans can go online now and get an estimate of their
    retirement earnings. And it's very accurate. What they used to
    do with the old printed statement is take their 35 years, type
    those into an online program that was not very accurate, and
    try to get the same information. So, for the vast majority of
    Americans, they can now get what they're really looking for,
    much more accurately.
        What we were planning on talking to the Congress about in
    the next 6 months, we think that we are close to being able
    provide the earning statement information online. We do not
    know for sure yet. It's primarily a question of authentication,
    and we're still working on that. So, we are in the process of
    canceling the contract, which is very expensive. We think, in
    the next 6 months, we'll be able to make a decision whether
    we're going to be able to provide that information safely and
    efficiently online, or whether we have to revert to the old way
    of doing things. But, in the meantime, it seemed like it made
    sense; given the tradeoffs of all the things that we're
    supposed to do that we can't do efficiently, that this is one
    of the things that it made sense to take a pause in doing.

                               PROGRAM INTEGRITY

        Senator Harkin. I understand. Very good.
        About program integrity: As you say, the continuing
    disability reviews save about $10 for every $1 spent.
    Redeterminations save about $7 for every $1 spent. What are the
    long-term budget implications of cutting administrative funding
    for these today, if we do cut them?
        Commissioner Astrue. Well, I think the key part of the
    issue, Mr. Chairman, is that even if we continue the same level
    of program integrity work--and with all the stresses of the
    agency, you'll note my commitment to program integrity work,
    because that had dropped steadily with the administrative
    funding cuts in the beginning of the decade. And they've gone
    up, year by year, on my watch, although we're not back to where
    we really should be in order to protect the trust funds
    appropriately.
        But, the issue really is, we are going to make a lot more
    mistakes that cost the trust fund money if we're not handling
    the cases upfront correctly. And what's going to happen if we
    have sudden and severe cuts is, the level of error will
    increase dramatically, and we'll need more staff, and it will
    take a lot of time, and it will not be a complete recovery
    effort, to try to fix that after the fact. As with most things
    in life, it's better to do it correctly upfront than try to fix
    the problems after the fact.

                            DISABILITY WAITING TIMES

        Senator Harkin. Last--I've only got a few seconds left;
    I'll ask my last question. And that has to do with the amount
    of time that you have reduced. On your watch, you've reduced
    the----
        Commissioner Astrue. Yes.
        Senator Harkin [continuing]. The waiting time considerably.
    I congratulate you on that. That's great leadership. And so,
    I've said this to some people, but ``Well, okay, then the time
    will go back up again, for people to get their disability
    claims.'' And, quite frankly, some people have said, ``Well,
    you know, so what? So, they have to wait another half a year or
    year. So what?'' Well, what's the response on that?
        Commissioner Astrue. Well, you know, my response is, I've
    been through this, personally. Very unexpectedly in 1985, I had
    to file for disability for my father. And I think that a lot of
    people who say things like that just don't appreciate what it's
    like to be in that position and how important--even with the 5-
    month waiting period for benefits and the 24-month waiting
    period for medical benefits--how important it is for the
    family, for financial planning, to know what's going to be
    available when. And I think anyone who's been through the
    process can't possibly say, ``Well, another year, another 2
    years, is just fine.''
        Senator Harkin. Thank you very much, Commissioner.
        Senator Shelby.

                          RECOVERY ACT FUNDING FOR SSA

        Senator Shelby. Thank you, Mr. Chairman.
        I'm a little baffled by the assumptions made by the Social
    Security Administration, in your testimony, with regard to
    fiscal year 2011 and 2012 budgets. You state, and I'll quote,
    ``The $350 million Recovery Act funding we used in fiscal year
    2010 to handle claims was not included in our continuing
    resolution level. Between having to recover mandatory cost
    increases and not having Recovery Act funding, we're operating
    at a significant loss over last year.''
        It's my understanding that the Social Security
    Administration received $500 million in the stimulus bill to
    address workload processing. These were onetime funds that
    should not, I believe, be considered in addition to the
    administration's baseline. The 2012 budget request is 9.4
    percent higher than 2010. This significant request for
    additional resources comes, of course, in an austere economic
    environment, where we should not be looking at how to throw
    money at a problem, but to work smarter.
        Instead of spending onetime stimulus funding on personnel,
    I believe the Social Security Administration should have been
    looking at ways to streamline the claims process. Maybe you
    have. The Social Security Administration's use of one-time
    funds to build new personnel into its baseline, I think is a
    dangerous mismanagement of Federal funds. Using one-time
    Recovery Act money, your agency hired 2,405 employees--more
    employees--to lower the disability backlog. Your own numbers
    show initial disability receipts and hearing receipts will
    start to decline in 2012.
        Why did you choose a long-term costly hiring strategy for a
    short-term problem?
        Commissioner Astrue. Well, Mr.----
        Senator Shelby. At least that's the way it looks to me.
        Commissioner Astrue. Mr. Shelby, in large part, because
    that's what the Congress told us to do. We expressed concern to
    the committees, at the time, that operating funds were being
    put into the Recovery Act instead of into the baseline, that
    there might be confusion in subsequent years. But, the
    committees of Congress that we talked to were quite clear that
    they knew that the only way to reduce the backlog in the short-
    term was to address some of the staffing issues, and said it
    would be adjusted--we were assured it would be adjusted in the
    future years. So, we did----
        Senator Shelby. Now, what does that mean, ``adjusted''? You
    include it in----
        Commissioner Astrue. That, in future authorizations and
    appropriations, there would be a recognition that these were
    not one-time capital expenditures. These people are different
    from a building. So, I agree with you----
        Senator Shelby. Who told you that?
        Commissioner Astrue. My understanding is that was Members
    of the Congress and members of committee staff. I mean----
        Senator Shelby. I never heard that.
        Commissioner Astrue [continuing]. There was no controversy
    at the time that we were going out and doing that hiring. In
    fact, I got quite a bit of criticism, from some individual
    Members, that we were not moving fast enough on some of the
    hiring. But, the civil service process, you know, is a long and
    difficult one. So, we did, in my view, exactly what the
    Congress told us to do.
        Senator Shelby. Well, a lot of people all over America,
    realize that this stimulus package, this money was--once it ran
    out, it was gone. I think you should have considered that.
    Obviously, you didn't.
        How will you manage the additional costs, in the future,
    when your payroll costs already topped $7 billion, over two-
    thirds of your budget?
        Commissioner Astrue. Well, most of our----
        Senator Shelby. How could you save money? Have you thought
    about how could you save?
        Commissioner Astrue. Oh, I get up every day----
        Senator Shelby. Sure.
        Commissioner Astrue [continuing]. And think about how to
    save money and how to make the process more efficient. But,
    what I think is important for the subcommittee to understand is
    that, unlike many other agencies that have discretion in terms
    of what kinds of grants they give or prioritization on
    enforcement, we have very little that is discretionary. Almost
    everything we are doing involves an entitlement to the American
    people, where we don't have choice whether we do it or not.
        And, at the end of the day, while we have done the best we
    can to improve efficiency with information technology and
    things like that, people have to do that work. And the people
    are very important to that. And, as it is, we're losing people
    at a disturbing rate. We're losing 3,500 people this year.
    We're expecting, under a continuing resolution, if it extends
    to next year, another 4,100 people. So, we're reducing people
    at an extremely fast rate.

                     REVERSAL RATE FOR DISABILITY DECISIONS

        Senator Shelby. I want to touch on some other stuff.
        We've been told that, after being rejected by the Social
    Security Administration for a disability claimant person, two-
    thirds of the claimants win their appeal. With such a high
    overturn rate, why are claimants not approved on initial
    review, if the work was done? And, if so, it would save a lot
    of money, it seems to me.
        Commissioner Astrue. Yeah. I think that's an arithmetic
    confusion, Mr. Shelby, because the numerator and the
    denominator are not the same. So, you have to realize that, in
    addition to the people--probably last year, if I remember
    correctly, over 1 million people who were approved at the
    initial level, and there were about 1.2 million people who
    received an adverse decision and did not appeal to the next
    level. And so, it's a relatively small number of the closer
    cases, as a general matter, that go up on appeal. So, the
    overall number of denials going from the initial decision to an
    appeal is actually very small.
        Senator Shelby. And how many--number-wise, what--how many
    cases are denied, then appealed nationwide, roughly, per year?
        Commissioner Astrue. How many are----
        Senator Shelby. Yeah.
        Commissioner Astrue. The allowance rate is down, I think,
    not even a statistically significant amount. But, it's my
    recollection, and we will provide for the record page 103 of
    our fiscal year 2012 justification of estimates for
    Appropriations Committees, which shows the flow of disability
    cases from the initial level all the way to Federal court
    appeals.
        Senator Shelby. Okay.
        [The information follows:]

         Figure 1. Fiscal Year 2010 Workload Data: Disability Appeals.

        Commissioner Astrue. It's about 62 percent at hearing.
        Senator Shelby. And how many cases are there?
        Commissioner Astrue. It's about 800,000 hearings a year.
        Senator Shelby. Eight-hundred thousand--that's a lot of
    cases over the next few years.
        Commissioner Astrue. It is a lot of cases, Mr. Shelby.
        Senator Shelby. Eight-hundred thousand cases.
        Commissioner Astrue. And I would say, you are correct about
    the importance of doing things promptly and upfront. So, one of
    the things that we've done, in the last couple of years, is
    because we have an electronic system, we can now pull out the
    cases that should be the easy and automatic cases, and allow
    them upfront. And that's part of how we've increased our
    accuracy, which had been flat at the first level at about 94
    percent. Even with all the influx of cases, we're up to about a
    98-percent accuracy rate now.

       COST-BENEFIT ANALYSIS OF HEARING VERSUS APPROVING A CASE INITIALLY

        Senator Shelby. I know I'm under a time constraint, but if
    you'd just----
        Commissioner Astrue. I'm sorry.
        Senator Shelby [continuing]. Say it for the record. Has the
    Social Security Administration performed a cost-benefit
    analysis to examine the cost of hearing a case versus approving
    a case initially? That is, an appeal. What--the--if someone's
    got merit in their initial claim, wouldn't it make sense to do
    the work to ascertain that, rather than have 800,000 cases on
    appeal?
        Commissioner Astrue. Well, we're certainly trying to do
    that. And, as I said----
        Senator Shelby. Assume it's got merit, you know? And if the
    appeal process throws back two-thirds of the cases, there's
    something wrong.
        Commissioner Astrue. Well, as I said, I think if we were
    approving a much lower percentage, then we'd be getting the
    complaint from the Congress that the odds are stacked against
    the claimants. So, it is a process that has been very carefully
    prescribed by the Congress, that we try to follow as closely as
    we can. And you have to realize that each decision, if I
    remember correctly, at the hearings and appeals level, in terms
    of net present value, is about a quarter million dollar
    decision. So, these are important decisions.
        And I don't think it's the right answer, from a trust fund
    point of view, to simply give that money away at the front end
    of the process. There are some cases that are very close, where
    reasonable people can disagree. It's very hard to tell with
    back pain, it's very hard to tell with depression. There are
    also cases up on appeal that initially are turned down,
    appropriately, because they're diseases that get progressively
    worse. And, by the time they get to the appeal, where we look
    at it fresh--it's not like a legal appeal, where you----
        Senator Shelby. Well, I've known cases where people who
    have filed for disability claims and have been denied. And, of
    course, to say they're not really that sick or they're not that
    disabled, and then they die before the appeal process. You know
    'em, too.
        Commissioner Astrue. Yes, that's----
        Senator Shelby. So, I think----
        Commissioner Astrue [continuing]. That does happen.
        Senator Shelby [continuing]. What we've got to do is
    determine the merits of cases.
        Commissioner Astrue. Absolutely. I agree with you, Mr.
    Shelby.
        Senator Shelby. Thank you.

                FUNDING NEED TO RUN AN EFFICIENT, EFFECTIVE SSA

        Senator Harkin. Thank you, Senator Shelby.
        Senator Mikulski.
        Senator Mikulski. Thank you, Mr. Chairman.
        Mr. Administrator, I have two questions: one on what you
    need to run an efficient, effective Social Security
    Administration; and then the other, additional info on the
    impact of the continuing resolution.
        I believe that demography is destiny. In other words, the
    population profile of the United States is predictable. We have
    a Census Department that tells us who it is. And what they tell
    us is, the Baby Boomer generation is here. If there are
    Boomers, there are demands on the application to Social
    Security. You have no control over it. Congress doesn't have
    any control over it. No political party or subgroup within a
    party has it. Tell me, from the standpoint of someone who's
    devoted his career to public service, what is it that you think
    you need to have for fiscal year 2012. What is the number of
    employees you need to have, and what is it that you need to
    have in the Federal budget to meet the sheer predictable
    population demands, let alone economic downturns or an
    unexpected event?
        Commissioner Astrue. Sure. That's a very fine question.
        As you know, Senator Mikulski, by statute my request to the
    President is disclosed to the Congress, and so that you know,
    the President's request for 2011 and 2012 was very close to my
    request. And we've laid out in the President's budget why we
    need----
        Senator Mikulski. But, for the record, what amount is it,
    and what will that buy?
        Commissioner Astrue. Well, what the President's level
    would--which is approximately $12.5 billion--would allow us to
    do is to meet the ongoing service needs of the country and
    continue on track to reduce the existing backlogs, not only at
    the hearing level, but at the front level, because we've gotten
    about two-thirds of 1 million more disability cases than we
    originally projected a few years ago. And we have to process
    that work.

                        EFFECTS OF CONTINUING RESOLUTION

        Under the continuing resolution, staff numbers are
    declining very rapidly. We are barely above the funding level
    where we need to furlough. And, at that point, we start to see
    degradation of service. We've been trying to hold the line as
    best we can. But, if we go much further with these kinds of
    dramatic staff reductions, the numbers that have been improving
    so well for the last 4 years----
        Senator Mikulski. Let me get----
        Commissioner Astrue [continuing]. Rapidly----
        Senator Mikulski [continuing]. To the point.
        First of all, I'm deeply troubled by the 3,500 employees
    that will be lost this year. That's 3,500 nationwide----
        Commissioner Astrue. Yes.
        Senator Mikulski [continuing]. Not in the headquarters,
    the----
        Commissioner Astrue. Yes, that's right.
        Senator Mikulski [continuing]. The mother ship in
    Baltimore----
        Commissioner Astrue. Yes, that's right.
        Senator Mikulski [continuing]. Is that correct?
        Commissioner Astrue. That is correct.
        Senator Mikulski. So, that's nationwide, and that's in the
    field offices, et cetera.
        Commissioner Astrue. Yes. And about 80 percent of the
    people, more or less, are in the field.
        Senator Mikulski. Now, is it because people now know that
    there's both a freeze, an impending furlough, and the serious
    threats of reductions in promised retirement benefits that have
    been proposed in some deficit reduction plans, such as going to
    a high five instead of a high three? Are people also getting
    ready, at the Social Security Administration, to retire at a
    more increasing rate? So, in addition to that which you need to
    replace employees who leave through natural attrition, they're
    going to start to bail out?
        Commissioner Astrue. Well, I think all those things are
    factors, and significant ones. I think if you look at it from a
    broad perspective--because we went 14 straight years with
    appropriations under the President's request, we did not do
    very much hiring for a long time. We had been an agency, at one
    point, of as many as 82,000 people. And we dropped, briefly--in
    the beginning of my watch, when we were on a continuing
    resolution for 15 months, if I remember correctly, to under
    60,000. So, we're up a little bit over that now, but we have an
    older workforce; we have a lot of people retiring, as a normal
    course of business. I think some of the things that have
    happened with civil service are accelerating that.
        But, I have to be candid with you, too; we also just gave
    everyone, without exception, the ability, earlier in the year,
    for early out, because we looked at the potential budget
    situation and, to Mr. Shelby's point, that the Congress is
    telling us that we can't afford those people. So----
        Senator Mikulski. Good. Now, let me jump in. We could be
    headed to a shutdown.
        Commissioner Astrue. Yes.

                    POSSIBLE EFFECTS OF GOVERNMENT SHUTDOWN

        Senator Mikulski. Because, I know that, in my subcommittee,
    in Commerce/Justice, I can't cut any more. And Senator Harkin
    must also be facing the same stress. So, we're heading to a
    showdown.
        Now, much has been said about the impact on Social
    Security. If there is a shutdown, will Social Security checks
    go out?
        Commissioner Astrue. So, this answer----
        Senator Mikulski. And will field offices----
        Commissioner Astrue. Sure.
        Senator Mikulski [continuing]. Stay open, or will they be
    closed?
        Commissioner Astrue. Sure. This answer gets a little bit
    complicated, depending on whether the Congress fails to pass a
    budget at all or takes deep cuts in our budget. So, it's a
    somewhat different answer.
        But, if the answer is addressed to a shutdown, where
    Congress does not pass a budget, then I think that the White
    House has made what will happen clear. Mr. Carney correctly
    laid out that, for most existing beneficiaries, checks will go
    out and they will not see an interruption of service. If you've
    had a change of address, if you're a new applicant, then we
    cannot pretend that we will be able to get a timely and
    accurate payment out.
        Senator Mikulski. And what about the field offices? Are
    they open or closed?
        Commissioner Astrue. Under a shutdown scenario in the
    Government, we have some latitude to keep some essential
    services open, but we will be open only on a very partial
    basis, for certain types of work, under a Government-wide
    shutdown.
        Senator Mikulski. I think this is a very severe crisis.
        Commissioner Astrue. I agree----
        Senator Mikulski. And I----
        Commissioner Astrue.--with you, Senator.
        Senator Mikulski. And, sir, I appreciate your factual and
    candid response. And it's our job to resolve the crisis. Thanks
    for being so candid.
        Commissioner Astrue. Thank you, Senator Mikulski.
        Senator Harkin. Thank you, Senator Mikulski.
        Senator Reed.
        Senator Reed. Thank you very much, Mr. Chairman.
        Thank you, Commissioner, for your testimony and for your
    very professional service.
        Commissioner Astrue. Thank you.

                          SSA ADMINISTRATIVE OVERHEAD

        Senator Reed. Just as background, sort of contrast, how
    would you evaluate your overhead, including all of your
    personnel and your systems, versus a comparable insurance
    entity in the country?
        Commissioner Astrue. I think that we stand up against, not
    only any Federal agency, but pretty much any large financial
    organization in the country. If I remember correctly--if I'm
    making a mistake, we'll correct it for the record--about 1.6
    percent, I believe, of our budget is for administrative costs.
    And it's been going down steadily, as a percentage of cost, for
    a number of years. So, this is, in my book--and I've been a CEO
    of publicly traded corporations, which relatively few agency
    heads have--an extraordinarily efficient organization. And I
    don't think there's a lot of fat left in this organization.
        Senator Reed. In fact, I think is--and I'm alluding to what
    was suggested by Senator Mikulski--we're reaching the point
    where, if we deny effective resources to the Department, this
    level of efficiency will be compromised----
        Commissioner Astrue. Yes.
        Senator Reed [continuing]. That, at some point, you just
    can't, you know, continue to maintain this level.
        Commissioner Astrue. Exactly, Senator Reed--we've run this
    experiment recently. So, we ran down the administrative budget
    for most of this decade. And very predictable things happened:
    backlogs grew, and program integrity work plummeted, at a long-
    term cost to the trust fund. It is only with great difficulty
    that we've been able to move the agency back in a positive
    direction and increase the program integrity work and bring the
    backlogs down.
        And what I would say to all of you now is, it's your
    choice. We've done everything that we know how to do. And
    whether we go backward or whether we go forward depends on what
    you decide to choose for funding for the agency.

                       ADEQUATE RESOURCES NEEDED FOR SSA

        Senator Reed. Well, I think it's ironic--I'll use that
    term--that you--we have one of the most effective programs in
    the history of this country, one of the most efficiently run
    programs in the history of this country--in fact, as you
    suggest, from your experience as a CEO of a private-sector
    country--company--much more effective than most of the vaunted
    public companies. And yet, we're at the point of disrupting it
    significantly, in terms of how it operates, if we don't provide
    adequate resources to you.
        So, I think it's clear that, you know, this is one of those
    cases--and they're not that frequent in any endeavor,
    particularly Government--where we have to reinforce success,
    not undercut it. And so, I would hope that we would reject some
    of the proposals--particularly the House proposal, it would
    have significant cuts, as I understand them--and support you at
    a time--and again, to Senator Mikulski's point--where,
    demographically, your burden is not going to get lighter, it's
    going to get heavier because of the people like me--not yet,
    but very soon.
        And I want you to be around for my 4-year-old daughter. So,
    you--we--I've got a vested interest.
        Commissioner Astrue. Well, my term runs pretty soon. So, I
    know----
        Senator Reed. I know it will.
        Commissioner Astrue [continuing]. I won't be there
    personally, but the wonderful people behind me will be there.

                     SERVICE CUTS DUE TO A LACK OF FUNDING

        Senator Reed. All right. Well, if that's a promise.
        Let me just now go down, sort of, the level--and again,
    suggested by Senator Mikulski--these cuts will come, not from
    the D.C., Washington, Baltimore, metro area. Most of them are
    from the local offices. We had the experience, in 2002, where
    adjudication officers in three of my communities in Rhode
    Island were consolidated. You know, again, you said, ``When you
    cut the budget every year, you start cutting into the--you
    know, the efficient operation.'' They were sent up to
    Massachusetts. I would assume that if the budget pressure
    continues to grow as is, you'll be making those same types of
    decisions.
        Commissioner Astrue. Exactly right. We are actually moving
    more work geographically around the country to take advantage
    of wherever places are less busy. So, we've done more of that
    than in the past. And, if we go into a crisis, then there'll be
    more work moving from one State to another as we try to manage
    things as best we can.
        Senator Reed. So, you'll have two situations going on:
    reductions in force----
        Commissioner Astrue. Right.
        Senator Reed [continuing]. Consolidations of offices. What
    that leaves, though, is big--potentially, big service gaps. I
    mean----
        Commissioner Astrue. Yes.
        Senator Reed [continuing]. It is a difference between a
    senior citizen in my State getting on a bus or getting--taking
    their car and driving 10 or 15 or 20 minutes to a local office
    and the difference of going to Boston, literally----
        Commissioner Astrue. Yes.
        Senator Reed [continuing]. And with all of the--that
    entails.
        Commissioner Astrue. Yes. You know, you've said it more
    articulately than I could, Senator, but the only thing I would
    add is, it's already happening. We're already starting to move
    backward because of the staff reductions.
        Senator Reed. Let me just--a final point is that we
    sometimes focus on the Social Security system as one that deals
    with seniors. But, you have families and children that we have
    to worry about. In fact, one of the startling statistics that
    I've seen recently is that, for the first time, the Great
    Depression, 25 percent of children in this country are living
    in poverty.
        Commissioner Astrue. Right. And----
        Senator Reed. That's a very, very shocking and, indeed,
    shameful statistic----
        Commissioner Astrue. And, in fact----
        Senator Reed [continuing]. Given this the----
        Commissioner Astrue [continuing]. If you look at----
        Senator Reed [continuing]. Wealthiest country.
        Commissioner Astrue [continuing]. Where the administrative
    effort is spent, we would be even more efficient if we were
    just a retirement organization; but we're not. We will take in
    about 3.3 million disability claims this year, and that's where
    the vast majority of the administrative effort goes. We're the
    largest repository of medical records in the world. Sometimes
    we have over 1,000 pages of medical records we need to review.
    And a lot of these are very difficult, close calls.
        That is, in fact, where a lot of the administrative time is
    spent, because the retirement process is pretty automatic. We
    try to make it even more automatic. We've gone from 10 percent
    to 40 percent of the people filing online, because we've
    improved--we've made it a much more user-friendly process. And
    we're trying to find the efficiencies wherever we can. But, the
    lion's share of the administrative effort is on the disability
    side. And there are just some limits on how much of that you
    can automate. And we'll have to make a lot of those decisions.
        Senator Reed. And--but, that has a huge impact on the
    quality of life of families and children in this country----
        Commissioner Astrue. Absolutely.
        Senator Reed [continuing]. Particularly as we see these
    growing statistics of childhood poverty. And your agency does
    make a difference; but if you don't have the resources, you
    can't.
        Commissioner Astrue. That's right.
        Senator Reed. Thank you.
        Senator Harkin. Commissioner, thank you very much for your
    great stewardship of a wonderful--or a wonderful part of our
    American society. Thank you for your stewardship of it. We have
    our work cut out for us, in terms of making sure that you can
    do your job well and make sure that people who rely upon Social
    Security--as Senator Reed just reminded us, not just elderly, a
    lot of kids out there, too, and people with disabilities,
    survivors--make sure that they can get timely help.

                         ADDITIONAL COMMITTEE QUESTIONS

        Commissioner Astrue. Thank you very much, Mr. Chairman.
        Thank you to everyone on the subcommittee. I appreciate
    this opportunity.
        Senator Harkin. Thanks, Commissioner.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                Questions Submitted by Senator Richard C. Shelby
        Question. You are permitted to transfer unobligated regular
    appropriations authority that is considered ``not needed'' to your
    information technology (IT) fund. Since fiscal year 2001 you have
    transferred $1.3 billion out of the operational Limitation on
    Administrative Expenses account into the IT Fund. This is at a time of
    record backlogs and wait times. Why were these Limitation on
    Administrative Expenses funds considered ``not needed?'' Wouldn't this
    funding have been better spent on integrity work, such as, disability
    and Supplemental Security Income reviews?
        Answer. Our ability to transfer unobligated administrative funds to
    our Information Technology Systems (ITS) account is a funding mechanism
    that Congress specifically authorized and that the Office of Management
    and Budget (OMB) manages closely. Congress included language in our
    fiscal year 2001 appropriation that allowed us to carry forward
    unobligated Limitation on Administrative Expenses (LAE) funds to invest
    in ITS costs. Congress has continued to provide this authority in every
    succeeding appropriations act since fiscal year 2001.
        We must justify to OMB any transfer of unobligated balances to the
    ITS account, and OMB must give us formal approval before we can
    transfer and spend any funds. Moreover, available ITS transfer funding
    factors into our annual budget request. During the budget process, we
    work with OMB to determine how much of our IT needs will be covered
    with funding we can transfer into the ITS account, thereby decreasing
    the amount of new funding we need to request in any given fiscal year.
        We have a long history of sound financial management practices that
    avoid Anti-Deficiency Act violations. At the beginning of each fiscal
    year, we put in place spending plans to use the full budget. We develop
    performance targets (i.e., numbers of completed claims, hearings,
    continuing disability review, redeterminations, etc.), estimate related
    costs, and negotiate these estimates with OMB. We allocate these annual
    resources as soon as we have an appropriation from Congress and
    approved apportionments from OMB. We continually monitor our resources
    and reallocate them to our highest priorities as the year progresses.
    We typically lapse only about 1 percent of our LAE funding each year.
    We do not lapse annual funding in order to transfer it to our ITS
    account. Nevertheless, with the complexity of our budget, two-thirds of
    which is payroll costs, a small amount of lapsed resources is
    unavoidable and often necessary to avoid an Anti-Deficiency Act
    violation. With nearly 80,000 Federal and State employees, even a small
    shift in salary or benefit costs can create a change of millions of
    dollars in our administrative budget. We also must be able to address
    unanticipated requirements, such as court decisions.
        When we receive a budget each year, we determine the level of staff
    we can fund and support in future fiscal years. Your suggestion that we
    could have better used annual administrative resources to complete more
    program integrity work would have required us to hire additional staff.
    Uncertainty about future funding makes it difficult to predict how many
    employees we can support in future years, and prolonged continuing
    resolutions can delay the hiring process. We cannot make long-term
    commitments to hire employees when future budgets may not support
    retaining them, potentially forcing us to implement furloughs or other
    drastic cost saving measures.
        ITS transfer authority has allowed us to make technology
    improvements that help our employees work more efficiently. Our IT
    investments have helped us achieve average annual employee productivity
    increases of about 4 percent each of the last 5 years. Most of our
    annual ITS funding is necessary for ongoing operational costs such as
    our 800 number service and our online services. It also helps us
    maintain sufficient capacity to store ever-increasing amounts of data.
    Prior year resources have helped us fund essential IT projects such as
    making our disability process fully electronic, developing robust and
    user-friendly online services, and opening our second data center.
    Without these IT investments, we would not have kept pace with the
    recent increases in claims. If we did not have the ITS transfer
    authority but still invested the same amount of resources in IT
    enhancements to improve employee productivity, we would have completed
    nearly 1 million fewer disability claims or nearly 500,000 fewer
    hearings since fiscal year 2001.
        Question. Today, what is the total level of funding in the so-
    called ``IT Fund,'' or the carryover funding from previous fiscal years
    for information technology and telecommunication activities? Of this
    amount, what level of funding did the Social Security Administration's
    fiscal year 2011 budget request state would be used in fiscal year
    2011? Is it correct that this would still leave a substantial amount of
    reserve funding in the IT Fund that would not be spent in this fiscal
    year? What level of funding specifically would remain in the IT Fund?
        Answer. The fiscal year 2011 column of the fiscal year 2012
    President's budget assumed that $480.4 million would be available in
    fiscal year 2011 to transfer to the no-year ITS account. Of that total,
    our fiscal year 2012 budget assumed that we would use $280 million in
    fiscal year 2011 and the remaining $200.4 million in fiscal year 2012
    for IT costs. Prior to March 2011, we had transferred $680.4 million
    from previous fiscal year unobligated balances to the no-year ITS
    account, which was the amount available in prior year accounts that was
    not needed for potential upward adjustments to prior year obligations.
    On March 18, 2011, the Additional Continuing Appropriations Amendments,
    2011 (Public Law 112-6, the sixth CR for fiscal year 2011) rescinded
    $200 million of the available $680.4 million. The Department of Defense
    and Full-Year Continuing Appropriations Act, 2011 (Public Law 112-10,
    enacted on April 15, 2011) rescinded an additional $75 million.
        Due to the rescissions in fiscal year 2011, we carried over only
    $32.5 million from fiscal year 2011 into the no-year ITS account in
    fiscal year 2012. In fiscal year 2012, we transferred $129.6 million
    from previous fiscal year unobligated balances to the ITS no-year
    account. In total, we have $162.1 million available in the fiscal year
    2012 no-year ITS account. This amount is less than the $200.4 million
    that we assumed would be available in the fiscal year 2012 no-year ITS
    account.
        Question. According to the Congressional Research Service, only 3
    percent of beneficiaries ever come off Social Security Disability
    Insurance (SSDI) rolls. In your testimony, you discussed the pilot Work
    Incentives Simplification Program (WISP) that would allow beneficiaries
    to return to work and continue to receive SSDI benefits for any month
    in which earnings were below the established threshold. I believe it is
    critical to the future of SSDI that beneficiaries who are able to work
    do. However, I remain concerned that other programs put in place by the
    Social Security Administration to incentivize work, such as the Ticket
    to Work program, have been failures. How do you implement this program
    to ensure those who are able to work in some capacity will do so?
        Answer. Congress established the Ticket to Work (Ticket) program in
    1999 to expand the universe of service providers to help beneficiaries
    obtain the services and supports they need to find and maintain
    employment. In 2008, we made regulatory changes to the Ticket program,
    which have significantly increased beneficiary and employment network
    (EN) participation. Since the change, the number of active ENs
    increased by nearly 50 percent and the number of beneficiaries that ENs
    placed in a job increased by 319 percent from a little over 4,000
    beneficiaries to over 16,895 beneficiaries.
        The most important distinction between the Ticket program and the
    Work Incentives Simplification Pilot (WISP) is that under the Ticket
    program, we must still apply our complex and often confusing work
    incentive rules. The Social Security Act (Act) includes a number of
    incentives to encourage disability beneficiaries to return to work. In
    the Social Security Disability (SSDI) program, the incentives include
    the trial work period (TWP) and the extended period of eligibility
    (EPE). In addition, there are special rules about impairment-related
    work expenses, expedited reinstatement, and medical insurance. Although
    we train our field office personnel to explain the work incentives and
    we publish information to help people understand the provisions, the
    work incentive provisions are complex and difficult to administer and
    understand. The work incentive rules are different for SSDI than they
    are for Supplemental Security Income (SSI) which make the rules even
    more complex if a person is entitled to both types of benefits. The
    goal of WISP, which we would first pilot, is to simplify SSDI work
    rules to encourage beneficiaries to return to work and reduce our
    administrative costs. WISP would eliminate complex rules on the TWP and
    the EPE. It would also eliminate performing substantial gainful
    activity as a reason to terminate SSDI benefits. If a beneficiary's
    earnings fell below a certain threshold, we could reinstate monthly
    benefit payments as long as the person remained disabled. WISP would
    allow us to replace the complex work continuing disability review
    process with a streamlined work review process, which would reduce
    improper payments. Finally, our WISP proposal would better align the
    SSDI program with the SSI program.
        Congress has held hearings to highlight the importance of program
    integrity and improved service. Program simplification is an answer to
    Congress' questions about how to improve in these areas.
        Question. There are no disincentives from fraudulently applying for
    Social Security Disability Insurance. Claimants are not fined and
    virtually no one is prosecuted for a false claim. How do we implement
    specific, targeted fixes to this program when there is no deterrent
    mechanism?
        Answer. One of our most successful efforts against disability fraud
    is the Cooperative Disability Investigations (CDI) program, which links
    our Office of Inspector General (OIG) and local law enforcement with
    Federal and State workers who handle our disability cases. These units
    are highly successful at detecting fraud before we make a disability
    decision and identifying overpayments. There are currently 25 CDI units
    nationwide.
        Since its inception in fiscal year 1998, CDI efforts nationwide
    have resulted in nearly $3.1 billion in projected savings: $1.9 billion
    to our disability programs and $1.2 billion to other programs, such as
    Medicare and Medicaid. Due to the success of the CDI program and our
    increased efforts to prevent improper payments, we plan to open
    additional units as resources permit.
        The Federal Government or States may prosecute an individual for
    fraudulently receiving SSDI benefits. The determination as to whether
    to proceed criminally rests with the appropriate prosecutor, either
    Federal or State. The Department of Justice may also pursue a claim
    under the False Claims Act. If a U.S. Attorney's Office declines to
    prosecute the case, our OIG may pursue an action for civil monetary
    penalties. If the OIG declines the case, we may pursue administrative
    penalties.
        We train our field employees to alert OIG to any cases of suspected
    fraud. We made nearly 19,000 such fraud referrals related to our
    disability programs in fiscal year 2011, from which the OIG opened
    about 4,600 cases. During this period, our OIG initiated 314 civil
    monetary penalty cases, successfully resolving 67 with $2,798,172 in
    penalties and assessments imposed.
        Additionally, we have nine attorneys assigned to a United States
    Attorney's Office as Special Assistants. These attorneys prosecute
    possible fraud cases referred by OIG that would not otherwise be
    prosecuted in Federal court. From fiscal years 2003 through 2011, our
    attorneys secured over $43.7 million in restitution orders and 814
    convictions or guilty pleas.
        Question. It is my understanding that the Social Security
    Administration has implemented two fast-track initiatives, known as
    Compassionate Allowances and Quick Disability Determinations, to
    improve processing of claims for those with severe disabilities. Please
    provide specific data on the decrease in time to approve claims under
    these programs compared to past claim processing times.
        Answer. The State disability determination services (DDS) render
    disability determinations for initial claims. In fiscal year 2011, the
    average time from the date the DDS received the claim until the DDS
    made a disability determination was approximately 80 days for all
    approved claims, 10 days for approved fast-track claims and 88 days for
    approved non-fast-track claims.
        Question. I am told that Continuing Disability Reviews yield more
    than $10 in lifetime program savings for every $1 spent and
    Supplemental Security Income redeterminations yield over $7 in lifetime
    program savings for every $1 spent. I find it alarming that an Office
    of the Inspector General Report recently found from 2005 to 2010 it is
    estimated that the Social Security Administration paid between $1.3
    billion and $1.6 billion in disability benefits that could have been
    avoided with full medical Continuing Disability Reviews. In recent
    years, Congress has provided specific funding for program integrity
    initiatives. What additional steps would you recommend be taken to
    support program integrity efforts that could lead to increased savings?
        Answer. For many years, the agency was forced to cut back on
    program integrity reviews due to inadequate funding. The same people
    who handle initial disability decisions and reconsiderations also
    complete medical continuing disability reviews. We must balance the
    amount of program integrity work we undertake with our work on incoming
    claims. Because of funding cuts, we hit the low point for these reviews
    in fiscal year 2007. In fiscal years 2008 through 2010, with additional
    funding, we increased our program integrity work, saving billions of
    program dollars. However, in fiscal year 2011, we were under a full-
    year continuing resolution, which prevented us from further increasing
    our program integrity work. We use complex algorithms to select the
    most cost-effective cases to review with our limited resources.
    Adequate funding is critical to our ability to increase this cost-
    effective work, but it is also important to understand that the same
    people who handle our program integrity work also handle other work,
    such as initial applications for benefits. Without sufficient and
    sustained funding, other work suffers as we increase program integrity
    work.
        Question. Please provide detailed information on the number of
    cases each year that are appealed to Federal district courts after
    being rejected by Administrative Law Judges at the Social Security
    Administration. Of this number, how many claimants win their appeals at
    Federal district courts? With regard to cases that are remanded to the
    Social Security Administration, how many of these cases are ultimately
    decided in favor of a claimant? Please describe possible factors that
    may play a role in claimants' success on appeal. What recommendations
    would you make to improve the process on the front end so that cases
    that win on appeal are approved in the beginning?
        Answer. In fiscal year 2010, claimants filed 13,158 complaints in
    Federal district courts concerning Social Security program (disability
    and non-disability) litigation matters. In fiscal year 2011, this
    number increased to 15,644, as we issued more decisions.
        In 2010, Federal district courts reversed the agency's decision in
    447 cases (or 3.7 percent of the 12,182 district court dispositions
    that year). In 2011, this number decreased to 380 cases (or 2.86
    percent of the 13,304 district court dispositions that year). District
    courts remanded 5,718 cases (46.9 percent) to the agency in 2010 and
    6,137 cases (46.12 percent) in 2011.
        In 2010, we issued dispositions in 6,028 cases that courts had
    previously remanded. We issued fully or partially favorable decisions
    in 4,048 of these cases (67.15 percent). In 2011, we issued
    dispositions in 6,285 cases that courts had previously remanded. We
    issued fully or partially favorable decisions in 4,176 of those cases
    (66.44 percent).
        The three most common causes of remand in our disability cases,
    which represent the vast majority of our program litigation, are: (1)
    insufficient reasons provided for rejecting a medical source or
    treating source opinion; (2) failure to consider or properly evaluate a
    particular impairment at step two of the sequential evaluation process;
    and (3) failure to accommodate limitations from all impairments in the
    residual functional capacity.
        With regard to recommendations on how to improve our decisionmaking
    so that we approve claims as early as possible. We hold nationwide
    training for our Administrative Law Judges at which attorneys from our
    Office of the General Counsel participate to discuss how to best
    evaluate medical evidence and draft decisions. In addition, we have
    initiatives to improve the quality of the information in a disability
    case file. For example, we have an Electronic Claims Analysis Tool, a
    web-based tool that automatically prompts an examiner with case-
    relevant regulations and instructions and requires the examiner to
    enter the necessary documentation before he or she can close a case.
                           NONDEPARTMENTAL WITNESSES

        Senator Harkin. Now we'll turn to our second panel.
        Senator Mikulski. Mr. Chairman, I regret, I've to get to
    another hearing. But, this was a terrific hearing, and you've
    got a great panel, here.
        Senator Harkin. We've got a----
        Senator Mikulski. I think we're----
        Senator Harkin [continuing]. Great panel, yeah.
        Senator Mikulski. Yeah. And what we're seeing in this is,
    under every rock is another rock.
        Senator Harkin. Right, exactly.
        Senator Mikulski. And we're now heading to the hard place.
        Senator Harkin. This is the----
        Senator Mikulski. We don't want a hard landing.
        Senator Harkin. These are the hard places. Thank you very
    much, Senator Mikulski.
        W. Lee Hammond is the president of the AARP and has been a
    member of its board of directors since 2002. He is a retired
    teacher, who served in the--Wicomico?
        Mr. Hammond. Wicomico.
        Senator Harkin [continuing]. Wicomico County schools for 30
    years. He currently serves on the U.S. Attorney's Healthcare
    Fraud Task Force and is a member of the Maryland Commission on
    Aging.
        Marty Ford is the acting director of the Arc of the United
    States and the United Cerebral Palsy Disability Policy
    Collaboration. She was previously the chair of the Consortium
    for Citizens with Disabilities and has continued to work with
    the consortium as a co-chair of the Task Force on Social
    Security and Long-term Services and Supports; received her law
    degree from the George Washington University National Law
    Center and her B.A. from the University of Virginia.
        Mr. Joe Dirango was--Dirago or----
        Mr. Dirago. Dirago.
        Senator Harkin. Dirago.
        Mr. Dirago--sorry about that--was elected the president of
    the National Council on Social Security Management Associations
    in November 2009. He previously served on the New York Region
    Management Society, for 13 years, and as chair of the National
    Council's Labor Relations Committee for 2 years. Mr. Dirago has
    worked for Social Security for 30 years. A graduate of State
    University of New York at New Paulz with a bachelor of science
    degree in economics.
        And, before we start with this panel, I'm also told that
    Nancy Shor, who is the executive director of the National
    Organization of Social Security Claimants' Representatives, is
    also with us here today. She's done great work on behalf of
    persons with disabilities. I have spoken and met with NOSSCR in
    the past, so I just wanted to take a moment to recognize both
    NOSSCR and Nancy Shor. I don't--I can't see where--right there
    in front of me.
        Nancy, thank you very much. And thank you for the great
    work that your organization does on behalf people, especially,
    with disabilities.
        Now, we'll start with our panel. All your statements will
    be made a part of the record in their entirety. I ask you to
    sum up, if you can, in 5 minutes or so.
        And we'll start Mr. Hammond and work across.
    STATEMENT OF W. LEE HAMMOND, PRESIDENT, AMERICAN
                ASSOCIATION OF RETIRED PERSONS (AARP)
        Mr. Hammond. Chairman Harkin, Ranking Member Shelby, and
    members of the subcommittee, good morning to all of you.
        And, Mr. Chairman, Wicomico presents a challenge wherever I
    go. So.
        Senator Harkin. Okay, thank you.
        Mr. Hammond. As the largest nonprofit, nonpartisan
    organization representing the interests of Americans age 50 and
    older, their families, AARP would like to thank the chairman
    and ranking member for holding this hearing and giving us the
    opportunity to voice our concerns about the ability of the
    Social Security Administration to adequately serve current
    recipients while responding to the needs of the new Boomer
    retirees and other program beneficiaries.
        AARP recognizes the budget deficit provides many
    challenges, and our members believe that it's important to work
    together across party lines to find responsible budget
    solutions that consider the health and financial well-being of
    all Americans.
        We also believe the Federal budget reflects the priorities
    of this Nation and her people. First and foremost, we must
    always consider the impact each proposed budgetary cut will
    have on people. We're not just talking about numbers and
    statistics. We're talking about our families, our loved ones,
    friends, and neighbors: real people.
        The Social Security Administration interacts with millions
    of Americans when they retire and seek the benefits that
    they've earned over a lifetime of work; with those who, through
    sickness or injury, become disabled and cannot longer support
    themselves or their families; with orphans of the 9/11
    terrorist attack; with families of soldiers killed in Iraq and
    Afghanistan; and with countless widows, widowers, and surviving
    dependents, who must continue on after the loss of a loved one:
    real people.
        Now, I'd like to address AARP's major concerns regarding
    the funding of the Social Security Administration. SSA was made
    an independent agency in 1995 to provide the program with
    consistent direction and professional management and to help
    insulate it against decisions not based on Social Security-
    related issues. However, becoming an independent agency has
    also placed added administrative burdens on the Social Security
    Administration, and we're very concern with the impact these
    additional responsibilities are having on the timely delivery
    of services to Social Security beneficiaries.
        The Social Security Administration performs this additional
    work as it meets the challenges of Boomers reaching the
    retirement age at a rate of 1 every 8 seconds by the end of
    this decade. Nearly 80 million new beneficiaries will be added
    to the Social Security rolls. It's not difficult to understand
    the enormity of the administrative task the agency is facing.
        With the increases in funding Congress has provided over
    the last 3 years, and significant increases in employee
    productivity, SSA has been able to make some progress in
    customer service. However, the longer-than-foreseen economic
    downturn has resulted in a record level of claims for the
    retirement and disability benefits. In fiscal year 2010, SSA
    received nearly 3.25 million initial disability claims, the
    highest in its 75-year history. Yet, at a time when additional
    funding is needed to handle the increased workload, the agency
    is dealing with the possibility of a Government shutdown as
    well as cutbacks resulting from enactment of spending levels
    below the current fiscal year. The House passed long-term
    continuing resolution H.R. 1, with a result in the aggregate
    funding loss of over $1 billion for the Social Security
    Administration. That proposal is unacceptable.
        As if service reductions were not enough, even the status
    quo would prevent program integrity efforts from realizing
    their potential. Congress has consistently provided for
    separate additional funds for SSA to conduct continuing
    disability reviews and SSI eligibility redeterminations. We
    believe that not enabling the agency to pursue these
    activities, simply because of an artificial barrier like the
    discretionary spending caps, would be downright foolish.
        Mr. Chairman, AARP strongly urges the subcommittee, and the
    Senate as a whole, to reject the deep cuts to SSA funding that
    are included in the House-passed resolution. Today, the bottom
    line is nothing--is that nothing short of the $11.5 billion,
    with no rescission of IT funds for fiscal year 2011, will
    ensure the ability of the SSA to adapt to the many critical
    challenges that confront them for the balance of this year.
    Social Security Administration customers, whether older,
    younger, or somewhere in between, are real people. They have
    the right to expect better service than they're receiving
    today. We sincerely hope that Congress and the President will
    not let them down, by providing the funding necessary to enable
    SSA to serve them promptly and properly.
        On behalf of the millions of AARP members, and of all
    Americans who are served by SSA, thank you for the opportunity
    to address the subcommittee.
        Senator Harkin. Mr. Hammond, thank you very much.
        [The statement follows:]
                      Prepared Statement of W. Lee Hammond
        Chairman Harkin, Ranking Member Shelby, and members of the Labor,
    Health and Human Services, and Education, and Related Agencies
    Subcommittee, good morning.
        As the largest nonprofit, nonpartisan organization representing the
    interests of Americans age 50 and older and their families, American
    Association of Retired Persons (AARP) would like to thank to Chairman
    Harkin, and Ranking Member Shelby for holding this hearing. AARP
    appreciates this opportunity to appear before the subcommittee to voice
    our concerns about the ability of the Social Security Administration
    (SSA) to adequately serve current recipients while responding to the
    needs of new Boomer retirees and other program beneficiaries. I am here
    today to speak to AARP's priorities with respect to funding for the SSA
    for fiscal year 2011 and beyond.
        While SSA funding is of great importance, we have equal concern for
    many other vital healthcare services and economic security programs.
    For example, AARP is concerned about sufficient funding for the
    Qualified Individual-1 program which helps more than 156,000 seniors
    nationwide afford to pay their Medicare premiums that would otherwise
    be unaffordable or cause great financial hardship; programs authorized
    under the Older Americans Act which provide needed assistance,
    including nutrition programs which free hundreds of thousands of our
    seniors from hunger, as well as job training and other services; and,
    the Low Income Home Energy Assistance that help millions of households
    with seniors avoid making that horrible choice between heating and
    eating, or paying for all the medicine they need to live healthy lives
    in homes, not institutions.
        As you complete action on the fiscal year 2011 budget and begin
    work on the fiscal year 2012 budget, we ask that you note the framework
    we have set forth for our appropriations and budget advocacy:
      --AARP recognizes that the Federal budget deficit provides many
            challenges, and AARP members believe it is important to work
            together across partisan lines to find responsible budget
            solutions that consider the health and financial well-being of
            all Americans.
      --We believe the budget reflects the priorities of this Nation and
            any budgetary cuts will impact people, not just programs.
      --AARP supports budget proposals that will help make healthcare more
            accessible and affordable for all Americans, including
            implementation of the Affordable Care Act.
        The SSA touches the lives of nearly every American, and was once
    known as the standard for Government agency service by which all others
    were measured. Over time, however, the agency's mission has been
    diluted by additional responsibilities not related to its core mission
    while the agency itself has faced a loss of staff and a budget that is
    woefully inadequate, especially given the increasing number of
    beneficiaries.
        The SSA was made an independent agency in 1995 to provide the
    program with consistent direction and professional management and help
    insulate it against decisions not based on SSA-related issues. However,
    in the ensuing years, the agency has been tasked with numerous other
    responsibilities that fall outside its core mission of managing the old
    age and survivors insurance, disability insurance, and Supplemental
    Security Income (SSI) programs. SSA now plays a key role in assessing
    the correct premium levels for parts B and D of Medicare. In addition,
    SSA processes applications for the Low Income Subsidy of Medicare part
    D and conducts outreach to those who may potentially qualify for the
    extra help.
        In recent years, the agency has also become an important element in
    the Nation's homeland security efforts as it conducts millions of
    Social Security Number (SSN) verifications for employment purposes and
    other immigration-related activities. In light of the added
    administrative burden these activities have placed on the agency, and
    the impact that burden has on the timely delivery of services to
    beneficiaries, AARP has grave concerns about proposals that would
    further expand these activities or mandate new ones.
        This extra work given to SSA by Congress comes at a time when the
    Nation is confronting a significant, long-anticipated demographic
    challenge, the coming of retirement age of the Baby Boom generation,
    which will add nearly 80 million new beneficiaries to the SSA rolls--
    nearly 13 million in the next 10 years alone, and upwards of 16,000 per
    working day. At the end of this decade, these Boomers will reach
    traditional retirement age at the rate of 1 every 8 seconds. It is not
    difficult, then, to understand the enormity of the task the agency
    faces in foreseeable work alone.
        For the most part, Congress has understood these challenges and has
    responded with added resources for SSA to handle this spike in demand.
    With the increases in funding Congress has provided over the last 3
    years and significant increases in employee productivity, SSA has been
    able to make some progress in customer service. However, the
    unforeseeably long-lasting economic downturn has caused even more
    Americans to turn to the SSA. Claims for retirement and disability
    benefits have risen to record levels.
        In fiscal year 2010, SSA received nearly 3,225,000 initial
    disability claims, the highest in its 75-year history. SSA ended fiscal
    year 2010 with initial disability claims pending at an all-time high of
    more than 842,000 cases. This year, SSA expects a record number of
    visitors to its field offices above the 45.4 million customers that
    requested assistance from the field offices in fiscal year 2010. These
    field offices are also responsible for processing an additional 1.2
    million SSI redeterminations in fiscal year 2011 as compared to fiscal
    year 2008, an increase of 100 percent. Furthermore, answer rates on
    telephone calls coming into the field offices remain at an unacceptably
    low level nationally as the rates of calls answered are less than 65
    percent.
        SSA field offices also processed more than 18 million requests for
    new and replacement SSA cards; field offices served thousands of people
    each day needing to report changes of address, changes in direct
    deposit information, and other issues that could affect their benefit
    payments. Field offices also play a significant role in helping people
    with their Medicare benefits and often work with State and local
    agencies regarding Medicaid and SNAP (formerly known as food stamps).
        Eliminating the hearings backlog continues to be SSA's highest
    priority, and one that AARP strongly supports. SSA ended fiscal year
    2010 with just more than 700,000 pending hearings nationwide--the
    lowest level in 5 years. At its peak, it took an average of 18 months
    for a hearing decision. As of January 2011, it took just more than a
    year.
        At a time when it would additional funding is needed to handle the
    incoming and pending workload, the agency is unfortunately dealing with
    the possibility of a Government shutdown, as well as cutbacks resulting
    from the enactment of spending levels below the current fiscal year.
        The House passed long-term continuing resolution, H.R. 1, would
    result in an aggregate funding loss of $1.093 billion for the SSA. That
    proposal is clearly unacceptable.
        SSA is already operating under a partial hiring freeze because of
    the current continuing resolution, which is likely to result in nearly
    3,500 lost jobs for 2011. These additional cuts could lead to SSA
    offices closing their doors, stopping all claims processing, and not
    answering the phones for about a month--1 month out of the seven
    remaining in 2011. In addition to office closures, many locations are
    already seriously understaffed due to employee attrition. Employees who
    retire or otherwise leave the agency are not replaced because the
    resources are just not available. In fiscal year 2009 staffing reached
    its lowest level since 1972, before SSI was established; yet SSA today
    has twice the number of beneficiaries it had in 1972.
        If the SSA shuts down for a month, it would be devastating to both
    the public and to SSA employees. Extended to the national level, it
    would mean that about 182,000 visitors would not be seen, about 33,000
    claims would not be taken, and almost 10,000 redeterminations would not
    be completed. Even 1 furlough day could be devastating to someone in a
    dire need situation desperate for a critical or immediate payment, or
    for a beneficiary needing verification information to qualify for food
    stamps, to obtain housing, or to get Medicaid. Another 70,000 fewer
    people will get a disability appeals hearing this year, which means
    workers waiting to present an appeal to a judge, who already wait more
    than a year, will wait longer. And, SSA would complete 32,000 fewer
    continuing disability reviews, which means wasting millions of dollars
    on improper payments now.
        As if service degradations were not enough, even the status quo
    would prevent program integrity efforts from realizing their potential.
    Congress has consistently provided for separate, additional funds for
    SSA to conduct Continuing Disability Reviews (CDR) and SSI eligibility
    redeterminations. When fully utilized, CDR's result in savings of more
    than $10 in program costs for every $1 in administrative funding used
    to conduct the reviews. SSI redeterminations help save $7 for every $1
    spent. Not enabling the agency to pursue these activities simply
    because of an artificial barrier like the discretionary spending caps
    would be very un-penny wise and grossly pound foolish.
        Mr. Chairman, AARP strongly urges the subcommittee and the Senate
    as a whole to reject the deep cuts to SSA funding that are included in
    the House-passed legislation. Today, the bottom line is that nothing
    short of $11.679 billion, with no rescission of IT funds for fiscal
    year 2011 will ensure the ability of the SSA to adapt to the many
    critical challenges that confront them for the balance of this year.
    Additional resources will also be required to fulfill its obligations
    in the next fiscal year and beyond. The SSA customers, whether they are
    older, younger or anywhere in between, have the right to expect better
    service than are receiving today--we sincerely hope that the Congress
    and the President will not let them down and provide the funding
    necessary to enable its workforce to serve them promptly and properly.
        On behalf of the millions of AARP members and all Americans who are
    served by SSA, I thank you for the opportunity to address the
    subcommittee.

        Senator Harkin. And now we'll turn to Ms. Ford.
        Ms. Ford.
    STATEMENT OF MARTY FORD, CO-CHAIR, CONSORTIUM FOR
                CITIZENS WITH DISABILITIES TASK FORCE ON
                SOCIAL SECURITY; ACTING DIRECTOR, THE ARC
                AND UCP DISABILITY POLICY COLLABORATION
    ACCOMPANIED BY NANCY G. SHOR, EXECUTIVE DIRECTOR, NATIONAL ORGANIZATION
                OF SOCIAL SECURITY CLAIMANTS' REPRESENTATIVES

        Ms. Ford. Chairman Harkin, Ranking Member Shelby, thank you
    for this opportunity to testify on behalf of the consumer
    advocacy provider and professional organizations working on
    behalf of children and adults with disabilities, and their
    families, in the United States.
        This hearing is extremely important to people with
    disabilities who may need the programs administered by SSA: the
    Supplemental Security Income Program and the disability
    programs in Title II, including the Disability Insurance
    Program and Medicare. These are crucial income-support programs
    serving disabled workers and their families, and children and
    adults with disabilities, who have limited incomes and
    resources.
        We believe that it is critical to continue to ensure that
    SSA provides adequate services to people applying for SSI
    entitled to disability benefits. We have worked for many years
    with the Congress and the administration to ensure that SSA has
    the funding necessary to reduce the huge backlogs in disability
    decisions. Just as the agency was bringing down the backlog,
    the recession began to have a substantial impact in building a
    new backlog in initial claims. Once again, we are facing the
    prospect of significantly increasing waiting times for
    disability decisions.
        Behind the numbers are individuals with disabilities whose
    lives are unraveling while waiting for decisions. Families are
    torn apart, their homes are lost, claimants' medical conditions
    deteriorate, their once-stable financial security crumbles, and
    some individuals die. Over the past few years, we have
    described extraordinary and unnecessary hardships that people
    with disabilities have endured as they wait for decisions on
    their claims.
        In my written testimony, we have included a very small
    sample of what is happening across the country to claimants who
    are forced to wait many months for their decisions.
        A woman in Oregon has received an eviction notice. Her
    husband's paycheck has already been garnished to pay for her
    medical bills. She has been waiting for a hearing, and then for
    the decision, since August.
        A young man in Texas has applied for SSI in February 2010,
    more than 1 year ago, due to a combination of intellectual and
    mental disabilities. He has just received a notice of denial at
    the reconsideration stage, and now will have to wait for a
    hearing, and then for a hearing decision.
        A man in North Carolina, with a combination of impairments,
    who needs a pacemaker, has been waiting for a hearing on his
    SSI claim since September. His representative estimates, based
    on the claims in that State, that he will have to wait til mid-
    to late-summer 2011 for his hearing.
        Your own constituent services staff are likely well aware
    of similar situations in your States. It is important to note
    that these are situations that are current when the processing
    times are improving, at least at the hearing level, as
    described by the Commissioner earlier.
        We are extremely concerned about what might happen if SSA's
    budget is further reduced to the level included in H.R. 1.
    Under the current continuing resolution, the Social Security
    Administration is already operating at a very bare-bones level.
    The cuts at the level in H.R. 1 will severely punish people who
    most rely on Social Security and SSI. The delivery of services
    should be strengthened, not weakened, during economic crisis.
        The Senate bill, the continuing resolution for the rest of
    2011, in total would provide $600 million more than H.R. 1 for
    SSA's operation. While this is not entirely what SSA requires
    to continue to meet the needs of the public and to address its
    IT needs for fiscal 2011, the Senate amount is certainly better
    than the House-passed bill. And we urge its adoption at a
    minimum of that amount of $11.8 billion.

                               PREPARED STATEMENT

        Finally, regarding fiscal year 2012, we believe that the
    President's budget proposal for SSA for 2012, of $12.5 billion,
    is the minimum needed to continue to reduce the backlogs and to
    increase the deficit-reducing/program-integrity work.
        The speed and quality of the disability process must
    continue to improve and should not be allowed to regress into
    the longer waiting periods of the recent past. These challenges
    can only be addressed if Congress and the administration work
    together to ensure that Social Security continues to be the
    safety net it was designed to provide for people with
    disabilities and their families, as well as retirees and
    survivors.
        Thank you for this opportunity to testify, and I'm happy to
    answer any questions.
        Senator Harkin. Thank you, Ms. Ford.
        [The statement follows:]
                        Prepared Statement of Marty Ford
        Chairman Harkin, Ranking Member Shelby, members of the
    subcommittee, thank you for this opportunity to testify at today's
    hearing on the fiscal year 2012 budget request for the Social Security
    Administration (SSA) and the impact of possible cuts to the fiscal year
    2011 budget.
        I am Marty Ford, Acting Director of the Disability Policy
    Collaboration of The Arc and United Cerebral Palsy. I am here in my
    capacity as a Co-Chair of the Consortium for Citizens with Disabilities
    (CCD) Social Security Task Force. CCD is a working coalition of
    national consumer, advocacy, provider, and professional organizations
    working together with and on behalf of the 54 million children and
    adults with disabilities and their families living in the United
    States. The CCD Social Security Task Force (hereinafter ``CCD'')
    focuses on disability policy issues in the title II disability programs
    and the Title XVI Supplemental Security Income (SSI) program.
        The focus of this hearing is extremely important to people with
    disabilities. The SSA administers the Disability Insurance (SSDI) and
    other title II disability benefits and Supplemental Security Income
    (SSI), significant crucial income support programs for people with
    disabilities. SSDI provides benefits to disabled workers and their
    families and SSI provides financial support to aged, blind, and
    disabled adults and children who have limited income and resources.
        We believe that it is critical to continue to ensure that SSA
    provides adequate services to people applying for SSI and title II
    disability benefits.
               impact of h.r. 1 on remainder of fiscal year 2011
        The House-passed H.R. 1, Full-Year Continuing Appropriations Act,
    2011, reduces the SSA's administrative spending level to $11.3 billion,
    a decrease from the fiscal year 2010 spending levels of $11.4 billion
    and leaving an already cash-strapped agency with fewer resources with
    which to process claims for people with disabilities and seniors.
        Under H.R. 1, the SSA would receive $430 million less than if it
    operated the rest of fiscal year 2011 under the current Continuing
    Resolution (CR), which is already $1.7 billion less than the
    President's proposed fiscal year 2011 budget. If SSA is forced to
    furlough employees to address the full $430 million shortfall from the
    current CR spending level, it will result in nearly a month of
    furloughs, having devastating effects on service to the American
    public. In 1 month of furloughs, SSA would complete 400,000 fewer
    retirement, survivor, and Medicare claims; 290,000 fewer initial
    disability claims (with processing time increasing by a month); 70,000
    fewer hearings; and 32,000 fewer continuing disability reviews. In
    addition, H.R. 1 severely cuts funds for vital information technology
    (IT) improvements and funds to build the critical new National Computer
    Center, which must be built to protect SSA electronic information and
    infrastructure.
        Under the current CR, the SSA is already operating at a very bare
    bones level. The proposed cuts in H.R. 1 will punish people who must
    rely on SSA and Medicare. We need to remember that there are real
    people behind these numbers. The delivery of services must be
    strengthened, not weakened, during economic crisis.
                    impact of senate amendment 149 to h.r. 1
        Senate Amendment 149, the full-year fiscal year 2011 continuing
    resolution offered by Senator Inouye on March 4, would provide $500
    million more for SSA's administrative expenses than would H.R. 1 for
    the remainder of fiscal year 2011. In addition, it rescinds $100
    million less from the special reserve fund for IT expenses. In total,
    the Senate bill provides $600 million more than H.R. 1 for SSA's
    operation. While this is not entirely what SSA requires to continue to
    meet the needs of the public and to address its IT needs for fiscal
    year 2011, the Senate amount is certainly better than the House-passed
    bill. We urge the adoption, at a minimum, of the amount included in
    Senate Amendment 149, totaling $11,821,500,000.
            impact on claimants for social security and ssi benefits
        Behind the numbers are individuals with disabilities whose lives
    unravel while waiting for decisions--families are torn apart; homes are
    lost; medical conditions deteriorate; once-stable financial security
    crumbles; and many individuals die. Over the past few years, we have
    described the extraordinary and unnecessary hardships endured by people
    with severe disabilities as they wait for decisions on their claims.
    The following stories are only a sampling of what is happening across
    the country to claimants who are forced to wait months and years for
    decisions on their appeals. Your own constituent services staff are
    likely well aware of similar situations in your State. It is important
    to note that these situations are current, when the processing times
    are improving, at least at the hearing level. We are extremely
    concerned about what will happen if SSA's budget is further reduced to
    the level proposed in H.R. 1.
      --Ms. C, a 46-year-old woman with fibromyalgia and depression lives
            in Omaha, Nebraska. She filed her request for hearing on August
            2, 2010. Her utilities were shut off on December 30, 2010, and
            she received an eviction notice on January 4, 2011. Although
            her husband works, his checks are being garnished for her
            medical bills. She cannot afford her medications and does not
            qualify for Medicaid because her husband works. Her
            representative requested critical case status (for expedited
            processing) on December 30, 2010. Her hearing was held on
            February 18, 2011, but she has not yet received a decision. The
            delay in scheduling a hearing and receiving a decision has been
            extremely difficult for her and her family. (From a
            representative in Omaha, Nebraska)
      --A 19-year-old young man lives with his foster mother in Plano,
            Texas; she is his sole source of support. He has a full-scale
            IQ of 65 and all of his schooling has been in special education
            classes. He also has some mental health diagnoses and has been
            in several inpatient psychiatric facilities. He was born
            prematurely with a positive drug screening and put into foster
            care at 13 months of age. He has chronic encephalopathy with
            psychomotor delays. He applied for SSI disability benefits in
            February 2010 and, more than 1 year later, he received his
            reconsideration denial in February 2011. Now he will have to
            wait for a hearing and hearing decision.
      --Mr. E is a 52-year-old man who formerly worked as a security guard.
            Because he has no income, he lives in a homeless shelter in
            eastern North Carolina. He is constantly in and out of the
            hospital. He has bipolar disorder and is an insulin-dependent
            diabetic with associated neuropathy, which causes burning pain
            in his feet and legs. He has a history of two heart attacks for
            which he has had stents. He needs a pacemaker for his heart but
            cannot get one until he is determined Medicaid eligible. He
            cannot get Medicaid until he is found eligible for SSI. He
            asked for a hearing on his SSI claim in September 2010, but he
            will probably wait until mid to late summer 2011 to get a
            hearing--if he lives that long. (From a representative in
            Raleigh, North Carolina)
      --A homeless woman in Manchester, New Hampshire requested her hearing
            in January 2010. After her representative submitted a ``dire
            need'' request for expedited processing, her hearing was held 1
            year later (January 6, 2011). She has had no access to medical
            care for her severe mental impairments (bipolar disorder,
            paranoia, and anxiety). She has not yet received a decision.
      --The same New Hampshire representative assisted a man who received a
            partially favorable decision from an Administrative Law Judge
            after a 15-month wait. He now has to wait an additional 90 days
            while his case lingers at the Decision Review Board for
            possible review. His home is being foreclosed on while he waits
            for the board to act on his partially favorable decision.
        ssa's limitation on administrative expenses for fiscal year 2012
        We believe the President's budget proposal for the SSA for fiscal
    year 2012 of $12.522 billion is the minimum needed to continue to
    reduce key backlogs and increase deficit-reducing program integrity
    work. With your support, SSA could continue to build on the progress
    achieved thus far, progress that is vital to millions of people who
    depend on their services, including people with disabilities. This
    funding level will allow SSA to continue working down disability
    backlogs, to implement efficiencies in programs, and to increase
    program integrity work.
        The budget will provide for the continuance of crucial income
    support programs. In fiscal year 2012, SSA expects to provide SSDI
    benefits to almost 11 million disabled workers and their family members
    and provide SSI benefits to more than 8.3 million beneficiaries.
        It is imperative that the SSA continue to reduce its disability
    hearings backlog and initial disability claims backlog. This budget
    request will allow SSA to reduce hearings and initial disability claims
    backlogs and simplify the work incentives in the Disability Insurance
    program. With the continued support of Congress, SSA is on track to
    meet its commitment to the American public to eliminate the backlog by
    fiscal year 2013. However, to reach this goal, it will need to
    adjudicate more than 800,000 cases in fiscal years 2011 and 2012, which
    is more than double what was handled 10 years ago. Yet, progress
    continues to be challenged with the current skyrocketing number of
    hearing receipts due to the increased number of people who are applying
    for benefits.
        We are pleased that SSA has implemented many productivity
    improvements which help provide fast and accurate service to the public
    at a lower cost, but the administration needs adequate funding to
    continue this. Congress and the administration must work together to
    ensure that millions of Americans do not experience significant waiting
    times for decisions on their claims. To do this, SSA needs full funding
    of the President's budget for fiscal year 2012.
        The President's proposed fiscal year 2012 budget will aid in
    processing mounting disability claims by creating programs such as
    Extended Service Teams for more efficiency, and expanding Federal
    capacity to decide claims and to assist Disability Determination
    Services in handling claims, improving online services, fast-tracking
    cases that obviously meet SSA's disability standards, paying medical
    consultants per case as opposed to per hour to increase productivity,
    and developing a disability case processing system.
        The President's budget request proposes a 5-year reauthorization of
    section 234 demonstration authority for the Disability Insurance
    Program, which would allow SSA to test program innovations. Using this
    authority, SSA has proposed a new Disability Work Incentives
    Simplification Pilot to provide beneficiaries with a simple set of work
    rules that would no longer terminate benefits solely based on earnings.
    As a result, beneficiaries would have more flexibility to try working,
    without fear of losing their benefits. After years of making similar
    recommendations to improve work incentives, we look forward to working
    with SSA on the details of this proposal.
        The budget request also proposes an extension through 2013 of SSI
    eligibility for 9 years for refugees, asylees, and certain other
    humanitarian immigrants.
        We also support SSA's plans to explore potential improvements to
    programs, such as the Disability Research Consortium to address the
    shortage of disability policy research and collaboration and to enhance
    efforts to expand disability research within and across disability
    programs. We would also like to work with SSA on the SSI Children's
    Pilot--Promoting Readiness of Minors in SSI (PROMISE)--to improve
    outcomes for children and families in the SSI program.
        We are also concerned that Amendment 195 to H.R. 1 would make it
    more difficult for people whose disability claims have been denied to
    take their claims to Federal district court since no funds would be
    available for payment of fees or expenses under the Equal Access to
    Justice Act. We believe that this could make legal representation
    unavailable to claimants who need to pursue their claims in Federal
    court. We urge the subcommittee to oppose inclusion of such language in
    the fiscal year 2011 and 2012 spending packages.
                                   conclusion
        For the remainder of fiscal year 2011, H.R. 1 would have a
    devastating impact on administration of the SSA programs and we urge
    the subcommittee to reject such drastic cuts. The harmful impact on the
    American people, particularly people with disabilities waiting for
    decisions on their claims for disability benefits, would be too great.
    Instead, we urge the adoption of at least the amount included in Senate
    Amendment 149 to H.R. 1.
        The President's budget proposal for fiscal year 2012 is the minimum
    needed to continue driving down disability backlogs, improve services
    to people with disabilities, increase efficiency, and keep pace with
    the rising demands of the American public. The speed and quality of the
    administration's disability process must continue to improve and should
    not be allowed to regress into the longer waiting periods of the recent
    past. These challenges can only be addressed if Congress and the
    administration work together to ensure that Social Security continues
    to be the safety net it was designed to provide for people with
    disabilities and their families, as well as retirees and survivors of
    workers and retirees.
        Thank you for this opportunity to testify. I would be happy to
    answer questions or provide you with additional information.
        This testimony is submitted on behalf of the undersigned
    organizations:
      --American Association of People with Disabilities
      --American Foundation for the Blind
      --Association of University Centers on Disabilities
      --Bazelon Center for Mental Health Law
      --Children and Adults with Attention-Deficit/Hyperactivity Disorder
      --Community Action National Network
      --Corporation for Supportive Housing
      --Council of State Administrators of Vocational Rehabilitation
      --Disability Rights Education and Defense Fund
      --Easter Seals
      --Epilepsy Foundation
      --Health and Disability Advocates
      --Lutheran Services of America--Disability Network
      --National Alliance on Mental Illness
      --National Association of Councils on Developmental Disabilities
      --National Association of Disability Representatives
      --National Council for Community Behavioral Healthcare
      --National Council on Independent Living
      --National Disability Rights Network
      --National Multiple Sclerosis Society
      --National Organization of Social Security Claimants' Representatives
      --National Spinal Cord Injury Association
      --The Arc of the United States
      --United Cerebral Palsy
      --United Spinal Association
      --VetsFirst, United Spinal Association
      --World Institute on Disability

        Senator Harkin. And now, Mr. Dirago, please proceed.
    STATEMENT OF JOE DIRAGO, PRESIDENT, NATIONAL COUNCIL OF
                SOCIAL SECURITY MANAGEMENT ASSOCIATIONS,
                INC., NEWBURGH, NEW YORK
        Mr. Dirago. Chairman Harkin, Ranking Member Shelby, and
    members of the subcommittee, I am the president of the National
    Council of Social Security Management Associations, NCSSMA, and
    the district manager of the Social Security office in Newburgh,
    New York. I appreciate this opportunity to speak on behalf of
    3,400 Social Security managers in field offices and teleservice
    centers around the country.
        NCSSMA's top priority is a strong and stable Social
    Security Administration, and we have significant concerns about
    funding the agency to maintain service levels vital to millions
    of Americans. Workloads are exploding as a result of the
    economic downturn and the 80 million Baby Boomers who will file
    for benefits by 2030. Even with increases in Internet filing in
    2010, over 45 million customers were served in field offices,
    and Social Security completed 100 million telephone calls last
    year.
        Appropriations for SSA are an excellent investment. With
    the additional funding Congress has provided, tremendous
    progress has been made. Annual productivity has increased an
    average of 4 percent, the last 4 years. In 2010, SSA produced
    approximately $6 billion in savings from our program integrity
    efforts.
        However, the repercussions of the current continuing
    resolution have already been felt. Feedback from our busy urban
    offices indicates many are struggling. The manager of an
    Alabama office indicates, ``Our employees are stretched to the
    limit, trying to keep up with the increased walk-in and
    telephone traffic. I really don't know how much more these
    hardworking people can absorb.''
        Most of SSA has been under a hiring freeze during the
    continuing resolution. If this continues for the rest of the
    year, it could result in the loss of 3,500 employees. A
    Kentucky manager says, ``The American public does not care that
    we are short on staff. They want to be seen quickly, have their
    calls answered, and get their issues resolved.''
        SSA projects that 50 percent of its employees will be
    eligible to retire by 2018. Because it takes 2 years to train a
    claims representative, concerns exist about this loss of
    institutional knowledge. Geographical staffing imbalances will
    occur, leaving some offices severely understaffed. This is
    especially problematic for small and rural offices. A manager
    in Iowa says, ``Our service area includes several counties.
    Last year, we lost two employees, now we find it very difficult
    to handle our telephone traffic and other priority workloads.
    Although the use of the Internet is rising, this is not the
    magic answer.''
        SSA offices provide valuable services to many diverse
    customers. My Newburgh office delivers assistance to the
    Wounded Warrior Transition Unit, at West Point, which has
    soldiers from eight States in the Northeast. Without
    replacement staff, benefits to these soldiers will be delayed.
        We respectfully request Congress consider our
    recommendations. For 2011, we urge you to fund SSA at no less
    than $350 million above the fiscal year 2010 enacted levels,
    with no rescission of funds. This level of funding will cover
    increased fixed costs and is essential to keep up with our
    workloads. We strongly support the President's fiscal year 2012
    budget request, and ask that Congress consider full funding to
    sustain the momentum achieved.
        NCSSMA also endorses additional funding to address program
    integrity workloads. For every $1 invested in medical
    continuing disability reviews and SSI redeterminations, $7 to
    $10 in program savings is realized.
        SSA must also be properly funded so that it may continue to
    invest in user-friendly online services and to allow for IT
    investments to improve service delivery. Any rescission of
    funds could jeopardize initiatives to implement technological
    efficiencies.
        Social Security is the safety net of America, and must be
    maintained as such. If adequate funding is not provided, public
    service will suffer, resulting in significant hardship for
    millions.
        We sincerely appreciate the subcommittee's ongoing support
    to ensure that we have the resources necessary to properly
    serve the American public.
        Thank you for the opportunity to testify at this hearing,
    and I respectfully request that you consider our
    recommendations.
        Senator Harkin. Mr. Dirago, thank you.
        [The statement follows:]
                        Prepared Statement of Joe Dirago
        Chairman Harkin, Ranking Member Shelby, and members of the
    subcommittee, my name is Joe Dirago and I am president of the National
    Council of Social Security Management Associations (NCSSMA). I have
    been the manager of the Social Security Administration (SSA) office in
    Newburgh, New York for 10 years and have worked for the SSA for 31
    years, with 27 years in management. On behalf of our membership, I am
    pleased for the opportunity to submit this written testimony to the
    subcommittee.
        NCSSMA is a membership organization of nearly 3,400 SSA managers
    and supervisors who provide leadership in 1,299 community based field
    offices and teleservice centers throughout the country. We are the
    front-line service providers for SSA in communities all over the
    Nation. We are also the Federal employees with whom many of your staff
    members work to resolve issues for your constituents who receive SSA
    retirement, survivors or disability benefits, or Supplemental Security
    Income (SSI). Since the founding of our organization more than 41 years
    ago, NCSSMA has considered our top priority to be a strong and stable
    SSA, one that delivers quality and prompt service to the American
    public. We also consider it a top priority to be good stewards of the
    taxpayers' moneys.
        Our testimony focuses on the key issues confronting the SSA. We
    have critical concerns about the dramatic growth in our workloads and
    receiving the necessary funding to maintain service levels vital to
    millions of people. Despite agency strategic planning, expansion of
    online services, significant productivity gains, and the best efforts
    of management and employees, SSA is faced with many challenges to
    providing the service that the American public has earned and deserves.
    Our testimony also provides our recommendations for addressing the
    obstacles confronting the SSA, information on the state of SSA
    operations, a review of the funding situation, and our detailed
    assessment of the major agency challenges.
                                recommendations
        The NCSSMA offers the following key recommendations to address the
    challenges confronting the SSA and to provide the service the American
    public has earned and deserves.
      --NCSSMA respectfully urges this subcommittee and Congress to
            consider funding SSA in fiscal year 2011 at no less than $350
            million above the fiscal year 2010 enacted levels with no
            rescission of Carryover Information Technology (IT) funds.
            Based upon our analysis of the President's proposed budget
            request, assessment of the current workload situation, and a
            projection of workloads for fiscal year 2012, we believe that
            funding SSA below this level would have a devastating impact on
            the agency's ability to deliver vital services to millions of
            Americans. This level of funding will cover inflationary
            increases and is critically necessary to keep up with our
            growing claims receipts, maintain the progress achieved on
            reducing the disability hearings backlog, process program
            integrity workloads, and to meet customer service expectations.
      --We strongly support the President's fiscal year 2012 budget request
            for the SSA and respectfully request that Congress consider its
            full funding to sustain the momentum achieved on our key
            priorities, maintain our front-line staffing levels, and to
            ensure appropriate levels of service to the American public.
      --NCSSMA strongly encourages Congress to consider providing SSA with
            additional funding to address program integrity workloads and
            other quality initiatives to improve the accuracy of payments.
            This would include the elimination of the medical Continuing
            Disability Review (CDR) backlog and conducting additional SSI
            redeterminations. For every $1 invested in program integrity
            initiatives, $7 to $10 in program savings is realized.
            Investment in program integrity workloads ensures accurate
            payments, saves taxpayers' dollars, and is fiscally prudent.
      --SSA must be properly funded so that it may continue to invest in
            improved user-friendly online services to allow more Internet
            transactions. This would result in fewer visitors and telephone
            calls to the field offices and provide relief from increasing
            claims and other workloads.
      --SSA is confronted with major challenges in managing its IT programs
            to keep up with rapidly expanding workloads. NCSSMA believes it
            is critical that SSA be adequately funded to allow for IT
            investments. This is necessary for SSA to replace our aging
            National Computer Center (NCC), to maintain systems continuity
            and availability, and improve IT service delivery. Any
            rescission of Carryover IT funds could seriously jeopardize
            SSA's initiatives to implement automation and technological
            efficiencies that address service delivery demands.
      --NCSSMA recommends consideration of legislative and/or regulatory
            proposals that can improve the effective administration of the
            SSA program, with minimal effect on program dollars. We believe
            these proposals have the potential to reduce operational costs
            and increase administrative efficiency. This includes enacting
            the Work Incentives Simplification Program (WISP) pilot,
            requiring quarterly reporting of wages, requiring that SSA be
            automatically provided with information on workers compensation
            cases, and developing an automated system to report State and
            local pensions affecting the Windfall Elimination Provision and
            Government Pension Offset (WEP/GPO).
                        current state of ssa operations
    Claims Workloads
        Over the last 7 years, the SSA has experienced a huge increase in
    retirement, survivor, dependent, disability, and SSI claims. The
    additional claims receipts are driven by the initial wave of the nearly
    80 million baby boomers who will be filing for SSA benefits by 2030--an
    average of 10,000 per day. Concurrently, there has been a surge in
    claims filed due to the economic downturn, which began in 2008. In
    fiscal year 2010 and fiscal year 2011, disability and retirement
    receipts alone are expected to exceed 1 million more than in fiscal
    year 2008.

    Field Office Visitors and Telephone Service
        While SSA field offices are processing many more claims, we are
    also seeing visitors in much greater numbers. Nationally, visitors to
    SSA field offices increased significantly from fiscal year 2007 through
    fiscal year 2010. In fiscal year 2010, field offices experienced 5
    weeks with more than 1 million visitors.
      --SSA visitors in fiscal year 2007--41,900,000.
      --SSA visitors in fiscal year 2008--44,457,180.
      --SSA visitors in fiscal year 2009--45,082,487.
      --SSA visitors in fiscal year 2010--45,430,364.
        In addition to the increased visitor traffic, SSA is experiencing
    unprecedented telephone call volumes. In fiscal year 2010, SSA
    completed 67 million transactions over the 800 number telephone
    network--the most ever. NCSSMA estimates that field offices received an
    additional 32 million public telephone contacts.
    Internet Contacts
        SSA's online electronic services, also known as ``eServices,''
    offer the public access to SSA services via the Internet. The use of
    SSA's Web site is growing and the American public is accessing it more
    often to receive information and report changes. eServices has helped
    significantly in dealing with the dramatic increases in SSA workloads
    resulting from the baby boomers and the economic downturn.
        SSA has promoted eServices extensively, including national public
    campaigns to promote awareness. The following data illustrates the
    volume and growth in SSA eServices.
      --Social Security Online had 133.6 million unique visitors in fiscal
            year 2010, an increase of more than 52 million from fiscal year
            2009. There have been 47 million visitors in the first 4 months
            of fiscal year 2011.
      --In fiscal year 2010, SSA's Web site had 34.8 million contacts to
            the Frequently Asked Questions, 11.6 million to the Field
            Office Locator menu, and 3.7 million contacts to the Retirement
            Estimator.
      --Online retirement claims increased 9.6 percent more than fiscal
            year 2009. The percentage of retirement claims filed online in
            fiscal year 2010 reached 36.8 percent, with 913,473
            applications taken.
      --Online disability claims usage increased 34.5 percent in fiscal
            year 2010 with 801,060 applications taken. For the first 4
            months of fiscal year 2011, 30.3 percent of all disability
            claims were filed online.
    Disability Workloads
        Nationwide, more than 3.2 million new initial disability claims
    were filed and sent to the Disability Determination Service in fiscal
    year 2010, an increase of more than 600,000 as compared to fiscal year
    2008.

        SSA's largest backlogs are in hearings to appeal initial decisions,
    processed by Administrative Law Judges (ALJs) at the Office of
    Disability Adjudication and Review. The chart below illustrates that
    hearing receipts continue to rise, and reached 721,841 in fiscal year
    2010. However, clearances exceeded receipts beginning in fiscal year
    2009, which helped reduce the backlog of SSA hearings to 705,367
    pending.

                 ssa funding fiscal years 2010, 2011, and 2012
    SSA Funding Accomplishments Fiscal Year 2010
        Appropriations to the SSA are an excellent investment and return on
    taxpayer dollars. With the additional funding Congress has provided in
    recent fiscal years and significant increases in employee productivity,
    tremendous progress has been made to enhance service to the public,
    reduce the hearings backlog, and to process additional workloads
    received because of the aging of the baby boomers and the economic
    downturn. In fiscal year 2010, SSA achieved the following:
      --Completed more than 300,000 more initial disability claims than in
            fiscal year 2009.
      --Served 45 million people who visited our 1,300 field offices.
      --Wait times in field offices for those without an appointment were
            reduced from 23.3 minutes in fiscal year 2009 to 20.7 minutes
            in fiscal year 2010.
      --With innovation and automation efforts, along with the hard work
            and dedication of our staff, SSA's annual productivity increase
            has averaged about 4 percent over the last 4 years.
      --In fiscal year 2010, SSA completed 67 million transactions over the
            800 number telephone network--the most ever. The telephone busy
            rate for the 800 number was reduced by half, from 10 percent in
            fiscal year 2008 to 4.6 percent in fiscal year 2010. Time spent
            waiting for an agent was reduced by more than 37 percent, from
            326 seconds in fiscal year 2008 to 203 seconds in fiscal year
            2010. Field office busy rates have also dropped dramatically
            from more than 50 percent to nearly 20 percent.
      --Program integrity efforts to process 2.4 million SSI
            redeterminations and 325,000 medical Continuing Disability
            Reviews (CDRs) produced more than $6 billion in estimated
            savings.
      --SSA expanded the Access to Financial Institutions (AFI) Initiative,
            which data matches assets of SSI individuals that exceed
            statutory limits. Expansion is to be completed in fiscal year
            2011 and SSA projects $900 million in lifetime program savings
            for each year the AFI process is used.
      --Cooperative Disability Investigation (CDI) units combat disability
            fraud. Since their inception in fiscal year 1998, the efforts
            of CDI units have resulted in nearly $2.6 billion in savings:
            $1.6 billion in disability programs and $967 million in
            projected savings in programs such as Medicare and Medicaid.
    SSA Funding for Fiscal Year 2011
        SSA is facing unprecedented workload challenges due to the economic
    downturn and the demand for SSA services from the baby boomers. We
    greatly appreciate the increased funding that SSA received for fiscal
    year 2009 and fiscal year 2010. This includes the $1 billion SSA
    received from the American Recovery and Reinvestment Act (ARRA). About
    half of that funding was directed to reducing the backlogs in SSA. Had
    SSA not received this funding, the service we provide in SSA would be
    much worse and the disability backlog would be unconscionable.
        For fiscal year 2011, the President requested $12.379 billion for
    SSA's administrative budget. The Limitation on Administrative Expenses
    (LAE) account budget request is an increase of $932 million or 8.1
    percent more than the fiscal year 2010 enacted level. Much of this
    increase is needed to cover inflationary costs for fixed costs such as
    rent, guards, postage, periodic step increases, career ladder
    promotions, and increased health benefit costs. Funding above current
    levels is absolutely necessary to keep up with our growing workloads,
    maintain the progress achieved on reducing the disability hearings
    backlog, process program integrity workloads, including SSI
    redeterminations and medical CDRs, and to meet customer service
    expectations.
        NCSSMA recognizes that there is no simple way to provide the
    necessary resources to SSA. However, we believe that funding SSA for
    fiscal year 2011 at the fiscal year 2010 level without covering
    inflationary increases would have a devastating impact on the agency's
    ability to deliver critical services to millions of Americans. SSA is
    the safety net of America and if adequate funding is not provided,
    public service will deteriorate, with longer waiting times, unanswered
    calls, increased backlogs, and significant hardship on needy
    beneficiaries.
        Funding SSA at the level passed by the House of Representatives
    (H.R. 1) would result in serious negative consequences to public
    service. If enacted in its current form, this legislation would reduce
    SSA's appropriated funding $125 million from the fiscal year 2010
    enacted level, rescind $500 million from the Carryover IT funding, and
    rescind $118 million from the NCC funding as part of an overall
    reduction in unobligated ARRA funding. This would likely result in an
    agency-wide hiring freeze, with no overtime available to address
    critical workloads, and employee furloughs. Drastic cutbacks would be
    necessary that would have a negative impact on operations and
    significant delays in all workloads would result. Disability backlogs
    could grow an additional 160,000 cases. Significant financial hardships
    could be created because of delays in payments. Agency productivity
    would erode significantly. Waiting times and telephone service would
    experience major deterioration. This would necessitate cutbacks in
    other budget areas, such as supplies and training, and in IT
    development expenditures. Spending in these areas would be purely for
    maintenance.
        NCSSMA is very concerned that the agency will be forced to impose
    furloughs if the fiscal year 2011 budget is not adequate. Furloughs
    would have a devastating effect on the public that depends on SSA for
    vital services, as well as our employees. Nationally, the furloughs
    could translate to the following approximate daily impact on SSA's
    operations:
      --180,000 daily visitors might not be seen in the 1,266 SSA field
            offices across the country;
      --16,000 retirement and survivors claims might not be taken from
            applicants;
      --12,600 disability applications might not be processed for
            individuals who are unable to work;
      --385,000 telephone calls to SSA could go unanswered;
      --50,000 individuals could fail to have a SSA card application
            processed;
      --1,440 medical CDRs, which save $10 for every $1 SSA invests in
            processing them, might not be processed;
      --10,000 fewer SSI recipients might not have redeterminations of
            their benefits completed to make sure payments are accurate.
            These reviews save $7 for each $1 SSA spends performing them.
        If SSA is funded at the fiscal year 2010 level for fiscal year
    2011, without covering inflationary increases of $350 million, this
    could reverse the positive progress that has been achieved in the last
    few years with all of SSA's workloads. Attempting to address the fiscal
    year 2011 workload demands at SSA with fiscal year 2010 resource levels
    is not a prudent course of action and would lead to significant
    cutbacks that would be devastating for members of the public who rely
    on SSA for essential services and assistance.
    President's Proposed Fiscal Year 2012 SSA Budget
        NCSSMA strongly supports the President's fiscal year 2012 budget
    request for the SSA. The total SSA budget request is $12.667 billion,
    which includes $12,522,200,000 in administrative funding through the
    LAE account. This is an increase of $143.3 million more than the fiscal
    year 2011 President's proposed SSA budget request.
        The following is a direct quote from the SSA fiscal year 2012
    budget overview:

        ``In fiscal year 2012, we will need a minimum administrative budget
    increase of $300 million just to cover our fixed costs, including rent,
    guards, postage, and employee salaries and benefits. We will need
    funding above that level to keep up with our growing workloads, reduce
    existing backlogs, and meet rising customer service expectations.''

        We respectfully request that Congress consider full funding of the
    President's fiscal year 2012 budget request for SSA to sustain the
    momentum achieved on our key priorities, maintain our front-line
    staffing levels, and to ensure appropriate levels of service to the
    American public. This funding request would allow SSA to do the
    following in fiscal year 2012:
      --Reduce the initial disability claims backlog to 632,000 by
            processing more than 3 million initial disability claims;
      --Conduct disability hearings for 822,500 cases in 2012 and reduce
            the waiting time for a hearing decision to below a year (to 326
            days) for the first time in a decade;
      --Reduce pending disability hearings to 597,000 from the fiscal year
            2011 level of 668,000 (estimated) and fiscal year 2010 level of
            705,367;
      --Complete additional program integrity workloads--process 592,000
            medical CDRs (up from 325,000 completed in fiscal year 2010)
            and 2.6 million SSI redeterminations (up from 2.4 million in
            fiscal year 2010). $938 million is dedicated in the fiscal year
            2012 budget request to continue these reviews that save
            significant program dollars by avoiding improper payments to
            beneficiaries. SSA estimates this program integrity funding in
            fiscal year 2012 will result in nearly $9.3 billion in savings
            over 10 years, including Medicare and Medicaid savings. The
            increased funding also improves the savings in fiscal year 2012
            over fiscal year 2010 by more than $3 billion.
        It is important to note that any backlogs and service deterioration
    related to inadequate fiscal year 2011 funding levels would have a
    collateral negative impact on fiscal year 2012 and beyond. Backlogs
    make SSA much more inefficient. Substantially more dollars are required
    to reduce a backlog than to prevent one because of the reworking of
    cases. Hiring delays also have long-term effects because of the amount
    of time it takes for new employees to gain proficiency.
                    review and assessment of ssa challenges
    Field Office Service Delivery Challenges
        Despite staff replacements authorized in recent SSA budgets,
    significant overtime hours worked, and increases in the use of Internet
    services, field offices are still struggling with tremendous workload
    demands. SSA field offices vary in terms of size, demographics, and
    location. However, all types of field offices are experiencing
    tremendous stress because of our increased workloads and additional
    visitor traffic. The effect of funding the SSA in fiscal year 2011 at
    fiscal year 2010 levels exacerbates the situation and has already had a
    significant impact on local field offices around the country.
        Frontline feedback from our busiest urban offices indicates that
    some have seen their visitor traffic explode with overflowing reception
    areas and increased waiting times. This can result in standing room
    only, lack of seating availability for disabled clients, and visitors
    waiting in the hallway or even outside. Managers of busy SSA field
    offices recently provided these comments:
      --We handle close to 2,000 visitors a week in my office. Recent
            losses due to retirement are affecting the service we provide,
            as we cannot interview the public fast enough. It seems like
            the more employees we put up to interview, the more the public
            comes in. Pulling employees from the back creates a backlog and
            reduction in staffing reduces our ability to handle those
            backlogs. If we cannot hire to fill losses, the public will
            wait longer and be disadvantaged. In addition, the safety of
            the employees becomes at risk as the public becomes frustrated
            at the long waits. (California)
      --Working in a busy office in Alabama, I can honestly say a yearlong
            continuing resolution at fiscal year 2010 funding levels would
            be catastrophic. Our employees are stretched to the limit
            trying to keep up with the increased walk-in and telephone
            traffic and I really do not know how much more these hard-
            working people can absorb. They are working at a dangerous
            level--working overtime to keep up--stress levels are high and
            this is evident if you spend some time in a field office. They
            will only be able to continue this pace for so long. Less
            funding and staffing will mean a decreased level of service to
            our deserving public. We talk about world-class service in our
            staff meetings; this will disintegrate into second-class
            service if we do not have the staff or the funding to handle
            the increasing workloads.
          We expect our working Americans to dutifully pay their SSA taxes;
            however, this comes with a promise. We promise to safeguard
            this money as an investment toward their retirement or the
            horrible possibility of a career-ending disability--a reward
            for their hard work and contribution to this great country.
            Inadequate funding and staffing will mean we have to tell them
            we appreciate their contribution, but we cannot fulfill our
            promise to provide timely benefits in their time of need, or
            when they are eligible for well-deserved retirement. They will
            just have to wait until we can ``get to their claim''. This is
            unacceptable. We don't give people the option of ``opting out''
            of SSA taxes when they experience financial troubles, but isn't
            that what we are doing here? We understand budget woes, but
            does this give us a valid excuse for punishing hard-working
            Americans? We seem to find funding for important causes and I
            can't think of a better cause than the public we serve who have
            spent their lives making a positive contribution to make
            America what it is today--let's take care of them. (Alabama)
      --On a daily basis, we average between 400 and 500 telephone calls on
            top of claims and postentitlement interviews. We assign six
            employees to telephones daily and we cannot handle the calls we
            receive. Last October we had 1 day in which we received more
            than 1,100 phone calls. How can we be expected to answer so
            many phone calls? Because of assignments to phone duty, I am
            unable to process approximately 240 SSI redetermination
            clearances a week. We are behind by about 20 percent in SSI
            redetermination clearances. (Florida)
        Most of SSA has been under a hiring freeze because of the current
    funding situation. A hiring freeze for all of fiscal year 2011 could
    result in a loss of more than 2,500 SSA Federal employees and up to
    1,000 State employees in the Disability Determination Services (DDSs).
    SSA field office managers recently provided the following frontline
    feedback about the effect of the current SSA hiring freeze on their
    offices:
      --A hiring freeze will be detrimental, especially to the processing
            of our disability workloads. Under the Commissioner's
            direction, we have made tremendous improvement in the time it
            takes to get a decision. Every year the bar is set higher and
            every year SSA staff exceeds expectations. However, in the past
            6 months alone, our office staff has been reduced from 57 to 53
            employees. We are anticipating a minimum of 4 more losses and
            will be down to 49 by the end of the year--a 14 percent decline
            in staff. SSA employees take pride in their work knowing that
            the American public depends on us for their financial security.
            Not having the resources to process workloads in a timely
            manner undermines the positive morale of the staff as well as
            undermining the public's trust in our agency. Meeting the
            demands of the public is a struggle every day. We juggle
            phones, walk-ins, appointments, and Internet claims daily.
            Despite the flexibility of our staff, we consistently have wait
            times of more than an hour. Claims Representatives consistently
            interview all day and have little time to work through mail or
            return phone messages. Not getting to mail or messages daily
            directly influences processing time to pay benefits. (Texas)
        As in-office visitors increase in already busy offices, there has
    also been an increase in the number of reported security incidents.
    Tensions escalate when visitors are in crowded reception areas and many
    become frustrated because of the extensive wait to be served. The
    societal trend of disruptive visitors to offices continues to be a
    challenge. The Office of the Inspector General (OIG) issued a report,
    Threats against SSA Employees or Property, on November 30, 1010.
    According to the report, ``SSA has experienced a dramatic increase in
    the number of reported threats against its employees or property. The
    number of threats increased by more than 50 percent in fiscal year 2009
    and by more than 60 percent in fiscal year 2010.'' This SSA manager
    expresses the connection between staff losses, increased workloads,
    public dissatisfaction and security concerns.
      --A hiring freeze for all of fiscal year 2011 would be devastating.
            We lost two employees over the past 8 months and could not
            replace them. As a result, we are seeing our visitor waiting
            times increase and we are not able to answer telephone calls,
            as we would like. By going from a staff of 18 to 16 employees,
            we are barely able to hold the line on our workloads and basic
            services. Another loss without replacement will undoubtedly
            cause the dam to break. We must have the resources to do the
            work. We are already seeing much more stress on our staff
            members due to assuming the workloads of the employees we lost,
            and we are seeing higher frustration levels from our callers
            and visitors. The American public does not care that we are
            short on staff, they want to be seen quickly, have their call
            answered quickly and get their issues resolved. I am concerned
            that this type of frustration will lead to more threats and
            acts of violence toward our staff members, not only in our own
            office, but also in field offices across the country.
            (Kentucky)
        SSA has a highly skilled, but aging workforce with about two-thirds
    of its more than 60,000 employees involved in delivering direct service
    to the public. SSA projects 50 percent of its employees, including 66
    percent of supervisors, will be eligible to retire by fiscal year 2018.
    Serious concerns exist about the agency's ability to sustain service
    levels with the tremendous loss of institutional knowledge from SSA's
    front-line service personnel. This SSA field office manager relates the
    challenges of dealing with staff retirements.
      --A recent article provided staggering statistics--by 2025, nearly 1
            in 4 Montanans will be older than age 65. This month, a tidal
            wave of baby boomers, 7,000 Americans each day reach that
            milestone. By 2015, projections rank Montana fourth in the
            Nation in percentage of seniors. By 2025, ``mature'' Montanans
            will number 240,000--up more than 100,000.
          By the end of the month, I will lose two employees--one to
            another Federal agency and the other cannot take the stress of
            the job. We ask a lot of our public servants in the SSA and
            deal daily with people living in stressful times. It is very
            difficult to please people living through hard economic times.
            As I lose two trained employees, I wonder what the impact will
            be on the level of service we provide. I have a very
            conscientious staff. They like to go the extra mile, and do
            whatever they can to help people. The impact of losing two
            staff members in these times of doing more with less will cause
            great strain to an already strained staff. The number of people
            that walk through our door and the number of phone calls we
            answer has risen tremendously. Staff and management alike are
            already filling in on the phones and at the counter to provide
            the public with the best possible service.
          It takes at least 2 years to train an individual to work in one
            of our offices. As we lose two individuals, we are already 2
            years and two people behind in providing public service to our
            aging population with a trained staff. A hiring freeze is not
            only demoralizing to our remaining staff members, but causes
            more stress to a demoralized public. (Montana)
        Geographical staffing disparities will occur with attrition leaving
    some offices significantly understaffed, which is especially
    problematic for the rural SSA field offices. These offices serve
    customers who often live vast distances away, may have no Internet
    service, and lack access to public transportation. In some rural areas,
    SSA may be one of the only Government agencies with a local office. SSA
    is the face of the Federal Government in many communities and the
    public expects their local SSA field office to help them with all of
    their Government-related issues. This SSA manager relates recent
    service delivery issues in their rural office.
      --We are a small office in Iowa and our service area includes several
            counties, which include some with the highest poverty rates in
            the State. For several years, we have had the necessary staff
            to handle our workloads and been able to provide some
            assistance to other offices. Last year we lost two employees,
            leaving us with a depleted staff. Now we are not able to handle
            our own workloads. Because we have a potential driving distance
            for claimants of 75 miles to come into the office, we have high
            telephone traffic. We find it very difficult to handle our
            telephone traffic and all of the workloads and priorities that
            should be done. Although use of the Internet is rising, this is
            not the magic answer. Stress on employees who are dealing with
            rising workloads, pending cases, priorities, deadlines, and
            unmet expectations (especially from within themselves) affect
            their outlook and physical health. (Iowa)
        SSA field offices provide valuable services to many diverse
    customers throughout the country. The service provided to our disabled
    veterans is vitally important. In September 2009, the U.S. Government
    Accountability Office (GAO) reported on SSA disability benefits to
    wounded warriors. The GAO report indicated that from 2001 to 2008, SSA
    processed more than 16,000 applications for disability from wounded
    warriors and their approval rate was about 60 percent. As the manager
    of the office that serves the USMA at West Point, I have concerns about
    our ability to assist our Wounded Warriors.
      --My office delivers vital services to the U.S. Army Wounded Warrior
            Transition Unit (WWTU) through the Soldier and Family
            Assistance Center. We visit this facility regularly and provide
            support and SSA services to soldiers from eight States in the
            Northeast. There are approximately 150 soldiers in the WWTU on
            an ongoing basis and we process more than 200 leads per year
            for SSA-related matters. My office staffing has been reduced
            from 35 employees in 2005 to 30, despite large increases in
            workloads. Without sufficient resources and replacement
            staffing, benefits to these members of our Armed Forces will be
            delayed or become seriously backlogged (New York)
        SSA workloads are expected to grow exponentially as the baby
    boomers retire. Reducing resources while work is significantly
    increasing is a prescription for substantial service delays and
    resulting inefficiencies as SSA tries to cope with the mounting
    backlogs and recontacts by the public. SSA is a very productive agency
    that efficiently uses the taxpayers' moneys and must be maintained as
    such.
    Program Integrity Investments
        SSA takes great pride in its stewardship responsibilities by
    ensuring individuals receive accurate payment of benefits. The agency
    is responsible for issuing more than $700 billion in benefit payments
    annually to approximately 60 million people. Tax dollars must be
    effectively managed to minimize the risk of making improper payments.
        Balancing service commitments with stewardship responsibilities is
    difficult given the complexity of the programs SSA administers, but the
    reduction of improper payments is one of SSA's key strategic
    objectives. The two most powerful tools for reducing improper payments
    are conducting medical CDRs and SSI redeterminations.
      --CDRs are periodic reviews of a disability beneficiary's medical
            condition to determine whether an individual is still disabled,
            or if benefits should be ceased because of medical improvement.
            Medical CDRs yield more than $10 in lifetime program savings
            for every $1 spent.
      --SSI redeterminations review nonmedical factors of eligibility, such
            as income and resources, to identify payment errors. SSI
            redeterminations yield a return on investment of more than $7
            in program savings over 10 years for each $1 spent, including
            Medicaid savings accruals.
        Investment in program integrity workloads to ensure accurate
    payments and save taxpayers' dollars is necessary and prudent. Adequate
    final appropriations from fiscal year 2008-fiscal year 2010 allowed SSA
    to address critical program integrity work. SSA invested $759 million
    toward program integrity efforts in fiscal year 2010. The 2.4 million
    SSI redeterminations and 325,000 medical CDRs completed in fiscal year
    2010 produced more than $6 billion in estimated savings (in
    overpayments prevented or projected to be collected).
        The President's fiscal year 2011 SSA budget request proposes SSA
    will accomplish 2.422 million SSI redeterminations and increase the
    number of medical CDRs conducted by 31,000 to 360,000 cases. If SSA is
    able to fulfill its fiscal year 2011 program integrity targets for
    medical CDRs and SSI redeterminations, the estimated program savings
    over the next 10 years is nearly $7 billion, including savings to
    Medicare and Medicaid.
        Program integrity investments have an important impact. Inadequate
    SSA funding in fiscal year 2011 may lead to furloughs or cutbacks that
    would prevent the completion of SSI redeterminations and medical CDRs.

                                                                           LOST PROGRAM INTEGRITY DOLLARS IN FISCAL YEAR 2011
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                                 Total cost
                                                                            SSI            Medical     Cost savings/loss                        savings/loss     FO/DDS estimated
                    Fiscal year 2010 workload period                 redeterminations    continuing     redeterminations  Cost savings/loss   redeterminations   employee salary    Long-term gain/
                                                                        and limited      disability       and limited      medical CDRs \4\     and limited            \6\              loss \7\
                                                                        issues \1\       reviews \2\       issues \3\                            issues \5\
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    Fiscal year 2011...............................................        2,464,684          360,044     $2,708,687,716     $3,931,680,480     $6,640,368,196     $1,809,240,000     $4,831,128,196
    1 work day.....................................................            9,859            1,440        $10,834,751        $15,726,722        $26,561,473         $6,935,276        $19,626,197
    10 work days...................................................           98,587           14,402       $108,347,509       $157,267,219       $265,614,728        $69,352,755       $196,261,973
    15 work days...................................................          147,881           21,603       $162,521,263       $235,900,829       $398,422,092       $104,029,133       $294,392,959
    20 work days...................................................          197,715           28,804       $216,695,017       $314,534,438       $531,229,456       $138,705,510       $392,523,945
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    \1\ SSI redeterminations and limited issues represent projected 551 redetermination and limited issue cases for fiscal year 2011.
    \2\ Medical CDRs are based on fiscal year 2010 projected to fiscal year 2011 (actual number may be higher).
    \3\ Cost savings/loss redeterminations and limited issues fiscal year 2011 projections in administrative costs to process this workload for the year; 1, 10, 15, and 20 work days represent long
      term program savings of $7 saved to $1 administrative dollars spent.
    \4\ Cost savings/loss medical CDRs fiscal year 2011 projections is adminstrative costs to process CDRs for the year; 1, 10, 15, and 20 work days represent long-term program savings of $10
      saved to $1 administrative dollars spent.
    \5\ Total cost savings/loss redeterminations and medical CDRs is total for this workload.
    \6\ FO/DDS estimated employee salary is estimated for FO/DDS employees for fiscal year 2011; 1, 10, 15, and 20 work days.
    \7\ Long-term gain/loss is fiscal year 2011 projection of total saved moneys (cost savings by processing SSI redeterminations and limited issues and CDRs minus salary costs); 1, 10, 15, and 20
      work days is total dollars lost (total dollars lost minus salary costs).

        SSA's OIG issued a report dated December 1, 2010, titled ``Top
    Issues Facing Social Security Administration Management--Fiscal Year
    2011.'' This report provides OIG's perspectives on the most serious
    management challenges facing SSA. The full report is available at
    http://www.ssa.gov/oig/ADOBEPDF/mgmt%20challenges%202011.pdf, but in
    part, the OIG report indicates there is a significant need to increase
    the number of medical CDRs conducted by SSA.

        ``From CY 2005 through CY 2010, we estimate SSA will make between
    $1.3 and $2.6 billion in disability benefit payments that could
    potentially have been avoided if full medical CDRs were conducted when
    they became due. Furthermore, although SSA plans to conduct an
    increased number of full medical CDRs in fiscal year 2011, a backlog of
    approximately 1.5 million full medical CDRs will most likely remain.''

        SSA budgetary constraints have caused the shortfall between the
    number of CDRs due and the number conducted each year. Adequate funding
    is needed for SSA to conduct all CDRs when they become due and to save
    program dollars. If SSA completes all of the 1.5 million medical CDRs,
    the lifetime program savings would be more than $15 billion.
        The OIG report also identifies potential cost-savings, which could
    be realized by SSA conducting additional SSI redeterminations:

        ``SSA decreased the number of SSI redeterminations conducted
    between fiscal years 2003 and 2009 by more than 40 percent. We
    estimated in a July 2009 report, SSI redeterminations, that SSA could
    have saved an additional $3.3 billion during fiscal years 2008 and 2009
    by conducting redeterminations at the same level it did in fiscal year
    2003.''

        The President's fiscal year 2012 SSA budget request indicates the
    funding recommended would allow SSA to conduct at least 592,000 medical
    CDRs and at least 2.6 million SSI redeterminations of eligibility in
    2012. SSA estimates that increased program integrity funding in fiscal
    year 2012 will result in nearly $9.3 billion in savings over 10 years,
    including Medicare and Medicaid savings.
        NCSSMA strongly encourages Congress to provide SSA with the
    necessary funding to reduce the medical CDR backlog and to conduct
    additional SSI redeterminations. Investment in program integrity
    workloads ensures accurate payments, saves taxpayers' dollars and is
    fiscally prudent. Failure to process these reviews has adverse
    consequences on the Federal budget and the ongoing administration of
    SSA programs.
    Quality Concerns
        With the ever-increasing workloads SSA must handle, concerns exist
    about the accuracy of work being performed. SSA employees are working
    at a high rate of production and their primary focus is on getting work
    processed, oftentimes at the expense of quality. Given the significant
    overall dollars involved in SSA's payments, even the slightest errors
    in the overall process can result in significant improper payments.
        Reduced staffing affects not only the number of employees available
    to complete production work, but also management and review positions
    that ensure quality work is completed. SSA is making efforts to improve
    quality of the work product with its new trainees. Most offices are
    completing proficiency reviews after new employees complete their
    training class. This will help develop a more technically proficient
    employee and improve our quality, but resources are necessary for this.
        SSA places a high priority on meeting workload goals, but meeting
    these goals and maintaining quality requires sufficient resources. The
    core problem relative to addressing quality concerns is the time and
    pressure to complete workloads. NCSSMA believes that conducting process
    reviews of cases is necessary and cannot be sacrificed at the expense
    of production.
      --The complexity of the SSI program makes the redetermination process
            a significant area of concern relative to accuracy of changes.
            A targeted assessment review of error-prone areas would be
            beneficial to ensuring a quality product.
      --Process reviews are necessary to address the accuracy of disability
            reports referred to the Disability Determination Services
            (DDSs). Improved report accuracy would result in appropriate
            decisions rendered in a shorter period of time, a critical
            factor given the pressure on our disability program.
      --Reviews of retirement and survivor claims are necessary to ensure
            that entitlement to benefits is not missed and claimants are
            selecting the most advantageous month of election, whether
            filing by telephone, in person or via the Internet. Having
            sufficient time to review a sample of all our work would allow
            managers to provide proper feedback and mentoring to employees
            and ensure continuing quality service.
    SSA Online eServices To Assist With Service Delivery Challenges
        The expansion of services available to the American public via the
    Internet has helped to alleviate the number of visitors and telephone
    calls to field offices. However, Internet services currently available
    represent only a portion of the total workloads accomplished by SSA. In
    spite of SSA's efforts to educate the public regarding Internet
    services, the willingness and ability of individuals to utilize the
    Internet is not keeping pace with the increasing demand for service.
        The agency goal for fiscal year 2012 is to process 50 percent of
    retirement applications and 38 percent of disability claims via the
    Internet. A study of SSA claims indicates that online claims take less
    time to process on average, with a timesaving for a retirement claim of
    12 minutes and 21 minutes for a disability claim. While eServices has
    assisted significantly with the high number of applications received,
    field office staff must still spend significant time to adjudicate
    these electronically initiated actions.
        Many of the high-volume transactions currently processed in field
    offices are not available on the Internet or are only being used by the
    public to a limited degree. In fiscal year 2010 SSA processed more than
    14.7 million SSA card-related actions and 5.4 million benefit
    verifications. This represents more than 40 percent of the 45.4 million
    visitors to SSA field offices. SSA cards cannot be processed online
    because there are security and authentication issues.
        NCSSMA believes that SSA must be properly funded in fiscal year
    2011 and beyond so that it may continue to invest in improved user-
    friendly online services to allow more online transactions. If
    individuals were able to successfully transact their request for
    services online, this would result in fewer contacts with field
    offices, improved efficiencies, and better public service. The agency
    requires the necessary funds for finalizing the authentication process
    to allow more postentitlement transactions to be processed via the
    Internet. With increasing workloads, it is also imperative that SSA
    offers a seamless Internet disability application that is easy to use
    and fully integrated with the medical portion of the claim.
    Disability Workload Processes
        Eliminating the disability hearings backlog continues to be SSA's
    top priority, and the agency has made a major resource investment to
    improve this situation. The agency's goal is to eliminate the backlog
    by 2013 and to improve processing time to 270 days. The Commissioner
    has implemented several initiatives to achieve this goal, including
    improving processes, compassionate allowances, improving efficiency
    with automation, and increasing adjudicatory capacity. Achieving these
    goals will depend on the available resources provided by SSA funding
    and the volume of new hearings received.
        It is important to understand that annual appropriated funding
    levels for SSA have a critical impact on the hearings backlog. One of
    the most significant reasons for the increase in disability hearing
    backlogs was the significant underfunding of SSA. From fiscal year 2004
    to fiscal year 2007, the final appropriated funding levels approved by
    Congress totaled $854 million less than the President's requests and
    $3.071 billion less than the Commissioner's requests.
        However, as you can see from the chart below, from fiscal year 2008
    to fiscal year 2010, the cumulative final appropriation level was $203
    million more than the President's requests. In addition, SSA received
    nearly $1 billion in ARRA funding. Half of the ARRA funds were
    designated to replace the aging SSA NCC. Much of the other ARRA funding
    has been utilized to help address the hearings backlog at SSA.

                    SSA FUNDING REQUESTS AND FINAL APPROPRIATIONS: FISCAL YEAR 2008-FISCAL YEAR 2010
                                                [In billions of dollars]
    ----------------------------------------------------------------------------------------------------------------
                                             Commissioner's   President's      Final        Final vs.     Final vs.
                                                 request        request    appropriation    President   Commissioner
    ----------------------------------------------------------------------------------------------------------------
    Fiscal year 2008.......................         10.420          9.597          9.745          .148         -.675
    Fiscal year 2009.......................         10.395         10.327         10.454          .059          .127
    Fiscal year 2010.......................         11.793         11.451         11.447         -.004         -.346
                                            ------------------------------------------------------------------------
          Total............................         32.608         31.375         31.646          .203         -.894
    ----------------------------------------------------------------------------------------------------------------

        The increased resources for SSA became even more essential as the
    agency's workloads grew at a very rapid pace following the beginning of
    the economic downturn. With the increased funding SSA has received in
    the last 3 fiscal years, the agency has hired 228 ALJs and 1,300
    additional support staff. The agency has also opened or expanded 19
    hearing offices, including a fifth National Hearing Center and 8 more
    hearing offices are to be opened this year.
        SSA's efforts have resulted in significant progress in reducing
    both the number of pending hearings and the amount of time a claimant
    must wait for a hearing decision. At the end of fiscal year 2010, the
    pending hearings were reduced to 705,367 cases nationwide, the lowest
    level in 5 years. In February 2010, the average processing time for a
    hearing was 365 days, the lowest level since December 2003. At its
    peak, it took nearly 18 months for a hearing decision.
        Even though this is positive news, the hearing offices are facing a
    significant wave of new hearings that are being filed, as seen in the
    chart below.

                                       ODAR PERFORMANCE DATA THROUGH FEBRUARY 2011
    ----------------------------------------------------------------------------------------------------------------
                                                          Hearing
               Fiscal year              Pending SSA     processing    Yearly hearing      Yearly        Average ALJ
                                         hearings          times         receipts      dispositions    dispositions
    ----------------------------------------------------------------------------------------------------------------
    2011 \1\........................     \2\ 722,872             371     \2\ 829,373     \2\ 784,693            2.44
    2010............................         705,367             426         721,841         737,616            2.38
    2009............................         722,822             491         625,003         660,842            2.37
    2008............................         760,813             514         591,888         550,805            2.3
    2007............................         746,744             512         581,687         547,951            2.19
    2006............................         715,568             483         561,609         558,978            2.2
    2005............................         708,164             443         598,726         519,359            2.2
    2004............................         635,180             391         634,175         561,461      ( \3\ )
    2003............................         556,369             343         662,733         571,928      ( \3\ )
    2002............................         463,052             333         596,959         532,106      ( \3\ )
    2001............................         392,397             307         554,376         465,228      ( \3\ )
    ----------------------------------------------------------------------------------------------------------------
    \1\ Fiscal year 2011 information is from October 2010 through February 2011.
    \2\ Fiscal year 2011 data is projected figure based on October 2010 through February 2011 performance.
    \3\ Not applicable.

        This chart projects that approximately 400,000 additional hearings
    will be filed from fiscal year 2009 through fiscal year 2011 than were
    filed in fiscal year 2008. This is attributable to the increased number
    of disability claims being filed since the economic downturn that began
    in 2008.
        The Congressional Budget Office (CBO) released a report July 22,
    2010: ``Social Security Disability Insurance: Participation Trends and
    Fiscal Implications.'' According to this report, disability
    beneficiaries tripled from 2.7 million to 9.7 million people from 1970
    to 2009. The CBO projects the number of disability beneficiaries will
    grow to 11.4 million by 2015. In fiscal year 2010, SSA received 619,306
    more initial disability claims than in fiscal year 2008. In fiscal year
    2011, SSA anticipates receiving 629,000 more initial disability claims
    than in fiscal year 2008.
        The rise in disability claims filings has also created backlogs in
    the State DDSs. At the end of fiscal year 2010, the number of pending
    initial disability claims was at an all-time high of 824,192 cases,
    which was 258,522 more than at the end of fiscal year 2008, a 46
    percent increase. In the first 5 months of fiscal year 2011, the number
    of initial disability claims pending has been reduced to 774,130. This
    foreshadows the second wave of cases coming to the hearing offices.
        To eliminate the hearings backlog in fiscal year 2013, SSA will
    need to adjudicate a record number of cases in fiscal years 2011 and
    2012--more than 800,000 each year. Complicating this monumental task is
    the furloughing of workers in 10 States, including DDS employees,
    despite the fact that SSA provides 100 percent of the funding necessary
    for the DDSs to operate. SSA must also deal with an anticipated
    retirement wave of ALJs, with 59 percent currently eligible for
    optional retirement.
        Despite these unprecedented challenges, SSA continues to utilize
    the additional resources received in the last 3 fiscal years to clear
    more disability claims and hearing cases. Unfortunately, the number of
    claims and hearings pending is still not acceptable to the thousands of
    Americans who depend on the SSA for SSI for their basic income, meeting
    healthcare costs, and support of their families. It is essential that
    adequate funding be provided to SSA to replace lost staff and work
    overtime to maintain the momentum achieved in reducing the number of
    disability cases pending and the time it requires to process these
    cases.
    Information Technology Investments
        SSA is confronted with major challenges in managing its Information
    Technology programs to keep up with rapidly expanding workloads. NCSSMA
    believes it is critical that SSA receive adequate funding to allow for
    much-needed IT investments. This is vitally necessary for SSA to
    replace our aging NCC, to maintain systems continuity and availability,
    and to improve IT service delivery. Any rescission of Carryover IT
    funds could seriously jeopardize SSA's initiatives to implement
    automation and technological efficiencies to address service delivery
    demands.
        The agency is in the process of replacing its NCC and has received
    ARRA funding for this purpose. The existing NCC is more than 30 years
    old and has significant structural issues that necessitate its
    replacement. Additionally, the NCC's capacity is severely strained by
    increasing workloads and expanding telecommunication services to
    support the agency's business.
        In the previously referenced OIG report dated December 1, 2010,
    managing the timing of the transition from the existing data center to
    a new center has become a concern.

        ``SSA estimates that by 2012, [its National Computer Center] as a
    stand-alone data center will no longer be able to support this
    expanding environment.''

        SSA has also made a major investment in improving its telephone
    service. The agency is in the midst of replacing telephone equipment
    with Voice over Internet Protocol (VOIP). The VOIP technology telephone
    system integrates SSA's networks and provides faster call routing. The
    agency is approximately 74 percent complete with this initiative, with
    936 of its 1,266 field offices now have the new VOIP equipment. SSA
    anticipates completion of this project by March 2012.
        With SSA's volume of telephone calls increasing, successfully
    implementing VOIP is essential to address growing public service
    demands. While early VOIP installations experienced problems with the
    equipment and services, the agency has made significant strides in
    addressing those concerns. Voice quality, management information data,
    and programming issues are being addressed and resolved, but SSA IT
    funding is critical to the successful completion of this major
    initiative.
    Legislative and/or Regulatory Actions To Improve SSA Program Efficiency
        NCSSMA recommends consideration of the following legislative and/or
    regulatory proposals that can improve the effective administration of
    the Social Security Program, with minimal effect on program dollars.
    NCSSMA believes these proposals, which are included in the fiscal year
    2012 budget request, have the potential to increase administrative
    efficiency and lower operational costs.
      --Enact the WISP.--This proposal would replace the complex work
            provisions in the Social Security Disability Program, including
            the trial work period, substantial gainful activity
            determinations, extended period of eligibility and expedited
            reinstatement, and replace these provisions with an earnings
            test comparable to that of RSI beneficiaries under full
            retirement age. This provision would simplify the entire work
            incentive process for the beneficiary and SSA. Work years saved
            by SSA currently spent in enforcing the prior provision could
            be redirected to other priority workloads.
      --Federal Wage Reporting.--This proposal would require employers to
            report wages quarterly; the proposal would not affect reporting
            of self-employment. Increasing the timeliness of wage reporting
            would enhance tax administration and improve program integrity
            for a range of programs. This program would give SSA more
            immediate access to earnings information for the SSI program,
            thereby decreasing underpayments.
      --Require That SSA be Provided With Information on Workers
            Compensation.--Provision of this information in an electronic
            fashion would greatly reduce the number of contacts necessary
            by SSA personnel to State and local governments, along with
            private insurance providers. Having accurate information at the
            time of determinations would ensure more accurate decisions,
            thereby reducing incorrect payments. This proposal would save
            both administrative and program dollars.
      --WEP/GPO.--NCSSMA supports the proposal to develop automated data
            exchanges for States and localities to submit useful and timely
            information on pensions that are based on work not covered by
            Social Security. These cases are complex and error-prone.
            Availability of this information would allow for more efficient
            case processing, as well as prevent future overpayments.
                                   conclusion
        The management and staff of the SSA are highly committed to serving
    the American public, but we must have the tools and resources to do so.
    SSA is the safety net of America and if adequate funding is not
    provided, public service will deteriorate, with longer waiting times,
    unanswered calls, increased backlogs, and significant hardship on needy
    individuals. The appropriated funding levels for fiscal year 2004
    through fiscal year 2007 did not adequately fund SSA and contributed to
    a degradation of service to the public. We hope there will be a careful
    assessment of what may be done to provide adequate funding for the SSA
    in fiscal year 2011 and beyond.
        In our view, which is shared by many others, Social Security is the
    most successful Government program in the world. We are a very proud
    and productive agency that efficiently uses the taxpayers' moneys, and
    the SSA must be maintained as such for future generations. NCSSMA
    sincerely appreciates the subcommittee's interest in the vital services
    the SSA provides and the ongoing support to ensure SSA has the
    resources necessary to serve the American public. We remain confident
    this increased investment in SSA will benefit our entire Nation.
        On behalf of the members of NCSSMA, I thank you again for the
    opportunity to submit this written testimony to the subcommittee and
    state our viewpoints. NCSSMA members are not only dedicated SSA
    employees, but are also personally committed to the mission of the
    agency and to public service. We respectfully ask that you consider our
    comments, and would appreciate any assistance you can provide in
    ensuring the American public receives the critical and necessary
    service they deserve from the SSA.

        Senator Harkin. And thank you all very much for your
    testimonies.
        We'll start a round of 5-minute questions, here.
        Mr. Dirago, we'll start with you. I held a field hearing at
    the University of Northern Iowa campus on February 5 this year.
    And we discussed these budget cuts like this, including to the
    Social Security Administration, on communities in Iowa. Jerry
    Nelson, a field office manager from Waterloo field office,
    testified. And he presented a pretty stark picture of the
    impact that budget cuts on Iowan's filing for disability
    benefits and walking through their door for even basic
    services.
        As a field office manager in Newburgh, New York--again, the
    impact--what is the impact of potential cuts like this on those
    who walk through your door and call you on the phone? Again,
    just give me a good example.
        Mr. Dirago. Well, waiting time in our offices is really an
    issue. In terms of the number of people walking into our
    offices on a daily basis, the average waiting time across the
    country is about 21 minutes. If we're not funded properly and
    we don't have replacement staff, those waiting times are going
    to go up significantly.
        The other effect would be the processing of our disability
    claims and the backlogs that would occur. If funding is not
    provided, there would be delays in that. Potentially, the
    hearings backlog progress would be reversed.
        Our telephone calls coming into the offices, there's a
    tremendous volume. Last year, I mentioned, 100 million
    telephone calls that SSA handled. My office alone receives
    about 4,000 telephone calls in a month. It's very difficult to
    get to those folks, and we try to do the best job that we can--
    --
        Senator Harkin. Four thousand phone calls. How many
    employees?
        Mr. Dirago. We have 30 employees in Newburgh.
        Senator Harkin. But, not all those would be employees who
    would be representatives that could handle a phone interview,
    are they?
        Mr. Dirago. Well, there's four management employees and the
    rest of the folks are on the front lines.
        Senator Harkin. So, that's 26, yeah?
        Mr. Dirago. Yeah.
        Senator Harkin. For----
        Mr. Dirago. And we do----
        Senator Harkin [continuing]. 3,000 calls.
        Mr. Dirago [continuing]. The best job we can. But,
    sometimes--you know, it--the resources are very short.
        The other impact that I would mention specifically is the
    program-integrity workloads. They're tremendously important.
    Last year, we did about 2.4 million in the agency. And that has
    a huge benefit. We already talked about the potential of $1 to
    $7 savings--$1-$7 in savings for every $1 invested. My office
    does in excess of 2,000 redeterminations. And again, if we
    don't have the resources, and if the staffing is not replaced,
    then we're not going to get to those workloads. And then the
    long-term effect would be negative.
        Senator Harkin. Someone told me also about the phone calls
    coming into your offices, that these are not usually 30-second
    phone conversations.
        Mr. Dirago. No, generally, the phone calls that come in,
    that are to the field offices, are often in regards to claims
    development, which could be to resolve issues on their
    disability applications; could be complex issues in the
    Supplemental Security Income Program, where you have to go into
    development of income and resources. So, oftentimes those
    telephone calls are 5 to 10 minutes, or even more. The
    telephone calls that go into the teleservice center sometimes
    can be resolved very quickly, where they may be just a request
    for location of an office or a request for a benefit
    verification. So, generally when folks call the local field
    office, they want to speak to someone in the local field office
    because they have an issue that needs to be addressed, with a
    particular claims representative, about their claim.
        Senator Harkin. And, while I'm very supportive of
    technology and putting more things online--Commissioner Astrue
    talked about that--as I travel around my State of Iowa, and I
    go to so many small towns and places, where we have a lot of
    elderly people that live by themselves--in many cases, in small
    houses, and the only thing they have is Social Security; that's
    all they've got--they just aren't too proficient online. And a
    lot of them don't even have online services. In rural areas,
    they just don't have it. And so, while technology's okay, it
    just doesn't reach, I think, a big segment of the population
    out there that are elderly. Now, that may change as the Baby
    Boomers start to retire and people who are used to using online
    services retire. But, I'm saying, for the present generation
    out there, I mean, some of them have never used computers
    before, have never gone online.
        Mr. Dirago. Yes. We've--in terms of the agency, right now
    we're at about 34 percent online, in terms of the claims filed,
    between a combination of retirement, survivors, and disability,
    which is very good. It's a significant improvement over prior
    years.
        The Commissioner's fiscal year 2012 goal is 50 percent in
    retirement and 38 percent in disability. But, you are correct,
    there's--rural counties, there's issues, in terms of access to
    the Internet; there's issues, oftentimes, with people's ability
    to handle the difficult process of processing----
        Senator Harkin. Right.
        Mr. Dirago [continuing]. A claim online, particularly
    disability claims. That's the large challenge.
        The one point I'd like to make--the agency is in the
    process of improving its disability online application, and
    that's an important initiative, and would be very helpful,
    because if more claims are taken online the--what we have to
    work on, in terms of the offices--we'd be better able to handle
    that. Because every one of those online claims still has to be
    handled within the office. So, the local field office reviews
    the claim, makes the decision, in terms of any entitlement
    factors, may pursue other development. In terms of the
    disability, they have to basically clean up the entire
    application so that the product that's sent to the disability
    determination services is accurate and so they can make a good
    decision.
        Senator Harkin. All right. Thank you. My time's up.
        Senator Shelby. Thank you, Mr. Chairman.
        Mr. Hammond, I'll direct the first question to you, if I
    could.
        In your testimony, you note that, while funding for Social
    Security Administration administrative expenses is critical,
    AARP has equal concern for many other vital programs.
    Specifically, you note the importance of sufficient funding to
    help seniors afford to pay Medicare premiums, for senior
    nutrition, and job-training programs, and the Low-Income Energy
    Assistance Program. Funding for these initiatives also falls
    within this jurisdiction of this subcommittee.
        As we work to craft a bill in these tough economic times,
    and to balance funding priorities for programs that serve our
    aging population, do you think a 9.4-percent increase for the
    Social Security Administration's administrative expenses is the
    best use of limited resources, especially, given substantial
    buildup of Social Security's reserve funds, which you know that
    this funding may take from other programs you believe are vital
    to seniors?
        Mr. Hammond. Sir, I think--pardon me, I forgot the
    microphone again.
        Senator Shelby. Go ahead.
        Mr. Hammond. I think it's very important for us to
    understand that Social Security is a real safety-net program
    for this country. We have millions of Americans who are now on
    Social Security. We have more millions of Americans who will be
    on Social Security within the next 10 to 15 to 20 years. Unless
    we provide a viable system that can take applicants, process
    their claims, and do it accurately and efficiently and quickly,
    we're going to have longer lists than we have now, waiting for
    some help. And, as Senator Harkin mentioned, many of those
    folks have Social Security as their only means of income. So,
    we need to beef up the Social Security Administration program
    to the point where it can handle these new applicants and the
    other applicants that are coming through SSI and through the
    disability claims department, and give them the resources that
    they need.
        Certainly, those other programs are very important to us.
    But, we think there needs to be bipartisan support to find
    solutions to those programs, too.
        Senator Shelby. Absolutely. What recommendations,
    specifically, would you make to the Social Security
    Administration to attain its goal of improving service to the
    public? That's very important to all of us.
        Mr. Hammond. I'm not here with any specific recommendations
    this morning, Senator, but I'd be happy to have staff----
        Senator Shelby. Could you do----
        Mr. Hammond [continuing]. Talk with you about that.
        Senator Shelby [continuing]. Some for the record? Would
    you----
        Mr. Hammond. Yes.
        Senator Shelby [continuing]. You or AARP----
        Mr. Hammond. Yes, we can do something----
        Senator Shelby [continuing]. So we can consider them.
        But--because we're interested in spending the money wisely,
    being efficient for the people who need assistance. Not to
    waste money, but to do it timely; as you are, I'm sure.
        Mr. Hammond. We can have staff do something on that regard.
        Senator Shelby. Ms. Ford, I've got a question for you, if I
    could.
        Ms. Ford. Sure.
        Senator Shelby. It's my understanding that the majority of
    the Social Security Administration's administrative expenses
    are attributed to the Disability Insurance Program. Given your
    work with the Consortium for Citizens with Disabilities, could
    you discuss briefly the impact of the Social Security
    Administration's efforts, to date, to fast-track disability
    claims? Specifically, has the disability community noted an
    improvement in the time to approve claims of those with severe
    disabilities through Social Security's fast track initiatives,
    known as Compassionate Allowances and Quick Disability
    Determinations? Is that program working? And, if it is, good;
    if it's not, how can we suggest they improve it, if you have
    some suggestions?
        Ms. Ford. Yes, Senator, we have been watching that and have
    worked with the administration, and note that those two
    programs have been working. The Quick Disability Determination,
    I believe that they are still able to decide cases in well
    under the 20 days. I can't cite, chapter and verse, the exact
    number of days. And the Compassionate Allowance Program has
    been able to choose certain types of impairments, where they
    can determine that the evidence is there and the type of
    impairment, and the evidence with it, will lead them to a quick
    decision. And they are----
        Senator Shelby. The right decision, right?
        Ms. Ford. The right decision quickly. And they are moving
    slowly, not too quickly. I think it's important not to move too
    quickly, so that they do it properly. And we believe that that
    is working.
        We want that to work well, because we think it's important
    that it not--I don't think it would be good to move too fast
    and have it work improperly. But, there is good promise there
    that the administration can move cases----
        Senator Shelby. Is it more----
        Ms. Ford [continuing]. Quickly, when the----
        Senator Shelby [continuing]. Efficient than it----
        Ms. Ford [continuing]. Evidence is there.
        Senator Shelby [continuing]. Used to be?
        Ms. Ford. Pardon?
        Senator Shelby. Is it a lot more----
        Ms. Ford. Oh, absolutely.
        Senator Shelby [continuing]. Efficient?
        Ms. Ford. Much more efficient.
        Senator Shelby. That's what I was saying.
        Ms. Ford. I wish I could cite you the----
        Senator Shelby. Okay.
        Ms. Ford [continuing]. The times, but I can't.
        Senator Harkin. If you can get some of that for the
    record----
        Ms. Ford. Yes. I'm sure----
        Senator Harkin [continuing]. It would be good.
        Ms. Ford [continuing]. And I'm sure the administration will
    be able to give that to you----
        Senator Harkin. Okay.
        Ms. Ford [continuing]. But we can get that for you.
        [The information follows:]
           Letter From the Consortium for Citizens With Disabilities
                                                         July 27, 2011.
    Hon. Tom Harkin,
    Chairman, Senate Appropriations Subcommittee on Labor, Health and Human
            Services, and Education and Related Agencies, Washington, DC.
    Hon. Richard C. Shelby,
    Ranking Member, Senate Appropriations Subcommittee on Labor, Health and
            Human Services, and Education and Related Agencies, Washington,
            DC.

    RE: Information for the record, Senate Committee on Appropriations,
            Labor-HHS Subcommittee hearing on the Social Security
            Administration budget, March 9, 2011
        Dear Chairman Harkin and Ranking Member Shelby: Thank you for the
    opportunity to testify on March 9, 2011 on behalf of the Consortium for
    Citizens with Disabilities (CCD) regarding funding for the Social
    Security Administration (SSA) in fiscal years 2011 and 2012. At the
    hearing, the Committee asked for additional information for the record
    regarding three topics.
    Compassionate Allowance and Quick Disability Determination
        Senator Shelby asked for additional information on efficiencies
    under SSA's Compassionate Allowance (CAL) and Quick Disability
    Determination (QDD) initiatives. Through CAL and QDD, cases receive
    expedited processing within the context of the existing disability
    determination process. I testified that these programs are working and
    provide an efficient way for SSA to arrive at accurate, timely
    determinations for people with some of the most serious impairments in
    cases where evidence can be quickly and easily obtained, and there is a
    high likelihood that they meet disability eligibility criteria.
        In fiscal year 2010, SSA identified 4.6 percent of all initial
    disability claims as CAL or QDD; SSA reports that it can ``complete
    these disability claims in days compared to months.'' \1\
    Unfortunately, statistics that quantify this are unavailable: SSA
    collects, but does not report, CAL and QDD processing times. The SSA
    Office of the Inspector General recently recommended adding data on CAL
    and QDD processing times and allowances to SSA's annual Performance and
    Accountability Report, and providing more detailed data on each
    program.\2\ Such data would help policymakers and the public better
    understand the efficiency and effectiveness of the CAL and QDD
    initiatives.
    ---------------------------------------------------------------------------
        \1\ Social Security Administration (November, 2010). Performance
    and Accountability Report for FY 2010. http://www.ssa.gov/finance.
        \2\ Office of the Inspector General, Social Security Administration
    (April, 2011). Performance Indicator Audit: The Social Security
    Administration's Fiscal Year 2010 Performance Indicators. A-02-10-
    11076.
    ---------------------------------------------------------------------------
    Social Security Beneficiaries With Disabilities
        Senator Shelby also asked how many people with disabilities receive
    Social Security. As of May, 2011 approximately 15,611,000 people
    received Social Security Old Age, Survivors, and Disability Insurance
    (OASDI), Supplemental Security Income (SSI), or both, on the basis of
    their own disability.\3\
    ---------------------------------------------------------------------------
        \3\ Social Security Administration (May, 2011). Monthly Statistical
    Snapshot, May 2011. Accessed July 1, 2011 at http://ssa.gov/policy/
    docs/quickfacts/stat_snapshot/index.html.
    ---------------------------------------------------------------------------
    Amendment 195 to H.R. 1
        Senator Harkin asked for additional information regarding Amendment
    195 to H.R. 1. This amendment would prohibit any Federal funds
    appropriated for the rest of fiscal year 2011 from being distributed
    under the Equal Access to Justice Act, 28 U.S.C. Sec.  2412 (``EAJA'').
        The EAJA was signed into law by President Reagan in 1980 after
    receiving broad bipartisan Congressional support. The EAJA provides
    attorneys' fees to individuals, small businesses, and nonprofits who
    prevail in claims against the Federal Government and who can prove that
    the Federal Government was not ``substantially justified'' in bringing
    or defending the case.
        The EAJA allows low-income and middle-income people who cannot
    otherwise afford an attorney to bring their claims. For example, the
    EAJA allows people with disabilities and seniors to appeal denials of
    Social Security benefits to Federal court, and veterans to appeal
    decisions to the Board of Veterans' Appeals and to the Court of Appeals
    for Veterans Claims. The fees paid under the EAJA are assessed against
    the Federal agency involved and, as a result, do not reduce the past
    due benefits received by the plaintiff/claimant.
        As discussed in my written testimony, CCD is concerned that by
    making legal representation less available, Amendment 195 would make it
    more difficult for people whose disability claims have been denied to
    pursue their claims in Federal court. For that reason, my testimony
    urged the Subcommittee to oppose inclusion of similar language in the
    fiscal year 2011 and 2012 spending packages.
        On May 25, 2011, legislation that would have a similar effect as
    Amendment 195 was introduced in both the House and Senate (Government
    Litigation Savings Act; H.R. 1996 and S. 1061). As more information and
    analysis on this legislation becomes available, we will forward it to
    you. Additionally, for more information about how the legislation may
    affect Social Security claimants, you may wish to contact Nancy Shor,
    Executive Director of the National Organization of Social Security
    Claimants' Representatives, at 201-567-4228 or nosscr@att.net.
        In closing, thank you for the opportunity to testify and for your
    leadership in considering the needs of people with disabilities. Please
    do not hesitate to contact me if you require any additional
    information.
                Sincerely,
                                            Marty Ford,
                     Consortium for Citizens with Disabilities,
                                  Co-Chair, Social Security Task Force.

        Ms. Ford. I think it--they are both good programs. We like
    to watch this carefully, because we want to be sure that the
    cases are being handled properly. But, yes, there is great
    promise there in making----
        Senator Shelby. Good.
        Ms. Ford [continuing]. Sure that cases can move more
    quickly.
        Senator Shelby. I also noted in your testimony that you
    expressed support for the administration's proposed Disability
    Work Incentives Simplification Pilot Program, which would
    provide beneficiaries with the flexibility to return to work
    without fear of losing their benefits. Could you elaborate on
    the concerns that beneficiaries have on trying to return to
    work? And what additional recommendations would you make?
    Because some people are temporarily disabled, and they might
    get better, but they've got to get back in the workforce, and
    it's hard.
        Ms. Ford. There are a lot of concerns that people with
    severe disabilities have about returning to the workforce. One
    is the issue of whether or not they're going to be able to
    maintain the medical care that they need. Once they become
    conditioned to the--you know, their new life with the
    impairment that they may have acquired, do they have the
    medical treatment and support that they need? And will they be
    able to maintain work? Some people find that they will be able
    to, and therefore they won't need the program anymore. Some
    people find that, in attempting to work, they may not be able
    to maintain that. Those experiences are what people are worried
    about. Will they be able to get back into the Social Security--
    --
        Senator Shelby. Sure.
        Ms. Ford [continuing]. System if they need it? And----
        Senator Shelby. That's very critical, though----
        Ms. Ford. Yeah.
        Senator Shelby [continuing]. To someone that's been out of
    the workforce. They don't want to use--lose their benefits;
    yet, if they could take a step toward work, and without losing
    them----
        Ms. Ford. Right.
        Senator Shelby [continuing]. It would be helpful, would it
    not?
        Ms. Ford. But--it would. But, if it took you 2 to 3 years
    to get into the program----
        Senator Shelby. I understand.
        Ms. Ford [continuing]. That's one of the problems. And so,
    if you knew that, once you were in the program, you could
    attempt work without having to go back----
        Senator Shelby. Sure.
        Ms. Ford [continuing]. Through that 2- or 3-year process,
    that you could just simply come back in, and that risk of
    having to reenter would----
        Senator Shelby. Sure.
        Ms. Ford [continuing]. Be gone, and you had an easy on-and-
    off. You could take those risks and attempt work. And that's
    what we would like to----
        Senator Shelby. Without fear of----
        Ms. Ford [continuing]. See happen.
        Senator Shelby [continuing]. Losing everything at once.
        Ms. Ford. Yes.
        Senator Shelby. To----
        Ms. Ford. Yes.
        Senator Shelby. In other words, try and see if they can
    swim----
        Ms. Ford. Right.
        Senator Shelby [continuing]. In the water, huh?
        Ms. Ford. Have a good connection to the medical--to the
    Medicare. And have a good connection to the----
        Senator Shelby. Sure.
        Ms. Ford [continuing]. Cash benefit, if you need it. And
    those are the things that we think could happen in the work
    incentive simplification (WIS) program, and that's why we would
    like to work with SSA----
        Senator Shelby. Well, that would help----
        Ms. Ford [continuing]. On that.
        Senator Shelby [continuing]. Help the program and help----
        Ms. Ford. Yes.
        Senator Shelby [continuing]. The people, would it not?
        Ms. Ford. I think it would help immensely.
        Senator Shelby. We worked on that.
        Ms. Ford. Yes.
        Senator Shelby. Mr. Dirago--is that right?
        Mr. Dirago. Yes.
        Senator Shelby. Your administration is the frontline
    service provider for the Social Security Administration in
    communities all over the Nation. Would you elaborate on the
    legislative and regulatory actions that you recommend in your
    written testimony, and to--as to simplify the work incentive
    process, to improve the Social Security Administration program
    efficiencies? That's very important.
        Mr. Dirago. Okay.
        Senator Shelby [continuing]. Because we've got a lot of
    people working at this. The Social Security has been a good
    program, but to say we can't improve it, is nonsense. You know?
    You just cited how we could improve it.
        Mr. Dirago. And I would just elaborate on the work
    incentive simplification, as well. That's probably the most
    significant legislative change that's included in the fiscal
    year 2012 budget request.
        The complexity of the--of disability work-incentive
    development is just beyond belief. You have trial work period,
    you have substantial gainful activity, you have extended period
    of eligibility. It's an extremely complex area for our
    technicians to resolve when individuals attempt to return to
    work. The proposal would greatly simplify that and make it more
    of an earnings test, as opposed to these complex decisions.
    And, as Ms. Ford just indicated, we would support it
    significantly, because it would reduce administrative costs, in
    terms of developing these cases.
        It would also overcome the fear that individuals have of
    returning to work, because, as was stated, individuals once--it
    takes them sometimes 2 years to get on the program; and, when
    they're on, they just don't want to try to go back to work,
    because they're fearful of losing the little economic security
    that they have. So, we would strongly encourage that.
        We also encourage--there's some wage matching that we
    encourage, in terms of windfall elimination provisions in
    Government pension offsets, where there could be some kind of
    automatic----
        Senator Shelby. What do you mean by that?
        Mr. Dirago. Well, in terms of if individuals receive some
    form of a public benefit, a Government retirement payment, so
    that there would be matching with Social Security records so
    that we can resolve any payment issues. So, that if there's
    more interfaces----
        Senator Shelby. Well, that's a question of information
    technology, isn't it?
        Mr. Dirago. Yes, it is.
        Senator Shelby. And the database you have----
        Mr. Dirago. Right.
        Senator Shelby. And that can be done.
        Mr. Dirago. Right. And there's also--Federal wage reporting
    would be something else, in terms of reporting wages on a
    quarterly basis; that would help us significantly.
        Senator Shelby. About how many people, roughly, are on
    Social Security disability in the Nation? Just roughly.
        Mr. Dirago. I don't want to misstate the number. I will
    get----
        Senator Shelby. Well, just roughly.
        Mr. Dirago [continuing]. It for you.
        Senator Shelby. Just give a ballpark figure.
        Mr. Dirago. Wow.
        Senator Shelby. Is it in the millions?
        Mr. Dirago. Oh, definitely in the millions.
        Senator Shelby. Is it 5 million, 10 million?
        Mr. Dirago. Hold on----
        Ms. Ford. Is it approximately 11?
        Mr. Dirago [continuing]. One second, here.
        Ms. Ford. I'm thinking 11 million. But, I----
        Senator Shelby. Eleven million? Could you furnish it for
    the record?
        Mr. Dirago. Absolutely.
        [Clerk's Note.--The information was provided in the July
    27, 2011 letter from the Consortium for Citizens With
    Disabilities.]
        Senator Shelby. Let's assume it's just 10 million--that's a
    lot of people.
        Now, in going back to what Ms. Ford said, if some of those
    people, statistically, will get better--some of them have
    different problems; some will never get better, we know that,
    and--but, if we could ferret out who is getting better.
        Mr. Dirago. Yeah, and that's part----
        Senator Shelby [continuing]. Who could work, and would like
    to work--and without throwing them in a ditch, to help them to
    get out, that would help vitalize this program, would it not?
    And for others that maybe are much more in need.
        Ms. Ford. Help--to give them the opportunities to----
        Senator Shelby. You see what I mean, Ms. Ford?
        Ms. Ford [continuing]. To try work and to get a----
        Senator Shelby. Absolutely.
        Ms. Ford [continuing]. Foothold in the workforce, without
    the fear of losing the support system that they've had to
    depend on.
        Senator Shelby. I know it's not a total analogy, but in
    welfare reform, I know, myself, people that were drawing
    benefits, especially single mothers, a lot of them, and dropped
    out of school and we didn't knock out their benefits. And a lot
    of them have gone and finished high school. I know some that
    have gone on--I know one that's an electrical engineer right
    now. But, if we had knocked out their benefits, their props,
    they would never have made that step toward the marketplace.
    And I think--isn't that what we want to do, where people are
    able and want to work again, Ms. Ford?
        Ms. Ford. Yes, absolutely.
        Senator Shelby. Okay.
        Ms. Ford. We need to give them an opportunity.
        Senator Shelby. Absolutely.
        Mr. Chairman, I thank you for your indulgence on your time.
        Senator Harkin. No, it was a good exchange.
        Now, that's what the President's proposal is going to,
    hopefully, going to try to do, is to test a new system out on
    this. And I'm looking forward to working with the
    administration on the implementation of this pilot program,
    starting next year. See if it works.
        I would hasten to add, though, that a lot of this
    information is--mentioned about the information technology, but
    I'm quick to point out that, in addition to the cuts in H.R. 1,
    it rescinds $500 million in reserves that we have for
    information technology upgrades in the Social Security
    Administration. So, on the one hand, we want to use information
    technology to help us do the work better and more efficiently;
    and then we take $500 million from the reserve fund for
    information technology upgrades and expenses. So, I just wanted
    to point that out, that that's another little whack out there
    that might happen.
        I just had one follow up question, Ms. Ford. In your
    testimony, you mention an amendment--an amendment to H.R. 1, I
    guess, was adopted, I guess--that will adversely impact the
    ability of disability claimants to obtain legal representation
    in Federal court. Could you discuss that a little bit more, and
    its impact on people with disabilities?
        Ms. Ford. It was the--let me find my copy, here.
        Senator Harkin. You said--mentioned amendment 195 or
    something? I don't----
        Ms. Ford. Yes, it was the--it would make it difficult for
    people whose claims have been denied to take their claims to
    Federal District Court, since no funds would be available for
    payment of fees or expenses, under the Equal Access to Justice
    Act. And we are fearful that that could make legal
    representation unavailable to claimants who need to pursue
    their claims in Federal court. And so, we just wanted to bring
    that to the subcommittee's and the full committee's attention
    to ensure that no such language would enter into the Senate
    bill.
        Senator Harkin. Do we have any--if you don't have the
    information now, maybe we could get it for the record, about
    how many claimants actually seek to take their cases to Federal
    court. I don't know if we know that, or not.
        Ms. Ford. When you mention Nancy Shor, she might have that.
        Do you have any idea?
        Ms. Shor. About 20,000.
        Ms. Ford. About 20,000 a year.
        Senator Harkin. About 20,000 a year actually seek to go to
    Federal--actually go to Federal court, or--actually go to
    Federal court.
        Ms. Ford. Currently, actually go to Federal court, yes.
        Senator Harkin. And what you're saying is that there's
    something in H.R. 1 that says that we don't provide legal
    representation any longer?
        Ms. Ford. That this would not allow them to receive--have
    their fees paid under the Equal Access to Justice Act, yes.
        Senator Shelby. Can I ask a question?
        Senator Harkin. We can----
        Senator Shelby. Are the fees paid out of the--say, if they
    had a back reward, and it depends on their work----
        Ms. Ford. As----
        Senator Shelby [continuing]. Say, an attorney's work. And
    they have to approve a fee?
        Ms. Ford. That's the case, as long as you're still in the
    administrative----
        Senator Shelby. Okay.
        Ms. Ford [continuing]. System. As long as you're still
    working your way through the Social Security system.
        Senator Shelby. Okay.
        Ms. Ford. But, once you've finished, at the appeals level
    of SSA, and then you head into Federal District Court, you're
    no longer working in that----
        Senator Shelby. Okay.
        Ms. Ford [continuing]. System. Correct?
        Ms. Shor. Close.
        Ms. Ford. Close.
        Nancy knows this better than I do.
        Senator Shelby. Okay.
        Ms. Ford. Should we submit something that describes that in
    more detail?
        Senator Harkin. Well, I might want to get more information
    on that, because I don't think that we ought to be in the
    business of denying access to court for people who have no
    money and they have a legitimate--or they feel they have a
    legitimate reason to go to Federal court to contest an
    administrative decision. I was not aware of that in the--in
    H.R. 1--not aware that that provision was in there.
        Did you have something?
        Senator Shelby. Mr. Chairman, I just want to follow up----
        Senator Harkin. Yes.
        Senator Shelby [continuing]. On that, if I may.
        Senator Harkin. Yes.
        Senator Shelby. Do you have some statistics--and, if you
    don't have it, I'm sure you could get it and furnish it for the
    subcommittee record--on--if 20,000--just roughly, 20,000 cases
    are appealed from the----
        Senator Harkin. ALJ.
        Senator Shelby [continuing]. Is it the--the appeal on the
    Supreme----
        Senator Harkin. Probably ALJ.
        Senator Shelby. Yes.
        Senator Harkin. Yes.
        Senator Shelby [continuing]. To the Federal court--Federal
    District Court--what's the--are the statistics on overturning
    the decision and everything? We'd be curious about that, too.
        Ms. Ford. I think----
        Senator Harkin. Well, you know what?
        Ms. Ford [continuing]. We'd have to get that----
        Senator Harkin. I think----
        Ms. Ford [continuing]. For the record.
        Senator Harkin. I think I'm going to call Ms. Shor up to
    the table. No reason we can't.
        Senator Shelby. Good idea.
        Senator Harkin. What the heck.
        So, we have a new witness here on this panel. Nancy Shor,
    the executive director of the National Organization of Social
    Security Claimants' Representatives.
        So, Ms. Shor, welcome to the subcommittee.
        Ms. Shor. Thank you very much.
        I did want to respond to the question you had, Senator
    Shelby, about the availability of a claimant's past-due
    benefits to pay the attorney's fee. That can be available for
    Federal court cases, as well as fees, pursuant to the Equal
    Access to Justice Act. And there's an offset so that it's not a
    double recovery.
        Senator Shelby. Okay.
        Ms. Shor. In response to your question about the statistics
    for outcome in Federal court, about 40 percent of cases
    annually are--the Commissioner's denial is affirmed--a handful
    are dismissed, a handful are paid outright, about 50 percent of
    the cases go back to the agency on----
        Senator Shelby. Are remanded back for a hearing.
        Ms. Shor. And about two-thirds of those cases--in about
    two-thirds of those cases, the claimant is successful.
        Senator Shelby. Okay. A lot of this could be prevented if
    you had all the information at the initial hearing, where you'd
    save money, but it'd also bring justice if somebody was really
    disabled.
        Ms. Shor. No question about it.
        Senator Shelby. Is that right?
        Ms. Shor. You're absolutely correct.
        Senator Shelby. That's--looks to me like that's where we
    ought to be working.
        Ms. Shor. Absolutely correct.
        Senator Shelby. Either, somebody's got merit or they don't,
    sometimes it's in between. Because the other is costly to the
    person who's denied, also costly to the person who--if the
    person's rewarded and they're really maybe not that disabled. I
    don't--I can't determine that.
        Okay.
        Senator Harkin. So, why do so many cases, 20,000 a year, go
    through this whole system and stuff if--I mean, is it just an
    interpretive question, or is it a question of judgment, how
    disabled a person is? Why is there so much difficulty, at the
    beginning, in ascertaining whether they quality or not, Ms.
    Shor?
        Ms. Shor. Senator, I think there are a variety of reasons.
    Some of it has to do with inadequate development of the case
    throughout the process, that there are impairments that this
    individual presents with that are never really researched and
    never adequately presented.
        I think there are also instances where the improper legal
    standards are applied throughout the process, and it isn't til
    a Federal judge steps in and directs the agency to correct an
    error that they've been making.
        There are people whose conditions worsen. They've got a
    degenerative type of disease so that, at the very beginning of
    the process, they are--their prognosis doesn't look so great,
    but, the day they apply, there could certainly be a contested
    question about whether they're disabled, that day. And, as the
    process proceeds, their conditions will deteriorate and
    additional evidence will become available.
        Senator Harkin. Complicated system.
        Ms. Shor. Complicated system.
        Senator Harkin. Not every case is the same. They're all
    different, and that's why sometimes people have to appeal these
    to ALJs and then on to Federal court, I guess. But, I did not
    know that there was this provision in H.R. 1 that would take
    that away.
        But, I just want to be clear that, with that provision in
    H.R. 1, are you saying that there are still funds available
    through the passthrough?
        Ms. Shor. The Equal Access to Justice Act provides an
    offset so that a claimant doesn't have to pay the entire fee
    that a--that is awarded for the court. In other words, if there
    were a $5,000 attorney fee awarded for the attorney's work,
    there could easily be a $3,000 or $4,000 fee awarded, under the
    Equal Access to Justice Act. That money goes to the claimant,
    the now successful beneficiary. And, of course, is desperately
    needed, because, almost by definition, this person has been out
    of work for probably 5 years, with the pace of processing of
    claims at the Social Security Administration. So, the Equal
    Access to Justice Act is an extremely important statute that
    defrays the cost of legal expenses for claimants who find
    themselves having to go to Federal court.
        Senator Harkin. I don't understand that. Let me rephrase
    it.
        If, in fact, $500 million was rescinded--$500 million was
    taken from the Special Reserve Fund for--no, no. I'm sorry,
    that's not it.
        If, in fact, the language, that was in H.R. 1, that says
    that these funds cannot be used for appeals to District Court--
    I don't have the exact language----
        Ms. Shor. No.
        Senator Harkin [continuing]. In front of me.
        Ms. Shor. Senator, the language in amendment 195----
        Senator Harkin. Yes.
        Ms. Shor [continuing]. Would stop the payment of Equal
    Access to Justice Act fees, Government-wide. So, it includes
    Social Security, but it includes all the other Federal agencies
    where plaintiffs are potentially eligible for Equal Access to
    Justice Act fees.
        Senator Harkin. Oh.
        Ms. Shor. So, although Social Security cases are the
    largest number of cases in which Equal Access to Justice Act
    fees are awarded, the per-case fee is tiny, compared to the
    amounts of Equal Access to Justice Act fees that are awarded in
    litigation having to do with a lot of other Federal agencies.
        So, amendment 195 doesn't contain the words, ``Social
    Security,'' it only talks about a prohibition on payment of any
    fees, in any type of case, pursuant to the Equal Access to
    Justice Act.
        Senator Harkin. How much money do we--are we talking about,
    do we know?
        Ms. Shor. I'm sorry, I don't. But, I could certainly supply
    it.
        Senator Harkin. Well, maybe I can get my staff to get it.
    Do we know?
        Senator Shelby. Can you get it for the record, then?
        Ms. Shor. Certainly.
        Senator Shelby. That would be good.
        Ms. Shor. Absolutely.
        Senator Harkin. Okay. Well, we'll get that for the record.
        Senator Shelby. Good.
        [Clerk's Note.--The information was provided in the July
    27, 2011 letter from the Consortium for Citizens With
    Disabilities.]
        Senator Harkin. Anything else?
        Senator Shelby. No, nothing.
        Senator Harkin. Well, listen. Thank you all very much.
        Thank you, Ms. Shor, for adding to our deliberations here.
        Senator Shelby. Our fourth panelist.
        Ms. Shor. Thank you very much.
        Senator Harkin. Yeah, yeah. But again, we wanted to have
    this hearing, to highlight the problems confronting the Social
    Security Administration, that we have jurisdiction over, only
    in terms of the administrative aspect of it. We don't have
    jurisdiction over policies, we don't have jurisdiction over
    solvency, and all that kind of stuff. That's another committee,
    that's not this committee. We just have a responsibility to
    make sure that the Social Security Administration gets enough
    money to fulfill its obligations, and to do so in a timely
    manner, to make sure that, you know, it's efficient and
    effective.
        So, I guess we're going to have votes today, on H.R. 1 and
    the alternative, at 3 p.m. today. And again, I just wanted to
    have this hearing, again, to highlight what might happen if, in
    fact, the H.R. 1 was enacted. And I think we've got some
    interesting testimony on the record.
        I would just state that, in administrative funding--I just
    want to be clear that--here's the data--for fiscal year 2010,
    we enacted $11.447 billion, from this subcommittee. The
    President's budget for fiscal year 2011 is $12.379 billion. The
    House continuing resolution has $11.322 billion. The Senate
    continuing resolution has $11.822 billion. And the fiscal year
    2012 President's budget is $12.522 billion. I just wanted to
    make sure all those figures are out there.
        Anybody else--do you have anything else at all?
        Senator Shelby. No.
        Senator Harkin. Okay.

                              SUBCOMMITTEE RECESS

        Thank you all very much. The subcommittee will stand
    recessed.
        [Whereupon, at 11:15 a.m., Wednesday, March 9, the
    subcommittee was recessed, to reconvene subject to the call of
    the Chair.]

                  MATERIAL SUBMITTED SUBSEQUENT TO THE HEARING

        [Clerk's Note.--The following testimonies were received
    subsequent to the hearing for inclusion in the record.]
    Prepared Statement of the American Federation of Government Employees,
                                    AFL-CIO
        Chairman Harkin, Ranking Member Shelby, and members of the Senate
    Appropriations Subcommittee on Labor, Health and Human Service,
    Education and Related Agencies, I thank you for the opportunity to
    present this statement regarding the Limitation on Administrative
    Expenses (LAE) for the Social Security Administration.
        As the President of the American Federation of Government
    Employees, National Council of SSA Field Operations, AFL-CIO, I speak
    on behalf of approximately 29,000 Social Security Administration (SSA)
    employees in over 1,300 facilities. These employees work in Field
    Offices, and Teleservice Centers throughout the country where
    retirement and disability benefit applications and appeal requests are
    received, processed, and reviewed.
        AFGE thanks the Senate Appropriations Committee for calling this
    important hearing, at a very critical time, to examine the SSA's budget
    needs for this year and next year, in order to support the proper
    administration of our programs. Our employees are very concerned about
    prospects for furloughs, loss of staff and overtime hours needed to
    keep up with rapidly expanding workloads, and general deterioration in
    service delivery. They care deeply about the public they serve, and the
    continuing uncertainty about future staffing and resources is
    generating high levels of stress.
    Background
        During the past 3 years, with increased staffing and funding, we
    have substantially reduced disability hearing backlogs and processing
    times, and turned more of our attention to long-neglected program
    integrity workloads. However, working without a budget for the past 5
    months, we have been struggling to keep up with rapidly growing
    requests for face-to-face and telephone service, and we could easily
    slip back. We are constrained by continuing resolutions that have been
    funding SSA operations at fiscal year 2010 levels, with a freeze on
    hiring in most parts of the Agency. Our clients are having more
    difficulty accessing service, waiting times are increasing, and
    backlogs have developed in initial disability benefit applications.
    Field Representatives who serve clients who are mobility-impaired or
    live in remote areas have all but disappeared. SSA Spokesman Mark
    Hinkle recently acknowledged that budget pressures have slowly done
    away with 1,500 of the 2,000 contact stations that existed in the
    1980s.\1\ The recession and the aging of the population have created
    unprecedented demands upon the employees we represent. We are concerned
    that, if there are further cuts in employee work years, we may be
    unable to keep up with record numbers of new claims for retirement,
    survivor, and auxiliary benefits. No matter how people access service,
    whether face-to-face, by telephone, or via the Internet, our employees
    need to be on the job to process new applications for benefits, and to
    ensure that payments are made to the right people, in the right amount,
    and on time.
    ---------------------------------------------------------------------------
        \1\ ``Social Security ends visits to seniors'', Boston Globe,
    January 12, 2011.
    ---------------------------------------------------------------------------
    Budget Battles
        The President proposed $12.379 billion to fund SSA administrative
    expenses for fiscal year 2011, and $12.522 billion for fiscal year
    2011. AFGE supports both requests.
        The Agency is limited to spending $11.447 billion, the fiscal year
    2010 level with a carryover of $480 million for a total of $11.927
    billion, under the current continuing resolution.
        The House recently passed H.R. 1, which would cut full year funding
    to $11.321 billion. Additionally, H.R. 1 also includes rescissions of
    $500 million from the SSA reserve fund and from a special IT
    appropriation of $118 million for the National Computer Center. This
    would provide SSA with $10.7 billion in overall spending for fiscal
    year 2011. This represents about a 5.5 percent decrease from fiscal
    year 2010 spending levels and would require $743 million in cuts before
    October 1, 2011. Such reductions would most likely cease all hiring at
    the Office of Disability and Adjudicative Review (ODAR), which is
    currently exempt from the present hiring freeze under the continuing
    resolution. Backlogs would escalate very rapidly, improper payments
    would grow, and furloughs of employees could be implemented for up to a
    month per employee. Public service will be devastated.
        The Senate has proposed a fiscal year 2011 budget of $11.822
    billion, which includes rescissions of $400 million of the agency
    reserve fund. This is essentially the same funding level as fiscal year
    2010. This budget would most likely prevent the furloughing of Social
    Security workers and allow SSA ``to keep the lights on.'' However, SSA
    would most likely be forced to operate under an agency wide hiring
    freeze for the remainder of fiscal year 2011, which would result in the
    loss of approximately 3,500 SSA and DDS employees by the end of the
    fiscal year. This will cause understaffing in offices around the
    country. Backlogs will continue to grow and decisions on benefit claims
    will take longer. Access to field offices and the 800 number would take
    much longer and waiting times would be expected to increase.
        SSA Commissioner Astrue and President Obama have determined the
    funding level that is required to maintain service, and to make needed
    improvements. The wide differences between the House and Senate
    proposals for fiscal year 2011 domestic discretionary spending have
    raised the specter of one or more Government shutdowns and budget-
    driven employee furloughs during the rest of this fiscal year. The
    adverse impact of a shutdown or furloughs on Social Security's clients,
    and on the hard-working employees dedicated to serving them, would be
    very serious. One week ago today, during their lunch breaks, Social
    Security employees in 96 facilities across the country joined with
    members of their communities to make the public aware of these threats.
    It is imperative that Congress pass a responsible budget for the rest
    of this year that allows SSA workers to continue to provide high
    quality service to the public, and avoid any interruption of services
    caused by shutdowns and/or furloughs.
    Penny Wise is Pound Foolish

        Constraints on spending and on front-line staffing have damaged the
    integrity of the programs themselves. Continuing disability reviews are
    not being conducted on schedule, and Supplemental Security Income (SSI)
    eligibility reviews are being done too infrequently. With insufficient
    staff to handle the work, SSA is forced to rely too much on self-
    reporting by mail, rather than on a full examination of eligibility
    factors through an interview by a trained SSA employee. Continuing
    disability reviews save about $10 for every $1 spent on them, and SSI
    reviews about $8 for every $1 invested in them. The President's
    requests for 2011 and 2012 would provide dedicated funds to conduct
    more Supplemental Security Income (SSI) eligibility redeterminations,
    and more continuing disability reviews for Social Security and SSI
    beneficiaries. Both the House and Senate are silent regarding this
    targeted funding, and both have rescinded the vast majority of the
    Agency reserves, funds that could have been used to support these
    critical workloads and others.
        Setting the work aside because of insufficient staff and funding is
    penny-wise and pound-foolish, but SSA has little choice because the
    disability claims and appeals crisis demands attention. These neglected
    workloads have contributed to record overpayments, nearly 9 billion in
    fiscal year 2007 \2\, and many of the overpayments are uncollectible,
    which has captured the interest of the Government Accountability
    Office. The last 2 fiscal years, SSA has been successful in reducing
    the overall amount of overpayments. However, with congressional
    proposals to reduce Government agency budgets and staffing, this
    success may be very short lived. Without adequate staff and budget,
    AFGE expects to see a new record number of overpayments, which may
    actually exceed SSA's annual administrative expense budget within the
    next few years. To make matters worse, the amount of funds lost to
    overpayments over the last 10 years exceeded $55 billion. These lost
    funds would have funded SSA's administrative expenses for at least 4
    years.
    ---------------------------------------------------------------------------
        \2\ Source of verification of all overpayments found in each
    respective OIG Annual Audit and SSA Performance Plans for each fical
    year listed.
    ---------------------------------------------------------------------------
    The Off Budget Solution
        The Omnibus Reconciliation Act of 1990 provided that SSA FICA taxes
    and benefits payments were ``off budget.'' Congress later interpreted
    that SSA's Limitation on Administrative Expenses (LAE) was not covered
    by the Omnibus Reconciliation Act of 1990, although the Social Security
    Act stipulates that administrative costs for the Social Security
    program must be financed by the Social Security Trust Fund. Since the
    SSA LAE (e.g., staffing, office space, supplies, technology, etc.) is
    ``on budget,'' Congress decides on a yearly basis the amount that will
    be authorized and appropriated to administer SSA programs. Often SSA is
    left with insufficient staff and limited overtime due to a combination
    of competing interests within the Labor, Health and Human Services,
    Education and Related Agencies appropriation and the congressional
    budget scoring system. These circumstances make it next to impossible
    to appropriate adequate administrative funds to enable SSA to complete
    the tasks assigned by Congress in a timely manner. Such shortages
    adversely affect disability appeals processing time and cause severe
    integrity problems.
        The Social Security Trust Funds, projected to run a $113 billion
    surplus this year, and over $128 billion next year, pay for the great
    majority of the operating costs for the programs we administer. AFGE
    proposes that the Congress take SSA's administrative accounts off
    budget now. We are very efficient, spending just 0.9 percent of income
    in Social Security program administration. The Agency would still be
    required to justify its budget requests to Congress, and receive
    approval to spend money, but there is no reason why SSA should have to
    compete for funding with the many other agencies in the Labor/HHS
    appropriation package, when our source of funding is almost entirely
    off budget.
        In an ``off budget'' environment Congress would continue to
    maintain spending authority but would be unencumbered by artificial
    caps and budgetary scoring rules. However, Congress would continue to
    appropriate SSA administrative expenses to ensure integrity and
    efficiency. Legislation should require SSA's Commissioner to document
    (in performance reports mandated under the Government Performance and
    Results Act) how funds have been and will be used to effectively carry
    out the mission of the Agency, to meet expected levels of performance,
    to achieve modern customer-responsive service, and to protect program
    integrity.
        Most importantly, GAO must annually inform Congress regarding SSA's
    progress in achieving stated goals. Congress should also mandate that
    SSA's Commissioner submit the proposed budget directly to Congress as
    is now only optional in the independent agency legislation (Public Law
    103-296, Sec. 101). This requirement to submit the SSA budget directly
    to Congress may also be a provision of ``off-budget'' legislation and
    would be endorsed by AFGE.
        Without sufficient funding of Social Security, the LAE will not go
    far enough to put the agency on a clear path to provide its mandated
    services at a level expected by the American public. SSA must receive
    enough funding to make disability decisions in a timely manner and to
    carry out other critical workloads. AFGE strongly urges Congress to
    separate SSA's LAE budget authority from the section 302(a) and (b)
    allocations for discretionary spending. The size of SSA's LAE is driven
    by the number of administrative functions it conducts to serve
    beneficiaries and applicants. Congress should remove SSA's
    administrative functions from the discretionary budget that supports
    other important programs.
        AFGE does not believe the American public deserves poor service
    from SSA. Some claimants while waiting for a disability hearings
    decision lose their homes, declare bankruptcy, and die. Their families
    suffer tremendous financial hardships; some lose everything during the
    prolonged wait for a decision. The public deserves efficient,
    expeditious service. Now is the time to make the correction, so that
    there is stability to run SSA programs that are so vital in providing
    family insurance and income security to 54 million beneficiaries.
        In closing, AFGE urges the Senate to do whatever is necessary to
    insure that SSA receives full funding to do the work that Congress
    demands from the Agency.
        AFGE thanks the Subcommittee for its time and consideration of the
    concerns addressed in this statement. AFGE is committed to serve, as we
    always have, as the employees' advocate AND a watchdog for clients,
    taxpayers, and their elected representatives.
                                     ______

        Prepared Statement of the National Committee to Preserve Social
                             Security and Medicare
        As President and Chief Executive Officer of the National Committee
    to Preserve Social Security and Medicare, I appreciate the opportunity
    to submit this statement for the record. With millions of members and
    supporters across America, the National Committee is a grassroots
    advocacy and education organization devoted to the retirement security
    of all citizens.
        Chairman Harkin, Ranking Member Shelby and members of the
    Subcommittee on Labor, Health and Human Services, Education, and
    Related Agencies, the National Committee appreciates your holding this
    hearing to examine funding for the Social Security Administration in
    fiscal year 2011 and fiscal year 2012.
        The National Committee is committed to preserving and strengthening
    Social Security. This includes ensuring a strong and stable Social
    Security Administration that delivers high-quality, prompt service to
    the public. We are certainly concerned about the tremendous funding
    challenges facing the Social Security Administration for the remainder
    of fiscal year 2011 and for fiscal year 2012. It is crucial that SSA be
    provided with adequate funding so that they are able to provide the
    American people with the level of service they expect and deserve, one
    that also prevents workloads from spiraling out of control.
        As you know, 54 million Americans receive Social Security benefits
    each month. The benefits they receive from this program constitute a
    vital lifeline that is critical to their economic well-being. Given the
    essential nature of Social Security, and the increasing demands of an
    aging population, I believe it is extremely important that the Social
    Security Administration be provided sufficient funds for operating
    expenses so it can meet the needs of the American people.
        In fiscal year 2010, the last time Congress enacted an
    appropriation for SSA, a total of $11.5 billion was made available for
    administering the Social Security program. The President, in his fiscal
    year 2011 budget, requested an appropriation of $12.4 billion. Instead,
    Congress has enacted a series of continuing resolutions that
    essentially freeze the Agency's funding at the fiscal year 2010 level.
        The House of Representatives recently passed a continuing
    resolution for the remainder of the fiscal year that proposes
    significant reductions in funding, including elimination of funds for
    vital systems improvement projects. The fiscal year 2011 continuing
    resolution being considered by the Senate increases funding over the
    House-passed amount, providing needed resources to this important
    Agency. While the President's fiscal year 2011 budget request would
    minimize service reductions and continue the Agency's progress toward
    reducing processing backlogs in the disability program, the Senate
    proposed funding level is a dramatic improvement over the funding cuts
    passed by the House.
        Staying within the reduced spending levels authorized in previously
    enacted continuing resolutions has been challenging for the Social
    Security Administration. The hiring freeze imposed on the Agency's
    field offices has resulted in significant staffing imbalances that have
    stretched the capability of the staff to provide timely and effective
    levels of public service.
        Further cuts would exacerbate these problems, resulting in longer
    waiting times for appointments to file for benefits, or for processing
    address changes or direct deposit information, delays in receiving
    Agency decisions, and busy signals at the Agency's toll-free 800
    number. In addition, we understand that further cuts may mean employee
    furloughs or even office closures, resulting in even greater reductions
    in service to America's seniors.
        While we believe the President's funding request would best serve
    the American people, we believe the funding levels proposed in the
    Senate's continuing resolution would provide the Agency with sufficient
    funding to avoid major service disruptions. We therefore urge all
    Senators to show their commitment to Social Security by providing the
    SSA with the resources it needs to do its job.
        Going forward, in order for SSA to fully meet its multitude of
    responsibilities, the agency will require no less than the $12.667
    billion recommended in the President's budget for its fiscal year 2012
    administrative funding. This level of funding is necessary due to the
    increase in requests for assistance from the American public due in
    large part to the economic downturn. SSA teleservice centers, hearing
    offices, Disability Determination Services (DDSs), and the nearly 1,300
    field offices are in critical need of adequate resources to address
    their growing workloads. Without this level of funding, SSA will be
    unable to cope with the continued increase in demand for services and
    maintain the progress it has already made in providing satisfactory
    service delivery to senior citizens, people with disabilities and
    others who rely on Social Security.

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2012

                                  ----------

                           WEDNESDAY, MARCH 30, 2011

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10:03 a.m., in room SD-124, Dirksen
    Senate Office Building, Hon. Tom Harkin (chairman) presiding.
        Present: Senator Harkin, Reed, Pryor, Mikulski, Brown,
    Shelby, Johnson, Kirk, and Moran.

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                            Office of the Secretary

    STATEMENT OF HON. KATHLEEN SEBELIUS, SECRETARY

                    OPENING STATEMENT OF SENATOR TOM HARKIN

        Senator Harkin. The Labor, Health and Human Services
    Appropriations Subcommittee will come to order.
        We welcome back Madam Secretary to the subcommittee. I want
    to first start by commending you for the outstanding work that
    you are doing to implement our healthcare reform law. It has
    been just 1 year since President Obama signed the Affordable
    Care Act into law, and already millions of Americans are
    reaping major benefits. Those benefits include very strong
    consumer protections. No longer can large health insurers use
    technicalities to cancel your policy if you get sick or impose
    lifetime limits on your benefits. No longer can children be
    denied coverage because of a preexisting health condition.
    Americans have greater access to preventative care than ever
    before, and of course, young adults can now stay on their
    parents' plan until age 26.
        In the past year, your Department has also awarded the
    first grants from the Prevention and Public Health Fund, a new
    fund that will not only improve the health of the American
    people but also help bend the cost curve on healthcare. This
    fund is already being used to help Americans stop smoking, as
    well as to reduce obesity and prevent costly chronic diseases
    like diabetes.
        Your plan for fiscal year 2011 expands on all of this work
    and adds an investment in childhood immunization which data
    shows saves about $6.30 for every dollar that we spend.
        Your Department is implementing these reforms with great
    skill and dedication, and I thank you for your leadership.
        I also want to assure you that as chairman of both this
    Appropriations subcommittee and the authorizing committee, the
    HELP Committee, your Department will continue to receive the
    resources you need to implement the Affordable Care Act. The
    American people will not allow the hard-earned protections and
    benefits in this law to be taken away. And neither will we.
        Reforming healthcare is not only the right thing to do, it
    will save taxpayers money and reduce the deficit by $210
    billion in the first decade and more than $1 trillion in the
    next. And those are not my estimates. They are from the
    nonpartisan Congressional Budget Office.
        I am well aware that some opponents of healthcare reform
    say they intend to use the Labor, HHS appropriations bill, our
    bill, as a vehicle for defunding the Affordable Care Act. That
    will not happen.
        Our topic today is the President's fiscal year 2012 budget
    request for the Department of Health and Human Services.
    Unfortunately, as we all know, Congress still has not closed
    the books on fiscal year 2011. That uncertainty makes it harder
    than usual to evaluate the President's request. For example,
    the House has proposed major reductions to key programs like
    community health centers, Head Start, and the National
    Institutes of Health. We do not yet know the outcome of
    negotiations to complete a budget for fiscal year 2011, but one
    of the things I want to cover in this hearing is what the
    impact of those potential cuts would be, that is, on community
    health centers, Head Start, and the National Institutes of
    Health (NIH).
        Overall, the President's proposed budget for fiscal year
    2012 is a good start. It is a tight budget. Total funding for
    the Department is almost flat compared with fiscal year 2010,
    but it does include some significant increases for key
    priorities like NIH, child care, Head Start, and of course,
    rooting out fraud and waste in Medicare and Medicaid.
        I also applaud the administration for proposing a new early
    learning challenge fund which is intended to improve the
    quality of early childhood education programs. The money for
    this new fund would go through the Education Department, but
    HHS would be a partner in that effort.
        However, some provisions in the President's budget are a
    cause for concern. I recognize that we are operating under
    significant fiscal constraints, but I am greatly disappointed
    by the proposed 50 percent cut to the community services block
    grant program. This funding is critically important for
    community initiatives that provide a safety net for millions of
    low-income people across the country, and I will do whatever I
    can to oppose that cut in any bill that comes out of this
    subcommittee.
        I am also concerned by the proposed $2.5 billion cut to the
    Low-Income Home Energy Assistance Program, as well as the small
    but important $30 million cut--that would be a 72 percent cut--
    to the Child Traumatic Stress Network.
        But as I said, overall the budget is a good start.
        Madam Secretary, I look forward to hearing your testimony.
        First, before I yield to Senator Shelby for his opening
    remarks, I have received statements from the full committee
    chairman, Senator Inouye and the vice chairman, Senator
    Cochran. Their statements will be inserted into the record at
    this point.
        [The statements follow:]
                Prepared Statement of Chairman Daniel K. Inouye
        Secretary Sebelius, given the unique geographic challenges in
    Hawaii it is imperative that we continue to work together to address
    the healthcare needs of our population. I would like to take this
    opportunity to thank you for your support in addressing the medical
    needs of the people in Hawaii. I will provide questions for the record.
                                     ______

                   Prepared Statement of Senator Thad Cochran
        Mr. Chairman, thank you for chairing this hearing to review the
    President's fiscal year 2012 budget for the Department of Health and
    Human Services. We are pleased to welcome the Secretary of Health and
    Human Services, Kathleen Sebelius to her third appearance before our
    Subcommittee, and we look forward to working with her to support our
    Nation's investment in healthcare, social services programs, medical
    research and disease prevention.
        I am pleased that your budget includes a $745 million increase for
    the National Institutes of Health. These additional dollars are
    essential if we are to continue to make scientific discoveries in
    cancer, autism, heart disease and the many other maladies that plague
    so many Americans.
        This subcommittee will be challenged to balance the competing needs
    of the programs contained in your $79 billion budget. We look forward
    to working with you to maintain our commitment to fiscal restraint
    while providing much needed increases for high priority programs.
        I am very sorry I cannot stay for the duration of this important
    hearing due to another hearing that requires my attention, but I am
    submitting questions for the record and I look forward to a response.

        Senator Harkin. Senator Shelby.

                     STATEMENT OF SENATOR RICHARD C. SHELBY

        Senator Shelby. Thank you, Mr. Chairman.
        Welcome, Secretary Sebelius.
        I look forward to hearing your testimony today on the 2012
    budget request.
        In this austere economic environment, Congress is
    struggling with difficult budget decisions. We all understand
    the valuable role that healthcare plays in the lives of our
    citizens, and we all want to make healthcare more affordable,
    more accessible, and on the cutting edge of scientific
    discoveries.
        However, in times of economic uncertainty when every
    Department should be exercising fiscal restraint, I am
    disappointed that the administration has not significantly
    reduced healthcare spending. In fact, on top of the 9 percent
    increase in the entire Department of Health and Human Services'
    budget request, the 2012 bill includes $4.2 billion in
    mandatory spending for the Affordable Care Act, ACA. This is
    $4.2 billion that, due to Senate rules, this subcommittee
    cannot reduce or rescind. It is simply more spending for
    another entitlement program.
        One of the most troubling aspects of the ACA is the
    Community Living Assistance Services and Supports (CLASS) Act.
    The CLASS Act we call it. The CLASS Act is a new voluntary
    Federal insurance program. Its goal is twofold: to provide a
    cash benefit to individuals with either a functional or
    equivalent cognitive limitation that become too disabled to
    work and to create a voluntary insurance program for healthy
    individuals looking to hedge against the risk of needing long-
    term care in the future. However, the CLASS Act's poor design
    attempts to accomplish these two incompatible goals with a
    single program. The result will be that the cost of serving
    disabled workers will push premiums to unacceptably high levels
    for those looking to purchase insurance, and they will decline
    to buy. I think this will quickly push the program to
    insolvency.
        The Congressional Budget Office predicts the CLASS Act will
    ``add to budget deficits by amounts on the order of tens of
    billions of dollars.'' The Department of Health and Human
    Services actuary states and says, ``There is a very serious
    risk that the program will be unsustainable.'' Even you, Madam
    Secretary, testified at the Senate Finance Committee hearing
    early this year and said, ``The bill as written is totally
    unsustainable.''
        In addition to the $4.2 billion included in mandatory
    spending for the ACA, the budget submission includes $450
    million in discretionary funding. Specifically, the budget
    proposes to spend $120 million on the financially unsustainable
    CLASS Act, $236 million for health insurance exchange
    operations, $38 million for healthcare.gov, and $28 million to
    help consumers navigate the private insurance market. Secretary
    Sebelius, we fundamentally disagree on the implementation of
    the ACA. However, one area of the ACA we should agree on is
    that $38 million to fund one website is unacceptable.
        Further, I am concerned that many important programs, such
    as the Community Health Center Fund, are moved to the mandatory
    side of the ledger and funded under the ACA. The question is,
    what happens if the ACA is repealed and agencies' baseline
    funding levels are too low to cover the cost of these programs?
        Finally, as we continue to review the 2012 budget, I
    believe we need to ensure that our entire Nation, not just
    population-rich urban areas, is reaping the benefits of
    healthcare programs. There are numerous consolidations in the
    budget that eliminate formula-funded grants which will result
    in the redirection of critical Federal funds from smaller,
    rural States to urban areas. I think we must continue to make
    certain that programs that are deemed competitive actually
    allow all States to compete on a level playing field.
        Mr. Chairman, the level of Federal spending, I believe, is
    unsustainable. We must make steps to reduce the deficit that
    burdens our Nation today and will continue to in the future.
    Every Federal program should be reviewed to ensure it is
    working effectively and efficiently and is a valuable use of
    taxpayer dollars. However, I remain cautious about arbitrary or
    across-the-board cuts to agencies and programs simply to score
    a political point. Congress needs to carefully examine programs
    to ensure that we are sustaining those that are effective and
    cutting those that are not.
        In particular, one of the most results-driven aspects of
    our entire Federal budget I believe is the National Institutes
    of Health. Research conducted at NIH reduces disabilities,
    prolongs life, and is an essential component to the health of
    all Americans. NIH programs consistently meet their performance
    and outcome measures, as well as achieve their overall mission.
        For example, in February, NIH research led to the
    announcement of a very promising cystic fibrosis therapy that
    targets the genetic defect that causes cystic fibrosis as
    opposed to only addressing its symptoms. The preliminary
    success of this drug, for instance, underscores the importance
    of the NIH whose innovative work on human genetics and other
    areas of basic science could potentially lead to treatments and
    even cures for some of our most devastating diseases.
        Mr. Chairman, I look forward to working with you to craft a
    bill that balances the needs of our healthcare system with our
    fiscal realities.
        Senator Harkin. Thank you very much, Senator Shelby.
        Now we will turn to our distinguished Secretary of Health
    and Human Services. Kathleen Sebelius became the 21st Secretary
    of the Department of Health and Human Services on April 29,
    2009. Prior to that, of course, in 2003 she was elected as
    Governor of Kansas and served in that capacity until her
    appointment as the Secretary.
        Prior to her election as Governor, the Secretary served as
    the Kansas State insurance commissioner.
        She is a graduate of Trinity Washington University and the
    University of Kansas.
        I believe this will make the Secretary's fourth appearance
    before this subcommittee since her appointment.
        Madam Secretary, we welcome you again. Your statement will
    be made a part of the record in its entirety, and please
    proceed as you so desire.

                  SUMMARY STATEMENT OF HON. KATHLEEN SEBELIUS

        Secretary Sebelius. Thank you, Mr. Chairman. Chairman
    Harkin, Ranking Member Shelby, members of the subcommittee, I
    need to do a special shout out to my fellow Kansan, Senator
    Moran, who is a new member of your subcommittee, Mr. Chairman.
    But I had the privilege of working with the Senator for years
    on Kansas business and now look forward to working with him in
    his new capacity here in the Senate.
        It is good to be with you and discuss the President's 2012
    budget for the Department of Health and Human Services.
        In the President's State of the Union Address, he outlined
    a vision of how the United States can win the future by out-
    educating, out-building, and out-innovating the world so we
    give every family and business the chance to thrive.
        Our 2012 budget is a blueprint for putting that vision into
    action. It makes investments for the future that will grow our
    economy and create jobs.
        But the budget recognizes we cannot build lasting
    prosperity on a mountain of debt. Years of deficits have put us
    in a position where we need to make some tough choices. In
    order to invest for the future, we need to live within our
    means.
        In developing our budget, we looked closely at every
    program in our Department. We cut waste when we found it, and
    when programs were not working well enough, we redesigned them
    to put a new focus on results. And, in some cases, we cut
    programs that would not have been cut in better budget times.
        Now, I look forward to answering your questions on the
    budget, but first I want to share some of the highlights that
    fall under the jurisdiction of this subcommittee which oversees
    more than $72 billion of our Department's $80 billion budget.
        Last week, as the chairman said, was the 1-year anniversary
    of the Affordable Care Act. Over the last 12 months, we have
    worked around the clock with partners in Congress and States to
    deliver on the promise of the law to the American people.
        Thanks to the new law, children are no longer denied
    coverage because of their preexisting health conditions.
    Families have new protections under the Patient's Bill of
    Rights. Businesses are beginning to get some relief from
    soaring healthcare costs, and seniors have lower cost access to
    prescription drugs and preventive care.
        We are building on this first year's progress by supporting
    innovative new models of care that will improve patient safety
    and quality while reducing the burden of rising health costs on
    families, businesses, cities, and States.
        We are also making new, important investments in our
    healthcare workforce and community health centers to make
    quality, affordable care available to millions more Americans
    and create hundreds of thousands of new jobs across the
    country.
        To make sure America continues to lead the world in
    innovation, our budget also increases funding for the National
    Institutes of Health. New frontiers of research like cell-based
    therapies and genomics have the promise to unlock
    transformative treatments and cures for diseases ranging from
    Alzheimer's to cancer to autism. Our budget will allow the
    world's leading scientists to pursue these discoveries while
    keeping America at the forefront of biomedical research.
        And because we know, Mr. Chairman, there is nothing more
    important to our future than the healthy development of our
    children, our budget includes significant increases in funding
    for child care and Head Start. Science shows that success in
    school is significantly enhanced by high quality early learning
    opportunities, which makes these some of the wisest investments
    we can make in America's future.
        But the budget does more than provide additional resources.
    We are also aiming to raise the bar on quality by supporting
    key reforms to transform the Nation's child care system into
    one that fosters healthy development and gets children ready
    for school. The budget proposes a new early learning challenge
    fund, a partnership with the Department of Education that helps
    promote State innovation in early education. These initiatives,
    coupled with the quality efforts already underway in Head
    Start, are an important part of the education agenda that will
    help every child reach their academic potential and make
    America more competitive.
        Our budget also recognizes that at a time when so many
    Americans are making every dollar count, we need to do the
    same. That is why we are providing new support for President
    Obama's unprecedented push to stamp out waste, fraud, and abuse
    in the healthcare system, an effort that well more than pays
    for itself. Last year, we returned a record $4 billion to
    taxpayers. The key part of this effort is empowering seniors to
    recognize and report fraud, and we have appreciated the support
    of Congress and especially Senator Harkin for the Senior
    Medicare Patrol Program, which is one of our best tools for
    doing that.
        In addition, the budget includes a robust package of
    legislative proposals to root out waste and abuse within
    Medicare and Medicaid. These proposals enhance prepayment
    scrutiny, expand auditing, increase penalties for improper
    actions, and strengthen CMS' ability to implement corrective
    actions. We address State activities that increase Federal
    spending. Over 10 years, on the conservative side, they will
    deliver at least $32 billion in savings.
        Across our entire Department, Mr. Chairman, we have made
    eliminating waste, fraud, and abuse a top priority, but we know
    that is not enough. Over the last few months, we have also gone
    through our Department's budget, program by program, to find
    additional savings and opportunities where we can make our
    resources go further.
        The President's 2012 budget makes tough choices and smart,
    targeted investments today so that we can have a stronger,
    healthy, and more competitive America tomorrow. That is what it
    takes to win the future and that is what we are determined to
    do.

                               PREPARED STATEMENT

        Again, thank you, Mr. Chairman, for having me here today
    and I look forward to our discussion.
        [The statement follows:]
                    Prepared Statement of Kathleen Sebelius
        Chairman Harkin, Senator Shelby, and Members of the Subcommittee,
    thank you for the invitation to discuss the President's fiscal year
    2012 budget for the Department of Health and Human Services (HHS).
        In President Obama's State of the Union address he outlined his
    vision for how the United States can win the future by out-educating,
    out-building and out-innovating the world so that we give every family
    and business the chance to thrive. His 2012 budget is the blueprint for
    putting that vision into action and making the investments that will
    grow our economy and create jobs.
        At the Department of Health and Human Services this means giving
    families and business owners better access to healthcare and more
    freedom from rising health costs and insurance abuses. It means keeping
    America at the cutting edge of new cures, treatments and health
    information technology. It means helping our children get a healthy
    start in life and preparing them for academic success. It means
    promoting prevention and wellness to make it easier for families to
    make healthy choices. It means building a healthcare workforce that is
    ready for the 21st century health needs of our country. And it means
    attacking waste and fraud throughout our department to increase
    efficiency, transparency and accountability.
        Our 2012 budget does all of this.
        At the same time, we know that we can't build lasting prosperity on
    a mountain of debt. And we can't win the future if we pass on massive
    debts to our children and grandchildren. We have a responsibility to
    the American people to live within our means so we can invest in our
    future.
        For every program we invest in, we know we need to cut somewhere
    else. So in developing this budget, we took a magnifying glass to every
    program in our department and made tough choices. When we found waste,
    we cut it. When we found duplication, we eliminated it. When programs
    weren't working well enough, we reorganized and streamlined them to put
    a new focus on results. When they weren't working at all, we ended
    them. In some cases, we cut programs we wouldn't in better fiscal
    times.
        The President's fiscal year 2012 budget for HHS totals $891.6
    billion in outlays. The budget proposes $79.9 billion in discretionary
    budget authority for fiscal year 2012, of which $72.4 billion is within
    the jurisdiction of the Labor, Health and Human Services, Education,
    and Related Agencies Subcommittee.
        The Department's discretionary budget is slightly below the 2010
    level. Within that total we cover the increasing costs of ensuring the
    safety of our food supply, providing medical care to American Indians
    and Alaska Natives, managing our entitlement programs, investing in
    early childhood, and advancing scientific research. We contribute to
    deficit reduction and meet the President's freeze to non-security
    programs by offsetting these investments with over $5 billion in
    targeted reductions. These reductions are to real programs and reflect
    tough choices. In some cases the reductions are to ineffective or
    outdated programs and in other areas they are cuts we would not have
    made absent the fiscal situation.
        The budget proposes a number of reductions and terminations in HHS.
      --The budget cuts the Community Services Block Grant in half, a $350
            million reduction, and injects competition into grant awards.
      --The budget cuts the Low Income Home Energy Assistance Program by
            $2.5 billion bringing it back to the 2008 level appropriated
            prior to energy price spikes.
      --The budget eliminates subsidies to Children's Hospitals Graduate
            Medical Education focusing instead on targeted investments to
            increase the primary care workforce.
      --The budget reduces the Senior Community Services Employment Program
            by $375 million, proposes to transfer this program from the
            Department of Labor to HHS, and refocuses the program to train
            seniors to help other seniors.
        The budget also stretches existing resources through better
    targeting.
      --The budget redirects and increases funding in CDC to reduce chronic
            disease. Rather than splitting funding and making separate
            grants for heart disease, diabetes, and other chronic diseases,
            the budget proposes one comprehensive grant that will allow
            States to address chronic disease more effectively.
      --The budget redirects prevention resources in SAMHSA to fund
            evidence-based interventions and better respond to evolving
            needs. States and local communities will benefit from the
            additional flexibility while funds will still be competed and
            directed toward proven interventions.
        These are the two goals that run throughout this budget: making the
    smart investments for the future that will help build a stronger,
    healthier, more competitive, and more prosperous America, and making
    the tough choices to ensure we are building on a solid fiscal
    foundation.
        The budget documents are available on our website. But for now, I
    want to share an outline of the budget, including the areas of most
    interest to this Committee, and how it will help our country invest in,
    and win, the future.
        That starts with giving Americans more freedom in their healthcare
    choices, so they can get affordable, high-quality care when they need
    it.
                              transform healthcare
        Expanding Access to Coverage and Making Coverage More Secure.--The
    Affordable Care Act expands access to affordable coverage to millions
    of Americans and strengthens consumer protections to ensure individuals
    have coverage when they need it most. These reforms create an important
    foundation of patients' rights in the private health insurance market
    and put Americans in charge of their own healthcare. As a result, we
    have already implemented historic private market reforms including
    eliminating pre-existing condition exclusions for children; prohibiting
    insurance companies from rescinding coverage and imposing lifetime
    dollar limits on coverage; and enabling many adult children to stay on
    their parent's insurance plan up to age 26. The Affordable Care Act
    also established new programs to lower premiums and support coverage
    options, such as the Pre-Existing Condition Insurance Plans Program and
    the Early Retiree Reinsurance Program. The Act provides Medicare
    beneficiaries and enrollees in most private plans access to certain
    covered preventative services free of charge. Medicare beneficiaries
    also have increased access to prescription drugs under Medicare Part D
    by closing the coverage gap, known as the ``donut hole,'' by 2020 so
    that seniors no longer have to fear being unable to afford their
    prescriptions. The Act also provides for an annual wellness visit to
    all Medicare beneficiaries free of charge.
        Beginning in 2014, State-based health insurance Exchanges will
    create affordable, quality insurance options for many Americans who
    previously did not have health insurance coverage, had inadequate
    coverage, or were vulnerable to losing the coverage they had. Exchanges
    will make purchasing private health coverage easier by providing
    eligible consumers and small businesses with ``one-stop-shopping''
    where they can compare a range of plans. New premium tax credits and
    cost-sharing reductions will also increase the affordability of
    coverage and care. The Affordable Care Act will also extend Medicaid
    insurance to millions of low-income individuals who were previously not
    eligible for coverage, granting them access to affordable healthcare.
        Ensuring Access to Quality, Culturally Competent Care for
    Vulnerable Populations.--The budget includes $3.3 billion for the
    Health Centers Program, including $1.2 billion in mandatory funding
    provided through the Affordable Care Act Community Health Center Fund,
    to expand the capacity of existing health center services and create
    new access points. The infusion of funding provided through the
    Affordable Care Act, combined with the discretionary request for fiscal
    year 2012, will enable health centers to serve 900,000 new patients and
    increase access to medical, oral, and behavioral health services to a
    total of 24 million patients.
        Reducing Health Care Costs.--New innovative delivery and payment
    approaches will lead to both more efficient and higher quality care.
    For example, provisions in the Affordable Care Act designed to reduce
    healthcare acquired conditions and preventable readmissions will both
    improve patient outcomes and reduce unnecessary health spending. The
    Innovation Center, in coordination with private sector partners
    whenever possible, will pursue new approaches that not only improve
    quality of care, but also lead to cost savings for Medicare, Medicaid,
    and CHIP. Rate adjustments for Medicare providers and insurers
    participating in Medicare Advantage will promote greater efficiency in
    the delivery of care. Meanwhile, new rules for private insurers, such
    as medical loss ratio standards and enhanced review of premium
    increases, will lead to greater value and affordability for consumers.
        Combating Healthcare Associated Infections.--HHS will use measures
    related to heathcare-associated infections (HAIs) for hospital value-
    based purchasing beginning in fiscal year 2013, as called for in the
    Affordable Care Act. The fiscal year 2012 budget includes $86 million--
    of which $20 million is funded in the Prevention and Public Health Fund
    Prevention Trust Fund--to the Agency for Healthcare Research and
    Quality (AHRQ), the Centers for Disease Control and Prevention (CDC),
    and the Office of the Secretary to reduce healthcare-associated
    infections. In fiscal year 2012, HHS will continue research on health-
    care associated infections and tracking infections through the National
    Healthcare Safety Network. HHS will also identify and respond to new
    healthcare-associated infections by conducting outbreak and
    epidemiological investigations. In addition, HHS will implement, and
    ensure adherence to, evidence-based prevention practices to eliminate
    healthcare-associated infections. HHS activities, including those that
    the Innovation Center sponsors, will further the infection reduction
    goals of the Department's Action Plan to Prevent Healthcare-Associated
    Infections. HHS has made progress in reducing HAIs. For instance, in
    2009, an estimated 25,000 fewer central line-associated blood stream
    infections (CLABSIs) occurred among patients in ICUs in the United
    States than in 2001 (a 58 percent reduction). Progress in reducing
    CLABSIs highlights the preventability of these infections, and HHS will
    continue to support HAI prevention in collaboration with States and
    facility partners.
        Health Services for 9/11 Terrorist Attacks.--To implement the James
    Zadroga 9/11 Health and Compensation Act, the fiscal year 2012 budget
    includes $313 million in mandatory funding to provide medical
    monitoring and treatment to responders of the September 11, 2001
    terrorist attacks and initial health evaluations, monitoring, and
    treatment to others directly affected by the attacks. In addition to
    supporting medical monitoring and treatment, HHS will use funds to
    establish an outreach program for potentially eligible individuals,
    collect health data on individuals receiving benefits, and establish a
    research program on health conditions resulting from the terrorist
    attacks.
                  advance scientific knowledge and innovation
        Accelerating Scientific Discovery to Improve Patient Care.--The
    budget includes $32 billion for the National Institutes of Health
    (NIH), an increased investment of $745 million over the fiscal year
    2010 enacted level, to support innovative basic and clinical research
    that promises to deliver better health and drive future economic
    growth. In fiscal year 2012, NIH estimates it will support a total of
    36,852 research project grants, including 9,158 new and competing
    awards.
        Recent advances in the biomedical field, including genomics, high-
    throughput biotechnologies, and stem cell biology, are shortening the
    pathway from discovery to revolutionary treatments for a wide range of
    diseases, such as Alzheimer's, cancer, autism, diabetes, and obesity.
    The dramatic acceleration of our basic understanding of hundreds of
    diseases; the establishment of NIH-supported centers that can screen
    thousands of chemicals for potential drug candidates; and the emergence
    of public-private partnerships to aid the movement of drug candidates
    into the commercial development pipeline are fueling expectations that
    an era of personalized medicine is emerging where prevention,
    diagnosis, and treatment of disease can be tailored to the individual
    and targeted to be more effective. To help bridge the divide between
    basic science and therapeutic applications, NIH plans to establish in
    fiscal year 2012 the National Center for Advancing Translational
    Sciences (NCATS), of which one component would be the new Cures
    Acceleration Network. With the creation of NCATS, the National Center
    for Research Resources will be abolished and its programs transferred
    to the new Center or other parts of NIH.
        Advancing Patient-Centered Health Research.--The Affordable Care
    Act created the Patient-Centered Outcomes Research Institute to fund
    research and get relevant, high quality information to patients,
    clinicians and policy-makers so that they can make informed healthcare
    decisions. The Patient-Centered Outcomes Research Trust Fund will fund
    this independent Institute, and related activities within HHS. In
    fiscal year 2012, the budget includes $620 million in AHRQ, NIH and the
    Office of the Secretary, including $30 million from the Trust Fund, to
    invest in core patient-centered health research activities and to
    disseminate research findings, train the next generation of patient-
    centered outcomes researchers, and improve data capacity.
        Advancing Health Information Technology.--The budget includes $78
    million, an increase of $17 million, for the Office of the National
    Coordinator for Health Information Technology (ONC) to accelerate
    health information technology (health IT) adoption and promote
    electronic health records (EHRs) as tools to improve the health of
    individuals and transform the healthcare system. The increase will
    allow ONC to assist healthcare providers in becoming meaningful users
    of health IT.
       advance the health, safety, and well-being of the american people
        Enhancing the Quality of Early Care.--The budget provides $6
    billion in combined discretionary and mandatory funding for child care.
    These resources will enable 1.7 million children to receive child care
    services. The Administration also supports reforms to the child care
    program to serve more low-income children in safe, healthy, and
    nurturing child care settings that are highly effective in promoting
    early learning; supports parental employment and choice by providing
    information to parents on quality; promotes continuity of care; and
    strengthens program integrity and accountability Additionally, the
    President's budget includes $8.1 billion for Head Start, which will
    allow us to continue to serve 968,000 children in 2012. The
    Administration is also working to implement key provisions of the Head
    Start Reauthorization, including requiring low-performing programs to
    compete for funding, that will improve program quality. These reforms
    and investments at HHS, in conjunction with the Administration's
    investments in the Early Learning Challenge Fund, are key elements of
    the broader education agenda designed to help every child reach his or
    her academic potential and improve our Nation's competitiveness.
        Preventing and Treating HIV/AIDS.--The budget supports the goals of
    the National HIV/AIDS Strategy to reduce HIV incidence, increase access
    to care and optimize health outcomes for people living with HIV, and
    reduce HIV-related health disparities. The request focuses resources on
    high-risk populations and allocates funds to State and local health
    departments to align resources to the burden of the epidemic across the
    United States. The budget includes $2.4 billion, an increase of $85
    million, for HRSA's Ryan White program to expand access to care for
    persons living with HIV/AIDS who are otherwise unable to afford
    healthcare and related support services. The budget also includes $858
    million for domestic HIV/AIDS Prevention in CDC, an increase of $58
    million, which will help CDC decrease the HIV transmission rate;
    decrease risk behaviors among persons at risk for acquiring HIV;
    increase the proportion of HIV infected people who know they are
    infected; and integrate services for populations most at risk of HIV,
    sexually transmitted diseases, and viral hepatitis. In addition, the
    budget proposes that up to one percent of HHS discretionary funds
    appropriated for domestic HIV/AIDS activities, or approximately $60
    million, be provided to the Office of the Assistant Secretary for
    Health to foster collaborations across HHS agencies and finance high
    priority initiatives in support of the National HIV/AIDS Strategy. Such
    initiatives would focus on improving linkages between prevention and
    care, coordinating Federal resources within targeted high-risk
    populations, enhancing provider capacity to care for persons living
    with HIV/AIDS, and monitoring key Strategy targets.
        Addressing the Leading Causes of Death and Disability.--Chronic
    diseases and injuries represent the major causes of morbidity,
    disability, and premature death and contribute to the growth in
    healthcare costs. The budget aims to improve the health of individuals
    by focusing on prevention of chronic diseases and injuries rather than
    focusing solely on treating conditions that could have been prevented.
    Specifically, the budget includes $705 million for a new competitive
    grant program in CDC that refocuses disease-specific grants into a
    comprehensive program that will enable health departments to implement
    the most effective strategies to address the leading causes of death.
    Because many chronic disease conditions share common risk factors, the
    new program will improve health outcomes by coordinating the
    interventions that can reduce the burden of chronic disease. In
    addition, the allocation of the $1 billion available in the Prevention
    Fund will improve health and restrain the growth of healthcare costs
    through a balanced portfolio of investments. The fiscal year 2012
    allocation of the Fund builds on existing investments and will align
    with the vision and goals of the National Prevention and Health
    Promotion Strategy under development. For instance, the CDC Community
    Transformation Grants create and sustain communities that support
    prevention and wellness where people live, learn, work and play through
    the implementation, evaluation, and dissemination of evidence-based
    community preventive health activities.
        Preventing Substance Abuse and Mental Illness.--The budget includes
    $535 million within the Substance Abuse and Mental Health Services
    Administration (SAMHSA) for new, expanded, and refocused substance
    abuse prevention and mental health promotion grants to States and
    Tribes. To maximize the effectiveness and efficiency of its resources,
    SAMHSA will deploy mental health and substance abuse prevention and
    treatment investments more thoughtfully and strategically. SAMHSA will
    use competitive grants to identify and test innovative prevention
    practices and will leverage State and Tribal investments to foster the
    widespread implementation of evidence-based prevention strategies
    through data driven planning and resource dissemination.
        Supporting Older Adults and their Caregivers.--The budget includes
    $57 million, an increase of $21 million over fiscal year 2010, to help
    seniors live in their communities without fear of abuse, and includes
    an increase of $96 million for caregiver services, like counseling,
    training, and respite care, to enable families to better care for their
    relatives in the community. The budget also proposes to transfer an
    Older Americans Act program that provides community service
    opportunities and job training to unemployed older adults from the
    Department of Labor to HHS. As part of this move, a new focus will be
    placed on developing professional skills that will enable participants
    to provide services that allow fellow seniors to live in their
    communities as long as possible.
        Pandemic and Emergency Preparedness.--While responding to the H1N1
    influenza pandemic has been the focus of the most recent pandemic
    investments, the threat of a pandemic caused by H5N1 or other strains
    has not diminished. HHS is currently implementing pandemic preparedness
    activities in response to lessons learned from the H1N1 pandemic in
    order to strengthen the Nation's ability to respond to future health
    threats. Balances from the fiscal year 2009 supplemental appropriations
    are being used to support recommendations from the HHS Medical
    Countermeasure Review and the President's Council of Advisors on
    Science and Technology. These multi-year activities include advanced
    development of influenza vaccines and the construction of a new cell-
    based vaccine facility in order to quickly produce vaccine in the
    United States, as well as development of next generation antivirals,
    rapid diagnostics, and maintenance of the H5N1 vaccine stockpile.
        The HHS Medical Countermeasure Review described a new strategy
    focused on forging partnerships, minimizing constraints, modernizing
    regulatory oversight, and supporting transformational technologies. The
    request includes $665 million for the Biomedical Advanced Research and
    Development Authority, to improve existing and develop new next-
    generation medical countermeasures and $100 million to establish a
    strategic investment corporation that would improve the chances of
    successful development of new medical countermeasure technologies and
    products by small and new companies. The budget includes $70 million
    for FDA to establish teams of public health experts to support the
    review of medical countermeasures and novel manufacturing approaches.
    Additionally, NIH will dedicate $55 million to individually help
    shepherd investigators who have promising, early-stage, medical
    countermeasure products. Finally, the budget includes $655 million for
    the Strategic National Stockpile to replace expiring products, support
    BioShield acquisitions, and fill gaps in the stockpile inventory.
      strengthen the nation's health and human service infrastructure and
                                   workforce
        Strengthening the Health Workforce.--A strong health workforce is
    key to ensuring that more Americans can get the quality care they need
    to stay healthy. The budget includes $1.3 billion, including $315
    million in mandatory funding, within HRSA, to support a strategy which
    aims to promote a sufficient health workforce that is deployed
    effectively and efficiently and trained to meet the changing needs of
    the American people. The budget will initiate investments that will
    expand the capacity of institutions to train over 4,000 new primary
    care providers over 5 years.
        Health Workforce Diversity.--As part of these health workforce
    investments, the budget also includes $163 million at HRSA for Health
    Workforce Diversity programs to improve the diversity of the Nation's
    health workforce and improve care to vulnerable populations. This
    funding will support training programs and scholarship opportunities to
    students from disadvantaged backgrounds enrolled in health professions
    and nursing programs.
        Expanding Public Health Infrastructure.--The fiscal year 2012
    budget supports State and local capacity so that health departments are
    not left behind. Specifically, the budget requests $73 million, of
    which $25 million is funded in the Prevention Fund, for the CDC public
    health workforce to increase the number of trained public health
    professionals in the field. CDC's experiential fellowships and training
    programs create an effective, prepared, and sustainable health
    workforce to meet emerging public health challenges. In addition, the
    budget requests $40 million in the Prevention Fund to support CDC's
    Public Health Infrastructure Program. This program will increase the
    capacity and ability of health departments to meet national public
    health standards in areas such as information technology and data
    systems, workforce training, and regulation and policy development.
     increase efficiency, transparency, and accountability of hhs programs
        Strengthening Program Integrity.--Strengthening program integrity
    is a priority for both the President and myself. The budget includes
    $581 million in discretionary funding, a $270 million increase over
    fiscal year 2010, to expand prevention-focused, data-driven, and
    innovative initiatives to improve CMS program integrity. The budget
    request also supports the expansion up to 20 Strike Force cities to
    target Medicare fraud in high risk areas and other efforts to achieve
    the President's goal of cutting the Medicare fee-for-service error rate
    in half by 2012. The proposed 10 year discretionary investment yields
    $10.3 billion in Medicare and Medicaid savings, a return of about $1.5
    for every dollar spent. In addition, the budget includes a robust
    package of program integrity legislative proposals to expand HHS
    program integrity tools and produce $32.3 billion in savings over 10
    years. We appreciate the support of Congress, particularly Chairman
    Harkin, on efforts to fight Medicare fraud. I look forward to working
    with the Subcommittee on this issue.
        In addition, the Affordable Care Act provides unprecedented tools
    to CMS and law enforcement to enhance Medicare, Medicaid, and
    Children's Health Insurance Program (CHIP) program integrity. The Act
    enhances provider screening to stop fraudsters from participating in
    these programs in the first place, gives the Secretary the authority to
    implement temporary enrollment moratoria for fraud hot spots, and
    increases law enforcement penalties. Additionally, the continued
    implementation of the Secretary's Program Integrity Initiative seeks to
    ensure that every program and office in HHS prioritizes the
    identification of systemic vulnerabilities and opportunities for waste
    and abuse, and implements heightened oversight.
        Implementing the Recovery Act.--The American Recovery and
    Reinvestment Act provides $138 billion to HHS programs as part of a
    government-wide response to the economic downturn. HHS-funded projects
    around the country are working to achieve the goals of the Recovery Act
    by helping State Medicaid programs meet increasing demand for health
    services; supporting struggling families through expanded child care
    services and subsidized employment opportunities; and by making long-
    term investments in health information technology (IT), biomedical
    research and prevention and wellness efforts. HHS made available a
    total of $118 billion to States and local communities through December
    31, 2010; recipients of these funds have in turn spent $100 billion by
    the same date. Most of the remaining funds will support a signature
    Recovery Act program to provide Medicare and Medicaid incentive
    payments to hospitals and eligible healthcare providers as they
    demonstrate the adoption and meaningful use of electronic health
    records. The first of these Medicaid incentive payments were made
    January 5, 2011. More than 23,000 grantees and contractors of HHS
    discretionary programs have to submit reports on the status of their
    projects each calendar quarter. These reports are available to the
    public on Recovery.gov. For the quarter ending December 31, 2010, 99.6
    percent of the required recipient reports were filed timely. Recipients
    that do not comply with reporting requirements are subject to sanction.
                                   conclusion
        This budget is about investing our resources in a way that pays off
    again and again. By making smart investments and tough choices today,
    we can have a stronger, healthier, more competitive America tomorrow.
    This testimony reflects just some of the ways that HHS programs improve
    the everyday lives of Americans.
        Under this budget, we will continue to work to make sure every
    American child, family, and senior has the opportunity to thrive. And
    we will take responsibility for our deficits by cutting programs that
    were outdated, ineffective, or that we simply could not afford. But, we
    need to make sure we're cutting waste and excess, not making across the
    board, deep cuts in programs that are helping our economy grow and
    making a difference for families and businesses. We need to move
    forward responsibly, by investing in what helps us grow and cutting
    what doesn't.
        My department can't accomplish any of these goals alone. It will
    require all of us to work together. I look forward to working with you
    to advance the health, safety, and well-being of the American people.
    Thank you for this opportunity to speak with you today. I look forward
    to our conversation.

        Senator Harkin. Thank you very much, Madam Secretary.
        We will start a round of 5-minute questions and recognize
    people in order of appearance at the subcommittee. So I will
    start, and then Senator Shelby, then we will go by order of
    appearance at the subcommittee.

                                   HEAD START

        Madam Secretary, I want to focus on early childhood
    programs, the impact of H.R. 1, the House-proposed bill, which
    would cut over $1 billion from Head Start and the child care
    programs. This would go well beyond whatever we did in the
    Recovery Act. It actually would cut the funding below the level
    where they stood prior to the Recovery Act.
        I just visited a Head Start center in Iowa, talked to
    parents there and the Head Start program people and the
    teachers, and the impact in my own State would be pretty
    severe. They estimate about 1,800 kids in Iowa would lose their
    Head Start program.
        Can you just tell us for the subcommittee what do you see
    as the impact of H.R. 1 on Head Start, what changes are you
    making to Head Start to ensure that children receive high
    quality services, and just a little bit about the early
    learning challenge fund and the purpose of it?
        Secretary Sebelius. Mr. Chairman, I share your interest and
    focus on early childhood education as being an investment that
    pays huge dividends in the long run. If H.R. 1 were to become
    the law, the budget for Head Start would be cut about $1.1
    billion below 2010 funding, and we think about 218,000 children
    across the country who are currently being served would lose
    those slots both in Head Start and in Early Head Start.
        The President, by contrast, has proposed an increase in
    Head Start, feeling that that is an investment that is
    important to make. Even though our budget is flat-lined, he has
    chosen to make an increase in that area, or recommend an
    increase.
        We have looked across the range of programs at Head Start
    and since studies have been done to indicate there has not been
    enough progress made as children become school-eligible and
    continue on in school, we are relooking at all kinds of
    features with the Department of Education in terms of school
    readiness. The programs are currently being upgraded and
    updated in great collaboration and partnership with the
    Department of Education.
        We are also, Mr. Chairman, recompeting the 25 lowest-
    performing quadrant of the programs, feeling that automatic
    ongoing funding has not provided an incentive to update and
    upgrade the quality.
        Senator Harkin. By the way, I commend your Department and
    your leadership in that area.
        Secretary Sebelius. Well, I think parents need to be
    assured that whatever out-of-home placement they choose for
    their child, whether it is a child care setting or Head Start
    or a school-based early education program, that the same goals
    are in place. And that is really what the early learning
    challenge grant is about.
        States--and I will take some credit for what we did in
    Kansas--are frankly a bit ahead in this. A lot of States have
    been very innovative in early child care and early education
    opportunities, putting all the placement folks at the table and
    insisting that the same kind of quality standards be in place.
        The early learning challenge grant would be a partnership
    with HHS and Department of Education who together run the scope
    of the child care programs and make sure that we are putting
    incentives in place to drive higher quality because children
    who enter school less prepared than their peers, often, by the
    third grade, are so far behind that they will never catch up.
    We know that having not only developmentally ready children but
    educationally ready children is a way to really open those
    doorways of opportunity, and that is what the focus has been.
        Senator Harkin. Thank you, Madam Secretary.

                            COMMUNITY HEALTH CENTERS

        My last question--I am running out of time--has to do with
    community health centers. I happen to think the community
    health center has been one of the great underpinnings of our
    health system in America, 1,100 of them nationwide providing
    the kind of healthcare that low-income people need when they
    walk in that door. Could you explain the impact of the proposed
    cuts in H.R. 1, what that would do, and how many patients we
    might lose?
        Secretary Sebelius. The billion dollars that would be,
    again, cut from the community health center funding below 2010
    would serve--we are calculating that about close to 3 million
    of the people currently served in community health centers
    would lose that opportunity, and 10 million who are looking
    forward to having access to community health centers would also
    not have those sites available. Along with the health center
    sites themselves are the healthcare providers, doctors, nurses,
    nurse practitioners, mental health professionals. So, with the
    Recovery Act, the Affordable Care Act, and the budget
    investments, the community health center footprint is scheduled
    to go from serving about 20 million Americans to serving 40
    million Americans in the most underserved areas, rural and
    urban, throughout the country.
        Senator Harkin. Thank you very much, Madam Secretary.
        Senator Shelby.

                                   CLASS ACT

        Senator Shelby. Secretary Sebelius, the CLASS Act attempts
    to address an important public policy concern, that is, the
    need for non-institutional long-term care, but it is viewed by
    many experts as financially unsound. The President's Fiscal
    Commission recommended reform or repeal of the CLASS Act. You
    stated to health advocacy groups--and I will quote you--that
    ``it would be irresponsible to ignore the concerns about the
    CLASS program's long-term sustainability in its current form.''
        The President's budget proposal includes a request of $120
    million for the CLASS Act which would be the first
    discretionary appropriation for the program. If you are unable
    to certify that it will be sustainable absent a massive
    taxpayer infusion of funds, why should Congress want to
    appropriate the requested $120 million in taxpayer funds for a
    program that a lot of the experts project will fail? And what
    will prevent the Department from subsidizing this alleged self-
    sustaining program with taxpayer funds once it is implemented
    and then fails? Is that a concern of yours?
        Secretary Sebelius. Senator, the law as written has some
    pretty clear directions that we have to be able to certify
    before benefits would become available to promote to the public
    for their voluntary enrollment that the program is not only
    sustainable short-term but sustainable long-term. It needs a
    20-year and a 75-year actuarial projection of sustainability.
        There also is a very clear directive in the law that
    prohibits any taxpayer dollars being spent to subsidize what
    may be a program that is on shaky financial ground.
        So those are the two guardrails that we are looking at very
    closely.
        We are working with actuaries. In fact, the head actuary
    from GenWorth, who has probably the biggest footprint in this
    space, has become our chief actuary on the CLASS modeling
    program. But looking at the flexibility that we have, frankly,
    to look at work requirements, premium indexing, and
    enrollment--three of the elements that are really critical to
    making sure you have a solvent program in the future, if indeed
    only the disabled community enrolls--this program is
    immediately insolvent in a fiscal manner because there will not
    be enough income to pay for the benefits.
        The money that you have referred to in the budget, which is
    being requested as an initial outreach and enrollment feature,
    is designed to make sure we have a solvent program, which means
    you need to reach into a younger, healthier population, market
    benefits----
        Senator Shelby. In other words, it is taxpayers' money you
    are asking for here. Right? $120 million.
        Secretary Sebelius. It is budgeted money that could make
    the CLASS program sustainable into the future. Yes, sir.
        Senator Shelby. The budget proposal for the CLASS Act also
    includes $93.5 million in new Federal spending for,
    ``information and education to ensure that an adequate number
    of individuals would enroll in the program.'' While I do not
    agree myself with Congress appropriating $120 million for an
    insolvent program, it makes even less sense to me to spend
    $93.5 million of that funding to promote a program that we know
    is structured currently to fail.
        How do you justify, Madam Secretary, spending such a large
    sum of money on promotion efforts, given you will be promoting
    a program that is not quite defined?
        Secretary Sebelius. Well, again, Senator, we would not
    promote a program that could not be sustained, and I am
    prohibited by law from doing that. So it is our intent to--and
    we are engaged in extensive outreach to look at the elements of
    the program that need to be adjusted in order to make sure it
    is sustainable. I have just mentioned three of them: the work
    requirements, the premium indexing issues, and the outreach
    efforts.
        The outreach is absolutely essential to engage the employer
    community and engage citizens who right now--frankly, most
    think that Medicare provides long-term care, which it does not.
    Most think that that is a benefit that they have to look
    forward to, and there really is no private market opportunity
    right now for the kind of residential assistance that most
    people want and need.
        Senator Harkin. We will do other rounds.
        Senator Shelby. I will come back.
        Senator Harkin. We have a lot of people here. I want to
    make sure everyone gets a chance.
        I will recognize in order now Senator Pryor, Senator
    Johnson, Senator Moran, Senator Reed, Senator Brown, and
    Senator Mikulski. Senator Pryor.

                             WASTE, FRAUD AND ABUSE

        Senator Pryor. Thank you, Mr. Chairman.
        And thank you, Madam Secretary, for being here.
        Let me follow up on something that we actually talked about
    1 year ago in this subcommittee, and we were talking about
    waste, fraud, and abuse. You had a request in I think for $110
    million to do a 2-year process, I guess you can say, to try to
    get all the Medicare payment data sets in one system. And I
    understand we have had some budget issues in the meantime, but
    I am curious about where you are in that process. I guess you
    got some of the money appropriated, but tell me where you are
    in that process?
        Secretary Sebelius. Well, Senator, there is a broad-based
    effort underway to put together what is called in the private
    market ``predictive modeling,'' the kind of data checks that
    credit card companies use to find if there is an aberrant
    billing pattern. So, if 10 flat screen TVs end up on your
    credit card, you are likely to get a call saying did you
    purchase 10 flat screen TVs before they actually send the money
    out the door. We have never had that ability with Medicare data
    in five or six different systems and not integrated.
        We are building that database. We are well down the line to
    modeling now what we can do, and with the Affordable Care Act,
    we were given new tools to actually be much more nimble in
    stopping payments before they go out the door. So the
    opportunity to go from the old ``pay and chase'' model, where
    the money went out and then we tried to put back together the
    scheme of the crooks and find them at some point, to actually
    stopping that from ever happening in the first place, using the
    very effective tools that the private sector has used for
    years, is well underway and we hope to be up and running. We do
    have a request in the budget that would continue not only that
    but the strike force opportunities and building that data
    system, enforcing scrutiny as providers come into the system,
    all of which we think will be very effective. Last year alone,
    Senator, we got about a 7 to 1 return on dollars out/dollars
    in, which I think just gives a prelude to what could be
    effective in terms of building some firewalls at the very front
    end.
        Senator Pryor. Great. At one point you had, I think, a
    deadline of trying to get this up and running at least in some
    measure maybe at the end of 2011. Are you still on track there?
        Secretary Sebelius. I think we have been a little bit
    frozen in terms of our capabilities of moving ahead. So there
    are some new assets in the Affordable Care Act that we are
    continuing to mobilize. We are still working on 2010
    assumptions in our budget, and as you know, one of the things
    that the House continuing resolution would do to our budget is
    take an additional $500 million out of CMS administrative
    overhead, reducing us to a level that is about 2006. So we are
    a little uncertain what the funding would be, but this is
    definitely a program that well pays for itself.

                 CHILDREN'S HOSPITAL GRADUATE MEDICAL EDUCATION

        Senator Pryor. In the President's budget, it eliminates
    funding to children's hospitals for graduate medical education.
    And I am concerned about that because pediatricians really are
    the primary care providers for our children. So when I see
    something like that, it makes me concerned that, in effect, we
    are going to harm the ability to train physicians to be primary
    care physicians for children.
        So what assurance can you give me today that this budget is
    not going to harm our ability to train more qualified
    pediatricians?
        Secretary Sebelius. Well, I share your concern, Senator,
    and can assure you that in rosier budget times this would not
    have been a proposal to take that $317 million out of the
    budget. There are some exclusive children's hospitals that have
    that funding. I would tell you that there is $40 million in our
    block grant for maternal and child health that trains
    pediatricians and pediatric residents across the country, as
    well as Medicaid training of about $3.89 billion, again some of
    which comes to pediatricians. So this is not the sole source of
    funding for pediatricians. But I share your concerns that
    primary care docs and particularly those who deal with children
    are critical.
        Senator Pryor. And I do not have time to ask the question,
    but there is a Government Accountability Office (GAO) report
    that came out this month. It is GAO-11-318SP, and it looks for
    opportunities to reduce potential duplication in Government
    programs, save tax dollars, and enhance revenue. And I notice
    that your Department is mentioned in here many, many times on
    ways that hopefully we can save money and stop duplication. We
    do not have time to really ask because other Senators are
    waiting, but I hope you will look at that----
        Secretary Sebelius. We are.
        Senator Pryor [continuing]. And take their recommendations
    to heart.
        Secretary Sebelius. Thank you.
        Senator Harkin. Thank you, Senator Pryor.
        And now we will turn to Senator Johnson. I want to welcome
    our new member to the committee and the subcommittee. As a
    matter of fact, I was just checking with my staff. This may be
    a unique situation where we have two Senators from the same
    State on the same subcommittee on the Appropriations Committee.
    So welcome to the subcommittee, Senator Johnson.

                              AFFORDABLE CARE ACT

        Senator Johnson. Well, thank you, Mr. Chairman. It is a
    privilege to serve on the subcommittee with you.
        Madam Secretary, it was a pleasure meeting you earlier.
        I want to center on the Affordable Care Act or law I guess.
    First of all, obviously your background is pretty impressive,
    being a health commissioner and Governor of the State. You
    obviously understand health insurance pretty deeply.
        Have you ever purchased, though, a healthcare plan for a
    group of individuals, other than the State? I mean for 50
    employees, 100 employees.
        Secretary Sebelius. Yes, sir. I ran the State health
    insurance program which was the largest covered group in Kansas
    for 90,000 covered lives. We negotiated 10 or 12 various
    competitive plans, kind of the exchange that we are looking to
    set up in States around the country. It is exactly that model.
        Senator Johnson. Again, that is a very large group,
    obviously. Just so you understand my background, I am an
    accountant by training, a business owner for the last 31 years,
    and I have been buying healthcare for the people that work with
    me for 31 years. So I understand fee-for-service. I understand
    a self-insured plan where you are buying inspector general
    coverage and specific coverage. I know about PPO's and HMO's.
    Obviously, with the background with my daughter, having to seek
    out the best surgical technique for her, I always made sure
    that the employees that worked with me had that exact same
    freedom in a fee-for-service type of plan to be able to go
    anywhere in the country to do that. So basically what I do is I
    bring the perspective of a business owner, a business manager
    who will be making the kind of decisions on healthcare coverage
    under this Affordable Care Act.
        So from my standpoint, this is a very complex bill, 2,700
    pages. We have another 6,200 pages, what I was reading, in
    terms of additional regulations that have been written since
    that point in time. So I try and simplify things. I am trying
    to look at the bigger picture. And so I would like to start by
    just asking some basic questions we can kind of agree on some
    figures here because I am a very reality-based guy. I want to
    look at facts and figures.
        So is it true that about 163 million people in America get
    their healthcare through an employer-sponsored plan? Is that
    about the correct number?
        Secretary Sebelius. I think it is about 180 million.
        Senator Johnson. The Congressional Budget Office (CBO) has
    issued a study, a report that claims that under the healthcare
    law now, that by 2016 the average cost of a family plan will be
    in excess of $15,000. Is that pretty much your----
        Secretary Sebelius. I assume that is accurate.
        Senator Johnson. It is. We will stipulate that.
        Is it also true that under the healthcare law now, if an
    employer with more than 50 employees does not provide, I guess,
    affordable coverage, the penalty to that employer will be
    $2,000 per employee?
        Secretary Sebelius. It is an employer responsibility. If
    that employee qualifies for the taxpayer subsidy that is in the
    bill, then there is, yes, a payment into the fund so that that
    cost is not shifted on to other taxpayers who are, indeed,
    providing coverage for their employees and paying for the
    subsidy.
        Senator Johnson. So the CBO has also estimated now that
    they are thinking--it is starting, I think, at 2.6 million
    rising to about 3.6 million employees will lose their coverage,
    will be dropped from their employer-sponsored care into the
    Government exchange. Is that about the right figure?
        Secretary Sebelius. Well, I know there were all sorts of
    studies done by all kinds of people, sir, during the course of
    the debate, and I think before we have a framing of a plan and
    the opportunity to look at how affordable these plans are, one
    of the directives, as you know, with the State-based plan is
    that it be affordable coverage. So I think there is not at all
    a firm number on how many employers will or will not do what
    they are voluntarily doing now.
        Senator Johnson. But that is how this thing has been scored
    dollar-wise in terms of the cost estimate. Around 3 million
    people.
        The average subsidy, according to CBO, per person in those
    exchanges will rise from about $4,500 to over $7,000 by the
    year 2021. Is that largely correct?
        Secretary Sebelius. The average subsidy--it is based on an
    income level to----
        Senator Johnson. Per person. I understand, but what has
    been budgeted is almost $7,000 by the year 2021. My concern is
    taking a look at the big picture here. I think we have grossly
    underestimated the number of employees that will lose their
    employer coverage plan under this healthcare act, be put in the
    exchanges under extremely high subsidy levels. If I am right,
    if my fears come true, we could be looking at tens of millions
    of people put in the exchanges at the tune of $5,000 to $7,000
    in subsidies. We could be doubling, tripling, quadrupling the
    cost of this healthcare bill. Rather than $150 billion, it
    could be easily one-half a trillion dollars per year. That is
    my concern.
        Secretary Sebelius. Well, Senator, I think, as you know and
    as a business person participating in the market, the market is
    entirely voluntary now for employers. I think the most cynical
    view is that employers will just dump all their employees,
    discontinue employee benefits, and I guess move people into
    some other option. I don't share that kind of cynical view. I
    think the voluntary marketplace, in fact, is going to be far
    more attractive. A lot of small business owners who now are
    paying 18 to 20 percent more for identical coverage to large
    business owners will have, for the first time, affordable
    options within an exchange to purchase coverage. I think that
    the opportunity for individuals, entrepreneurs, farm families,
    and others who right now are on the edge of the market or often
    outside the market will have affordable options. And I think
    the large employers who we talked to who will not see much
    difference in their choices, except they will stop paying the
    approximately $1,000 per policy tax for everyone who is
    accessing the healthcare system without affordable coverage
    that gets shifted onto everybody who has coverage.
        I guess I think that while there is a scenario that says
    everybody would voluntarily walk out of the market and dump
    their employees, I think just the opposite is going to happen.
    We have not seen that in the one State that is really up and
    running--in Massachusetts. Employers have not dropped their
    coverage, have not dumped employees. They, in fact, are
    continuing, and Massachusetts is now at about a 97 percent
    coverage rate. So I think that is an encouraging at least
    precursor of what may be coming.
        Senator Johnson. Thank you.
        Senator Harkin. Thank you, Senator.
        Senator Moran.
        Senator Moran. Mr. Chairman, thank you.
        Senator Harkin. Again, welcome to the subcommittee. Senator
    Moran and I have done a lot of work in the past on farm issues.
    Now we can work on health issues.

                             RURAL ACCESS HOSPITALS

        Senator Moran. I look forward to continuing that working
    relationship, and I am honored to serve Kansas in the United
    States Senate by the side of my colleagues here today and
    honored to have my former Governor with us this afternoon so
    that I can ask a few questions.
        Secretary, my thoughts for questioning you today really
    revolve around some pretty significant Kansas issues related to
    healthcare and your role. And they are, of course, related to
    the issue of healthcare in a rural setting.
        The IPAB at the moment fails to account for critical access
    hospitals. Congress carved out exceptions to the payment
    mechanism that we have in place but did not carve out critical
    access hospitals, and I would like your reaction to that
    related to that because I am fearful that if that carve-out
    does not occur and decisions are made by those policymakers not
    responsible to rural America, those critical access hospitals
    could easily be a target for reduced spending which in my view
    causes the demise of access to healthcare in rural America.
        Related to that is the budget item for providing the doc
    fix. In so many instances today, our rural hospitals are now
    employing physicians. And they do that out of necessity. The
    ability to track a physician to a rural community is
    restricted, is limited. And so in many instances, our rural
    hospitals pay the salaries of physicians. Their ability to do
    that will be greatly damaged if we lose the ability to be
    reimbursed as we are currently as critical access hospitals.
    But it is compounded by the problem that in the 29.5 percent
    reduction in payments to physicians under Medicare, if we do
    not put a doc fix in place. So we have the circumstance in
    which many hospitals will have declining revenues and
    increasing costs. Of course, a hospital has little viability if
    there are not physicians in that community admitting patients
    to those hospitals.
        So my question is--I have only been in the Senate 2 months,
    but I have learned that I have to ask more than one question in
    the one question in the 5 minutes that I am allowed. But my two
    questions that are related to each other is what is the plan
    for the carve out for critical access hospitals and what is the
    administration's plan in regard to the so-called doc fix, the
    sustainable growth rate problem that we face. There is a fix in
    the President's budget for the next couple of years, but
    nothing beyond that. And it is significant amounts of dollars
    that we need to figure out how we are going to pay and I very
    much would welcome your input on both those items.
        Secretary Sebelius. Well, thank you, Senator, for those
    questions. I do want to tell the chairman that you are not only
    an expert now on rural agricultural issues but rural health
    issues because Senator Moran started when he was a Kansas
    senator working on rural health issues and has continued that
    interest. So I look forward to the opportunity to work on some
    of these enormous challenges.
        The rural access hospitals, as you know, Senator, are paid
    at a different rate. So they are paid, I think it is now, 101
    percent of costs, and that does not change with anything with
    IPAB. The other hospitals are negotiated rates. And so I think
    that the lack of a carve out was due to the fact that there is
    a different payment structure.
        But I share your concern that somehow being focused on by
    recommendations in the future with the Independent Payment
    Advisory Board is precarious territory. And I would look
    forward to working with you on how to look at that structure
    going forward. But I do think the differential in the payment
    rates was one of the areas that the drafters of the Affordable
    Care Act looked at.
        In terms of the sustainable growth rate and the ability to
    pay Medicare providers adequately and commit to that payment
    into the future, I think it is one of the most significant
    looming issues. As you know, it well predates the Affordable
    Care Act. This has been a discussion for the last decade. The
    President has, as you said, in his budget proposed about a 2\1/
    2\ year offset for the fix going forward.
        But there is no doubt that we need, on a very bipartisan
    basis, to sit down and look at what is the long-term ability to
    make sure that doctors do not have this looming crisis. I have
    now been in my job slightly longer than you have been in yours,
    but I can tell you that it is certainly the single most raised
    topic by physicians dealing with Medicare. And I do think it is
    something that while we have proposed offsets for the next
    couple of years, we need to at least have a 10-year or
    permanent fix which could be part of the ongoing deficit
    conversations or into the future. But there is no question that
    that has to be solved long term.
        I would tell you, though, also that the Affordable Care Act
    has a couple of features that are particularly focused on rural
    areas where Medicare providers are paid. Starting this year, an
    enhanced rate for serving in underserved areas where there are
    access issues that are particularly addressed in terms of not
    only the health service corps, but nurse practitioners, and
    nurse-provided health centers, that are again, targeted for
    rural and underserved areas that I think also are going to be
    critically important as you look at healthcare delivery because
    it is not only affordable, it is available healthcare.
        Senator Harkin. Thank you very much, Senator.
        Senator Moran. Thank you, Mr. Chairman.
        Senator Harkin. And now Senator Reed.

                   LOW INCOME HOME ENERGY ASSISTANCE PROGRAM

        Senator Reed. Thank you very much, Mr. Chairman.
        Thank you, Madam Secretary, for your service.
        Let me begin also by thanking you for the investment in the
    budget for health professions. We had a chance to talk about
    the need for primary care physicians and nurse practitioners,
    and the budget represents a good step forward. I know we have
    to do more, but thank you for what you have done.
        I want to focus quickly on two areas. One was alluded to by
    the chairman. That is the cuts in LIHEAP. When the budget was
    being prepared, prices in the oil markets were a little tamer.
    They are now seemingly out of control. I know there have been
    some long-term reductions, at least moderation in the natural
    gas market, but up our way we depend heavily on heating oil and
    together with the 12 percent unemployment rate, we are
    anticipating a huge, huge crisis next winter in terms of
    heating. And so these LIHEAP cuts are going to be very
    difficult to bear.
        Can you talk about how you got to this recommendation? And
    two, is there any way going forward that you have the
    flexibility to adapt to these increased prices?
        Secretary Sebelius. Well, again, Senator, you and I have
    had this conversation, and I know that you are not only
    concerned, but have been a real leader in the low energy
    assistance area. What this budget does--and again, I can assure
    you this is not an easy choice for anyone--is return the LIHEAP
    funding to the historic traditional levels. The LIHEAP budget
    more than doubled in fiscal year 2009 and continued that in
    2010 and 2011. This goes back to what was the historic rate.
    And it cuts $2.5 billion which is a very significant cut in the
    LIHEAP funding. I would not say that I have flexibility, if it
    is moving money from somewhere else into LIHEAP, probably not
    unless the direction of the Congress is aimed in that area.
        So again, I do not think there is an easy answer for this.
    It was traditionally the level of funding before there was a
    dramatic increase, but will it leave a lot of people who have
    relied on that help and support for the last couple of years in
    much more difficult circumstances? No question.
        Senator Reed. Well, just to reemphasize the point, we are
    looking at over 11 percent unemployment in my State. That was
    one of the reasons I think for the increase, the recognition of
    the difficult times. But the new factor is not a stable but
    potentially accelerating price for particularly heating oil,
    and we will have to revisit this again, unfortunately, I think,
    as we go forward, Madam Secretary.

                        IMMUNIZATION--SECTION 317 FUNDS

        Let me switch to a second area in the remaining time I
    have, and that is the section 317 funds for immunization.
    Immunization is such a critical part of healthcare. We do not
    have to state the benefits. When children are immunized, they
    are protected and they save tremendous amounts of--billions of
    dollars in avoided health care problems.
        The 317 funds as proposed--there seems to be a tradeoff now
    between the 317 funds and the prevention trust fund which was
    incorporated in the new healthcare act. The prevention trust
    fund is designed, at least in your proposal, for infrastructure
    improvements, but that will take away money from the actual
    acquisition of the vaccines that are necessary. Unfortunately,
    what we have seen in Rhode Island is a slippage in coverage for
    children. We have gone down from almost 90 percent to less than
    that. I have less than a moment for you to comment on that.
        Secretary Sebelius. Well again, Senator, this is a critical
    area, and Chairman Harkin already mentioned it. What the budget
    proposes is the same funding level that we have had in the 317
    program, and then, as you noted, an additional $100 million
    that would be spent out of the prevention fund for what are
    more likely to be sort of one-time investments whether it is
    school vaccination clinics or outreach efforts that States can
    employ.
        One of the challenges, as you well know, is that not only
    in Rhode Island but in States across the country, the health
    staff, the infrastructure to distribute vaccines, to do
    outreach to have kids vaccinated across the country has been
    severely hampered in cuts. So we are really trying to calibrate
    our resources and make them flexible to States, and I think
    that additional $100 million for fiscal year 2011 is a critical
    component. Up to 50 percent could be used for vaccination
    purchase or for actually immunizing kids. And we think States
    can use that to really make sure that they are filling the
    holes in their own strategies.
        Senator Reed. Thank you, Mr. Chairman.
        Senator Harkin. Thank you, Senator Reed.
        Senator Brown.

                 CHILDREN'S HOSPITAL GRADUATE MEDICAL EDUCATION

        Senator Brown. Thank you, Mr. Chairman.
        I wanted to mention that I appreciate Senator Pryor's
    concern about children's GME. I also am concerned. I know
    Senator Harkin is. For 10 years, he and I have worked on this
    issue and it began when I was at Akron Children's Hospital some
    years ago and saw that we had no way with the squeeze of
    managed care to fund particularly children's pediatric
    specialist training. I appreciate your answer. I appreciate
    just about everything you do. But I think that these other ways
    of funding graduate medical education for children for training
    pediatricians is far too inadequate. So I hope that you will
    revisit this issue as it comes forward.
        Thank you for coming to Columbus on the patient safety
    issue. My State has done some remarkable things in patient
    safety in hospitals, and I think that is going to bring a lot
    of cost savings that I think opponents to the healthcare bill
    have not recognized. None of that was scored as we know, the
    work that Senator Mikulski did and Senator Harkin and others.
    But that kind of preventive care, that kind of patient safety,
    everything from the Pronovost checklist to so much else will
    clearly help us restrain healthcare costs that the opponents to
    healthcare really barely addressed. And I am really proud to
    have been part of that.

                           MAKENA, KV PHARMACEUTICAL

        Two issues I want to bring up. One is a conversation that
    we had last week on the Makena, KV Pharmaceutical. For my
    colleagues who do not know the background, a drug, a
    progesterone, that was administered once a week for 20 weeks at
    a cost of about $10 a shot for high-risk pregnant women who had
    typically had a low birth weight or a preterm birth in their
    past, was making such a difference in cutting the rate of low
    birth weight babies.
        This drug company, KV Pharmaceutical, out of St. Louis that
    really spent some money to do the clinical trials, although the
    Government had done them 7 or 8 years earlier and paid for it,
    raised their price once they got FDA approval from $10 a shot,
    $200 for the whole regimen of treatment, to $1,500 a shot, or
    $30,000 for the regimen of treatment, which will mean terribly
    high costs and burden for those women, for Medicaid, for
    insurance companies, for businesses and will also clearly
    result in an increased number of low birth weight babies.
        So I just wanted you, if not in the hearing today, to
    recommend administrative or legislative strategies that we can
    employ to do something about this. We have tried, frankly, to
    embarrass the company. We have tried to look at the Food and
    Drug Administration (FDA) when Dr. Hamburg testified to our
    subcommittee not too long ago to another subcommittee here
    about that. And we are looking for answers legislatively,
    administratively. If you would speak to that.
        Secretary Sebelius. Well, Senator, as you know, the FDA is
    really prohibited from considering price in terms of drug
    approval, which I think is an appropriate policy.
        Having said that, one of the things that the company has
    done is to actively notify pharmacists that the FDA will be
    enforcing a noncompounding rule. We have put out a statement
    today saying that is not the case. The FDA will not be
    conducting any enforcement action over the opportunity for
    pharmacists to continue to do what they have been doing, which
    is compounding this treatment and having it available to
    patients throughout the country unless there is some specific
    safety issue, which has not come to our attention yet. And we
    are continuing to work on what other options we may have, but
    we wanted pharmacists throughout the country to understand that
    in spite of the drug company's warning, that is not really the
    policy of the Food and Drug Administration.

                                PEDIATRIC CANCER

        Senator Brown. Thank you. And we will continue on that.
        A low birth weight baby in the first year of life costs on
    the average $51,000, putting aside the human cost to the child,
    to the baby, the family, and everyone else. And we know what
    that is going to do to costs of Government, and I would hope
    that people very bipartisanly would go to work on this.
        Last point, Mr. Chairman, in the brief time I have. There
    is no comprehensive pediatric cancer registry, which makes it
    difficult to compare State by State statistics. Ohio is,
    unfortunately, home to what we think of as five different sorts
    of cancer clusters. There is one in Clyde, Ohio where many
    children have been afflicted and several died. Caroline Pryce
    Walker, named after Ohio Congresswoman Deborah Pryce's
    daughter, Childhood Cancer Act was signed into law in 2008. It
    authorizes $30 million annually over 5 years for pediatric
    cancer clinical trials. I would just ask you to work with us on
    this whole Clyde, Ohio cancer cluster. The cause has not been
    determined. We are looking to HHS to work with other agencies
    to research this and other kinds of cancer clusters around the
    country.
        Secretary Sebelius. Well, Senator, I would welcome that
    opportunity because this question has come up a couple of times
    in committee and I know you are trying to parse your way
    through. But again, one of the very troubling features of H.R.
    1 in the House would have a huge detrimental effect on NIH
    trials because not only does it cut a significant amount of
    resources, $1.6 billion, but it also has a lot of language that
    would micromanage trials. And we feel that many of the clinical
    trials now underway dealing with cancer, dealing with autism,
    dealing with others would have to stop taking any additional
    patients immediately if that language were to be adopted. So
    just to put a little warning on the radar screen.
        Senator Harkin. Senator Mikulski.
        Senator Mikulski. Thank you, Mr. Chairman.
        Madam Secretary, I really just want to welcome you to the
    subcommittee. Before I go to my questions, I just want you to
    know I think you are doing a great job. You have one of the
    largest, most complex agencies within our Federal Government,
    and we want to salute you on what you are doing and also the
    fact that you are even in public service. Someone with your
    background could certainly be in the private sector. One of
    those insurance companies would snap you up in a minute and
    multiply your salary over and over again.
        Secretary Sebelius. Maybe not.

                    IMPACT OF A FEDERAL GOVERNMENT SHUTDOWN

        Senator Mikulski. Well, maybe not now.
        But anyway, I just wanted to say that, because I think
    there is a lot of intensity involved in these hearings.
        This is a very quiet hearing, and I am surprised because we
    are on the brink of a shutdown. Whether you call it a shutdown
    or a slowdown, we are on the brink I think of a catastrophic
    situation. And we are only 10 days away from it. My question to
    you as Secretary of HHS is the implications and the operational
    consequences if we go to a shutdown. With the people who work
    at HHS, could you tell me how many work at HHS, and in the
    event of a shutdown, how many would be deemed nonessential and
    how many would be possibly furloughed?
        Secretary Sebelius. Senator, I am not sure I can give you
    the precise numbers right now. We do have a look-back to 1995
    when a shutdown occurred and have looked at some of the
    services and operations that were slowed down or even stopped.
    It has a pretty widespread effect on healthcare delivery and
    human service availability throughout the country because we do
    touch lives each and every day.
        Senator Mikulski. Well, let me jump in. I have major iconic
    agencies from the Federal Government and beneficiaries in my
    State. And they are also globally recognized and globally
    envied. They have names like the National Institutes of Health,
    the Food and Drug Administration, beneficiaries of HHS funds,
    Nobel Prize winning institutions like Johns Hopkins, important
    institutions like the University of Maryland.
        Let us go to NIH. If there was a shutdown, could you tell
    me the consequences on NIH either both in terms of the
    employees who would be nonessential, what would be the impact
    on clinical trials, what would be the impact on grant
    beneficiaries like at Johns Hopkins?
        Secretary Sebelius. Well again, Senator, I hesitate to give
    you specifics because I do not have them here. I can tell you
    there are conversations going on, and our best indication is
    the look-back.
        But having said that, we know that critical trials are
    underway. Research goes on day in and day out. Thousands of
    people are affected not only on the campuses that you referred
    to but certainly in grant programs throughout this country
    which provide jobs and economic opportunity.
        Senator Mikulski. If there is a shutdown, would grant
    beneficiaries continue to get their funds?
        Secretary Sebelius. Dubious. I do not know what the funding
    cycle would be.
        Senator Mikulski. I think this is really a big deal. So if
    you are in the midst of a clinical trial, whether it is cancer
    or autism, even if we looked at the ``A'' words, AIDS, autism,
    arthritis.
        Secretary Sebelius. I can tell you, having met with Dr.
    Collins as recently as 3 days ago, he currently, because of the
    uncertainty just of the 2011 budget and the numbers he has to
    work with, has given information to grantees all over the
    country that he cannot assure them that ongoing funding is
    available, and has given a very cautionary note about what they
    should do in the future. So we are operating under extremely
    uncertain territory right now.
        Senator Mikulski. Well, how will you proceed?
        Secretary Sebelius. We continue to be hopeful that there
    will be a resolution which will give us at least a framework
    for the remainder of this fiscal year which, as you know, we
    are halfway through. But certainly we have given great notice
    to all of our 11 agency directors and everyone throughout the
    Department that we are operating on 2010 estimates but to
    prepare for the possibility of significant differences.
        Let me just give you a snapshot outside of NIH.
        Senator Mikulski. Go to any agency. I mean, I raised it----
        Secretary Sebelius. We are two-thirds of the way through a
    school year with Head Start. If indeed there were to be a cut
    right now, we are not sure the programs even have enough money
    to make that cut. So, there would be programs that would be
    shut down immediately across the country because they literally
    do not have enough in their budgets to take the possible cuts.
    So we are trying to model scenarios that are very difficult to
    try and administer.
        Senator Mikulski. Well, Madam Secretary, I know my time is
    up.
        But, Mr. Chairman, you know, there is this belief that
    somehow or another a shutdown will only occur in Washington
    with people who ostensibly are overpaid or the lights will go
    out on the Washington Monument. I am terrified that the lights
    will go out at Johns Hopkins, the University of Maryland. I am
    concerned that the lights will go out in my Head Start programs
    in the rural parts of my State where they are needed. So, Mr.
    Chairman, I think we might have to ask Senator Inouye. We need
    to have maybe an all-hands-on-deck hearing on what are the
    consequences to this.
        Anyway, I exceeded my time. Thank you.
        Thank you very much, Madam Secretary.
        Senator Harkin. Thank you, Senator.
        Senator Kirk.
        Senator Kirk. Thank you.

                 CHILDREN'S HOSPITAL GRADUATE MEDICAL EDUCATION

        With all respect, I hope we can reject the administration's
    proposal to zero out children's graduate medical education. And
    you just head about that as well. I think for, obviously, like
    Children's Memorial Hospital in Chicago, La Rabida, et cetera,
    I hope we go with regular order on this because the current
    system--I do not have faith that the proposal would adequately
    provide the trained physician needs in pediatrics. And I hope
    the subcommittee goes in that direction.
        Senator Harkin. I can assure the gentleman that I share his
    concern.
        Senator Kirk. Thank you.

                      WASTE, FRAUD, AND ABUSE IN MEDICARE

        I would say, Madam Secretary, you have about a $580 million
    request to root out Medicare waste, fraud, and abuse, and you
    are running around an 8 to 1 ratio of dollars provided to
    dollars saved, which is good.
        Another thing that with Ranking Member Shelby and the
    chairman that we are working on is to upgrade the very outdated
    Medicare card. This is the Medicare card as it currently
    exists, and it has none of the standard upgrades that is
    available on ID's that are available today.
        Now, the Department has funded a pilot project for DME
    equipment in Indianapolis, but it is totally outdated. It is
    only providing a mag swipe which for $30 can be completely
    counterfeited and I think does not represent the technology
    that is used by the Federal Government.
        This is a common access card of the U.S. military, and 20
    million of these have been issued at a cost of approximately $8
    each. What I just saw, because I was alert and had a lot of
    coffee at the time, is Transportation Security Administration
    (TSA) agents have common access cards. So that whole 70,000-man
    agency now has this. The critical thing is not just the
    enhanced bar code, the optical variable ink, the picture, the
    signature, and the chip, but it is all on the back as well.
        As far as I know, the Department of Defense (DOD) reports
    not a single CAC card has been counterfeited, whereas this card
    is pretty easy to counterfeit and the Social Security card
    being almost no barrier to counterfeit.
        We have agreed to team up and look at how we can use what
    is commonly available, and I am hoping you take a look at--and
    I would ask you to reach out to Secretary Gates and his team
    because I think if we had legislation that went forward to say
    to seniors, if you want to protect your ID and help root out
    waste, fraud, and abuse, for an $8 fee you can get an enhanced
    Medicare card. And I hope we do not reinvent the wheel. I hope
    that in fact we reinvent nothing. We just expand the CAC card
    to 40 million seniors.
        But I wonder if you could explore that.
        Secretary Sebelius. Well, Senator, I would love to have our
    team work with you on this issue. I do know that there has been
    concern that DOD's card is generations ahead of what we are
    looking at. It is, as you might understand, a slightly
    different universe. They have a closed network system. We have
    about 1 million providers. So, it is a challenge of different
    proportions. But we do have a new administrator who is
    specifically charged with program integrity at CMS, a position
    never created before. He is helping to build the new system and
    look at ways--and I would love to ask him to follow up with you
    and your staff because we would love to take a look at what you
    are talking about.
        Senator Kirk. I am going to be very much in train with the
    chairman and ranking minority here. But I think that a lot of
    seniors in this age of identity theft would be pretty
    reassured.
        Secretary Sebelius. Well, and we are trying, among other
    things, to establish the fraudulent card database, because it
    is not only seniors losing their card, but it is providers. So
    we have got the challenge on both fronts. But I agree with you.
    Things that could prevent that in the front end are what we are
    looking at. So, I will have Dr. Budetti follow up with you
    right away. Thank you.
        Senator Kirk. Thank you, Mr. Chairman.
        Senator Harkin. I will exercise a little chairman's
    prerogative here. I will just back up to what Senator Kirk
    said. Senator Kirk brought this up when Mr. Budetti testified
    here a few weeks ago. So it would be good for you to contact
    him and have him start closing this loop. I concur
    wholeheartedly with Senator Kirk. I think this is something
    that we just have not paid much attention to and we should. I
    hope we can close the loop on this this year --
        Secretary Sebelius. You bet.
        Senator Harkin [continuing]. And move head on it very
    aggressively.
        Secretary Sebelius. It sounds like a great bipartisan
    proposal. All for it.
        Senator Harkin. Actually a great proposal.
        Madam Secretary, we will start a second round here of
    questions for 5 minutes.

                                   CLASS ACT

        The CLASS Act was raised by my good friend, Senator Shelby.
    I remember when we discussed this in the healthcare debate and
    in developing the legislation. I can tell you, as the chief
    sponsor of the Americans with Disabilities Act, now in its 21st
    year, and the chief sponsor of the Americans with Disabilities
    Act amendments which were just signed into law by President
    Bush in 2008, I was very concerned about the CLASS Act and how
    it would work. Too many people in our country simply have no
    recourse, have no way of setting aside some funds really for a
    possible disability that could happen to them or for long-term
    care as they grow older.
        Right now, one out of six people who reach the age of 65
    will spend more than $100,000 on long-term care. Yet, only
    about 8 to 10 percent of Americans have private long-term care
    insurance coverage. Medicaid now pays more than $110 billion--
    $110 billion--annually for long-term care for both the elderly
    and the disabled.
        So I was one of those. I was very cautiously supportive of
    the CLASS Act. I was concerned about whether it would work or
    not and how viable it would be. That is why we put into the
    legislation the language that would give authority to you, to
    the Secretary, to change the program to make sure that it is
    financially solvent.
        So again, I guess my question to you, Madam Secretary, is
    simply that. Are you confident enough that under the
    legislation you have the authority to make any changes in the
    program to make it financially solvent in the long term?
        Secretary Sebelius. Yes, Mr. Chairman, I do think that the
    concern about actuarial solvency in the future is one that is
    very real, and I have stated that on earlier occasions. Both as
    an insurance commissioner working on solvency issues but also
    setting up the framework for what an HMO has to have in reserve
    and how you model that into the future is something that I take
    very seriously. And I think the legislation is very clear that
    we cannot turn the switch on in this program unless we can
    effectively demonstrate through actuarial models that this is a
    solvent program.
        Part of the challenge--and Senator Shelby referred to this
    earlier--is what the outreach looks like and what the take-up
    rate is. If the premiums are too high, the take-up rate will be
    very low and only accessed by those who desperately need it. If
    indeed there is a broader education effort--and I have to tell
    you part of the education effort is directly tied to the fact
    that most Americans believe that Medicare covers long-term
    care. That is a commonly held belief and often not until they
    get close to needing long-term care is there a realization that
    really the only program covering long-term care is Medicaid and
    that is only if your income is eligible.
        So part of the outreach which would have to be done early
    on and again to younger, healthier workers is the opportunity
    to set aside some income. And again, we are not talking about
    competing on long-term care insurance policies. That market
    would stay in place. This is really for a range of residential
    services. What we also know is that people want to age in
    place. They want opportunities to have assistance to stay in
    their own homes for a longer period of time, to have care
    around areas that they may not be able to do as readily as they
    could have years ago and not have a nursing home as the only
    option.
        But it would need a broad take-up rate, competitively
    priced policies, and if that cannot be modeled successfully, we
    will not turn the switch on.
        Senator Harkin. Thank you very much, Madam Secretary.
        Senator Shelby.

                         CHRONIC DISEASE GRANT PROGRAM

        Senator Shelby. Madam Secretary, the President's budget
    proposes the elimination of the preventative health services
    block grant and proposes a new consolidated chronic disease
    grant program at the Centers for Disease Control and Prevention
    (CDC). The budget justification in my understanding says this
    new grant program will not be a formula grant structure but,
    rather, it will be competitive. Rural areas and States without
    capacity will be, I believe, disproportionately affected by
    competition.
        I am concerned that the new chronic disease grant program
    will create a scenario where the rich get richer and the poor
    get poorer. What are your plans to ensure that State health
    departments have the capacity to compete for funds at the
    Centers for Disease Control?
        Secretary Sebelius. Well, Senator, I----
        Senator Shelby. Is that a concern of yours?
        Secretary Sebelius. I share the concern that often some of
    the, I would say, more underserved areas are also those with
    the higher levels of chronic disease. So the worst of all
    worlds would be to have a situation where the revenue does not
    follow the disease patterns.
        The new CDC proposal is to consolidate a series of
    separately funded disease programs. Not only does the budget
    propose an increase in funding--about $72 million above what
    the current level is--but I would suggest gives States the
    flexibility of really directing these resources to their target
    areas. Every State would get resources. Let me make that clear.
    This is not 100 percent of the funds are competed for and there
    could be losers and winners. So every State would have a level
    of funding, and over and above that, there would be some
    additional competition, but it would very much tie I think the
    disease profiles in often some of the most underserved areas to
    the resources.
        But we have heard this proposal was greatly informed by
    State health officers who asked us--often they are dealing with
    heart disease and diabetes and three or four chronic conditions
    that have the same underlying causes. And so rather than having
    that funding channeled through separate silos, they said give
    us the flexibility of really addressing our State profile, our
    situations in a more strategic manner. So that information with
    the State health officers is part of what informed this
    proposal to have a chronic disease program and get rid of the
    separate silos.

                     CONGRESSIONAL REQUESTS FOR INFORMATION

        Senator Shelby. On another subject, Madam Secretary. You
    have evidenced a commitment to work with Congress--you have
    said this before--to implement the Affordable Care Act.
    However, some of my colleagues on the HELP authorizing
    committee, specifically Senator Enzi and Senator Hatch have
    talked to me, and have many outstanding requests for
    information from your Department. I know it is a big
    Department. It is very important that the Committees on
    Appropriations work with their authorizing committees to
    conduct oversight and assess the impact that the law is having
    on patients, employers, States, and taxpayers.
        To ensure that the Congress has the necessary information
    to make informed decisions about the implementation of the new
    law going forward, Madam Secretary, would you commit--and have
    you committed before--to have your Department respond to
    congressional requests, including letters and hearing questions
    for the record within 30 days of the request? It is my
    understanding from Senators Enzi and Hatch there have been 52
    requests and 67 percent no response or incomplete response. Is
    that a concern to you? It is to them.
        Secretary Sebelius. Senator, we are committed to responding
    thoroughly and as timely as possible. We have delivered
    hundreds of boxes, thousands of pages of materials. I have had
    two hearings in the Senate Finance Committee, and I can assure
    you we are trying to get the information as quickly as
    possible. The level of requests is significant and takes an
    enormous amount of time and energy to gather the materials, but
    we are working as fast as we possibly can to be responsive and
    as timely as possible.
        Senator Shelby. So you are basically committing to be
    responsive to their requests.
        Secretary Sebelius. Yes, sir.
        Senator Shelby. Thank you.
        Thank you, Mr. Chairman.
        Senator Harkin. Thank you, Senator Shelby.
        Senator Johnson.

                              AFFORDABLE CARE ACT

        Senator Johnson. Thank you, Mr. Chairman.
        Madam Secretary, I would like to kind of go back to the
    earlier questions I was asking about what I consider just
    really understated cost estimates for the healthcare act. You
    know, back in the 1960s when they passed Medicare, they
    projected out 25 years and said that Medicare would cost $12
    billion in 1990. In fact, it ended up costing $110 billion,
    almost 10 times the original estimate. My concern is our
    Federal Government has not gotten any better at estimating
    costs.
        So you had mentioned, when I started talking, a little bit
    about the incentives embedded in this bill for not only
    employers to drop coverage but now it is for employees to want
    to get into the exchanges because there are such high levels of
    subsidies. You talked about that being cynical. I am trying to
    be realistic, and I am not the only one I think that has that
    same viewpoint.
        Douglas Holtz-Eakin, a former CBO director, has issued a
    pretty good study where he is talking about a very detailed
    decision matrix that pretty well shows that it is in the
    employer's best interest and the employee's best interest for
    about 35 million people to take advantage of those subsidies
    and the exchanges.
        Yesterday I believe The Hill reported that Joel Ario, I
    believe--I am not sure I am pronouncing that right, but he is
    the head of the health insurance exchange office within your
    agency--was quoted by saying that if exchanges worked pretty
    well, then the employer can say this is a great thing. I can
    now dump my people into the exchange and it would be good for
    them and good for me.
        And that is just what I want to explain. The decision that
    an employer is going to be going through is I can pay $15,000 a
    year to provide healthcare coverage or I can pay a $2,000
    penalty, and by doing that, I am making my employee eligible
    for, in some cases, in excess of $10,000 in subsidies. Right
    now, in 2018, according to the way the healthcare bill is
    written, a family that earns $64,000 will be eligible for a
    $10,000 subsidy. And you know, let us face it. When the Federal
    Government offers subsidies, they are generally taken advantage
    of. So I think it is totally unrealistic to expect only 3
    million out of 180 million people to take advantage of those
    subsidies.
        And my question is what happens if I am right. What if
    Douglas Eakin is right and it will be at least 35 million or
    even higher? For every 10 million additional people, it is
    going to cost $50 billion in additional costs, and that is 33
    percent higher than the original cost estimate for this
    healthcare act.
        Secretary Sebelius. Well, Senator, first of all, the
    Affordable Care Act has a ban on large employers even
    considering exchanges for at least their first 3 years. So your
    scenario in 2018 for large employers is not a possibility
    because they would not be eligible to enter into an exchange.
    And I think the ban is written in such a way that Congress will
    reconsider at the end of 3 years whether that should indeed be
    extended, and the vast majority right now who have stable
    coverage at least in the employer market is in the large
    employer area.
        Second, I think that while there are a whole variety of
    scenarios, what I know about the existing market is that small
    employers have been abandoning the market altogether. The trend
    rate for the last 10 years has been sharply downward. So
    employees who either are self-employed or farm families or who
    are working for a small employer are less and less and less
    likely to have any affordable options and therefore are
    shopping on their own in what is a very fragile individual
    market. So the trend rate is not good at all.
        I think there are, again, some very optimistic
    opportunities in creating State-based exchanges where small
    employers for the first time will have the pooling flexibility
    that their large competitors have. They will have an
    opportunity to essentially shop without a very sophisticated
    human resources (HR) department in a predesigned marketplace
    and will have the benefit right now of tax credits that we are
    seeing for the first time in a very long time bringing some of
    those folks back into the market.
        So I think the large employee marketplace will stay
    relatively stable and stay fairly much the same, although
    hopefully their costs will go down as the CBO predicts, and the
    small marketplace, which has been disintegrating dramatically
    over years, will again be stabilized.
        Senator Johnson. What is the definition of a large
    employer? What is the definition that will be excluded from
    these exchanges?
        Secretary Sebelius. I think the large employer is 100 or
    more employees.
        Senator Johnson. Thank you.
        Senator Harkin. Senator Moran.

                       INDEPENDENT PAYMENT ADVISORY BOARD

        Senator Moran. Mr. Chairman, thank you again.
        I want to go back to a couple of topics that we visited
    about earlier, Secretary, and then add a third one.
        Back to the IPAB. I want to make sure I understand that you
    indicated that there was a justification for not including
    critical access hospitals in the provisions that eliminate the
    potential for the independent board's decision. Does something
    need to be done now or are they safe for a while?
        Secretary Sebelius. All I was suggesting, Senator, is that
    I am speculating that the reason that critical access hospitals
    were treated differently in the original proposal was that
    critical access hospitals are paid differently in the current
    system. So their payment protection stays in place. The law
    requires that they get paid based on cost. And that is not the
    case of other hospitals.
        Senator Moran. Do you support exempting critical access
    hospitals from the IPAB through 2019 like the other hospitals?
        Secretary Sebelius. Well, I would be supportive of taking a
    look at what the proposal would look like. I share your concern
    that critical access hospitals are vitally important, and I
    just need to look at all the framework that protects them right
    now.

                        MEDICARE SUSTAINABLE GROWTH RATE

        Senator Moran. I actually think that because they are paid
    differently, they may be a greater target. But there is a
    justification that apparently you and I share for why they are
    paid differently.
        On my other question about the so-called ``doc fix,'' is my
    understanding that the administration has a plan for 2012-2013,
    but no concrete plan beyond that?
        Secretary Sebelius. We have not proposed 10 years of
    offsets. As you know, up until probably 1 year ago, the doc fix
    was done in a limited fashion a year at a time and never paid
    for. I think the President has said it is important to pay for
    it. He has proposed in this budget to have what amounts to
    about 2\1/2\ years of pay-fors going forward and says we look
    forward to working with Congress on a permanent fix for this
    situation.
        Senator Moran. Well, I made my position clear on the
    Affordable Care Act, and that is known. But regardless of your
    position on that legislation, the system falls apart if we do
    not make the doc fix substantial and permanent.
        Secretary Sebelius. There is no question and I have said
    that since the outset. As you noted, I mean, the Affordable
    Care Act is not what caused the gap in payment and it is not
    what will fix it. It really is, I think, something that needs
    to be discussed in the overall Medicare system.
        Senator Moran. I fear that part of the potential demise of
    our healthcare delivery system will be related to the
    Government's reimbursement of healthcare providers, that it is
    inadequacy, and we will potentially have more providers paid
    for by the Government under the Affordable Care Act, and if you
    add more people, more providers who are paid at a rate less
    than what it costs to provide the service, we lose the
    physicians who provide those services, we lose the hospitals
    that deliver those services. And so this seems to me to be an
    overriding consideration that we just have got to get to.
        Finally, your successor's successor has asked for a waiver
    under the MOE.
        Secretary Sebelius. My successor's successor.
        Senator Moran. Yes. Is that true?
        Secretary Sebelius. Who is my successor's--I do not know
    what we are talking about.
        Senator Moran. It depends on what position you have got.
    That is true. You have held so many positions. The current
    Governor of the State of Kansas has asked for a waiver. I am
    interested in knowing the status of that request and what
    criteria that you have in place or will put in place to make
    those determinations.
        Secretary Sebelius. Well, it is my understanding, Senator--
    and I think this is the most updated information--that while
    there has been some suggestion by Governor Brownback that he
    would come to our office with some specifics, we do not have
    anything other than the notion that maybe a waiver would be a
    good idea. As far as I know, we have no paper. We have no
    proposal. We have no notion of what it is that he is talking
    about.
        We are working actively around the country with States
    around not only what they can do to lower their pressing
    healthcare costs but ways that other States have taken
    advantage of the current law to deliver more effective services
    at a lower cost and would look forward to working on Kansas or
    any other State. But it is my understanding we really do not
    have anything other than a letter saying we are going to come
    to you with a proposal.
        Senator Moran. Thank you, Secretary. Appreciate our
    conversation this morning.
        Mr. Chairman, thank you.
        Senator Harkin. Thank you, Senator.
        Secretary Sebelius. My predecessor's predecessor. Okay.
    Successor. That is right. I had predecessors too.
        Senator Harkin. Do we need a more Kansas----
        Secretary Sebelius. No, no, no. I am just sorting that
    title out.
        Senator Moran. There is very little good news in the Kansas
    world these days.
        Secretary Sebelius. We are all bemoaning the Jayhawks.
        Senator Harkin. I watched that game. That was quite a game.
        Secretary Sebelius. Painful for some of us.
        Senator Harkin. That is true.
        Well, Madam Secretary, thank you again for your appearance
    here. Thank you for your stewardship of this vast and complex
    Department. Thank you so much for the clarity and the
    forthrightness of your responses here today.

                         ADDITIONAL COMMITTEE QUESTIONS

        The record will stay open for 10 days for other statements
    or inclusions of questions by other Senators.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                   Questions Submitted by Senator Tom Harkin
        Question. Madame Secretary, your budget includes $765 million to
    fund the advanced development of the drugs and vaccines that we need to
    defend against bioterrorism or a public health emergency. The
    Department would like to fund this advanced development by means of
    transfers from the Project BioShield Special Reserve Fund (SRF). As you
    know, the purpose of BioShield is to provide a financial incentive to
    pharmaceutical companies by guaranteeing that the Federal Government
    will buy these drugs for the national stockpile. Unless adequate
    resources remain in BioShield, we may be calling into question the
    Federal Government's commitment to buy these products and therefore
    making it more risky for the private sector to remain in the
    countermeasure business.
        Is there a risk of undermining the entire process of developing
    drugs and countermeasures for the stockpile if significantly more
    Project BioShield balances are used for other purposes? What is the
    Department's plan to reauthorize BioShield and replenish the SRF when
    it expires at the end of fiscal year 2013?
        Answer. Project BioShield and the Special Reserve Fund have
    provided a market guarantee to attract the interest of industry to
    medical countermeasures development, and in this they have succeeded.
    This market guarantee, however, does little to make drug development
    easier or faster. We are just beginning to see the fruits of our
    decade-long investment in medical countermeasure development.
    Initiatives--such as the Strategic Investor, the Centers of Innovation
    in Advanced Development and Manufacturing and additional support for
    regulatory science at the Food and Drug Administration--planned to be
    undertaken following the Medical Countermeasures Enterprise Review of
    last year are designed specifically to remove obstacles to success and
    to increase the flow of products through the pipeline, so that Project
    BioShield can realize its full potential.
        The authorities added to the Public Health Service Act by the
    Pandemic All Hazards Preparedness Act have supported advancements in
    preparedness and response investments and capabilities. They have
    proven beneficial to the Project BioShield program by providing
    increased flexibility to support a more robust medical countermeasure
    pipeline to respond to chemical, biological, radiological, nuclear
    (CBRN) and other emerging threats. There are a number of expiring
    authorizations and authorities that should be reauthorized to ensure we
    can continue to adequately prepare for public health incidents.
        In 2004, in the DHS Appropriations Act (Public Law 108-90),
    Congress provided advance appropriations of $5.593 billion for CBRN
    countermeasures acquisition from fiscal year 2004 to fiscal year 2013.
    Congress subsequently passed the Project BioShield Act (Public Law 108-
    276) to authorize the use of these funds for this purpose. The Special
    Reserve Fund (SRF), as the Project BioShield appropriation is called,
    was intended to serve as a statement of the U.S. Government's
    commitment to medical countermeasures development and a market
    guarantee to industry as it undertook the arduous process of developing
    novel medical countermeasures.
        Since its inception, eight products have been acquired using
    Project BioShield funds and deliveries have been initiated or completed
    to the Strategic National Stockpile, at an aggregate expenditure of
    $2.192 billion. Additionally, since the creation of the SRF, $25
    million has been rescinded, $995 million had been made available for
    the support of BARDA medical countermeasure advanced development, and
    $441 million has been transferred for NIH basic research and for BARDA
    and NIH pandemic influenza preparedness. Of the funds obligated to date
    for purposes other than medical countermeasure acquisition, the vast
    majority have contributed directly to maintenance and development of
    the medical countermeasure pipeline.
        In May 2011, HHS anticipates an award of $433 million for the late-
    stage development of an antiviral drug to treat individuals infected
    with smallpox. The fiscal year 2012 President's budget requests $1.5
    billion, including a request that another $665 million be made
    available for advanced research and development and that $100 million
    be made available to establish the proposed Medical Countermeasure
    Strategic Investor Initiative, which if enacted would leave $742
    million for acquisitions between now and the end of fiscal year 2013.
        Investments at BARDA have focused heavily on supporting advanced
    research and development in recent years, and Project BioShield
    acquisitions will also continue through the rest of fiscal year 2011
    and into fiscal year 2012.
        Question. Madame Secretary, there is a critical need to focus on
    drug abuse prevention. Specifically, we should provide sufficient
    funding for evidence-based programs that address the use and abuse of
    alcohol, marijuana and other illegal drugs. Our country is facing what
    the Office of National Drug Control Policy has called an ``epidemic''
    of prescription drug abuse. Prescription drugs account for the second
    most commonly abused category of drugs, behind marijuana. For this
    reason I included language in last year's Senate Report 111-243
    indicating my concern about efforts by the Substance Abuse and Mental
    Health Services Administration (SAMHSA) to blend mental health and
    substance abuse prevention funding:

        ``Given the paucity of resources for bona fide substance use and
    underage drinking prevention programs and strategies, the Committee
    instructs that money specifically appropriated to CSAP for substance
    use prevention purposes shall not be used or reallocated for other
    programs or initiatives within SAMHSA. In addition the Committee is
    instructing SAMHSA to maintain a specific focus on environmental and
    population based strategies to reduce drug use and underage drinking
    due to the cost effectiveness of these approaches.''

        Your Department recently issued a Request for Applications for the
    Strategic Prevention Framework State Prevention Enhancement Grants,
    funded through the Centers for Substance Abuse Prevention (CSAP). The
    first goal listed for potential grantees is to: ``With primary
    prevention as the focus, build emotional health, prevent or delay onset
    of, and mitigate symptoms and complications from substance abuse and
    mental illness.'' The third goal listed relates to suicide prevention.
        Question. While I recognize that there are common risk and
    protective factors for substance abuse disorders and mental illness,
    substance abuse prevention programs are unique in focusing on the
    environmental strategies for preventing drug and alcohol abuse. Will
    the grants issued under this RFA be consistent with the intent of the
    language included in last year's Senate Committee report?
        Answer. There is a critical need to focus on substance abuse
    prevention. As you point out, substance abuse prevention requires
    unique environmental and population-based approaches, but it also
    requires a focus on common risk and protective factors that put all the
    Nation's children at risk. SAMHSA has taken a leadership role, along
    with colleagues at NIH, CDC, and ACF, to consider the best way to
    encourage States and communities to work collaboratively on the
    prevention of substance abuse and on ways to build resilience that will
    help our young people, their families, and the systems that serve them.
        As you note, a common set of risk and protective factors affects
    the development of certain mental and substance use disorders in youth.
    The scientific evidence supports an approach that addresses both
    substance abuse and mental health prevention in tandem. The 2009
    Institute of Medicine Report Preventing Mental, Emotional, and
    Behavioral Disorders Among Young People provides evidence for these
    common factors. In addition, we know that youth with mental illnesses,
    such as depression, are much more likely to use/abuse alcohol or use
    substances. A high proportion of youth are under the influence of
    alcohol, illegal substances, or nonmedical use of prescription drugs
    when they attempt or die by suicide. These issues are not disconnected.
    For too long, we have focused on the unique aspects of prevention of
    mental illness and substance use/abuse when the evidence shows that
    both the substance abuse and the mental health fields can benefit from
    employing environmental strategies and supporting the emotional health
    of youth.
        All SAMHSA grants and contracts are aligned with SAMHSA's Strategic
    Initiatives. The grants to be issued under the Strategic Prevention
    Framework State Prevention Enhancement Grants (SPE) request for
    applications (RFA) support SAMHSA's Strategic Initiative #1--Prevention
    of Substance Abuse and Mental Illness. These grants are intended to
    focus solely on substance abuse prevention and are strictly consistent
    with the intent of the language included in the fiscal year 2011 Senate
    Committee report. The language you reference in the RFA is a
    description of SAMHSA's Strategic Initiative, which addresses both
    substance abuse and the development of emotional health.
        We have issued this RFA to assist States, Tribes, and U.S.
    Territories in conducting one intensive year of capacity building and
    strategic planning to strengthen and enhance their substance abuse
    prevention infrastructures to better support communities of high need
    throughout the Nation. Through stronger, more strategically aligned
    substance abuse prevention infrastructures, SPE grantees will be better
    positioned to apply the Strategic Prevention Framework (SPF) process to
    achieve more collaborative, cost-effective coordination of services and
    to implement data-driven, environmental, and population-based
    strategies to reduce substance abuse, including underage drinking.
        The fiscal year 2012 President's budget for SAMHSA includes two
    separate State Prevention Grants, one for substance abuse and one for
    mental health, reflecting the highest priority of HHS on prevention
    generally and of SAMHSA on the prevention of both substance abuse and
    mental illness--with separate approaches for each. These programs will
    continue HHS/SAMHSA's priority to promote emotional health as well as
    supporting Congress' direction to focus on environmental and
    population-based strategies to reduce illicit drug use and underage
    drinking. Likewise, the fiscal year 2012 Budget continues separate
    funding to implement underage drinking prevention strategies under the
    Sober Truth on Preventing (STOP) Underage Drinking Act.
        Question. Madame Secretary, since fiscal year 2002 this Committee
    has included funding for the embryo adoption public awareness campaign.
    The purpose of this program is to educate Americans about the existence
    of frozen embryos resulting from in-vitro fertilization and which may
    be available for adoption. In total, we've provided over $23 million
    for this program throughout its history.
        Please provide an indication of how successful this program has
    been. For example, how many adoptions have been made since the start of
    the program?
        Answer. Because it is a health awareness effort, the impact (and
    consequently the success) of the Frozen Embryo Donation/Adoption Public
    Awareness Campaign is difficult to directly link to the number of
    embryos ``adopted'' in a given year. The success is better measured by
    the level of public awareness of the issue among the target population
    (in this case infertile couples). The first comprehensive and
    scientific attempt to assess the overall impact of the Frozen Embryo
    Donation/Adoption Public Awareness Campaign will be conducted in 2012
    through the National Survey of Family Growth, which will survey a
    nationally representative sample of infertile couples about their level
    of awareness of the availability of frozen embryos for adoption.
    Estimates derived from the CDC's surveillance system of Assisted
    Reproductive Technology indicate that about 2,000 frozen embryos are
    adopted each year--a number that has been relatively static since 2004.
                                     ______

                Questions Submitted by Senator Daniel K. Inouye
    ninr's role in the national center for advancing translational sciences
                                    (ncats)
        Question. Madam Secretary, scientific inquiry, planned and
    conducted by nurses, is a vital part of improving the health and
    healthcare of Americans. Nursing research has been a long time catalyst
    for many of the positive changes that we have seen in patient care over
    the years. The National Institute of Nursing Research (NINR) was given
    an fiscal year 2010 appropriation of $145.575 million and has requested
    $148.114 million for fiscal year 2012. That would be an increase of
    $2.539 million (1.7 percent), which is in line with the increases
    requested for many of the other NIH Institutes. The overall increase
    requested by NIH for fiscal year 2012 is 2.4 percent. About $1.2
    million of the requested increase would support additional funding for
    NINR's research grants and training awards. About $1 million of the
    increase would support NINR's share of Institute contributions to
    several trans-NIH initiatives.
        NIH has proposed the creation of a new National Center for
    Advancing Translational Sciences (NCATS) to provide the infrastructure
    and technologies to bring important discoveries from basic research to
    fruition through new diagnostics and therapeutics. What role might NINR
    have in working with NCATS?
        Answer. Nursing science is historically grounded in the translation
    of research and science, and is an essential scientific nexus for these
    efforts across the United States and around the globe. NINR and its
    scientists, intramural and extramural, are leaders in the translation
    of research into health and healthcare interventions. NINR supports
    preclinical basic and applied research that integrates biological and
    behavioral sciences. NINR scientists are employing new scientific
    technologies from diverse fields including neuroscience, genetics and
    genomics, molecular biology, biochemistry, and physiology in order to
    improve quality of life through health promotion, disease prevention,
    and management of symptoms. NINR and nursing science invests in the
    infrastructure, resources, and scientific capacity building and
    training critical for the success of these efforts.
        NINR would collaborate with the proposed National Center for
    Advancing Translational Sciences (NCATS) to maintain and enhance
    translational and interdisciplinary initiatives across the NIH, as well
    as with other government and nongovernment organizations. NINR
    currently leads and participates in several interdisciplinary
    collaborative programs and partnerships that support translational
    science including: the NIH Public Trust Initiative; the NIH Pain
    Consortium; and the Clinical and Translational Science Awards (CTSAs).
        In particular, the Clinical and Translational Science Awards (CTSA)
    program is a major trans-NIH initiative that, since its launch in 2006,
    has proven to be a critical component in the NIH efforts to accelerate
    research translation. CTSA funded projects touch on all aspects of
    translational research including community-based participatory studies,
    implementation science, and health services research. Central to the
    CTSA program are multifaceted team science, broadly supported
    collaborations, and the training and mentoring of the next generation
    of interdisciplinary translational scientists--all of which are also
    central foci of nursing science.
        NINR encourages its scientists to become leaders in the CTSAs.
    Working with NIH partners and groups such as the CTSA Nurse Scientists
    Special Interest Group, NINR co-sponsors CTSA-related workshops and
    symposia to identify research opportunities, highlight successful
    exemplars, and develop strategies to maximize the diverse disciplinary
    strengths of nursing science. While several current CTSA's include
    scientists from nursing specialties who are at the leading edge of
    translational and interdisciplinary research, NINR supports the goal of
    the CTSA Nurse Scientist Special Interest Group to elevate nurse
    scientists to leadership roles in future CTSAs.
       adoption of best practices by healthcare professionals and their
                                    patients
        Question. NINR supports many activities to enhance the evidence
    base for healthcare decisions, including assessing the effectiveness of
    new therapies and healthcare interventions for individuals and within
    diverse populations. What are your successes and frustrations with
    seeing measurable changes in the adoption of such best practices by
    healthcare professionals and their patients?
        Answer. NINR investigators and research efforts emphasize the
    development and use of evidence-based interventions with individuals in
    diverse, real-world settings. Nurses and nurse scientists play primary
    roles in the translation of research findings into standard practice
    because of their prominence in front-line health service provision
    across clinical settings. Currently, over 90 percent of NINR-supported
    projects are clinically focused.
        As a science committed to the translation of evidenced-based
    research to the clinician, clinic, and community, nursing science
    shares the frustration of the translation-gap between research and
    clinical practice. Acknowledging this, nurse scientists are overcoming
    the barriers to translation and adoption of research findings through
    highly collaborative, interdisciplinary scientific efforts. NINR
    supports research efforts from a broad spectrum of disciplines,
    involving academic and clinical scientists in settings ranging from
    bench laboratories to hospital bedsides.
        NINR has experienced successful translation and adoption of
    evidence-based programs in key areas such as transitional care, and
    patient and caregiver interventions. An NINR-supported program
    partnered an interdisciplinary group of caregivers with older heart
    failure patients to ease their transition from clinical to home care.
    In a randomized clinical trial, the program was successful in reducing
    re-hospitalization rates for this high-risk group of patients, and in
    addition, it reduced total costs by about 38 percent, or $3,500 per
    patient. Another NINR-supported program improved the knowledge and
    coping mechanisms for parents of premature infants by facilitating
    positive parenting behaviors and lowering parental stress. This
    intervention also decreased the length of NICU hospitalization by about
    4 days and the associated hospital costs by about $4,800 per infant.
    NINR has also supported the development of a behavioral intervention
    that significantly reduced the incidence of post-stroke depression in
    stroke survivors, compared to patients who only received
    antidepressants. Immediate benefits, as well as sustainable
    improvements, remained for at least 1 year post-intervention. An
    intervention such as this one potentially can have a profound impact on
    the long term health outcomes of individuals who have survived a
    stroke.
        NINR will continue supporting the adoption of evidence-based
    research into practice through such research programs as the NINR
    Centers Program. Across the United States, these Centers function as
    translational research hubs within schools of nursing. Promoting
    collaboration between disciplines and across institutions through the
    use of shared resources and expertise, this program is designed to
    increase research capacity, accelerate translational research, enhance
    mentorship of doctoral students and early career scientists, and expand
    the science of investigators working on multiple projects. NINR Centers
    provide the stable base needed to develop broad, interdisciplinary
    translational programs of research to speed the application of research
    into practice.
        ninr's participation in programs to keep up the supply of nurse
                                  researchers
        Question. NIH has various grant and training programs that are
    meant to encourage young investigators to pursue research careers and
    try out innovative ideas. How does NINR participate in those programs
    to keep up the supply of nurse researchers?
        Answer. NINR is committed to encouraging, supporting, and
    developing the next generation of nurse scientists. NINR training
    activities are designed to achieve the vision of creating an
    innovative, multidisciplinary, and diverse scientific workforce. In
    addition to supporting pre- and post-doctoral research fellowships and
    career development awards in the extramural community, NINR also leads
    and participates in a number of training programs through its
    Intramural Research Program (IRP).
        NINR training activities support individual and institutional
    graduate and post-graduate research fellowships, as well as career
    development awards, including awards to trainees from under-represented
    and disadvantaged backgrounds. These programs provide the next
    generation of scientists with the necessary, interdisciplinary
    education and research skills that will enable them to improve clinical
    practice, enhance quality of life for those with chronic illness, and
    support preventative health. For example, NINR supports investigators
    under the NIH K99/R00 Pathway to Independence (PI) program, in which
    promising postdoctoral scientists receive both mentored and independent
    research support for up to 5 years.
        The NINR IRP also supports several research training opportunities
    through programs such as the NINR Summer Genetics Institute, a 1-month
    program designed to increase the research capability in genetics among
    graduate students and faculty in nursing and to develop and expand the
    basis for clinical practice in genetics among clinicians. NINR also
    participates in the NIH Graduate Partnerships Program (GPP), in which
    doctoral students from schools of nursing with established NINR-
    supported training programs can complete their dissertation research
    within the IRP. NINR also sponsors the Pain Methodologies Boot Camp,
    which is a 1-week intensive research training course in pain
    methodology at NIH that is aimed at increasing the research
    capabilities of graduate students and faculty through distinguished
    guest speakers, classroom discussions, and laboratory training.
        An expanded scientific workforce with expertise in these areas of
    research will significantly contribute to evidence-based improvements
    and reforms to the healthcare system in the coming years. Collectively,
    NINR training activities address the national shortage of nurses by
    contributing to the development of the nursing faculty needed to teach
    and mentor individuals entering the field.
       ninr's plans in research on autism, cancer and alzeimer's disease
        Question. Does NINR have any particular plans that respond to the
    Presidential Initiatives in research on autism, cancer, and Alzheimer's
    disease?
        Answer. NINR is committed to continuing efforts to support research
    that informs the provision of quality care and improving quality of
    life for persons with autism, cancer and Alzheimer's disease (AD) and
    other dementias, as well as supporting their informal caregivers.
    Recent efforts in autism at NINR include the examination of the effects
    of an intervention based on self-regulation human-animal interaction
    theory (e.g. therapeutic horseback riding) on children and adolescents
    with autism, as well as the development of a peer-mentored disaster-
    preparedness program for adults living with autism and other
    developmental disabilities. NINR is also co-sponsoring an NIH funding
    opportunity to support research into the origins, causes, diagnosis,
    treatment, and optimal service delivery in autism spectrum disorders.
        NINR's cancer research focuses on developing the evidence-base for
    enhancing the individual's role in managing disease, managing
    debilitating symptoms, and improving health outcomes for individuals
    and caregivers. Several NINR-supported scientists are examining how
    clinicians and patients work through the treatment and support
    decisionmaking process, across the trajectory from diagnosis to end-of-
    life and palliative care or illness remission. NINR currently supports
    numerous projects in the area of cancer pain research, including
    studies to investigate the underlying molecular mechanisms that cause
    cancer treatment-related pain, as well as a patient-controlled
    cognitive-behavioral intervention for cancer symptoms. Another study is
    developing and testing a physician-nurse team intervention to provide
    clear and timely end-of-life and palliative care communication to
    parents of children with brain tumors. NINR-supported research also
    focuses on cancer recurrence prevention and improved quality of life
    through such scientific efforts as the development of cancer screening
    programs for diverse populations, a genetic cancer risk assessment tool
    to improve screening efforts, and a psycho-educational telehealth
    intervention for rural cancer survivors. NINR also reaches directly to
    the public through such efforts as the development and dissemination of
    the NINR publication, ``Palliative Care: The Relief You Need when
    You're Experiencing the Symptoms of Serious Illness'' which has been
    downloaded from the NINR website nearly one million times.
        NINR research on interventions for older adults with AD focuses on
    areas such as: alleviating symptoms such as pain, discomfort, and
    delirium; improving communication for clinicians; and memory support.
    For example, NINR is currently supporting a project to test the
    effectiveness of an activity-based intervention designed to increase
    quality of life by reducing agitation and passivity and increasing
    engagement and positive mood in nursing home residents with dementia.
    Another NINR-funded study involves an evidence-based, nurse
    practitioner-guided intervention for patients with AD or other
    dementia, as well as their family caregivers. The intervention is
    expected to improve overall quality of life by decreasing depressive
    symptoms, reducing burden, and improving self-efficacy for managing
    dementia in caregivers. NINR also emphasizes research on interventions
    aimed at improving quality of life and reducing burden for caregivers.
    Recognizing the challenges often experienced by caregivers, NINR
    supports research on strategies to improve the skills caregivers need
    to provide in-home care, to reduce stress and burden, and to maintain
    and improve their own health and emotional well-being. Together NINR
    and the National Institute on Aging are supporting the Resources for
    Enhancing Alzheimer's Caregiver Health (REACH) II program, a
    comprehensive, multi-site intervention to assist AD caregivers by
    providing strategies to manage stress, maintain social support groups,
    and enhance their own health. Multiple efforts across the Federal
    Government are currently underway to implement REACH II in the
    community, such as through the Administration on Aging's Alzheimer's
    Disease Supportive Services Program.
        Question. What is the current nursing shortage and how are current
    initiatives impacting that shortage?
        Answer. Strengthening and growing the primary care workforce--
    including nurses and nurse practitioners--is critical to reforming the
    Nation's healthcare system. In fiscal year 2010, the ACA Prevention and
    Public Health Fund supported $31 million for the training of 600 new
    nurse practitioners and nurse mid-wives by 2015 and $15 million for
    Nurse-Managed Clinics, which provide primary care and wellness services
    to underserved and vulnerable populations. The fiscal year 2012 budget
    includes $20 million for these Clinics.
        The fiscal year 2012 budget includes $333 million, an increase of
    $43 million over fiscal year 2010, to support the training of nurses
    and advance practice nurses. The fiscal year 2012 budget initiates a 5-
    year effort to fund the training of an additional 4,000 new primary
    care providers--including 1,400 advance practice nurses.
        Question. Is the Department investing in any efforts to assure that
    nurses are available in the regions that need them the most?
        Answer. The Administration supports several programs that encourage
    nurses to practice in underserved areas and facilities throughout our
    Nation. Applicants with initiatives benefitting rural and underserved
    areas are given preference for all Public Health Service Act Title VIII
    nursing workforce funding.
        In addition, the Nurse Education Loan Repayment Program and Nursing
    Scholarship Program offer financial support for nurses who agree to
    serve in healthcare facilities facing critical shortages of nurses.
        The Affordable Care Act provides $1.5 billion for the National
    Health Service Corps over the next 5 years, which will help bolster the
    supply of clinicians--including nurse practitioners--serving at rural
    health clinics, community health centers, and other primary care sites
    with a shortage of health professionals.
        Question. H.R. 1 proposes to reduce funding for the Nurse Education
    and Loan Repayment program by two-thirds. Is this a good idea to reduce
    funding when there is such a well documented nursing shortage?
        Answer. The Nursing Education Loan Repayment and Scholarship
    programs provide financial incentives to nurses who agree to work at
    healthcare facilities with a critical shortage of nurses. The proposed
    reduction in H.R. 1 would support approximately 850 fewer nurses than
    would otherwise be supported. The fiscal year 2012 budget includes $94
    million, the same level as fiscal year 2010, for this program in
    recognition of the key role that it plays in supporting the recruitment
    and retention of nurses in underserved areas.
        Question. How is it that HHS says we have a nursing shortage when I
    hear that graduating nursing can't find jobs?
        Answer. While there remains an overall shortage of nurses, nursing
    shortages vary geographically and by sector (e.g., hospitals, nursing
    homes). More nurses are delaying retirement and increasing their hours
    due to the economic downturn, which has allowed for some temporary
    easing in the nursing shortage in some parts of the country. However,
    the shortage is still substantial in many parts of the country, and
    without sustained production of nurses, the situation will worsen.
        Question. Will the funds appropriated from the Community Health
    Center Fund (Sec. 10503 of the Patient Protection and Affordable Care
    Act) be used to expand this program? If yes, what are the planned
    program expansions?
        Answer. Native Hawaiian Health Care Programs are not eligible for
    funding under Section 10503 of the Patient Protection and Affordable
    Care Act.
        Question. How would proposals to use some or all of the community
    health center fund in lieu of the annual health center appropriation
    affect: the program in general; the ability to sustain program
    investments made using American Recovery and Reinvestment Act (ARRA
    Public Law 111-5) funds; the ability to expand the program; and the
    Native Hawaiian healthcare system that is funded from the annual health
    center appropriation?
        Answer. In fiscal year 2011 the combined resources from the
    Community Health Center Fund and discretionary appropriations will
    enable the program to sustain investments made using American Recovery
    and Reinvestment Act funds as well as create new health center sites.
    In total, the Health Center Program will receive a nearly $400 million
    increase in fiscal year 2011 above fiscal year 2010 levels.
        Question. Secretary Sebelius, there are many different departments
    and agencies responsible for our Nation's preparedness and response to
    a natural or man-made disaster. Can you talk about the unique role EMSC
    plays in those efforts?
        Answer. The Emergency Medical Services for Children (EMSC) Program
    under section 1910 of the Public Health Service Act (42 U.S.C. 300w-9)
    is the only Federal program that focuses specifically on improving the
    pediatric components of emergency medical care. The program was created
    to address gaps in the provision of quality emergency medical care to
    children, and to address the specific anatomical, physiological and
    developmental needs of children. The program focuses on improving the
    everyday pediatric readiness of the Nation's EMS system to provide the
    appropriate infrastructure for disaster preparedness. Furthermore, EMSC
    focuses on emphasizing pediatric specific issues in disaster care of a
    child in a non-pediatric facility, family reunification, surge capacity
    due to the increased vulnerability of children in disaster and transfer
    to other facilities for higher levels of care.
        Question. Are our Nation's hospitals, ambulances, and first
    responders better prepared to treat pediatric patients as a result of
    the EMSC program?
        Answer. During the 2010-11 assessment of performance measures, the
    55 funded State Partnership grantees collected data from over 2,600
    emergency departments, approximately 6,660 BLS/ALS agencies, and
    conducted an assessment of more than 22,000 vehicles that transport
    children in emergency situations.
        Findings from select measures demonstrate improvement in the
    Nation's pre-hospital provider's access to pediatric medical guidance
    in the field, more Basic Life Support (BLS) and Advanced Life Support
    (ALS) transport vehicles carrying essential pediatric equipment and
    States supporting pediatric continuing education for BLS/ALS providers.
        Question. How has the EMSC program helped States be better prepared
    for the disaster response and recovery of children?
        Answer. The EMSC program is funding projects that will guide
    practice in the EMS field for which minimal evidence exist to guide
    appropriate delivery of care. Findings are translated into tool kits
    and resources that are readily available to States and local
    communities. The EMSC National resource center is working with multiple
    partner-agencies to develop a web-based resource tool with disaster
    related products, publications and resources. This will be available to
    States and local communities as they developed their disaster plans.
        EMSC is also working with States to develop models of regionalized
    care where pediatric resources may be limited. State and Territory
    grantees in the Pacific Basin are working on an inter-island agreement
    for regionalized care for the pediatric patient. This type of model can
    be used in disaster planning as well in which specialty care is
    limited, geographical boundaries may require coordination of many
    agencies and a prior infrastructure will be essential.
        EMSC collaborates with all agencies and systems involved in
    providing care to the pediatric patient and are active in contributing
    to the special situation of disaster. EMSC continues to provide
    important insight to disaster planning since issues of special
    equipment, surge capacity, regionalized care are integral to everyday
    readiness of pediatric emergency care.
        Question. What would a cut along the lines of that proposed in H.R.
    1 mean for the 127 health center sites that have opened within the past
    year and the almost 3.7 million new patients currently receiving care
    at a health center because of the investments through the American
    Recovery and Reinvestment Act?
        Answer. Funding levels provided in H.R. 1 would impact the ability
    of the Health Center Program to fully fund the 127 new access point
    grants originally supported by the Recovery Act and would also impact
    the number of patients currently served at health centers, including
    the 3.7 million patients served through the Recovery Act.
        Question. Can you tell us how many applications for new health
    centers HRSA has received?
        Answer. Over 800 applications have been received for the fiscal
    year 2011 New Access Point funding opportunity.
        Question. How many awards does HRSA intend to fund?
        Answer. HRSA is in the process of determining how many Health
    Center New Access Points through Affordable Care Act funding in fiscal
    year 2011.
        Question. How many awards would HRSA make if H.R. 1 is enacted?
        Answer. Under H.R. 1, there would have been no new funding
    available to support Health Center New Access Points in fiscal year
    2011.
        Question. Can you describe the overarching impact on the healthcare
    system of the continued health center expansion, as outlined in the
    President's fiscal year 2012 budget request?
        Answer. The President's fiscal year 2012 budget request for health
    centers, more high quality, cost-effective, preventive and primary
    healthcare services will be made available nationwide.
        Question. Madam Secretary, what additional benefits do health
    centers bring to their local communities, in addition to the creation
    of jobs and generation of economic activity?
        Answer. Health centers increase access to healthcare through an
    innovative model of community-based, comprehensive primary healthcare
    that focus on outreach, disease prevention, and patient education
    activities. For example, evaluations have found that:
      --Uninsured people living within close proximity to a health center
            are less likely to have an unmet medical need, less likely to
            have postponed or delayed seeking needed care, and more likely
            to have had a general medical visit.\1\
    ---------------------------------------------------------------------------
        \1\ Hadley J and Cunningham P. Availability of Safety Net Providers
    and Access to Care of Uninsured Persons. Health Services Research
    2004;39(5):1527-1546.
    ---------------------------------------------------------------------------
      --Health center uninsured patients are more likely to have a usual
            source of care than the uninsured nationally (98 percent versus
            75 percent).\2\
    ---------------------------------------------------------------------------
        \2\ Carlson, BL et al, ``Primary Care of Patients without Health
    Insurance by Community Health Centers.'' April 2001 Journal of
    Ambulatory Care Management  24(2):47-59.
    ---------------------------------------------------------------------------
        Increasing access and reducing disparities in healthcare requires
    quality providers who can deliver culturally-competent, accessible, and
    integrated care. Health centers recognize this need and support a
    multi-disciplinary workforce designed to treat the whole patient. For
    example, evaluations have found that:
      --Health center patient rates of blood pressure control were better
            than rates in hospital-affiliated clinics or in commercial
            managed care populations, and racial/ethnic disparities in
            quality of care were eliminated after adjusting for insurance
            status.\3\
    ---------------------------------------------------------------------------
        \3\ Hicks LS, et al. The Quality of Chronic Disease Care in US
    Community Health Centers. Health Affairs 2006;25(6):1713-1723.
    ---------------------------------------------------------------------------
      --A high proportion of health center patients receive appropriate
            diabetes care.\4\
    ---------------------------------------------------------------------------
        \4\ Maizlish NA, Shaw B, and Hendry K. Glycemic Control in Diabetic
    Patients Served by Community Health Centers. American Journal of
    Medical Quality 2004;19(4):172-179.
    ---------------------------------------------------------------------------
      --Health center low birthweight rates continue to be lower than
            national averages for all infants. In particular, the health
            center low birthweight for African-American patients is lower
            than the rate observed among African-Americans nationally (10.7
            percent versus 14.9 percent respectively).\5\
    ---------------------------------------------------------------------------
        \5\ Shi, L., et al. America's health centers: Reducing racial and
    ethnic disparities in perinatal care and birth outcomes. Health
    Services Research, 2004; 39(6):1881-1901.
    ---------------------------------------------------------------------------
      --Health centers play a critical role in providing healthcare
            services to rural residents who tend to have higher rates of
            chronic diseases, such as the 27 percent of rural residents
            suffering from obesity \6\ and nearly 10 percent diagnosed with
            diabetes.\7\
    ---------------------------------------------------------------------------
        \6\ Bennett, K. J., Olatosi, B., & Probst, J.C. (2008). ``Health
    Disparities: A Rural--Urban Chartbook.'' South Carolina Rural Health
    Research Center.
        \7\ Pleis JR, Lethbridge-Cejku M. Summary health statistics for
    U.S. adults: National Health Interview Survey, 2006. National Center
    for Health Statistics. Vital Health Stat 10(235). 2007.
    ---------------------------------------------------------------------------
      --Over the past 4 years, cost increases at health centers have been
            at least 20 percent below national increases.\8\
    ---------------------------------------------------------------------------
        \8\ Centers for Medicare and Medicaid Services, Office of the
    Actuary, National Health Statistics Group: National Health
    Expenditures: 2002-2005.
    ---------------------------------------------------------------------------
      --Rural counties with a community health center site had 33 percent
            fewer uninsured emergency room/department visits per 10,000
            uninsured population than those without a health center.\9\
    ---------------------------------------------------------------------------
        \9\ Rust George, et al. ``Presence of a Community Health Center and
    Uninsured Emergency Department Visit Rates in Rural Counties.'' Journal
    of Rural Health Winter 2009 25(1):8-16.
    ---------------------------------------------------------------------------
      --The cost of treating patients with diabetes in health center
            settings was approximately $400 less than that experienced by
            other primary care settings.\10\
    ---------------------------------------------------------------------------
        \10\ Proser M, Deserving the Spotlight: Health Centers Provide
    High-Quality and Cost Effective Care. J Ambulatory Care Management,
    2005; 28(4): 321-330.
    ---------------------------------------------------------------------------
      --In 2009, health centers generated over $11 billion in revenues and
            employed over 123,000 full-time equivalents.
        Question. I noticed that the fiscal year 2011 Application and
    Guidance released in November of 2010 did not include pharmacist as
    part of the eligible participants in NHSC loan repayment program. Are
    there any plans in the near future to include pharmacists in the NHSC
    loan repayment program?
        Answer. The National Health Service Corp (NHSC) program is
    currently conducting an analysis of the Loan Repayment Program (LRP)
    statute and program policies, which includes a review of the
    disciplines the NHSC supports.
        The inclusion of pharmacists or other disciplines must be
    consistent with the statute that established the NHSC to recruit and
    retain primary medical, dental and mental healthcare providers to
    provide primary health services to underserved populations in health
    professional shortage areas. The Public Health Service Act, which
    authorized the NHSC, defines ``primary health services'' as ``health
    services regarding family medicine, internal medicine, pediatrics,
    obstetrics and gynecology, dentistry, or mental health, that are
    provided by physicians or other health professionals'' (42 U.S. Code
    Sec. 254d(a)(3)(D)). To date, pharmacists have not been considered an
    eligible discipline for participation in the NHSC program.
        As part of the discipline review, the NHSC has also conducted a
    survey of Community Health Centers and other NSHC-approved sites to
    determine the demand for additional disciplines in the NHSC. The
    results of this survey are currently under review. Any updates to the
    eligible disciplines will be announced through program guidance.
        Question. Currently, HRSA collects data on healthcare shortage
    areas for primary care. Given the poor outcomes in pregnancy in this
    country and the shortage of physicians and midwives, are there any
    plans to look at identifying maternity care shortage areas?
        Answer. Health Professional Shortage Areas (HPSAs) are designated
    by the Department as those areas having shortages of primary medical
    care, dental or mental health providers. HPSAs may be geographic (e.g.,
    a county or service area), demographic (e.g., low-income population) or
    institutional (e.g., federally qualified health center). Among the
    factors considered in the designation process are the numbers of
    healthcare providers in the area. For the primary care HPSA
    designation, Obstetricians/Gynecologists (OB/GYNs) are included in the
    provider count when the Department evaluates the number of primary care
    providers in an area. As you know, the Affordable Care Act required the
    establishment of a Negotiated Rulemaking Committee (Committee) to make
    recommendations regarding a revised methodology, criteria and process
    for making such shortage designations. The Committee is considering the
    role of OB/GYNs in the development of revised criteria for primary care
    shortage designation. There are not, however, current plans to
    separately identify maternity care shortage areas.
        Question. In the remote islands of Hawaii women have few options
    for giving birth. We know that freestanding birth centers have improved
    access to care and made significant impact on disparities for mothers
    and babies. What plans, if any, are there to provide funding to develop
    more of these freestanding birth centers in underserved communities?
        Answer. The Health Center Program does not provide funding
    specifically for the development of birthing centers. However, health
    centers may choose to address the primary healthcare needs of their
    target populations through a variety of services including obstetrics
    care and site locations within their approved Health Center Program
    grant.
        Question. The Maternal and child health services block grant
    facilitate in planning, promoting, coordinating and evaluating
    healthcare for pregnant women, mothers, infants, and children, children
    with special healthcare needs, and families in providing health
    services for those populations who do not have access to adequate
    healthcare. I am concerned that decreased funding for this important
    program may have a negative impact on our Nation. Would you please
    describe the rationale behind decreasing funding for Maternal Child
    Block Grants in the fiscal year 2012 budget?
        Answer. The fiscal year 2012 budget proposes a decrease to the
    Maternal and Child Health Block Grant. The proposed budget would reduce
    funding for categorical research grants and not from the MCH grants to
    States, in order to respond to the priorities in the fiscal year 2011
    final appropriations.
        Question. In 2000, Congress launched an important national program,
    the National Child Traumatic Stress Initiative, which focuses on a
    child traumatic stress, a critical public health problem. With over 130
    funded and affiliate programs, this SAMHSA program addresses the
    specific needs of children and families who are exposed to a wide range
    of trauma, including physical and sexual abuse, violence in families
    and communities, natural disasters and terrorism, accidental or violent
    death of a loved one, refugee and war experiences, and life-threatening
    injury and illness. Over the past 10 years, this program has had strong
    bipartisan and bicameral support. The program has been shown to be
    extraordinarily effective in expediting science to service through a
    collaborative and systems change approach that is helping children and
    families recover by improving the treatment and services they receive.
    In Hawaii, we have a strong program through our Catholic Charities
    Center, and have seen firsthand the benefits of this initiative.
        Secretary Sebelius, in fiscal year 2010 the funding for this
    program was $40,798,000. In fiscal year 2012, the funding drops to
    $11,300,000 a 72 percent cut from fiscal year 2010 funding levels.
    Would you please describe the rationale behind cutting funding to this
    valuable program?
        Answer. SAMHSA is committed to developing and disseminating trauma-
    informed services by expanding efforts to infuse trauma-informed
    related activities and lessons learned from the 10-year history of the
    National Child Traumatic Stress Network (NCTSN) across its entire grant
    portfolio. SAMHSA's commitment to bring trauma-informed services to
    scale will reach beyond individual programs and grantees, build on the
    success of the NCTSN, and include a focus on a diverse mix of
    communities (e.g., military families) and trauma-related experiences
    (e.g., environmental, historic, economic) while allowing States to
    focus resources in communities with the greatest needs. SAMHSA is also
    working with the Administration on Children and Families (ACF) and the
    Department of Justice (DOJ) to provide technical assistance and share
    evidence-based practices and products garnered generated from the
    NCTSN. The fiscal year 2012 request for NCTSN does not terminate or
    reduce any existing grants.
                                     ______

                    Questions Submitted by Senator Herb Kohl
        Question. I am concerned about the timeline of implementing the
    physician sunshine provisions (section 6002) of the Affordable Care
    Act. Shining light on industry payments to physicians will help
    demonstrate the importance of proper research relationships, while
    exposing and eliminating conflicts of interest and providing important
    information to patients about their health choices.
        As you know, the Department of Health and Human Services (HHS) has
    a deadline of this October to establish the procedures by which
    industry must report information. However, it would be helpful to
    release guidance as soon as possible. Businesses and industry will need
    time to develop their internal systems to comply with the disclosure
    deadline of March 31, 2013. As you develop the guidance, I encourage
    you to work closely with stakeholder groups to ensure that the data
    collected will be useful and consistent with the legislation's intent.
        With these deadlines looming, what is HHS's plan for implementation
    of the sunshine regulations? Has your staff been meeting regularly with
    stakeholder groups? What is your timetable for proposing the scope of
    reportable information? Included in your response, please detail which
    office will be drafting and finalizing these rules and why that office
    was chosen.
        Answer. HHS is moving forward with the implementation of the
    Affordable Care Act's requirements related to Section 6002,
    ``Transparency Reports and Reporting of Physician Ownership or
    Investment Interests.'' After reviewing the responsibilities this
    provision delegates to the Department, I decided that the Centers for
    Medicare & Medicaid Services (CMS) would be the most appropriate agency
    to implement all of the requirements. CMS is currently in the process
    of rulemaking to establish procedures for reporting and more
    information will be forthcoming as the process moves forward. CMS'
    Center for Strategic Planning and the Center for Program Integrity have
    dual responsibility for developing these regulations. To prepare for
    rulemaking, they have individually met with at least seven different
    industry stakeholders, and consulted with State agencies from Minnesota
    and Massachusetts, which already have considerable experience with this
    type of data collection. In addition, on March 24, 2011, CMS held an
    open door forum to discuss the provision and to solicit feedback from
    almost 500 industry participants. CMS is working hard to meet the
    requirements and the deadlines of the physician sunshine provision,
    including providing industry with the information they will need to
    comply with it.
        Question. An estimated 75 percent of all pregnant women use 4 to 6
    prescriptions or over-the-counter drugs at some time during their
    pregnancy. I am concerned that a proposed rule to improve pregnancy
    labeling has been pending at the Food and Drug Administration (FDA) for
    nearly 3 years after comments were received in August, 2008. I have
    corresponded with HHS and Commissioner Hamburg about this rule and have
    not received an adequate response regarding a timeline for its
    finalization. I ask again, what is the status of this rule? Given the
    importance of this issue to safeguarding the health of pregnant women,
    I think getting this proposed rule finalized should be a priority. Is
    it a priority for HHS and the FDA?
        Answer. Publication of the rule regarding drug labeling for
    pregnant and lactating women remains a priority within FDA. Earlier
    this year, my staff met with your staff to discuss the status of this
    rule, and as they made clear, FDA staff is actively working on the
    rule. After a rule is prepared, it undergoes a clearance process prior
    to publication. Because the timeframes for preparing the regulation and
    completing each step of the clearance process could be affected by
    various, unpredictable, factors, FDA cannot say for certain when the
    final rule will publish. Please be assured that FDA is committed to
    finalizing this rule as promptly as possible.
                         ncats and the effect on ctsas
        Question. I am concerned about the reorganization within the
    National Institutes of Health (NIH) that will affect the Clinical and
    Translational Science Awards (CTSA) program, in which Wisconsin has a
    substantial stake. The NIH invested $42 million into the University of
    Wisconsin (UW) in a 5-year CTSA commitment. UW has successfully
    leveraged an additional $40 million in local resources. Together, over
    the past 4 years these dollars have enabled UW to: (1) train young
    scientists in clinical and translational research; (2) pursue clinical
    and translational research endeavors through a streamlined and more
    efficient research infrastructure; (3) create interdisciplinary
    research teams that can pursue diversified research more easily; (4)
    sustain a multi-disciplinary partnership across the State with other
    major Wisconsin institutions, including the Marshfield Clinic; and (5)
    partner with more than 100 community organizations to form research
    partnerships and perform collaborative research aimed at improving
    health in the community and eliminating health inequities.
        The CTSA also promoted intrastate collaboration with UW, whose
    efforts have been complemented by independent and collaborative
    activities at the Medical College of Wisconsin, where a similar CTSA
    grant was awarded. These entities have all made major investments of
    resources and capital to deliver on their commitments to CTSA--in
    infrastructure, faculty, and research initiatives, to name a few.
        Given the impact of CTSA in Wisconsin, I request clarity regarding
    the future of this program. The President's budget proposed that the
    CTSA program become part of the new National Center for Advancing
    Translational Sciences (NCATS) at NIH. However, the future of CTSA and
    its scope remains in question. With this in mind, I ask that you
    provide me with information about plans regarding CTSAs with respect to
    the following: (1) potential and/or planned changes in the CTSA mission
    or the scope of the CTSA program in 2011 and beyond, particularly the
    goal aimed at engaging communities in clinical research efforts; (2)
    potential and/or planned changes in the CTSA budget and in the number
    of institutions that may or are likely to receive CTSA funding in 2011
    and beyond; (3) potential and/or planned changes in eligibility
    criteria for participants in the CTSA program; and (4) potential and/or
    planned changes in the process or rules for applicants to receive CTSA
    funding.
        Answer. The Clinical and Translational Science Awards (CTSA) are
    slated to be moved into the proposed National Center for Advancing
    Translational Sciences (NCATS) in fiscal year 2012. We believe that
    this will be a natural fit; it will serve the CTSAs well to be in an
    institute that has a complementary mission to their own, which is to
    advance translational sciences.
        The CTSAs conduct and support a wide range of translational
    research, including therapeutics discovery and development, community
    engagement, education and training, and regulatory sciences. Their
    contributions in these areas are critical to the mission of NCATS and
    the NIH as a whole. However, Director Collins understands the
    importance of a smooth transition of this program to a new center. His
    goal is to ensure that the CTSAs can continue their important work as
    we move to stand up NCATS by October 1. To meet that goal, in April
    2011, he convened a trans-NIH working group (the NIH CTSA/NCATS
    Integration Working Group) to: (a) enumerate the roles and capabilities
    of the CTSAs that can support and enhance the mission of NCATS; (b)
    identify CTSA needs and priorities that should be understood and
    addressed by NIH and NCATS leadership; and (c) propose processes for
    ensuring a smooth transition from NCRR to NCATS.
        This group, which is chaired by Dr. Stephen Katz, Director of the
    National Institute of Arthritis and Musculoskeletal and Skin Disorders
    (NIAMS) will consult with a group of CTSA principal investigators, the
    CTSA Consortium Executive Committee (CCEC), who have been involved in
    many discussions with the NIH working group as they carry out their
    charge. The working groups' recommendations will help Dr. Collins and
    his senior staff make informed decisions about the CTSAs that will
    ensure a smooth transition into NCATS. No decisions regarding the
    administration of the currently awarded CTSAs will be made until they
    have completed their work.
        CTSA investigators who are not part of the CECC can engage with the
    NIH in a number of different ways: utilize the CECC as a conduit of
    information both from and to NIH; attend CTSA leadership meetings that
    will be held this summer; and provide input directly to NIH through
    CTSA staff or the website Feedback NIH.
        Question. In 2009, I worked to ensure that long-term care
    facilities were eligible for health information technology (HIT)
    funding included in the American Recovery and Reinvestment Act by
    expanding the general definition of ``healthcare provider'' to also
    include nursing and other long-term care facilities. What is the status
    of providing HIT funds to long-term care providers? What has been done
    to help long-term care providers access these funds?
        Answer. The Office of the National Coordinator for Health
    Information Technology (ONC) administers grant programs that support
    health information exchange within the long-term care community. ONC
    provided $265 million to Beacon communities across the Nation. For
    example, Bangor, Maine's Beacon community is bringing long-term care
    facilities together with hospitals and other physicians to coordinate
    care by using health IT.
        Additionally, through the State HIE Challenge Grant, ONC awarded
    $6.8 million to four grantees for work in improving long-term and post-
    acute care transitions through health information exchange. Grant
    funding supports the following activities:
      --Identification of the data elements for health information exchange
            that are relevant to acute to long-term care transitions.
      --Determination of strategies to meet improved acute to long term
            care transition goals.
      --Development of consumer friendly language for personal health
            records (PHRs), conversion of transfer forms to electronic
            format, and dissemination of best processes for ensuring safe
            care transitions--all of which will be integrated into health
            information exchange for acute to long-term care transitions.
      --Implementation of pilot programs at local and/or regional levels to
            test health information exchange for acute to long-term care
            transitions, which can then be expanded to the State and
            national levels.
        ONC is also engaging with the long-term care provider community in
    its efforts to establish a clinical electronic infrastructure and
    engaging long-term care providers in developing the Electronic Health
    Record (EHR) Incentive program's ``Meaningful Use'' definition.
        Question. This year offers a prime opportunity to reshape and
    modernize aging services through the reauthorization of the Older
    Americans Act (OAA). As Chairman of the Senate Special Committee on
    Aging, I am looking forward to working with Assistant Secretary
    Greenlee to reauthorize the OAA. Has the administration set any
    priorities for OAA reauthorization? Please provide a timeline for when
    we might expect to receive an OAA proposal from the administration.
        Answer. Over the past year, the Administration on Aging conducted
    the most open system for providing input on recommendations for
    reauthorizing the Older Americans Act in its history, convening and
    receiving reports from more than 60 reauthorization listening sessions
    held throughout the country, and receiving online input from interested
    individuals and organizations, as well as from seniors and their
    caregivers. This input represented the interests of thousands of
    consumers of the OAA's services, and we continue to receive input and
    work with advocates on a variety of issues.
        Based in part upon this extensive public input process, we think
    that reauthorization can strengthen the Older Americans Act and put it
    on a solid footing to meet the challenges of a growing population of
    seniors. We look forward to working with you and the Special Committee
    on Aging on bipartisan reauthorization legislation.
        The following are some examples of areas that we would like to
    discuss with the Committee as you consider legislation:
      --Ensuring that the best evidence-based interventions for helping
            older individuals manage chronic diseases are utilized. A
            number of evidence-based programs have proven effective in
            helping participants adopt healthy behaviors, improve their
            health status, and reduce their use of hospital services and
            emergency room visits.
      --Improving the Senior Community Service Employment Program (SCSEP)
            by integrating it with other seniors programs. The President's
            budget proposes to move this program from the Department of
            Labor to the Administration on Aging within HHS. The goal of
            this move is to better integrate this program with other senior
            services provided by AoA. We would like to discuss with you
            adopting new models of community service for this program,
            including programs that engage seniors in providing community
            service by assisting other seniors so they can remain
            independent in their homes.
      --Combating fraud and abuse in Medicare and Medicaid by embedding the
            Senior Medicare Patrol Program (SMP) in the OAA as an ongoing
            consumer-based fraud prevention and detection program. The SMP
            program serves a unique role in the Department's fight to
            identify and prevent healthcare fraud by using the skills of
            senior volunteers to conduct community outreach and education
            so that seniors and families are better able to recognize and
            report suspected cases of Medicare and Medicaid fraud and
            abuse. In fiscal year 2009, the program educated over 215,000
            beneficiaries in over 40,000 group education sessions and one-
            on-one counseling sessions, resolving or referring for further
            investigation over 4,000 complaints of potential fraud, error,
            or abuse.
        Question. The Elder Justice Act established the Elder Justice
    Coordinating Council to meet and make recommendations relating to elder
    abuse, neglect and exploitation. By law, this council is tasked with
    meeting twice annually and reporting to Congress by March, 2012. What
    is the status of and timetable for implementing the Elder Justice
    Coordinating Council?
        Answer. As of March 30, 2011, we have accepted nominations to the
    Elder Justice Advisory Board, which makes recommendations to the Elder
    Justice Coordinating Council. The timetable for further action is under
    development.
                                     ______

                  Questions Submitted by Senator Patty Murray
                                 trauma funding
        Question. The Administration's fiscal year 2012 budget proposal
    includes $765 million ``to enhance the advanced development of next
    generation medical countermeasures against chemical, biological,
    radiological and nuclear threats.'' The budget proposal also provides
    $655 million ``to ensure the availability of medical countermeasures
    from the Strategic National Stockpile during a public health
    emergency.''
        Given this significant investment in biodefense, I am concerned
    that the Administration's budget does not similarly support our
    Nation's fragile trauma centers and systems, which will most certainly
    be called upon in the event of another terrorist attack or public
    health emergency. It is very concerning to note that 23 trauma centers
    have closed over the past decade and 45 million people lack access to a
    trauma center within 1 hour following injury during which definitive
    treatment can make the difference between life and death. In addition,
    $80 billion annually is attributed to trauma medical expenses and $326
    billion is estimated for lifetime productivity losses for almost 50
    million injuries that required medical treatment.
        While the Administration's fiscal year 2011 budget includes
    funding, albeit decreased, for Public Health and Emergency Preparedness
    grants and Hospital Preparedness grants, these funds do not fully
    address the urgent needs of our trauma centers and systems.
        Given these facts, what is the Administration doing to make the
    necessary investments in our Nation's trauma centers and systems?
        Is the Administration working to fund the National Trauma Center
    Stabilization Act and the Trauma Care Systems Planning and Development
    Act (Public Health Service Act sections 1201-4, 1211-32, 1241-46 and
    1281-2) so that all Americans have access to trauma care during every
    day traumatic events or in the event of another terrorist attack?
        Answer. While there is no funding for the National Trauma Center
    Stabilization Act and the Trauma Care Systems Planning and Development
    Act in the HHS 2012 budget, the Secretary of Health and Human Services
    delegated to the Assistant Secretary for Preparedness and Response the
    authorities vested in the Secretary under sections 1201-1232 of title
    12 of the Public Health Service Act, parts A through C of title 12, (42
    USC Sec. 300d through 300d-32), as amended, to administer grants and
    related authorities for trauma care. This also included the transfer of
    authority from the Health Resources and Services Administration to ASPR
    the authorities transferred in the affordable care act. These sections
    include four grant programs relating to trauma and emergency medical
    care. In addition, section 1201 also provides, among other things, the
    authority to sponsor workshops and conferences related to trauma and
    emergency care and to conduct and support research related to trauma
    and emergency care. This was an important first step in implementing
    provision of the Affordable Care Act relating to trauma programs. While
    these activities have not received funding, ASPR has undertaken a
    cooperative venture with CDC's National Center for Injury Prevention
    and Control to assist high-profile cities in improving their plans to
    respond to mass casualty events caused by major traumatic events such
    as terrorist bombing. Additionally, since the establishment of the
    Hospital Preparedness Program, over $3.3 billion has been provided to
    hospitals to improve overall surge capacity and strengthen the
    capability of hospitals and healthcare systems to plan, respond to, and
    recover from all hazard events.
                                title x funding
        Question. Title X is the Nation's cornerstone family planning
    program for low-income women. Each year approximately 5 million low-
    income individuals receive basic healthcare, including cancer
    screenings, birth control, and HIV testing, at clinics receiving funds
    under this program.
        As we consider recommendations for the coming year, we're mindful
    that the House-passed fiscal year 2011 continuing resolution eliminates
    all $317 million in funding for the Title X program.
        Given that 6 in 10 women who receive care at a Title X health
    center consider it their primary source of medical care, what would be
    the effects of zeroing out the program?
        Answer. The Title X Family Planning program is the only Federal
    grant program dedicated solely to providing individuals with
    comprehensive family planning and related preventive health services.
    The program establishes the framework for the delivery of publicly
    funded family planning services in the United States, providing funding
    to more than 4,500 sites across the United States, including State and
    local health departments, freestanding clinics, hospitals, family
    planning councils, and Planned Parenthood agencies. At least 90 percent
    of Title X program funds are used to provide clinical services. Title X
    services include preventive health services such as cervical cancer
    screening, contraceptive counseling and supplies, pelvic exams, breast
    and cervical cancer screening, basic infertility counseling, clinical
    breast exams, HIV and STI tests, and other services related to
    reproductive health and family planning. Title X-funded agencies served
    an estimated 5 million individuals each year. At least 90 percent of
    the Title X clients served each year have family incomes at or below
    200 percent of the Federal poverty level. For many, a family planning
    clinic is their entry point into the healthcare system and is
    considered to be their usual source of care. This is especially true
    for women with incomes at or below 100 percent of the Federal poverty
    level, who are uninsured, Hispanic, or black. One-quarter of all poor
    women who obtain contraceptive services do so at a site that receives
    Title X funding, as do 17 percent of poor women obtaining a Pap test or
    pelvic exam and 20 percent obtaining services for a sexually
    transmitted infection.
        In fiscal year 2009, it is estimated that nearly 1 million
    unplanned pregnancies were averted by services provided at Title X
    agencies, including more than 233,000 among teens. In 2009, 2,035,017
    female clients received screenings for cervical cancer. It is estimated
    that these screenings contributed to preventing approximately 670 cases
    of invasive cervical cancer. In 2009, more than 2.5 million clients
    were tested for Chlamydia and Gonorrhea, and nearly 800,000 were tested
    for syphilis. In 2009, nearly 1 million HIV tests were conducted.
    Services provided at Title X-supported clinics were estimated to
    account for $3.4 billion in savings in 2008 alone. Title X is also
    cost-effective--Title X-funded centers saved taxpayers an estimated
    $3.4 billion in 2008--or $3.74 for every $1 spent on contraceptive
    care. Unintended pregnancy has been linked with numerous negative
    maternal and child health outcomes. More broadly, contraception can
    enable women and couples to plan and space births, allowing them to
    invest in higher education and to participate more broadly in the
    Nation's workforce. Title X also provides a critical source of funding
    for our Nation's public healthcare infrastructure, which would look
    quite different in the absence of Title X funds. In short, in the
    absence of Title X, rates of unintended pregnancy, infertility and
    related morbidity, and abortion would be considerably higher. In
    addition, the public health infrastructure would be negatively
    impacted, at a considerable cost to the overall healthcare system.
                     federal funding for planned parenthood
        Question. As you know, the House-passed fiscal year 2011 continuing
    resolution prohibits Planned Parenthood from receiving any Federal
    funds. Planned Parenthood operates approximately 575 health centers
    across the country that receive Title X funds to provide non-abortion-
    reproductive healthcare like pap smears, birth control, and cancer
    screenings.
        Could you tell me what the impact of disqualifying Planned
    Parenthood from all Federal funds would be on women and families across
    the country, were this policy adopted for into next year's budget?
        Answer. More than 800 Planned Parenthood clinics receive some
    portion of their funding through a variety of federally funded public
    health programs, including Title X and Medicaid. Medicaid is by far the
    largest source of funding. For some beneficiaries of these public
    health programs, Planned Parenthood serves as a critical source of
    services and supplies to prevent unplanned pregnancy, screen for
    cervical and breast cancer, vaccinate to prevent cervical cancer, and
    obtain pelvic exams and patient education and counseling. Barring
    Federal funding to Planned Parenthood agencies could create barriers to
    these services, many of which are critical to women's health. Planned
    Parenthood estimates that it serves 1.8 million clients with Federal
    funds, and provides nearly 4 million STI tests and more than 900,000
    cervical cancer screening tests. Without access to these basic
    services, rates of STIs, unplanned pregnancy, and abortion could
    increase.
        Question. Can you describe the overarching impact the continued
    health center expansion, as outlined in the President's fiscal year
    2012 budget request, will have on the healthcare system, in terms of
    the cost-effectiveness and quality of services that health centers
    provide? And what about other benefits--like jobs generated and
    economic impact?
        Answer. Through the President's fiscal year 2012 budget request for
    health centers, more high quality, cost-effective, preventive and
    primary healthcare services will be made available. Through the fiscal
    year 2012 budget request, health centers are projected to employ
    thousands of additional staff.
        Question. As you know, the Balanced Budget Act of 1997 established
    that teaching hospitals may count, for the purposes of indirect (IME)
    post-graduate physician education payments, resident time spent in non-
    hospital settings, so long as certain conditions are met. One of these
    conditions set out in the legislation is that the ``hospital must incur
    all or substantially all of the costs for the training program in the
    nonhospital setting . . .''.
        However, CMS, in its final rules for the Inpatient Prospective
    Payment System (IPPS) in 2004, interpreted the law to mean that the
    resident time is allowed only when one hospital sponsors the resident's
    participation in the non-hospital experience. This interpretation puts
    many shared residency rotation programs, including family medicine
    residency programs, in my State at risk, at a time when we should be
    encouraging more residency programs, not less.
        Congress made clear that this was not the intention of the original
    legislation in Section 5504 of the Patient Protection and Affordable
    Care Act. This section modifies rules governing when hospitals can
    receive indirect medical education (IME) and direct graduate medical
    education (DGME) funding for residents who train in a non-provider
    setting so that any time spent by the resident in a non-provider
    setting shall be counted toward direct and indirect medical education
    if the hospital incurs the costs of the stipends and fringe benefits.
        Are there discussions ongoing at HHS to alter the current
    interpretation of resident shared rotation and IME payments,
    particularly in light of provisions in the Affordable Care Act?
        Answer. As you note in your question, section 5504 of the
    Affordable Care Act addresses the situation in which more than one
    hospital incurs the costs of training programs at non-provider
    settings. The provision allows hospitals to count, on a prospective
    basis only, a proportional share of the time that a resident spends
    training in such settings when more than one hospital incurs the costs.
    The Centers for Medicare & Medicaid Services (CMS) finalized its
    proposal to implement section 5504 in the CY 2011 Hospital Outpatient
    Prospective Payment System final rule, which was published in the
    Federal Register on November 24, 2010. The final rule allows hospitals
    to share the costs of resident training at non-provider sites, so long
    as those hospitals divide the resident time proportionally in
    accordance with a written agreement. In doing so, the final rule
    requires that hospitals have a reasonable basis for establishing the
    proportion and that the hospitals document the amount they are paying
    for the salaries and fringe benefits of the residents for the amount of
    time the residents are training at that site.
    funding for the national institute for occupational safety and health's
                         education and research centers
        Question. The Administration's fiscal year 2012 budget request
    zeroed out all funding for the National Institute for Occupational
    Safety and Health's (NIOSH) Education and Research Centers.
        What was the original programmatic intent for the National
    Institute for Occupational Safety and Health (NIOSH)-funded Education
    and Research Centers (ERCs)? As part of your reply to this question,
    please provide a copy of the original program announcement for the
    record.
        Has HHS assessed whether this NIOSH program has fulfilled its
    statutory mandate under Section 21 of the Occupational Safety and
    Health Act of 1970 to provide an adequate supply of safety and health
    professionals?
        Has HHS assessed the impact on ERCs from zeroing funding for the
    program in fiscal year 2012?
        Answer. The original programmatic intent of the ERC program, which
    was established in 1977 in response to Section 21(a) of the
    Occupational Safety and Health Act, was to create ``education programs
    to provide an adequate supply of qualified personnel to carry out the
    purposes of the Act''. The program was envisioned as a commitment to
    training future professionals to work in industry, public health, and
    academia. NIOSH has established partnerships with 48 academic
    institutions that comprise the academic network responsible for the
    Nation's occupational safety and health professional training
    infrastructure. Through university-based ERCs, NIOSH supports academic
    degree programs and research training opportunities in the core areas
    of industrial hygiene, occupational health nursing, occupational
    medicine, and occupational safety, plus specialized areas relevant to
    the occupational safety and health field. NIOSH also supports ERC
    short-term continuing education programs for occupational safety and
    health professionals and others with worker safety and health
    responsibilities. Please see attached program announcement from 1976.

                        [ERC Program Announcement, 1976]

                  DEPARTMENT OF HEALTH, EDUCATION AND WELFARE
                             Public Health Service
                           center for disease control
     grants for occupational safety and health educational resource centers
                               program guidelines
        The National Institute for Occupational Safety and Health is
    implementing a new national competition for training project grants to
    support a limited number of Occupational Safety and Health Educational
    Resource Centers. It is proposed to establish by 1980, subject to the
    availability of funds, at least 10 Center's--at least one in each
    Department of Health, Education, and Welfare Region.
    Authority
        Grants for Educational Resource Centers will be awarded under the
    Institute's basic training grant authority, the Occupational Safety and
    Health Act of 1970 (29 U.S.C. 670a). Except as otherwise indicated in
    these guidelines, the basic policies of the Public Health Service
    Grants Policy Statement (HEW Publication No. (OS) 77-50.000 (Rev.)
    October 1, 1976) are applicable to this program as are the HEW
    regulations on Grants for Educational Programs in Occupational Safety
    and Health (42 CFR Part 86).
    Background and Objectives
        In 1971, the Institute established training grant programs to
    assist public or private nonprofit educational institutions in
    establishing, strengthening or expanding graduate, undergraduate or
    special training of persons in the field of occupational safety and
    health in order to provide an adequate supply of qualified personnel to
    carry out the purposes of the Act. (Catalog of Federal Domestic
    Assistance 13.263). Past and current training project grants have
    provided support for primarily, single discipline and single level
    occupational safety and health training programs, e.g., in occupational
    medicine, occupational health nursing, industrial hygiene, safety
    engineering, etc., at either the graduate, undergraduate or technical
    and paraprofessional level. The multidisciplinary scope of occupational
    health and safety has been recognized by many to be diverse and
    complex. It has also been realized that special problems arise at the
    workplace from which new concepts develop that do not fall within any
    single, traditional discipline. Yet, within this framework, increased
    numbers of people must be educated to achieve effective prevention of
    the many occupational health and safety hazards that occur at the
    workplace.
        The objective of this competition is to provide a mechanism for
    combining and expanding existing activities and arranging for
    coordinated multi-discipline and multi-level training and continuing
    education in occupational safety and health under a single grant
    servicing a geographic region. The program is intended to afford
    opportunity for full- and part-time academic career training, for cross
    training of occupational safety and health practitioners, for mid-
    career training in the field of Occupational Health and Safety, and
    access to many different and relevant courses for students pursuing
    various degrees. Further, the combination of these should result in
    cross-fertilization among the various disciplines and levels of
    occupational safety and health practice.
        It is anticipated that Centers will form from bases of ongoing
    educational, research and training activities in occupational safety
    and health. It is not intended to generate these activities de novo as
    this would not net the objectives of this program.
    Eligibility Requirements
        An eligible applicant is any public or private nonprofit
    educational or training agency or institution located in a State:
    provided that no agency or institution is eligible for assistance for a
    separate training project grant in any project period in which it
    receives an educational resource center grant. However, this will not
    preclude an existing training grant from being incorporated into an
    educational resource center grant award.
        A Center may be comprised within one educational institution or
    agency or within an association of two or more institutions or
    agencies. Educational and administrative justification for any joint
    arrangement must, however, be fully documented in the application. If
    such proposals are made, each institution, proposing to participate in
    a joint arrangement must also participate in the application by
    delineating the educational and training activities that in totality
    constitute the Educational Resource Center and which, through
    interaction and proximity, will improve the probability of the success
    of the total program, as indicated in the guidelines below. Current
    Public Health Service policy covering consortia and collaborative
    arrangements must be complied with. A proposal for a Center which is in
    effect a collation of unrelated training activities will not be
    considered responsive.
    Characteristics of an Educational Resource Center
        An Occupational Safety and Health Educational Resource Center
    should be an identifiable organizational unit within the sponsoring
    organization and shall have the following characteristics:
      --Cooperative arrangements between a medical school (with
            anestablished program in preventive or occupational medicine);
            school of nursing and school of public health or its
            equivalent, and school of engineering or its equivalent. Other
            schools or departments with relevant disciplines and resources
            may be expected to be represented and contribute as appropriate
            to the conduct of the total program, e.g., toxicology,
            biostatistics, environmental health, law, business
            administration, education, etc.
      --A Director who possesses a demonstrated capacity for sustained
            productivity and leadership in occupational health and safety
            training, He shall oversee the general operation of the Center
            Program and shall, to the extent possible, directly participate
            in training activities.
      --A full-time professional staff representing various disciplines and
            qualifications relevant to occupational safety and health to be
            capable of planning, establishing, and carrying out or
            administering training projects undertaken by the Center.
      --Training and research expertise, appropriate facilities and ongoing
            training and research activities in occupational safety and
            health areas.
      --A program for conducting education and training of occupational
            physicians, occupational health nurses, industrial hygienists/
            engineers and safety personnel. There shall be full-time
            students in each of these core disciplines, with a goal of a
            minimum of 30 full-time students. Training may also be
            conducted in other occupational safety and health career
            categories, e.g., industrial toxicology, biostatistics and
            epidemiology, ergonomics, etc. Training programs shall include
            appropriate field experience including experience with public
            health and safety agencies and labor-management health and
            safety activities.
      --Impact on the curriculum taught by relevant medical specialties,
            including radiology, orthopedics, dermatology, internal
            medicine, neurology, perinatal medicine, pathology, etc.
      --A program to assist other institutions or agencies located within
            their region including schools of medicine, nursing and
            engineering, among others, by providing curriculum materials
            and consultation for curriculum/course development in
            occupational safety and health, and by providing training
            opportunities for faculty members.
      --A specific plan for preparing, distributing and conducting courses,
            seminars and workshops to provide short-term and continuing
            education training courses for physicians, nurses, industrial
            hygienists, safety engineers and other occupational safety and
            health professionals, paraprofessionals and technicians,
            including personnel of labor-management health and safety
            committees, in the geographical region in which the Center is
            located. The goal shall be that the training be made available
            each year to a minimum of 200-250 trainees representing all of
            the above categories of personnel, on an approximate
            proportional basis with emphasis given to providing
            Occupational Safety and Health training to physicians in family
            practice, as well as industrial practice, and industrial
            nurses. Where appropriate, it shall be professionally
            acceptable in that Continuing Education Units (as approved, for
            example, by the American Medical Association, American Nursing
            Association, etc.) may be awarded, These courses should be
            structured so that either educational institutions, public
            health and safety agencies, professional societies or other
            appropriate agencies can utilize them to provide training at
            the local level to occupational health and safety personnel
            working in the workplace. Further, the Center shall have a
            specific plan and demonstrated capability for implementing such
            training directly and through other institutions or agencies in
            the region, including cooperative efforts with labor unions and
            industry trade associations where appropriate, thus serving as
            a regional resource for addressing the problems of occupational
            safety and health that are faced by State and local
            governments, labor and management.
      --Specific mechanisms to implement the cooperative arrangements,
            e.g., between departments, schools/colleges, universities,
            etc., necessary to insure that the comprehensive, multi- or
            core-disciplinary training and education that is intended shall
            be engendered.
      --A Board of Advisors or Consultants, with representation of the user
            and affected population, including representation of employers
            and employees, of the Center outreach and continuing education
            and training programs should be established by the grantee
            institution to assist the Director of the Center in periodic
            evaluation of the Center activities.
        An application for a Center grant must address each of the above
    points. The nature and organization of the appropriate administrative
    teaching and support staffs and necessary supplies, equipment,
    facilities, etc., should be clearly detailed in the proposal and
    clearly related to the budget requested. This program cannot provide
    funds for new construction or major alterations or renovations, thus
    facilities must be available for the primary needs of the proposed
    Center activities.
    Criteria for Review
        The applications for Occupational Safety and Health Educational
    Resource Centers solicited in this announcement will be evaluated in
    national competition. The review is expected to involve a site visit.
    The reviewing applications criteria utilized include:
      --The overall potential contribution of the project toward meeting
            the needs for qualified personnel to carry out the purposes of
            the Occupational Safety and Health Act of 1970, the expressed
            purpose of which is to ``assure so far as possible every
            working man and woman in the Nation safe and healthful working
            conditions and to preserve our human resources--by providing
            for training programs to increase the number and competence of
            personnel engaged in the field of occupational safety and
            health.''
      --The need for training in the areas outlined by the application,
            including projected enrollment, recruitment, regional needs
            both in quality and quantity, similar programs, if any, within
            the geographic area.
      --The extent to which arrangements for day-to-day management,
            allocation of funds and cooperative arrangements are designed
            to effectively achieve Characteristics of an Educational
            Resource Center, above.
      --The extent to which curriculum content and design includes
            formalized training objectives, minimal course content to
            achieve certificate or degree, course descriptions, course
            sequence, related courses open to students, time devoted to
            lecture, laboratory and field experience, the nature of the
            latter (primarily applicable to academic training).
      --Previous record of training in this or related areas, including
            placement of graduates.
      --Methods proposed to evaluate effectiveness of training.
      --The competence, experience and training of the Center Director and
            of other professional staff in relation to the type and scope
            of training and education involved.
      --Institutional commitment to Center goals.
      -- Academic and physical environment in which the training will be
            conducted, including access to appropriate occupational
            settings.
      -- Appropriateness of the budget required to support each component
            of the program.
    Operational Aspects
        Although the mechanism for support for the Center will be a
    training grant, it will differ from other grants in its emphasis on
    priority of occupational safety and health training in the medical and
    nursing disciplines and in conducting an outreach program in curriculum
    development and continuing education projects designed to increase
    admissions to and enrollment in occupational safety and health training
    of persons who, by virtue of their background and interest or position,
    are likely to engage or participate in the delivery of occupational
    health and safety services.
        While it is expected that each Center will plan, develop, direct
    and execute its own program, it must also be responsive to the
    identified needs of the National Institute for Occupational Safety and
    Health, both in content and direction. The award of a Center grant will
    establish a special collaborative relationship between the National
    Institute for Occupational Safety and Health and the grantee
    institution. NIOSH staff, with consultation and assistance from
    representatives of the kinds of user groups of the Center program
    (e.g., academic labor, management and public health and safety
    agencies) will provide initial and continuing review and evaluation of
    the Center programs.
        From 2005 to 2010, the number of trained occupational safety and
    health (OSH) professionals has steadily increased. There were 1,191
    graduates during the past 5 academic years (from 2005-06 to 2009-10).
    Of these 1,191 ERC graduates 978 (82 percent) entered careers in OSH or
    entered more advanced degree programs in OSH. This is due to the
    increase in awareness of OSH and the comprehensive curriculum which
    provides a variety of continuing education opportunities for OSH
    professionals. Of the 287 ERC graduates in 2009-2010, 234 (82 percent)
    entered careers in OSH or entered more advanced degree programs in OSH.
        Within the context of a budget that requires tough choices, we put
    forth a proposal to discontinue Federal funding for the ERCs. We
    recognize the vital role of occupational safety and health professional
    training. This proposal is one of many difficult reductions we proposed
    as part of the fiscal year 2012 budget.
    funding for the national institute for occupational safety and health's
                   agriculture, fishing and forestry program
        Question. The Administration's fiscal year 2012 budget request also
    zeroed out all funding for the National Institute for Occupational
    Safety and Health's (NIOSH) Agriculture, Fishing and Forestry Program.
        How does the rate of occupational injury and illness and fatalities
    in agriculture, fishing and forestry (AgFF) compare with injury rates
    in general industry.
        Did the 2007 National Academy (NA) review of NIOSH's Agriculture,
    Forestry and Fishing research program recommend elimination of the AgFF
    program?
        Did the NA review recommend relocating AgFF research activities to
    the Department of Labor or USDA?
        Answer. The fatality rate in the Agriculture, Forestry, and Fishing
    industry is more than seven times higher than that of general industry.
    Although the data from 2009 are still provisional, based on the Bureau
    of Labor Statistics (BLS), Census of Fatal Occupational Injuries,
    workers in the Agriculture, Forestry, and Fishing industry had an
    average fatality rate of 28.1 per 100,000 full-time equivalent workers
    from 2006-2009 while general industry had an average rate of 3.8 per
    100,000 full-time equivalent workers during the same time period. The
    rate of nonfatal occupational injuries and illnesses in the
    Agriculture, Forestry, and Fishing industry is slightly higher at a
    rate of 5.6 per 100,000 full-time equivalent workers than that of
    general private industry at a rate of 4.1 per 100,000 full-time
    equivalent workers from 2005-2009.
        While the 2007 National Academy (NA) review of NIOSH's
    Agricultural, Forestry and Fishing research program raised some
    questions about the impact of this research on workplace injury and
    illness, it did not recommend elimination of the AgFF program.
        The NA review did not recommend relocating AgFF research activities
    to the Department of Labor or USDA. Instead, NA recommended that the
    AgFF program continue to partner with appropriate Federal and State
    agencies and establish additional interagency partnerships to increase
    the capacity for carrying out research and transfer activities.
                                     ______

                Questions Submitted by Senator Mary L. Landrieu
                          child welfare finance reform
        Question. Could you explain the Administration's vision for foster
    care reform, and why the need for reform is so urgent?
        Answer. The President's budget proposes $2.5 billion over 10 years
    to align financial incentives with improved outcomes for children in
    foster care and those who are receiving in-home services or post-
    permanency services from the child welfare system, in order to prevent
    entry or re-entry into foster care. We envision States that receive
    performance-based funding to be able to support activities that can
    improve outcomes for children who have been abused or neglected or at
    risk of maltreatment. We believe our proposal will keep the focus on
    moving child welfare in the right direction, particularly during these
    difficult budget times in States. The proposal incentivizes all States
    to improve outcomes by allowing them to earn additional funds that can
    be invested in activities that can drive further progress for the
    children and families served.
        We look forward to working with Congress on developing specific
    details, guided by the principles outlined in our fiscal year 2012
    budget:
      --Creating financial incentives to improve child outcomes in key
            areas, by reducing the length of stay in foster care,
            increasing permanency through reunification, adoption, and
            guardianship, decreasing rates of maltreatment recurrence and
            any maltreatment while in foster care, and reducing rates of
            re-entry into foster care;
      --Improving the well-being of children and youth in the foster care
            system, transitioning to permanent homes, or transitioning to
            adulthood;
      --Reducing costly and unnecessary administrative requirements, while
            retaining the focus on children in need;
      --Using the best research currently available on child welfare
            policies and interventions to help the States achieve further
            declines in the numbers of children who need to enter or remain
            in foster care, to better reach families with more complex
            needs, and to improve outcomes for children who are abused,
            neglected, or at risk of abuse or neglect; and
      --Expanding our knowledge base by allowing States to test innovative
            strategies that improve outcomes for children and reward States
            for efficient use of Federal and State resources.
                    chafee foster care independence program
        Question. Can you explain why, in light of the rising number of
    foster youth who ``age out'' of care, the Administration has not
    proposed to increase funding for Chafee?
        Answer. In an environment of limited resources, we have chosen to
    provide additional funds to align financial incentives with improved
    outcomes for children in foster care and those who are receiving in-
    home services or post-permanency services from child welfare system, in
    order to prevent entry or re-entry into foster care. States may use
    these funds to provide services to youth who are in foster care before
    they age out as well as provide post-permanency services to those who
    age-out of the foster care system. We believe our proposal will keep
    the focus on moving child welfare in the right direction, particularly
    during these difficult budget times in States.
        Question. If Congress does not meet the President's budget request
    of $3.3 billion for the Health Centers Program, what will be the impact
    on rural and urban underserved populations? Can you also describe the
    economic impacts of not adequately funding the Health Centers Program?
        Answer. It will reduce to some extent the expansion of the Health
    Center Program (and its associated economic impact) into new
    underserved rural and urban communities.
        Question. Recognizing the vital role School Based Health Centers
    play in serving as a safety net provider for our children and
    adolescents, why wasn't funding for the operations of School Based
    Health Centers included in the fiscal year 2012 budget request? For
    fiscal year 2013, do you see putting School Based Health Centers in the
    President's budget as an approach that could be utilized to grant
    greater access to care for our youth?
        Answer. School-Based Health Centers may apply for operational
    support under the Community Health Center program. For example,
    interested school-based health centers could have applied for the
    Affordable Care Act New Access Point opportunity announced last August
    to support new healthcare service delivery sites, if Health Center
    Program eligibility criteria were met. Previous operational funding for
    health center sites serving school-aged populations and/or located in
    schools has been awarded under the Community Health Center Program.
        Question. HHS, as well as other Federal agencies, has found great
    success with telehealth programs in the treatment of high-cost
    patients. As these programs advance, where do you see the best
    opportunities not only to maximize cost savings but to provide patients
    with better care and improve clinical outcomes?
        Answer. The Telehealth Network Grant Program (TNGP), grants have
    offered underserved populations the opportunity to access a diverse
    variety of clinical services to underserved people in rural areas which
    include: allergy, asthma control, cardiology, diabetes care and
    management, pain management, remote patient monitoring, and a variety
    of other services.
        For the relatively more mature Telehealth Networks (TNGP-TH)
    provisions, one clinical health outcome measure, diabetes case
    management, is being collected, as well as several outcome measures
    related to improving access and program efficiency. One of the
    responsibilities of OAT's Regional Telehealth Resource Centers (TRCs)
    is to track evidence-based telehealth practices in their regions, and
    share that information through the technical assistance that they
    provide to HRSA grantees, rural and other underserved communities. The
    TRCs share information about cost savings, improved quality and
    increased access through telehealth applications via their websites,
    webinars, conference calls, presentations at conferences, and one-on-
    one consultations.
        Question. What are the other areas within the Department of Health
    and Human Services where Federal support for telehealth technology can
    be initiated or expanded?
        Answer. HRSA's formal telehealth authority is through ORHP's OAT,
    as mentioned in the previous question. HRSA's ORHP is not aware of
    other areas within the Department of Health and Human Services where
    Federal support for telehealth technology can be initiated or expanded.
        Question. What areas within HHS, including the Centers for Medicare
    and Medicaid Services and the Center for Medicaid and Medicare
    Innovation could be used to increase Federal support for telehealth?
        Answer. CMS continually looks for ways to expand the use of
    telemedicine in our programs to provide high quality healthcare
    services in the most efficient manner possible. To that end, CMS
    annually considers requests from the public to add to the list of
    telehealth services covered by Medicare Part B, and adds new telehealth
    services as appropriate as part of the Medicare Physician Fee Schedule
    rulemaking process. CMS also recently finalized new rules for
    telemedicine services to ensure that patients in rural or remote areas
    will continue to receive access to high quality, cutting-edge medical
    care through the use of telemedicine from many of their local
    hospitals. The new finalized rules streamline the process that
    hospitals and critical access hospitals (CAH) use for credentialing and
    granting privileges to physicians and practitioners who deliver care
    through telemedicine. The new rule will also permit hospitals to more
    easily partner with non-hospital telemedicine entities, such as
    teleradiology facilities, to deliver specialty care via telemedicine.
                                     ______

                Questions Submitted by Senator Richard J. Durbin
     the effect of reducing nih funding to 5 percent below fiscal year 2010
        Question. In February the House passed an appropriations bill for
    fiscal year 2011 that proposed cutting the National Institutes of
    Health's (NIH's) budget by $1.6 billion or 5 percent compared to NIH's
    fiscal year 2010 budget.
        Please provide the NIH's perspective on how such a cut would impact
    the NIH and our Nation's economic recovery?
        Answer. A $1.6 billion decline from NIH's fiscal year 2010 budget
    levels could have adverse consequences for the research community and
    could delay current research efforts. It could result in lost
    opportunities to develop more cost effective diagnostics and treatments
    in areas such as developmental disorders, addiction, mental illness,
    infectious disease, cancer, heart disease, and neuro-degeneration.
        Specifically, in the area of translational research, more than 100
    clinical trials and studies for more precise tests and more effective
    treatments of common and rare diseases affecting millions of Americans
    could be halted or curtailed. Medical practices that could have been
    shown obsolete or needlessly expensive would not be fully evaluated.
        In the area of basic research, in just the last 2 years, advances
    in whole genome sequencing, methods to grow stem cells not derived from
    human embryos, automated equipment that can perform thousands of
    experiments at the same time, and previously untried drug design
    techniques have all become available for the first time, providing
    unprecedented opportunities for research advances at relatively low
    cost, many of which could be delayed by these budget cuts. Reductions
    in funding the pipeline of basic research could slow the discovery of
    fundamental knowledge about how we grow, age and become ill. Valuable
    research supporting the prevention of a host of costly, debilitating
    chronic conditions could suffer setbacks. Some projects could be
    difficult to pursue at reduced levels and could be cancelled; others
    could require scope modifications that would dramatically alter the
    potential research outcomes.
        Budget cuts could effect universities and the private-sector.
    Grantee personnel budgets may be reduced. Training grants could be
    materially impacted and the population of qualified research trainees
    and advanced science instructors could diminish. Some universities,
    especially those with research programs in earlier stages of
    development, may need to prioritize between training new physicians and
    scientists and closing laboratories. In the private sector, high-tech
    and low-tech small-business suppliers could face order cancellations.
    New equipment prototypes and laboratory methods important to private-
    sector pharmaceutical and device research could delay development,
    leaving fewer product options available for U.S. companies to offer as
    exports in response to the expected rapid rise in health spending in
    China and the developing world. Supplies of highly-trained technology
    workers in America could further diminish.
        Question. Approximately how many NIH-funded jobs could be lost as a
    result of a 5 percent cut to the agency's budget?
        Answer. NIH estimates that 10,500 full-time-equivalent (FTE)
    positions could potentially be lost as a result of a $1.6 billion cut
    to the agency's budget. This estimate is based on the average number of
    FTE per million dollars of funding reported by recipients of research
    funds under the Recovery Act.
        Question. Congenital Heart Disease (CHD) is one of the most
    prevalent birth defects in the United States and a leading cause of
    birth defect-associated infant mortality. Due to medical advancements
    more individuals with congenital heart defects are living into
    adulthood, unfortunately our Nation has lacked a population-
    surveillance system for adults with CHD. The healthcare reform law
    included a provision, which I authored, that authorizes the CDC to
    track the epidemiology of congenital heart disease, with an emphasis on
    adults with CHD and expanding surveillance. If adequately funded, what
    could be the public health impact of this surveillance system and how
    could it advance our understanding of the prevalence or CHD across
    subgroups (including age and race/ethnicity).
        Answer. Development of population-based surveillance for congenital
    heart disease across the lifespan would be a critical first step in
    generating information on prevalence across different age groups, race/
    ethnicity and socioeconomic groups in the population, as well as
    possible determinants of health disparities in neurocognitive outcomes,
    disabilities, survival, and quality of life. This population-based
    approach to identifying and following affected persons over time would
    have a significant public health impact by:
      --Estimating the true prevalence of CHD in the United States.--It is
            estimated that about 1 million adults are living with CHD in
            the United States, and given the improvements in treatment and
            decreasing mortality, this number continues to grow. However,
            this estimate is imprecise without population-based
            surveillance systems to track adolescents and adults with CHD.
            Accurately determining national prevalence estimates of CHD
            requires high-quality population-based surveillance of a
            representative sample of affected individuals using
            standardized surveillance methods.
      --Estimating the healthcare costs associated with CHD.--All adults
            with CHD have significantly higher rates of healthcare
            utilization than their peers. Furthermore, if adults with CHD
            develop other chronic conditions, such as diabetes, the
            interactive effect of the congenital anomaly with the other
            diseases remains unknown. Currently, estimates of direct costs
            for adults are often specific to inpatient admissions, and do
            not include hospitalizations in which CHD was not the primary
            reason for admission nor costs associated with outpatient
            visits, prescription medications, or other indirect costs for
            the affected individuals, their families, and society.
            Therefore, information from a population-based surveillance
            system would improve planning for the future utilization of
            healthcare resources and enhance our understanding of the
            economic costs of CHD among adults.
      --Identifying factors associated with adverse outcomes across the
            lifespan.--Persons with CHD are at risk for adverse health
            outcomes such as neurodevelopmental and cognitive outcomes and
            premature death, yet little is known about risk factors for
            these outcomes and how they differ among subpopulations.
            Identifying and following affected persons over time to track
            adverse outcomes could help us understand factors such as
            health disparities that might predispose to or ameliorate
            adverse outcomes, and characterize the health services needs of
            this population.
      --Providing reliable, evidence-based information to guide diagnosis,
            management, and secondary prevention efforts.--Currently, many
            adults with CHD in the United States receive inadequate care
            because of the lack of information to guide the clinical
            management of a child with a congenital heart defect as he or
            she ages into adulthood. Adults and their healthcare providers
            have become increasingly aware of the need for reliable,
            evidence-based information to guide diagnosis, management, and
            secondary prevention efforts.
          Collecting and analyzing data on outcomes over time could improve
            understanding of the long-term course of CHD, the factors that
            might influence such course, and the health services needs
            across the lifespan. These data could also help inform efforts
            to develop effective primary and secondary prevention
            strategies directed at reducing the public health impact of
            CHD. The data could also be used to develop and evaluate the
            effectiveness of interventions such as guidelines for routine
            preventable care for children, adolescents, and adults with CHD
            designed to reduce poor outcomes and high cost of treating
            individuals who otherwise do not seek or receive adequate care
            until in a medical crisis.
        Question. Currently, when a person enrolls in Medicare, their
    Social Security Number (SSN) is used the basis of their Medicare
    identification number. The Social Security Inspector General has
    indicated that this creates a risk of identity theft and fraud and has
    suggested that the SSN be removed from the Medicare card. How do you
    think this risk to Medicare beneficiaries and the Federal program could
    be reduced?
        Answer. CMS is currently investigating the viability and costs of a
    range of options for removing the SSN from Medicare beneficiary cards.
    There are considerable costs associated with changing the Medicare
    beneficiary identifier, not only for CMS but also for our public and
    private sector partners. The SSN identifier in the health insurance
    claim number (HICN) is the basis of eligibility for Medicare, and is
    integrated in more than 50 CMS systems, as well as communications with
    our partners in the Social Security Administration, State Medicaid
    departments, private Medicare health and drug plans, and over 2 million
    healthcare providers and suppliers. The risks of disruptions in
    beneficiaries' access to care are considerable.
        I want to emphasize, however, that CMS shares your concerns about
    the importance of safeguarding and protecting Medicare beneficiaries
    from identity theft. We have taken many important steps to minimize the
    display of SSNs or HICNs on Medicare cards. We removed the SSN from
    various notices and publications sent to beneficiaries, and from
    beneficiary reimbursement checks. We prohibited Part C and D Plans from
    using the SSN or HICN as a beneficiary identifier. We have also taken
    action to educate beneficiaries about steps they should take to prevent
    identity theft and fraud, including posting information on the CMS
    website, and adding information to the ``Medicare & You'' Handbook.
        Question. On December 20, 2010 you sent a response letter entitled
    ``Concern on Hepatitis'' to Members of Congress, which directed
    Assistant Secretary Dr. Howard Koh to convene an interagency working
    group tasked with developing an HHS Action Plan on Viral Hepatitis. Can
    a specific date be provided for when the Action Plan will be released?
    Once the Action Plan is released how will HHS prioritize resources and
    give direction to the various Departmental operating divisions to
    ensure steps are taken to curtail the escalating costs associated with
    viral hepatitis and the costly outcomes such as liver cancer and end-
    stage liver disease?
        Answer. We anticipate that the HHS Action Plan for the Prevention
    and Treatment of Viral Hepatitis will be released on May 12, 2011. The
    Action Plan will help HHS improve its current efforts to prevent viral
    hepatitis by leveraging opportunities to improve coordination of viral
    hepatitis activities across HHS operating divisions and by providing a
    framework for HHS to engage other governmental agencies and
    nongovernmental organizations in viral hepatitis prevention and care.
    For example, the Action Plan calls for the alignment of HHS guidelines
    for the diagnosis of Hepatitis B and Hepatitis C infection. Such
    alignment will improve provider understanding, thus supporting
    screening efforts and promoting earlier diagnosis of viral hepatitis.
    Identifying and disseminating best practices regarding prompt linkage
    of persons testing positive for viral hepatitis into needed care and
    treatment and developing effective medical management models for use in
    priority populations, like injection drug users, will improve care
    outcomes and reduce the negative health outcomes of chronic hepatitis.
    Finally, on the basis of available funding, the NIH will expand
    existing clinical trial networks to expand studies of viral hepatitis
    treatment. Improving treatment for hepatitis C and other causes of
    viral hepatitis will eventually decrease the number of persons with
    chronic hepatitis, thus decreasing the costly sequelae of end stage
    liver disease.
                                     ______

                    Questions Submitted by Senator Jack Reed
          cdc state cancer registries (pediatric cancer surveillance)
        Question. The fiscal year 2012 budget for the Centers for Disease
    Control and Prevention (CDC) proposes to consolidate a variety of
    programs that address chronic disease into a Coordinated Chronic
    Disease Prevention and Health Promotion Grant Program. This program
    will mix core funding with competitive grants to States and other
    entities. CDC's cancer-related efforts are included in this new
    program.
        As the author of the Conquer Childhood Cancer Act, which authorized
    investment in childhood cancer surveillance efforts--among other
    provisions--I am particularly concerned that the consolidation will
    take attention away from sub-populations. For example, more timely and
    accurate data collection of pediatric cancer cases and treatments can
    help researchers determine appropriate treatments and interventions. I
    helped secure $3 million for this effort last year and it was welcome
    news to the entire pediatric cancer community.
        It appears that with the new approach, States will allocate funds
    to improving outcomes among large populations where very small changes
    can make a big difference. While this will help them secure additional,
    competitive grant funding, there are smaller populations that will
    likely receive less attention.
        How will you ensure that States continue to apply the funds they
    receive to continue to build their pediatric cancer surveillance
    efforts?
        Answer. The President's fiscal year 2012 budget proposes to
    consolidate eight separate disease-specific budget lines--Heart Disease
    and Stroke, Diabetes, Cancer, Arthritis and other Conditions,
    Nutrition, Health Promotion, Prevention Centers, and non-HIV/AIDS
    adolescent and school health activities including Coordinated School
    Health--into a single comprehensive grant program, the Coordinated
    Chronic Disease Prevention and Health Promotion Grant Program. This
    consolidation is intended to provide integrated services to State and
    local health departments by maximizing the reach and impact of every
    dollar invested by CDC to prevent chronic diseases and promote health
    in a variety of environments, including schools, and to a variety of
    sub-populations, including children.
        The National Program of Cancer Registries (NPCR) is essential to
    CDC's efforts to prevent and control cancer. Representing 96 percent of
    the population, data from NPCR are vital to understanding the Nation's
    cancer burden and are fundamental to cancer prevention and control
    efforts at the national, State, and local level. Information about
    cancer cases and cancer deaths is necessary for health agencies to
    report on cancer trends, identify populations with the highest cancer
    burden in order to target interventions, assess the impact of cancer
    prevention and control efforts, participate in research, especially on
    small and disparate populations, such as American Indians/Native
    Alaskans, and respond to reports of suspected increases in cancer
    occurrence. NPCR is the main source of data on rare cancers--including
    some pediatric cancers--which can be difficult to study in regional
    registries. CDC remains committed to conducting public health
    surveillance, monitoring, and tracking trends in chronic disease risk
    factors, incidence, and mortality while enhancing access and
    utilization of population-based surveillance data at the State and
    local level.
        Pediatric cancer is an important public health issue, and has far
    reaching social, emotional, and physical impacts on children and their
    families. CDC has implemented a range of key activities related to the
    Caroline Pryce Walker Conquer Childhood Cancer Act. To date, CDC has:
      --Hosted an expert panel to identify gaps in pediatric cancer
            research and surveillance. This panel helped inform CDC's
            decision to build cancer registry infrastructure in ways that
            facilitate pediatric cancer research, enhance registry capacity
            and reporting speeds, and create new data linkages for research
            use.
      --Secured contractor support to simplify and streamline the process
            for seeking multiple State institutional review board (IRB)
            approval for conducting pediatric cancer research. Work is
            being done to assess State level barriers to research across
            multiple States requiring linkage to registries or patient
            contact, and to identify optimal State policies for research.
      --Developed a Funding Opportunity Announcement (FOA) to supplement 12
            central cancer registries through NPCR to support pediatric
            cancer surveillance, including early case capture. Funded
            cancer registries will identify, recruit, and train all
            potential sources for reporting pediatric and young adult
            cancer cases, and develop procedures and mechanism to implement
            early case capture. This FOA will be released in summer 2011.
       cdc environmental health (healthy homes/lead poisoning prevention)
        Question. The President's budget proposes to consolidate and reduce
    by 50 percent the funding for CDC's Healthy Homes/Lead Poisoning
    Prevention. I am particularly concerned that the budget proposes
    reducing funding for a program--designed to ensure safe housing--that
    is extremely cost effective particularly for New England.
        In Rhode Island, 70 percent of the State's housing stock was build
    prior to 1978, when the use of lead paint was prevalent and 10 percent
    are still in need of desperate repair. Over the past 10 years, Rhode
    Island has received $40 million for lead poisoning prevention
    initiatives and, as a result, just 2.3 percent of children are found to
    have elevated lead blood levels in 2007, which is down from 8.8 percent
    in 1997.
        Cuts to this program will fall squarely on the backs of low-income
    families and communities of color since they are disproportionately
    impacted by environmental health hazards. It will result in a decrease
    in blood lead screening rates and efforts to eliminate lead hazards
    that still exist today. What are the long-term impacts that reducing
    this funding will have on States, healthcare costs, lost school days
    for students, and loss of productivity for parents?
        Answer. The goal of the new CDC Healthy Environments consolidated
    program is to maintain a multi-faceted approach through surveillance,
    partnerships, implementation and evaluation of science-based
    interventions to address the health impact of environmental exposures
    in the home and to reduce the burden of asthma through comprehensive
    control efforts. As the Healthy Environments program is implemented,
    the number of funded recipients will decrease from 40 to 34 to
    implement Healthy Homes programs and only State health departments will
    be eligible to apply for funding; this will help save significant
    overhead costs as fewer resources will need to be devoted to grantee
    management when there are fewer individual grantees. A healthy homes
    approach works to mitigate health hazards in homes such as lead
    poisoning hazards, secondhand smoke, asthma triggers, radon, mold, safe
    drinking water, and the absence of smoke and carbon monoxide detectors.
    Findings indicate that multi-component, multi-trigger home-based
    environmental interventions are effective at improving overall quality
    of life, reducing healthcare costs and improving productivity. By
    integrating the National Asthma Control Program (NACP) and the Healthy
    Homes/Childhood Lead Poisoning Prevention Program, CDC's aim is to
    establish and maintain a more coordinated approach to this multifaceted
    public health challenge.
        Question. Can you please explain the impact on Rhode Island, and
    the country, if discretionary funding were to be reduced from its
    current 2010 level, in terms of patients served, patient health status,
    and the economy as a whole?
        Answer. Reductions in the annual health center appropriation level
    will impact the ability of the Health Center Program to meet projected
    patient targets nationally and in Rhode Island. Depending on the size
    of the reduction, it may limit or eliminate the Program's ability to
    expand the program and/or sustain current program investments and
    achievements.
                                     ______

                   Questions Submitted by Senator Mark Pryor
        Question. I understand that the Health Resources and Services
    Administration funding is proposed to be reduced in the
    Administration's fiscal year 2012 budget proposal. Further, the
    Administration is proposing to eliminate the Public Health Improvements
    account based on the fact that this account is entirely earmarked.
        What Federal funding streams are available for hospitals to apply
    for facilities and equipment grants?
        Answer. The Health Resources and Services Administration's (HRSA)
    Office of Rural Health Policy (ORHP) published a manual last year,
    targeted to critical access hospitals, outlining the various steps
    involved in planning, financing and carrying out construction
    projects.HRSA also facilitates the funding of equipment for rural
    hospitals to provide or receive clinical services at a distance through
    the Telehealth Network Grant Program (TNGP) administered by HRSA/ORHP's
    Office for the Advancement of Telehealth (OAT). The TNGP supports not-
    for-profit organizations and offers up to $250,000 per year in funding
    to demonstrate how telehealth programs and networks can improve access
    to quality healthcare services in underserved rural and urban
    communities. By statute, the TNGP limits equipment expenditures to 40
    percent of each grant award. We anticipate that a TNGP funding
    opportunity announcement will be released in fiscal year 2012, subject
    to appropriations. Although the TNGP funds equipment, its focus is the
    funding of telehealth networks that provide clinical services to
    underserved populations and the evaluation of telehealth technology's
    effectiveness.
        Question. Are any of these funding sources targeted at rural
    hospitals?
        Answer. Rural Hospitals are eligible to apply for the USDA funding
    and TNGP funding. The Telehealth Network Grant Program (TNGP),
    administered by the Health Resources and Services Administration
    (HRSA)/Office of Rural Health Policy's (ORHP) Office for the
    Advancement of Telehealth (OAT) is a primary conduit for demonstrating
    how telehealth programs and networks can improve access to quality
    healthcare services in underserved rural and urban communities. TNGP
    grants demonstrate how telehealth networks improve healthcare services
    to: (a) expand access to, coordinate, and improve the quality of
    healthcare services; (b) improve and expand the training of healthcare
    providers; and/or (c) expand and improve the quality of health
    information available to healthcare providers, patients, and their
    families.
        Question. The fiscal year 2012 budget request for LIHEAP totals
    $2.569 billion. This is down from an fiscal year 2011 request of $5.3
    billion and an fiscal year 2010 enacted level of $5.1 billion.
        While I understand the budget constraints that we are facing right
    now, I am concerned about families losing this assistance. What
    resources are out there to assist families with energy costs in lieu of
    LIHEAP assistance?
        I know there are several formulas used to calculate how funding is
    distributed. In Arkansas, we are put at a disadvantage in the summer
    months because most of the funding is spent on heating during the
    winter and little is left over for cooling during the summer. Residents
    in southern States rely on LIHEAP for cooling as well as heating. How
    can the LIHEAP funding be adjusted so that southern States can better
    help their citizens during the hot summer weather?
        Answer. Several other ACF programs, including TANF and the Social
    Services and Community Services Block Grants, provide assistance to low
    income people which may be used for home energy costs. Outside of HHS,
    assistance for home weatherization is provided by the Department of
    Energy. The fiscal year 2012 President's budget requested $320 million
    for this purpose, an increase of 52 percent above fiscal year 2010.
    States also provide substantial home energy assistance, $2.6 billion in
    fiscal year 2009, primarily from rate assistance from publically
    regulated utilities and State/local home energy assistance funds.
        LIHEAP block funds are distributed to States by statutory formula.
    States determine how to distribute their allocation between heating and
    cooling assistance. Prior to 1984, funds were allocated to States based
    largely on their numbers of low income people and the National Weather
    Service's standard measure for the need for heat. In 1984, Congress
    enacted the new formula to adjust State allocations to reflect total
    home energy costs (heating and cooling) by low income households. This
    formula takes effect when the appropriation for the formula grant
    exceeds $1.975 billion. Since fiscal year 2009, LIHEAP appropriation
    language has capped the amount of funding distributed by the new
    formula at $840 million.
        Question. Frequently, I hear concerns about the availability of
    healthcare providers in rural areas. Many of the rural areas in
    Arkansas have an aging community of healthcare providers, and the
    citizens of those communities are worried about preserving access to
    care. Can you discuss priorities you are working on to ensure we have
    enough healthcare providers to deliver quality healthcare in rural
    areas?
        Answer. The President's budget included funding to support rural
    healthcare that focus on improving recruitment and retention of
    healthcare providers in rural areas. The Health Resources and Services
    Administration's (HRSA) National Health Service Corps (NHSC) serves as
    a key resource in this area as 60 percent of the placements for NHSC
    practice in rural areas. In addition, HRSA's Office of Rural Health
    Policy is funding the Rural Training Track (RTT) Technical Assistance
    Center grant to support the existing rural training tracks around the
    country and to assist communities in developing new RTT programs. HRSA
    also supports the work of the National Rural Recruitment and Retention
    Network, a 50 State consortium of clinician recruiters who work to
    match doctors, nurses and dentists with an interest in rural practice
    with rural communities in need of a practitioner. Last year, the Rural
    Recruitment and Retention Network supported the placement of more than
    1,030 clinicians in rural areas.
        Question. State-based health insurance exchanges will be created to
    make affordable, quality insurance options available to every American.
    Debates have been taking place in some States about whether or not
    States should move forward in setting up exchanges that will be run by
    State governments before the Supreme Court rules on the
    constitutionality of the individual mandate. Can you briefly describe
    the opportunities States have to establish exchanges and what the role
    could be for either State governments or the Federal Government
    depending on what decisions States make?
        Answer. To receive a multi-year Establishment grant, States must
    commit to establishing an Exchange. Recognizing that not all States are
    far enough along to make this determination, grants for up to 1 year of
    funding will not require a State to commit to operating its own
    Exchange. By statute, Territories must commit to establishing, and
    ultimately establish, an Exchange to receive any Exchange grant
    funding.
        Through both the Planning and Establishment grants, States are held
    to achieving milestones for important Exchange implementation
    activities such as insurance market research, stakeholder consultation,
    and assessment of current State eligibility and enrollment systems. If
    a State ultimately chooses not to implement its own Exchange, or HHS
    determines a State is not ready to operate an Exchange by 2014, HHS may
    benefit from this work when it establishes a federally operated
    Exchange in that State.
                                     ______

                Questions Submitted by Senator Richard C. Shelby
                                   class act
        Question. The CLASS Act attempts to address an important public
    policy concern--the need for non-institutional long-term care--but it
    is viewed by many experts as financially unsound. The President's
    fiscal commission recommended reform or repeal of the CLASS Act. You
    stated to health advocacy groups that, ``it would be irresponsible to
    ignore the concerns about the CLASS program's long-term sustainability
    in its current form.'' The President's budget proposal includes a
    request of $120 million for the CLASS Act, which would be the first
    discretionary appropriation for the program. If you are unable to
    certify that it will be sustainable absent a massive taxpayer infusion
    of funds, why would Congress want to appropriate the requested $120
    million in taxpayer funds for a program that experts project will fail?
        Answer. We share your view that the CLASS Act addresses an
    important public policy concern. About 14 million people spend more
    than $230 billion a year on long-term services and supports to assist
    them with daily living. Four times that many rely solely on unpaid care
    provided by family and friends. Despite public misperception that
    Medicare and Medicaid will cover their long-term care costs, Medicare
    is only available for time-limited coverage of very specific types of
    skilled nursing facility services and while Medicaid is the largest
    public payer of these services, it is only available for people with
    few financial resources, such as those who were forced to spend their
    retirement on long-term care and have no place left to turn. The CLASS
    program represents a significant new opportunity for all Americans who
    work to prepare themselves financially to remain as independent as
    possible under a variety of future health circumstances.
        The Affordable Care Act requires HHS to develop an actuarially
    sound benefit plan that is fiscally sustainable. The discretionary
    request will finance the start up costs associated with establishing
    the CLASS program. All programs have start up costs, and this one is no
    different. This funding will be used to establish a solid benefit plan,
    develop an IT system to help consumers enroll, and implement an
    information and education plan to ensure participation and fiscal
    sustainability. This bridge will enable the program to begin enrolling
    individuals and collecting premiums, which will then be used for
    benefits once participants are vested and have an eligible claim.
        I appreciate your consideration of this request, recognizing that
    HHS is still in the process of developing the actuarially sound benefit
    plan. We will not implement a program unless it is solvent and
    sustainable, as required by the statute. Prior to collecting any
    premiums, HHS will publish a notice of proposed rulemaking and present
    three actuarially sound benefit plans, as required by statute, to the
    CLASS Independence Advisory Council. These transparent processes will
    help HHS ensure the CLASS program starts with every expectation of
    sustainability; thus, the $120 million request will help the program
    with its critical startup activities, such as ensuring a significant
    education and outreach effort for broad enrollment.
        Question. What will prevent from the Department from subsidizing
    this alleged self-sustaining program with taxpayer funds once it is
    implemented and then fails?
        Answer. The law clearly states that the program must be able to pay
    for benefits with the premiums it takes in and that no taxpayer dollars
    may be used to pay for CLASS benefits. Section 3208(b) of the CLASS Act
    prevents HHS from using taxpayer funds to pay benefits. Specifically,
    the Act states ``No Taxpayer Funds Used To Pay Benefits--No taxpayer
    funds shall be used for payment of benefits under the CLASS Independent
    Benefit Plan. For purposes of this subsection, the term `taxpayer
    funds' means any Federal funds from a source other than premiums
    deposited by CLASS program participants in the CLASS Independence Fund
    and any associated interest earnings.''
        Question. The budget proposal for the CLASS Act includes $93.5
    million in new Federal spending for ``information and education'' to
    ensure that an adequate number of individuals will enroll in the
    program. While I do not agree with Congress appropriating $120 million
    for an insolvent program, it makes even less sense to spend $93.5
    million of that funding to promote a program that we know as currently
    structured will fail. How do you justify spending such a large sum of
    money on promotion efforts given you will be a promoting a program that
    is not yet defined?
        Answer. This $93.5 million will be used to educate Americans about
    the immense costs of long-term care and their ability to financially
    prepare for these costs. While a direct objective of this effort will
    be to expand the risk pool of individuals voluntarily enrolling in the
    CLASS program, we expect it to also help Americans begin other private
    preparations for these costs and ultimately reduce demands on State and
    Federal budgets. By October 1, 2012, HHS is required by statute to
    designate an actuarially solvent benefit plan that is solvent
    throughout a 75-year period. These funds will be used to promote this
    benefit plan, which will have been made available for comment before
    final designation.
        Question. Given the significant actuarial concerns raised about the
    solvency of the CLASS program, will you agree that all education and
    outreach materials about the CLASS program will be vetted by
    independent actuaries who can attest to their completeness and
    accuracy? I am concerned because it is my understanding that the
    Medicare actuary did not sign off on the 2010 Medicare mailer that
    stated, ``keep Medicare strong and solvent.'' Clearly, that statement
    was not entirely accurate and CMS spent $18 million to distribute these
    false claims.
        Answer. HHS is required to designate an actuarially sound benefit
    plan that is solvent throughout a 75-year period. By law, the methods
    and assumptions used to determine the actuarial status of the CLASS
    Independence Fund will be reviewed and certified by the Chief Actuary
    of the Centers for Medicare & Medicaid Services and the financial
    solvency of the program will be documented in an annual report to
    Congress. The education and outreach materials will be consistent with
    these reviews.
        Question. Modeling suggests that if you have a 2-3 percent
    participation rate the program is not sustainable. Absent massive media
    campaigns, how do you know that there will be greater participation?
    How do you know the market will receive this concept?
        Answer. Broad participation is necessary to mitigate adverse
    selection and ensure the solvency and sustainability of the CLASS
    program. The proposed $93.5 million information and education effort
    will help inform eligible Americans about enrolling in the program. In
    addition, HHS will focus on recruiting employers to participate in the
    program, further improving enrollment. We also intend to conduct
    research to determine the best ways to communicate with consumers about
    the program and their options, and we will discuss the findings from
    this research with the CLASS Independence Advisory Council to help
    inform our estimates of participation in the program.
        Question. On March 22, the Wall Street Journal highlighted the
    problems with the Social Security Disability Insurance system,
    including the inconsistent standards used by State offices that
    adjudicate claims. As an example, the article pointed to one
    administrative law judge in Puerto Rico that approved 98 percent of the
    Social Security disability claims he heard during fiscal year 2010. I
    am concerned that the inconsistent standards across States in the
    Social Security Disability Insurance system could apply to the CLASS
    Act. Secretary Sebelius, will the CLASS Act require a new State-based
    system to process claims and if so, how will you ensure standards
    remain consistent across States?
        Answer. Section 3205 of the statute precludes use by the CLASS
    program of the State determination system for Social Security
    disability claims. At this time, we are considering how to implement
    the eligibility assessment process through which participants will
    claim benefits. Considering the voluntary, self-funded nature of this
    national program, we believe the eligibility assessment system should
    be consistent across the Nation. Thus, one possible approach that we
    are considering is contracting with a neutral third-party
    administrator, like the type servicing private long-term care insurance
    carriers, to ensure standardization of assessments consistent with the
    CLASS Act and its regulations.
                       prevention and public health fund
        Question. If the Prevention and Public Health Fund is repealed, how
    will agencies fund the programs you have moved?
        Answer. The Administration strongly opposes legislation that
    attempts to erode the important provisions of the Affordable Health
    Care that are making healthcare more accessible and affordable for all
    Americans. The Prevention and Public Health Fund is central to reducing
    the burden of chronic disease and reducing the healthcare costs
    associated with treating these diseases. Repeal of the Prevention and
    Public Health Fund would affect current year plans and have a direct
    programmatic impact. The Prevention Fund is central to reducing the
    burden of chronic disease and reducing the healthcare costs associated
    with treating these diseases. HHS has not replaced the entire base of
    program funding with Prevention and Public Health resources. Rather,
    the fiscal year 2011 allocation primarily builds on the prevention
    activities underway at HHS.
        Question. The Affordable Care Act gives the Committee on
    Appropriations transfer authority for the mandatory funding provided
    through the Prevention and Public Health Fund. In fiscal year 2010, the
    Prevention Fund transferred $500 million toward prevention efforts, and
    in fiscal year 2011 $750 million should be transferred. Each fiscal
    year 2011 continuing resolution that has passed has included the
    transfer of these funds. Clearly it is the intent of the Committees on
    Appropriations to direct the transfer of this funding. Yet, you
    announced a spending plan for these funds on February 9, 2011, without
    the enactment of a full year appropriations bill. This means those
    dollars will be obligated without any congressional input or oversight.
    Is it the Department's intention to obligate these funds without
    Congressional transfer authority?
        Answer. The Affordable Care Act in section 4002 gives the Committee
    on Appropriations transfer authority for the mandatory funding provided
    through the Prevention and Public Health Fund. If Congress had directed
    the transfer of fiscal year 2011 Prevention and Public Health Fund
    resources, the Department would have followed the transfer provided in
    law. The full-year appropriations bill for fiscal year 2011, however,
    did not direct the transfer of these funds, and section 4002 of the
    Affordable Care Act gives the Secretary authority to transfer resources
    from the appropriated amount within HHS.
        Question. OMB claims that the ``Education Research Centers overlap
    activities offered by the Department of Labor's Occupational Safety and
    Health Bureau.'' However, the mandate of the two agencies is different.
    The National Institute for Occupational Safety and Health is mandated
    to conduct research and provide professional training in occupational
    safety and health, while OSHA is mandated to regulate occupational
    safety and health conditions in the workplace and provide worker
    training. Therefore, Madam Secretary, where is the overlap?
        Answer. OSHA's Outreach Training Program (OTP), OSHA Training
    Institute (OTI) Education Center, and Resource Center Loan Program all
    focus on employee training. OTP provides employee training in basic
    occupational safety and health courses in construction or general
    industry safety and health hazard recognition and prevention while the
    Resource Center Loan Program offers a collection of training videos to
    help increase employee knowledge of workplace safety. The OSHA Training
    Institute (OTI) Education Center program was initiated as an extension
    of the OSHA Training Institute, which is the primary training provider
    of the Occupational Safety and Health Administration. OTI targets
    Federal and State compliance officers and State consultants, other
    Federal agency personnel, and the private sector. While these programs
    focus on employee training, the ERCs support professional training and
    provide academic programs and research training in the core areas of
    industrial hygiene, occupational health nursing, occupational medicine,
    and occupational safety.
        Question. The OMB justification for elimination of Education
    Research Center's is that the original programmatic plan was to provide
    funding for institutions to develop and expand existing occupational
    health and safety training programs and that this goal has been met.
    However, the statutory goal of the Education Research Centers is ``to
    provide an adequate supply'' of qualified occupational safety and
    health professionals. Has this goal been met? Before you answer, Madam
    Secretary, I would like to point out that according to the Bureau of
    Labor Statistics, employment of occupational health and safety
    specialist and technicians is expected to increase 11 percent during
    the timeframe of 2008-2018.
        Answer. No. The establishment of a set of high quality training
    programs was the necessary first phase of the original long-range plan.
    The subsequent and critical steps for providing an adequate supply of
    qualified safety and health practitioners and researchers require
    ongoing resources to provide trainee support (for example, stipends,
    tuition and fee reimbursement, and research supplies), and to maintain
    the training program infrastructure, which includes a high-quality
    faculty and training environment. Within the context of a budget that
    requires tough choices, we put forth a proposal to discontinue Federal
    funding for the ERCs. We recognize the vital role of occupational
    safety and health professional training. This proposal is one of many
    difficult reductions we proposed as part of the fiscal year 2012
    budget.
        Question. In the fiscal year 2012 budget request, the President
    eliminates funding for the Children's Hospitals Graduate Medical
    Education program. In explaining the elimination, the Administration
    said it ``prefers to focus on targeted investments to increase the
    primary care workforce.'' Although they represent 1 percent of all
    hospitals, children's hospitals train more than 40 percent of general
    pediatricians. Since the inception of the program, children's hospitals
    have increased their training by 35 percent, helped address workforce
    shortages, and improved access to care. When there is a need for an
    expanded physician workforce nationwide, why are you supporting the
    elimination of a program that trains the primary care workforce for
    children?
        Answer. Within the context of a budget that requires tough choices,
    we put forth a proposal to discontinue these general subsidies. This
    proposal is one of many difficult reductions we would not have put
    forth under different fiscal circumstances. We recognize the vital role
    that children's hospitals and pediatric providers play in providing
    quality healthcare to our Nation's children.
        Children's hospitals would continue to be able to compete for
    funding through the competitive grant programs for which they are
    eligible. For example, six children's hospitals received over $16
    million in fiscal year 2010 from the Primary Care Residency Expansion
    program funded by the Affordable Care Act. Pediatric residencies can
    also be supported through the new Teaching Health Center Graduate
    Medical Education Program created by the Affordable Care Act, which
    supports primary care medical residents in community-based ambulatory
    care settings.
                                     ______

                  Questions Submitted by Senator Thad Cochran
        Question. The President's fiscal year 2012 budget for the
    Department of Health and Human Services proposes the elimination of the
    Delta Health Alliance at the Health Resources and Services
    Administration and also proposes the elimination of the Delta Chronic
    Disease Assessment and the Centers for Disease Control and Prevention.
    Mississippi has the highest obesity rate in the nation. What are your
    plans to address the health problems in the Mississippi Delta region?
        Answer. The Health Resources and Services Administration (HRSA)
    currently supports 21 Health Centers in Mississippi and they focus on
    providing access to quality healthcare for underserved populations. In
    addition, HRSA's Office of Rural Health Policy (ORHP) has several grant
    programs which are available to address health disparities in the
    Mississippi Delta Region.
                 mississippi state department of health funding
        Question. The President's budget proposes the elimination of the
    Preventive Health and Health Services Block Grant and proposes a new
    consolidated chronic disease grant program at the Centers for Disease
    Control and Prevention. The budget justification says this new grant
    program will not be a formula grant structure, but rather it will be
    competitive. Rural areas and States without capacity will be
    disproportionately affected by competitions. I am concerned that the
    new chronic disease grant program will create a scenario where the rich
    get richer and the poor get poorer. What are your plans to ensure that
    State health departments have the capacity to compete for funds at the
    Centers for Disease Control?
        Answer. Chronic diseases--such as heart disease, stroke, cancer,
    diabetes, and arthritis--are among the most common, costly, and
    preventable of all health problems in the United States. Historically,
    CDC has funded categorical programs in State health departments to
    address these diseases as well as their common risk factors of obesity,
    poor nutrition and/or inadequate physical activity. Under the current
    structure, not all States are funded for these programs.
        Because of the inter-relatedness of many common chronic diseases
    and their risk factors, the Coordinated Chronic Disease Prevention and
    Health Promotion Grant Program will support essential public health
    functions at the State level including epidemiology, evaluation,
    policy, communications and program management. Such an approach will
    strengthen State based coordination and therefore improve program
    efficiencies, provide leadership and support for cross-cutting
    activities and enhance the effectiveness of chronic disease prevention
    and risk factor reduction efforts across the included categorical
    programs.
        State health departments are eligible to receive funding through
    the Coordinated Chronic Disease Prevention Program. State health
    departments are required to deliver programming that reaches across the
    State and reduces specific disparities within the State, including
    rural areas. In addition, recognizing the importance of supporting all
    States, including rural areas, $115 million of the $528 million
    available is intended to support all State health departments,
    territories, and some Tribes to establish or strengthen leadership,
    expertise, coordination of chronic disease prevention programming,
    surveillance and evaluation. In addition, health departments will be
    eligible to apply for competitive awards to strengthen coordination of
    chronic disease prevention programs and implement evidence-based
    prevention strategies. These competitive grants to State health
    departments, territories, some tribes and other entities will support
    activities addressing:
      --Policy and environmental approaches to improve nutrition and
            physical activity in schools, worksites and communities;
      --Interventions to improve delivery and use of selected clinical
            preventive services; and
      --Community programs to support chronic disease self management to
            improve quality of life for people with chronic disease and to
            prevent diabetes, heart disease and cancer among those at high
            risk.
                                     ______

                 Questions Submitted by Senator Lamar Alexander
        Question. As a former Governor, I am deeply concerned with the
    Medicaid expansion in the new health law. Tennessee's previous Governor
    Bredesen, a Democrat, has called it ``the mother of all unfunded
    mandates'' and estimated that it will cost Tennessee and additional
    $1.1 billion for 2014-2019, and that is even with the Federal
    Government is paying 100 percent of the expansion population from 2014-
    2016. CBO recently estimated that it will cost States $60 billion
    through 2021.
        The new law also mandates that Medicaid primary care physicians be
    reimbursed at 100 percent of Medicare rates in 2013-2014, for which the
    Federal Government will pay for those 2 years. But this creates a
    funding cliff for 2015. To keep doctors in their programs, States will
    either be forced to continue to pay Medicaid primary care physicians
    100 percent of Medicare rates, or these physicians will effectively see
    a 40-50 percent cut for in 2015. According to the TennCare Director,
    the requirement to increase provider reimbursement to 100 percent of
    Medicare would cost Tennessee roughly an additional $324 million per
    year.
        How are States going to shoulder these additional burdens in the
    current budget crises most of them are experiencing? Is the
    administration considering any kind of flexibility options to offer to
    States in order to avoid being crushed by all the mandates and
    maintenance of effort requirements?
        Answer. We recognize that the economic downturn has forced States
    to make hard choices to control State spending, and that there are no
    easy answers. Recognizing the challenges facing States, I sent a letter
    to Governors in early February outlining existing flexibility and
    reaffirming the Department of Health and Human Services'--and the
    Center for Medicare & Medicaid Services'--commitment to working with
    States to improve care and manage costs in the Medicaid program. As
    part of that effort, CMS has undertaken an unprecedented level of
    outreach to States to help them strategize on ways to improve the
    efficiency of their Medicaid programs in light of current State budget
    challenges. To accomplish this task, CMS has created Medicaid State
    Technical Assistance Teams (MSTATs) that are ready to provide intensive
    and tailored assistance to States on day-to-day operations as well as
    on new initiatives. As of mid April, CMS has been contacted by 22
    States for technical assistance. We are ready to continue working with
    States to explore new ways to manage their programs that will increase
    efficiency, reduce spending, and improve health for Medicaid
    beneficiaries.
        Question. One of the problems with the Medicaid expansion is that
    there is an access problem for patients in the program being unable to
    see a doctor willing to treat them. There are varying reports on
    providers not willing to see Medicaid patients, like the 2006 report
    from the Center for Studying Health System Change Only stating that
    only about one-half of U.S. physicians accept new Medicaid patients.
        Even the CMS chief actuary stated in an analysis done in April, ``.
    . . it is reasonable to expect that a significant portion of the
    increased demand for Medicaid would be difficult to meet, particularly
    over the first few years.''
        By adding 16-18 million more people into the program, what is your
    administration doing to address access issues for all these new
    beneficiaries?
        Answer. I am committed to ensuring access for Medicaid
    beneficiaries. The Affordable Care Act provision which helps States
    boost their payment rates to Medicare levels for 2 years is a good
    first step, as are all of the provisions that reform our healthcare
    delivery system to align payments with higher quality care. Federal
    funding will be available to cover 100 percent of the initial cost of
    the mandated increases in provider payment for primary care services.
        The newly formed Medicaid and CHIP Payment and Access Commission
    (MACPAC) will play an important role by providing research and analysis
    on provider payment rates and access in the Medicaid program. In the
    initial MACPAC report, issued in March 2011, there was extensive
    discussion about the difficulties in analyzing access issues, and the
    need to develop additional data sources and new analytic approaches. On
    May 6, 2011, we published a proposed rule that integrated the MACPAC
    approach into a strategy to develop a transparent process for States to
    collect and analyze access issues. We anticipate working closely with
    MACPAC to learn about best practices and approaches in sustaining
    access in 2014 and beyond.
        Question. Has HHS done an analysis of how many providers are not
    seeing new or any Medicaid patients? If not, can CMS look into this?
        Answer. Access to providers by Medicaid recipients is of paramount
    importance. As a requirement for States' participation in the Medicaid
    program, they must ensure that ``payments are consistent with
    efficiency, economy, and quality of care and are sufficient to enlist
    enough providers so that care and services are available to the general
    population in the geographic area.'' As noted above, CMS is currently
    undertaking rulemaking to provide guidance to States on compliance with
    this requirement, which includes a framework for State and Federal
    review. Through the rulemaking process, we are welcoming public notice
    and comment on our proposed approach, which provides for States to
    review access through a three-part framework, focusing on beneficiary
    needs, provider enrollment, and service utilization.
        Because States have primary responsibility for managing data on
    eligible beneficiaries and for enrolling and reimbursing Medicaid
    providers, States have the most accurate and up to date information on
    the number of providers participating in each State's Medicaid program,
    the percent of those accepting new Medicaid patients, and whether those
    numbers are comparable to the availability of providers for the general
    population in the area. Our proposed strategy is to require States to
    perform the initial analysis of available data and issue access reports
    for both Federal and public scrutiny.
        Question. In your January testimony to the HELP Committee, you
    mentioned tax credits as a way that the law will keep down premiums. I
    realize that people who receive the tax credits or subsidies will pay
    less out of their own pocket for premiums, but are you saying that
    these tax credits/subsidies will bring down the underlying premiums and
    or the underlying cost of healthcare?
        Answer. Many provisions of the Affordable Care Act make healthcare
    more affordable for American families and businesses, including tax
    credits and premium assistance, new oversight of private insurance
    premiums growth, delivery systems reforms that will bend the healthcare
    cost curve, and larger purchasing pools through Exchanges.
        Insurers often raise premiums to protect themselves against
    unpredictable market conditions. Premium tax-credits offered through
    Exchanges make health insurance coverage attainable for individuals who
    have not previously been able to afford the costs of health insurance
    and will enable wider participation in the health insurance market.
    Keeping more people in the insurance market at all times, and not just
    when they get sick, will lead to greater predictability and stability
    in the individual market.
        Question. According to estimates from Senate Finance minority tax
    staff last year, only 7 percent of Americans would qualify for
    subsidies and would see these cost savings. What about everyone else?
    Even CBO has said premiums for families buying coverage on the
    individual market would see premiums increase by $2,100 a year.
        Answer. Even after full implementation of health reform, most
    Americans will continue to receive insurance through their employers,
    as has traditionally been the case. CBO estimates that nearly 20
    million Americans without access to affordable or adequate coverage
    through their employers or other sources will receive premium tax
    credits or cost-sharing subsidies through the Exchanges.
        Question. You also stated in your HELP testimony that the new law
    ``is bringing down premiums for consumers by limiting the amount of
    premiums insurers may spend on administrative costs and by giving
    States resources to beef up their review process.''
        How do you square this statement with recent news articles that
    some insurers are raising premiums as a result of the new law?
        Answer. According to our analysis and those of some industry and
    academic experts, any potential premium impact from the new consumer
    protections and increased quality provisions under the Affordable Care
    Act will be minimal. We estimate that the effect will be no more than 1
    to 2 percent. This is consistent with estimates from the Urban
    Institute (1 to 2 percent) and Mercer consultants (2.3 percent).
    Insurers themselves have also reached a similar conclusion.
    Pennsylvania's Highmark, for example, estimates the effect of the
    legislation on premiums from 1.14 to 2 percent.
        Any premium increases will be moderated by out-of-pocket savings
    resulting from the law. These savings include a reduction in the
    ``hidden tax'' on insured Americans that subsidizes care for the
    uninsured. By making sure that high-risk individuals have insurance and
    emphasizing healthcare that prevents illnesses from becoming serious,
    long-term health problems, the law will begin to reduce costs resulting
    from the treatment of patients at the acute stage of illness. The law
    prioritizes prevention, making many services available without cost-
    sharing, invests in prevention in communities across the country, and
    contains a series of provisions designed to improve the way we pay for
    care.
        In addition to the coverage and delivery system changes that will
    begin to bend the cost curve, the law provides valuable new tools to
    ensure that consumers are getting value for their premium dollar.
    Already, we have provided 44 States and the District of Columbia with
    resources to strengthen the review and transparency of proposed
    premiums. CMS is making up to $250 million available for States to
    improve their rate review infrastructure and to fight unreasonable
    rates. Rate review allows States to examine and in some cases reject or
    modify the insurance rate before implementation. At the end of the
    year, the new medical loss ratio standard requires carriers to rebate
    premiums back to consumers if they fail to meet the standard. Rate
    review and medical loss ratios work together to help consumers. We will
    also keep track of insurers with a record of unjustified rate
    increases; those plans may be excluded from health insurance Exchanges
    in 2014.
        Question. There has been a lot of news coverage lately about the
    more than 1,100 annual limit waivers granted by your administration.
    Additionally, several States have applied for waivers from the medical
    loss ratio (MLR) requirement.
        Would it not make more sense for HHS to consider a blanket waiver
    of annual benefit limits and MLR standards until 2014?
        Answer. The Center for Consumer Information and Insurance Oversight
    (CCIIO)'s waiver policy represents a transition to 2014, when annual
    limits will be eliminated and limited medical benefit plans will be a
    thing of the past. Until 2014, the transition ensures that insurance
    plans that can remove annual limits do so. Those that cannot remove
    annual limits without significantly raising premiums or reducing access
    to benefits can receive waivers. This transition assures that Americans
    can keep this limited coverage until more comprehensive coverage
    options are available to all in 2014. CCIIO is approving 1 year waivers
    and collecting data on limited benefits plans that will inform our
    approach for future years.
        The medical loss ratio provision allows CCIIO to adjust the
    percentage if the potential exists to destabilize the individual market
    in a State. To date, one State, Maine, has received a reduced loss
    ratio. Each State market is different and CCIIO has established a
    process by which a State may apply, if they believe the potential
    exists for disruption. CCIIO will evaluate each application against the
    criteria set forth in regulation and guidance.
        Question. Does the HHS have contingency plans for larger than
    expected expenditures for subsidies if more employers drop coverage
    than expected?
        Answer. The reforms in the Affordable Care Act are intended to
    complement and strengthen the existing employer-based insurance system,
    not to replace it. We believe that the MLR requirements, review of
    annual rate increases, and delivery system reforms will help slow the
    growth of insurance costs to businesses so they can continue to provide
    the insurance their employees and families need and depend on.
        The Congressional Budget Office has found that any decrease in
    employer-sponsored coverage because of the Affordable Care Act would be
    minimal. On the contrary, the Affordable Care Act provides tremendous
    benefits for employers that will encourage them to continue to offer
    health insurance coverage to their employees. In the coming years, the
    Congressional Budget Office estimates that health insurance premiums
    could decrease by up to 3 percent for employers. The new law also
    provides $40 billion in tax credits to help small businesses purchase
    coverage for their employees. In 2014, small businesses will be able to
    purchase private insurance through the Exchanges, which will provide
    them with the same purchasing power as large businesses.
        Question. In the last Congress, HHS received enormous
    appropriations of tax dollars with very little Congressional direction
    on the use of those funds going forward. HHS received $1 billion as
    part of the Federal stimulus program and approximately $2 billion more
    per year in the future as part of the new healthcare law, all for the
    Mobilizing for Action through Planning and Partnerships (MAPP)
    intervention grants. HHS was given these enormous streams of taxpayer
    dollars without clear direction on the specifics of how those funds
    should be used.
        CDC appears to be using these taxpayer dollars to fund advocacy
    organizations at the State and local level who engage in legislative
    advocacy for higher taxes and restrictions focused on consumer goods,
    which raises a number of serious concerns. Using Federal tax dollars
    for legislative advocacy is against the law, as the appropriation
    itself is subject to a restriction clearly prohibiting that the agency
    from using Federal funds to engage in direct or grassroots lobbying for
    changes in State or local laws. There also is a Federal criminal
    statute--the Anti-Lobbying Act--making it a criminal offense to
    ``influence in any manner . . . an official of any government, to
    favor, adopt, or oppose, by vote or otherwise, any legislation, law,
    ratification, policy or appropriation.''
        As a former Governor, I think it is totally inappropriate for the
    executive branch to unilaterally decide what is or isn't a good State
    or local law worthy of financial support. If the Administration has a
    legislative agenda, it should work with the Congress to enact it
    through the legislative process.
        In response to questions about the use of these funds during
    congressional hearings last year, CDC Associate Director Pechachek,
    stated that, ``The prohibition against lobbying does not mean that
    communities are prohibited from interacting with policy makers such as
    legislators in order to promote the goals of the Communities Putting
    Prevention to Work Program.''
        How can a program have as a main, underlying objective to seek
    changes in State and local laws when the Federal Government
    specifically prohibits the use of Federal grant moneys to engage in
    direct or grassroots lobbying? Do you agree with this concern?
        How much of the billions of dollars in spending under the stimulus
    and new healthcare law has been used to support efforts to change local
    and State laws? Would you provide this Committee with the details of
    that information?
        Answer. As part of the American Recovery and Reinvestment Act
    (ARRA), Congress provided $650 million in funding for CDC to implement
    the Communities Putting Prevention to Work (CPPW) program. In addition,
    approximately $44 million from the Prevention and Public Health Fund
    supported quality but unfunded CPPW grantees, as well as media and
    evaluation, in fiscal year 2010. CPPW grantees are tackling important
    health problems, focusing on tobacco, nutrition and physical activity.
    Addressing these health challenges requires action at the community
    level, often to make changes that give individuals greater
    opportunities to make healthy choices.
        CDC strictly adheres to all Federal laws prohibiting the use of
    Federal funds to lobby, and even goes beyond statutory requirements to
    restrict the activities of grantees at the local level when Federal
    funds are involved. CDC regularly educates all grantees on Federal laws
    related to funding awards, including anti-lobbying provisions. CDC
    references Additional Requirement (AR)-12 ``Lobbying Restrictions'' in
    all of its Funding Opportunity Announcements (FOAs), and all
    prospective recipients must agree to these restrictions prior to
    receiving funds. The AR states, in part, ``Any activity designed to
    influence action in regard to a particular piece of pending legislation
    would be considered `lobbying.' That is, lobbying for or against
    pending legislation, as well as indirect or `grass roots' lobbying
    efforts by award recipients that are directed at inducing members of
    the public to contact their elected representatives at the Federal or
    State levels to urge support of, or opposition to, pending legislative
    proposals is prohibited. As a matter of policy, CDC extends the
    prohibitions to lobbying with respect to local legislation and local
    legislative bodies.''
        CDC is careful to monitor the use of Federal funding, and to ensure
    that grantees comply with Federal law and the specific guidance of the
    Funding Opportunity Announcement and conditions outlined in the AR-12.
    However, anti-lobbying provisions do not prohibit communities from
    interacting with policymakers through proper official channels, in
    order to educate them about the burden of chronic diseases and their
    associated risk factors, as well as evidence-based strategies to
    promote health. There are many activities that are allowable under
    Federal law which community leaders may decide to pursue; moreover,
    policy change does not have to include formal legislative action. For
    example, health departments may choose to work with local
    transportation and planning departments to ensure that urban design
    policies include opportunities for people to be active. Local
    businesses may voluntarily decide to change their food procurement
    policies and to provide a greater selection of healthy food options for
    employees in vending machines and cafeterias. Transit systems may
    determine on their own to make their trains and buses smoke-free. Each
    of these is an example of a type of policy change that impacts people
    in their daily lives, without requiring legislative action at the
    local, State, or Federal levels.
        CDC supports community efforts to foster these types of linkages
    between health departments and key stakeholders from multiple sectors
    across a community, while strictly adhering to all Federal laws
    prohibiting the use of Federal funds to lobby. CDC carefully monitors
    the activities of grantees and the use of Federal funds to ensure
    compliance with Federal law, the specific guidance of the Funding
    Opportunity Announcement, and conditions outlined in AR-12.
        Question. One of the major concerns I have heard from constituents
    about the new health law is that it will lead to government control and
    rationing. Treatment choices should be made between doctors and
    patients, rather than by folks in Washington, DC.
        While the FDA has announced its decision to withdraw its approval
    for Avastin for breast cancer treatment, the European equivalent (the
    EMEA) has confirmed the use of Avastin for breast cancer. Shouldn't
    American women on Medicare have access to this drug as well?
        Answer. I recognize the critical importance of the physician-
    patient relationship, especially in deciding an appropriate drug
    therapy treatment. The Medicare statute authorizes coverage of items
    and services that are reasonable and necessary for the diagnosis or
    treatment of illness or injury in the Medicare population.
        At this time, CMS is not making any changes to its coverage or
    reimbursement policies for Avastin and is waiting until the resolution
    of the FDA process before deciding whether to make any changes. While
    we do periodically consider new evidence about Medicare-covered drugs
    or treatments to evaluate whether changes in coverage decisions are
    warranted, it would be premature to speculate on possible changes in
    Medicare coverage of Avastin, if any, that may be made in response to
    future FDA actions.
        Question. Avastin is an expensive treatment option. Can you affirm
    that the FDA was looking purely at science rather than the cost of the
    drug when making its decision?
        Answer. The Food and Drug Administration (FDA) is responsible for
    protecting the public health by ensuring that drugs and biologics are
    safe and effective. In determining whether a product should be labeled
    for a particular indication, FDA takes seriously our obligation to
    carefully weigh the risks and benefits for the patient. Specifically,
    FDA considers whether the benefits of the drug, including the magnitude
    of those benefits, outweigh the product's potential toxicities for the
    indicated use. The Food and Drug Administration does not factor costs
    into its drug approvals or safety related decisions. FDA's Center for
    Drug Evaluation and Research has proposed to remove Avastin's
    indication for metastatic breast cancer based on the Center's
    evaluation of efficacy and safety data available from clinical trials,
    without considering the cost of the drug. FDA has not yet reached a
    final decision on this proposal, and this matter will be the subject of
    a hearing in June 2011.
        Question. More than 40 States have laws in place to ensure those on
    private insurance have access to cancer drugs even if they are ``off-
    label.'' Shouldn't women on Medicare have the same guarantee?
        Answer. At this time, CMS is not making any changes to its coverage
    or reimbursement policies for Avastin and is waiting until the
    resolution of the FDA process before deciding whether to make any
    changes. While we do periodically consider new evidence about Medicare-
    covered drugs or treatments to evaluate whether changes in coverage
    decisions are warranted, it would be premature to speculate on possible
    changes in Medicare coverage of Avastin, if any, that may be made in
    response to future FDA actions. I would note, however, that, generally,
    Medicaid coverage of a drug is contingent upon that drug having FDA
    approval. I cannot speak to the process behind the coverage decisions
    of other insurance providers.
        Question. If many of the roughly 18,000 women using Avastin for
    metastatic breast cancer find it effective, and scientific experts at
    the National Comprehensive Cancer Network, the leading cancer
    compendia, support its use, can you assure me that Medicare will not
    restrict coverage of this product?
        Answer. I recognize the critical importance of the physician-
    patient relationship, especially in deciding an appropriate drug
    therapy treatment. The Medicare statute authorizes coverage of items
    and services that are reasonable and necessary for the diagnosis or
    treatment of illness or injury in the Medicare population.
        At this time, CMS is not making any changes to its coverage or
    reimbursement policies for Avastin and is waiting until the resolution
    of the FDA process before deciding whether to make any changes. While
    we do periodically consider new evidence about Medicare-covered drugs
    or treatments to evaluate whether changes in coverage decisions are
    warranted, it would be premature to speculate on possible changes in
    Medicare coverage of Avastin, if any, that may be made in response to
    future FDA actions.
                                     ______

                 Questions Submitted by Senator Lindsey Graham
        Question. Can you explain FDA's process for approving drugs for new
    indications?
        Answer. Secretary Sebelius: In order for a new indication for a
    drug or biologic product to be marketed in the United States, it must
    be shown to be safe and effective for its intended new use.
        In 1998, FDA published guidance for manufacturers planning to file
    applications for new indications of approved drugs or biologic
    products. In this guidance, FDA articulated its thinking on the
    quantity of evidence needed in particular circumstances to establish
    substantial evidence of effectiveness. The guidance discussed the
    standards and data requirements for approval of new indications so that
    duplication of data previously submitted in the original application
    could be avoided. In particular, FDA addressed situations in which a
    single adequate and well-controlled trial of a specific new use could
    be supported by information from other adequate and well-controlled
    trials, such as trials in other stages of a disease, or in closely
    related diseases.
        The new drug or biologics licensing application that is submitted
    by the manufacturer in support of a new indication must include the
    requisite clinical trial information demonstrating safety and
    effectiveness, and supportive clinical pharmacology, preclinical and
    product quality information, as needed. FDA scientists review the
    submitted information and determine whether or not the product may be
    approved for the new use if the benefits of treatment are found to
    outweigh the risks for the intended population.
        Question. Am I correct in my understanding that FDA does not
    consider the cost of a drug during its approval process? If cost is
    considered, how does that cost factor into FDA's decision to approve
    drugs for certain indications?
        Answer. Yes, you are correct. In deciding whether to approve a
    drug, FDA cannot and does not take price into account.
        Question. I am aware that Avastin is a very expensive drug, and I
    have been made aware of concerns that cost could have been a factor in
    FDA's decision to remove the breast cancer indication from Avastin's
    label. Did Avastin's cost play any role in FDA's decision regarding the
    drug?
        Answer. The Food and Drug Administration is responsible for
    protecting the public health by ensuring that drugs and biologics are
    safe and effective. In determining whether a product should be labeled
    for a particular indication, FDA takes seriously its obligation to
    carefully weigh the risks and benefits for the patient. Specifically,
    FDA considers whether the benefits of the drug, including the magnitude
    of those benefits, outweigh the product's potential toxicities for the
    indicated use. The Food and Drug Administration does not factor costs
    into its drug approvals or safety related decisions. FDA's Center for
    Drug Evaluation and Research has proposed to remove Avastin's
    indication for metastatic breast cancer based on the Center's
    evaluation of efficacy and safety data available from clinical trials,
    without considering the cost of the drug. FDA has not yet reached a
    final decision on this proposal, and this matter will be the subject of
    a hearing in June, 2011.
        Question. What is HHS's policy for awarding grants to organizations
    that advocate for specific policy positions?
        I have heard concerns that Federal stimulus dollars targeted to
    public health were awarded to advocacy organizations who lobby State
    and local governments for specific policy changes regarding food and
    beverages. Can you provide details regarding the grant-making process
    for public health programs including the information required for
    proposal when submitted and how often HHS audits grant recipients to be
    sure they are complying with the aims of the HHS' grant programs?
        Answer. Applicants for (and recipients of) Federal grants,
    cooperative agreements, contracts, and loans are prohibited by 31
    U.S.C. 1352, ``Limitation on use of appropriated funds to influence
    certain Federal contracting and financial transactions,'' from using
    appropriated Federal funds to pay any person for influencing or
    attempting to influence any officer or employee of an agency, a member
    of Congress, an officer or employee of Congress, or an employee of a
    Member of Congress with respect to the award, extension, continuation,
    renewal, amendment, or modification of any of these instruments. These
    requirements are implemented for HHS in 45 CFR part 93, which also
    describes types of activities, such as legislative liaison activities
    and professional and technical services that are not subject to this
    prohibition. Applicants for HHS grants with total costs expected to
    exceed $100,000 are required to certify that they: have not made, and
    will not make, such a prohibited payment; will be responsible for
    reporting the use of non-appropriated funds for such purposes; and will
    include these requirements in consortium agreements, other subawards,
    and contracts under grants that will exceed $100,000 and will obtain
    necessary certifications from those consortium participants and
    contractors.
        Disclosure reporting is required after award as indicated and must
    be certified annually either through providing submitting disclosure
    statements by doing so on the SF-LLL, Disclosure of Lobbying
    Activities. Where there are no disclosures to report the grantee
    certifies this fact by signing the face page of the application without
    the need to submit the forms. The grantee certifies that there are no
    lobbying activities to report when they sign the face page of the
    application.
        Consistent with Federal law, in its grant programs, CDC references
    Additional Requirement (AR)-12 ``Lobbying Restrictions'' in all of its
    Funding Opportunity Announcements (FOAs), and all prospective
    recipients must agree to these restrictions prior to receiving funds.
    The AR states, in part, ``Any activity designed to influence action in
    regard to a particular piece of pending legislation would be considered
    `lobbying.' That is, lobbying for or against pending legislation, as
    well as indirect or `grass roots' lobbying efforts by award recipients
    that are directed at inducing members of the public to contact their
    elected representatives at the Federal or State levels to urge support
    of, or opposition to, pending legislative proposals is prohibited. As a
    matter of policy, CDC extends the prohibitions to lobbying with respect
    to local legislation and local legislative bodies.''
        CDC is careful to monitor the use of Federal funding, and to ensure
    that grantees comply with Federal law, the specific guidance of the
    FOAs, and conditions outlined in AR-12. Grants or cooperative
    agreements funded by the American Recovery and Reinvestment Act are
    also subject to this policy. We note, however, that many organizations
    engage in advocacy using funding from other sources, and that this does
    not bar them from applying for and receiving funding from CDC.
    Recipients are permitted to use their own funds to lobby, so long as it
    can be demonstrated or shown that the funds that were used for lobbying
    were entirely separate from any appropriated funds they received from
    the Federal Government. Recipients are required to disclose all
    lobbying activities along with their application. CDC only provides
    funds to undertake activities outlined in the FOA.
        CDC's Procurement and Grants Office (PGO) provides specific
    budgetary oversight to ensure the appropriate use of Federal funds. CDC
    grants management specialists and program staff are significantly
    involved in the planning and monitoring of recipient activities, review
    and approval of spending details, and tracking of grantee drawdown of
    funds. PGO staff participate in annual site visits to all funded
    communities. One example is the Communities Putting Prevention to Work
    (CPPW) program, which has a robust plan for performance monitoring in
    order to ensure that Federal funds are used effectively and
    appropriately. The plan positions CDC staff to identify early warning
    signs that a program is using Federal funds for unauthorized and
    inappropriate activities. Furthermore, an electronic performance
    monitoring system provides a central repository for collecting
    information from a number of program monitoring sources. CDC also
    complies with other mandatory directives, such as OMB Circular A-133,
    which requires every organization receiving $500,000 in aggregate
    Federal grants to submit to annual financial audit. The results of
    these audits are used in periodic grantee reviews to identify grantees
    that may present a risk to the control or integrity of fund use.
        Question. I have heard concerns that Federal stimulus dollars
    targeted to public health were awarded to advocacy organizations who
    lobby State and local governments for specific policy changes regarding
    food and beverages. Can you provide details regarding the grant-making
    process for public health programs including the information required
    for proposal when submitted and how often HHS audits grant recipients
    to be sure they are complying with the aims of the HHS' grant programs?
        Answer. Applicants for (and recipients of) Federal grants,
    cooperative agreements, contracts, and loans are prohibited by 31
    U.S.C. 1352, ``Limitation on use of appropriated funds to influence
    certain Federal contracting and financial transactions,'' from using
    appropriated Federal funds to pay any person for influencing or
    attempting to influence any officer or employee of an agency, a Member
    of Congress, an officer or employee of Congress, or an employee of a
    Member of Congress with respect to the award, extension, continuation,
    renewal, amendment, or modification of any of these instruments. These
    requirements are implemented for HHS in 45 CFR part 93, which also
    describes types of activities, such as legislative liaison activities
    and professional and technical services that are not subject to this
    prohibition. Applicants for HHS grants with total costs expected to
    exceed $100,000 are required to certify that they: have not made, and
    will not make, such a prohibited payment; will be responsible for
    reporting the use of non-appropriated funds for such purposes; and will
    include these requirements in consortium agreements, other subawards,
    and contracts under grants that will exceed $100,000 and will obtain
    necessary certifications from those consortium participants and
    contractors.
        Disclosure reporting is required after award as indicated and must
    be certified annually either through providing submitting disclosure
    statements by doing so on the SF-LLL, Disclosure of Lobbying
    Activities. Where there are no disclosures to report the grantee
    certifies this fact by signing the face page of the application without
    the need to submit the forms. The grantee certifies that there are no
    lobbying activities to report when they sign the face page of the
    application.
        Consistent with Federal law, in its grant programs, CDC references
    Additional Requirement (AR)-12 ``Lobbying Restrictions'' in all of its
    Funding Opportunity Announcements (FOAs), and all prospective
    recipients must agree to these restrictions prior to receiving funds.
    The AR states, in part, ``Any activity designed to influence action in
    regard to a particular piece of pending legislation would be considered
    `lobbying.' That is, lobbying for or against pending legislation, as
    well as indirect or `grass roots' lobbying efforts by award recipients
    that are directed at inducing members of the public to contact their
    elected representatives at the Federal or State levels to urge support
    of, or opposition to, pending legislative proposals is prohibited. As a
    matter of policy, CDC extends the prohibitions to lobbying with respect
    to local legislation and local legislative bodies.''
        CDC is careful to monitor the use of Federal funding, and to ensure
    that grantees comply with Federal law, the specific guidance of the
    FOAs, and conditions outlined in AR-12. Grants or cooperative
    agreements funded by the American Recovery and Reinvestment Act are
    also subject to this policy. We note, however, that many organizations
    engage in advocacy using funding from other sources, and that this does
    not bar them from applying for and receiving funding from CDC.
    Recipients are permitted to use their own funds to lobby, so long as it
    can be demonstrated or shown that the funds that were used for lobbying
    were entirely separate from any appropriated funds they received from
    the Federal Government. Recipients are required to disclose all
    lobbying activities along with their application. CDC only provides
    funds to undertake activities outlined in the FOA.
        CDC's Procurement and Grants Office (PGO) provides specific
    budgetary oversight to ensure the appropriate use of Federal funds. CDC
    grants management specialists and program staff are significantly
    involved in the planning and monitoring of recipient activities, review
    and approval of spending details, and tracking of grantee drawdown of
    funds. PGO staff participate in annual site visits to all funded
    communities. One example is the Communities Putting Prevention to Work
    (CPPW) program, which has a robust plan for performance monitoring in
    order to ensure that Federal funds are used effectively and
    appropriately. The plan positions CDC staff to identify early warning
    signs that a program is using Federal funds for unauthorized and
    inappropriate activities. Furthermore, an electronic performance
    monitoring system provides a central repository for collecting
    information from a number of program monitoring sources. CDC also
    complies with other mandatory directives, such as OMB Circular A-133,
    which requires every organization receiving $500,000 in aggregate
    Federal grants to submit to annual financial audit. The results of
    these audits are used in periodic grantee reviews to identify grantees
    that may present a risk to the control or integrity of fund use.

                              SUBCOMMITTEE RECESS

        Senator Harkin. And with that, again, Madam Secretary,
    thank you and the subcommittee will stand recessed.
        [Whereupon, at 11:37 a.m., Wednesday, March 30, the
    subcommittee was recessed, to reconvene subject to the call of
    the Chair.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2012

                                  ----------

                             WEDNESDAY, MAY 4, 2011

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10 a.m., in room SD-124, Dirksen
    Senate Office Building, Hon. Tom Harkin (chairman) presiding.
        Present: Senators Harkin, Brown, Shelby, and Cochran.

                              DEPARTMENT OF LABOR

                            Office of the Secretary

    STATEMENT OF HON. HILDA L. SOLIS, SECRETARY

                    OPENING STATEMENT OF SENATOR TOM HARKIN

        Senator Harkin. The Subcommittee of Labor, Health and Human
    Services, and Education, and Related Agencies will now come to
    order.
        First of all, welcome back to the subcommittee, Madam
    Secretary. Your appearance today comes at a critical point for
    your Department and for our Nation's workforce.
        After a long and difficult recession, our economy is slowly
    recovering, but too many workers are unemployed or
    underemployed, and more needs to be done to ensure that all
    Americans benefit from economic growth, not just the few at the
    top. At the same time, Congress and the administration must
    work together to reduce our budget deficits and restore fiscal
    discipline.

                      FISCAL YEAR 2011 APPROPRIATIONS BILL

        A first step was taken last month when we completed action
    on the fiscal year 2011 appropriations bill. This bill made
    significant cuts to the Department of Labor, more than $800
    million, or 6 percent below the fiscal year 2010 level. And
    yet, we maintained important investments in employment and
    training programs, worker protections, and the fight against
    the worst forms of child labor. The cuts could have been more
    damaging. The House alternative, H.R. 1, targeted programs that
    serve the most vulnerable Americans, including drastically
    cutting job training for people who have lost their jobs as a
    result of layoffs. It's hard to see the wisdom of a cut like
    that when the real unemployment rate really is close to 16
    percent in this country. Thankfully, the fiscal year 2011 bill
    rejected that approach.

                                FISCAL YEAR 2012

        Now we turn to fiscal year 2012. Regrettably, we already
    know that programs that benefit American workers are once again
    being targeted for draconian cuts. The budget passed by the
    House last month takes the approach that the deficit should be
    addressed by enacting yet another tax cut bonanza for those at
    the top while ripping the social safety net for seniors, people
    with disabilities, and low income, and slashing funding for
    education and training. In fact, the House budget would cut
    education and training programs by 15 percent in fiscal year
    2012.
        I believe there's a better way, and history offers a guide.
    When President Clinton took office in 1993, he faced a similar
    situation in terms of the budget. He proposed a balanced
    approach that included spending cuts and necessary revenue
    increases while continuing to make crucial investments in
    education, infrastructure, and research, areas that are
    absolutely essential if we're going to create jobs and stay
    competitive in the global economy. The plan worked, and worked
    brilliantly. It created large budget surpluses, 22 million new
    jobs, and 116 consecutive months of economic expansion, the
    longest in American history. I believe we need that same
    balanced approach today.
        Madam Secretary, there is no question that the fiscal year
    2012 budget for the Department of Labor will remain tight. But,
    the President rightly puts a high priority on programs that are
    critical to our long-term fiscal health, especially in the
    areas of employment and training, as well as a new workforce
    innovation fund that Congress created in the fiscal year 2011
    bill.
        I'm also pleased to see that the budget request continues
    the Disability Employment Initiative that Congress started in
    fiscal year 2010. With almost 80 percent of Americans with
    disabilities not currently in the labor force, we need to do
    much better, and I believe this initiative will help.
        Your budget also proposes important investments that will
    help address mine safety and health, worker misclassification,
    and workplace safety and health activities. I was particularly
    pleased to see a proposed increase for Bureau of International
    Labor Affairs (ILAB), which leads our fight against the worst
    forms of child labor around the world. And I thank you for
    that, Madam Secretary.
        On a related note, I'd like to thank you for your efforts
    on the framework of action to support the implementation of the
    Harkin-Engle Protocol targeted at child labor in the cocoa
    sectors of Ghana and the Ivory Coast.
        Madam Secretary, I know you are well aware of the many
    important priorities competing for resources in our Labor-HHS
    appropriations bill. Your testimony in this hearing will help
    inform us as we do that work.
        And before we hear from you, Madam Secretary, I would yield
    to Senator Shelby for his opening statement.

                     STATEMENT OF SENATOR RICHARD C. SHELBY

        Senator Shelby. Thank you, Mr. Chairman.
        Madam Secretary, I look forward to hearing your testimony
    today on the 2012 budget request. As the chairman has said,
    we're in difficult economic times. The unemployment rate is 8.8
    percent. When you consider the underemployed and those who have
    stopped looking for work, which the Department of Labor does
    not incorporate in the unemployment statistics, the real
    unemployment rate is actually much higher, at 16.2 percent.
        The Federal deficit is $1.65 trillion. In fiscal year 2012,
    I believe we need to make cuts to our discretionary budget. I
    don't think we have any choice. The Department of Labor's
    fiscal year 2012 budget request reduces Federal spending by 5
    percent, compared to fiscal year 2010 levels. And while the
    Department of Labor should be recognized for cutting spending,
    a feat not accomplished by every Department in the year 2012, I
    do not believe, myself, a 5-percent reduction within the
    Department of Labor goes far enough. In this difficult economic
    environment we need to cut spending today.

              DUPLICATION IN DEPARTMENT OF LABOR TRAINING PROGRAMS

        To get Federal spending under control in the long term, we
    must reduce spending in the short term. The first place to
    begin to reduce expenditure is by eliminating duplication among
    Department of Labor training programs. On March 1, the
    Government Accountability Office, GAO, released a report on
    duplication within Federal programs. I'm concerned that 44 of
    the 47 Federal employment and training programs that the GAO
    identified overlap with at least one other program. I would
    think we could all agree that providing the same services to
    the same population but through separate administrative
    structures does not make sense. Many Federal workforce programs
    meet important skill needs. But, the workforce system could be
    better aligned across agencies and streamlined to ease access
    for both workers and employers. And while I understand the
    implementation could be challenging, collocating services and
    consolidating administrative structures would increase
    efficiencies, and it would certainly reduce costs.

                    GOVERNMENT ACCOUNTABILITY OFFICE REPORT

        To the greatest extent possible, we should not have
    duplication within the Federal Government, and certainly not
    within one Department. The GAO report makes a number of
    recommendations that would move the system in that direction.
    And I think our subcommittee needs to seriously consider them.
        Second, as the GAO report pointed out, we do not know the
    effectiveness of most of the Department of Labor programs. In
    last year's testimony before this subcommittee, Madam
    Secretary, you stated that you understand the importance of
    evaluating the Department of Labor workforce programs, and you
    have, quoting you, ``a new commitment to program evaluation.''
    Those were your words. A year later, I see few results. Job
    Corps has not had a rigorous evaluation since 2003--8 years
    ago. The program's funding, under the Workforce Investment Act
    was supposed to be evaluated in 2005, and now we will not have
    results until 2013. How can this subcommittee make funding
    decisions without having thorough reviews of programs? I
    believe we should have clear metrics and a results-driven
    evaluation process to ensure that we fund only the most
    successful programs.
        Finally, over the past 10 years, the Federal Government's
    regulatory reach has greatly expanded. The administration
    continues to want to extend that reach, even though costly new
    regulations, I believe, are oppressing economic growth in the
    business community. According to the Center for the Study of
    American Business at Washington University, $1.3 trillion is
    lost each year in total U.S. economic activity due to Federal
    regulations throughout our Government. We need to work together
    to reduce excessive burdens on businesses and job creation
    while still maintaining workplace health, safety, and basic
    employment protections.
        I'm particularly concerned regarding draft rule proposals
    on welfare benefit plan disclosures and on the definition of a
    fiduciary. I will have questions for the record on both of
    these topics.
        Mr. Chairman, I thank you for holding this hearing. I look
    forward to continuing to work with you as we move toward the
    2012 appropriation process.
        Senator Harkin. Thank you very much, Senator Shelby.
        Senator Cochran. Mr. Chairman, may I ask unanimous consent
    to join you and Senator Shelby in welcoming the witness----
        Senator Harkin. Absolutely.
        Senator Cochran [continuing]. And having my statement be
    included at this point in the hearing record?
        Senator Harkin. Absolutely. Absolutely----
        Senator Cochran. Thank----
        Senator Harkin. [continuing]. Senator Cochran.
        Senator Cochran. Thank you. Welcome.
        [The statement follows:]

                   Prepared Statement of Senator Thad Cochran

        Mr. Chairman, thank you for calling this hearing to discuss
    funding for the Department of Labor for fiscal year 2012. I
    appreciate Secretary Solis attending today and look forward to
    her testimony.
        Madame Secretary, I want to thank you for your continued
    support of Job Corps and the YouthBuild program within the
    fiscal year 2012 budget. Workforce development programs
    targeted at youth are critical to developing occupational
    skills as they work toward their chosen career field.
    Mississippi has three Job Corps centers that serve over 1,400
    students each year and six YouthBuild programs throughout the
    State. These programs have given numerous out-of-school, out-
    of-work Mississippi youth the opportunity to obtain their
    General Equivalency Diploma (GED) or high school diploma and
    gain critical vocational training. I look forward to continuing
    to work with you on these important programs.
        Thank you, Mr. Chairman.

        Senator Harkin. And any other Senators who are not here, or
    may come later, their written statements will be made a part of
    the record.
        Secretary Solis was confirmed as the 25th Secretary of
    Labor on February 24, 2009. First elected to public office in
    1985, as a member of the Rio Hondo Community College board of
    trustees, Secretary Solis also served in the California State
    Assembly from 1992 to 1994; in 1994, made history by becoming
    the first Latina elected to the California State Senate. As the
    chairwoman of the California Senate Industrial Relations
    Committee, she led the battle to increase the State's minimum
    wage. She also authored a record 17 State laws aimed at
    combating domestic violence. Secretary Solis also was a
    management analyst with the Office of Management and Budget
    (OMB) in the Civil Rights Division and, as we know, also served
    as a U.S. Representative from the 32d congressional district in
    California from 2001 to 2009. Secretary Solis graduated from
    the California State Polytechnic University, in Pomona, and
    earned her master's degree at the University of Southern
    California.
        So, Madam Secretary, you have a sterling background, and a
    background that fits in very well with your job and your
    leadership at the Department of Labor. And let me, again, just
    thank you for that great leadership that you've provided over
    the last couple of years. We have seen, I think, dramatic
    improvement in the morale. And we've see a lot of good things
    happening out there, especially in areas of worker safety and
    worker health protections. And I just want to compliment you
    for that and welcome you back to the subcommittee.
        Your statement will be made a part of the record in its
    entirety. And you can please proceed as you so desire.
        Thank you.

                    SUMMARY STATEMENT OF HON. HILDA L. SOLIS

        Secretary Solis. Thank you so much, Chairman Harkin and
    Vice Chairman Shelby and, obviously, Senator Cochran, for being
    here. It's a pleasure to come back here before you, to the
    subcommittee, and provide my testimony to you.
        Since I came before you last year, there have been a lot of
    changes in our economy, as you well know, and throughout our
    country. But, what has not changed is the desire of the
    American public, and that is for us to work together to address
    the challenges facing working-class people and especially those
    people that are underemployed or unemployed. While there is
    broad agreement that the Government has to start living within
    its means, I hope we can also agree that we have to make those
    investments that will allow our future to prosper by out-
    innovating out-competing, out-educating, and making sure that
    everyone here has a fighting chance to be successful. For the
    Department of Labor, that means preparing Americans for jobs of
    tomorrow as well as ensuring that those jobs are both safe and
    that they are fair.
        The President's 2012 budget reflects difficult choices but
    retains the critical investments needed to get America back to
    work and in safe jobs. It also does so in a way that shows our
    commitment to innovation. I want to thank you, Mr. Chairman,
    for supporting the Workforce Innovation Fund within this recent
    budget agreement. I look forward to working together with you
    to build on the initial investment in a way that will make the
    public workforce investment system more efficient, more
    streamlined, more targeted to best serve our Nation's workers.
    This is an example of where we did make a tough choice in the
    budget. Instead of adding funds on top of existing programs, we
    redirected funding from a slower spending statewide set-aside
    to create a competitive grant program. Some of the concerns
    that Senator Shelby has raised I believe will be addressed in
    this Innovation Fund.

                            WORKFORCE INVESTMENT ACT

        There was a similar choice that we had to make that you had
    to make, as well: recent cuts that were made in the Workforce
    Investment Act, overall. In crafting the future of WIA, the
    Workforce Investment, I hope that we can find a way to strike a
    good balance between local service dollars, statewide
    activities, and competitive grants that don't replicate or
    duplicate programs. I'm looking for ideas to provide new areas
    and innovative pursuits, as also--and looking, also, for a
    system that will help provide those reforms that we're talking
    about here today.
        I know that you've also faced tough choices in eliminating,
    in fiscal year 2011, funding for green job training programs.
    As the economy recovers, however, I strongly believe that green
    jobs still will remain a growing segment of this economy and
    will take us further, in the 21st century, to cut our
    dependence on foreign oil and as well as relying on those
    countries that may not be supportive of our goals, overall.
        Preparing workers for these jobs will be a vital component
    of winning the future, and restoring the investment will allow
    us to continue to work with industry to ensure that American
    workers have the opportunity to gain the skills and credentials
    to move into better and high-paying jobs. And hopefully those
    jobs will stay here on our shores.
        I also want to emphasize that our budget maintains our
    commitment to helping the most vulnerable populations, those
    that are veterans, women, and other people that serve us well,
    here in our country. We focus our resources and our Nation's--
    on our Nation's veterans, including additional funds to help
    veterans in transition to civilian employment, and for homeless
    veterans, as well.
        One of my priorities in that program is targeting women
    veterans, many who are coming home have served us abroad and
    are finding it very, very difficult to find employment, but
    also, to help their families. We maintain the funding, in both
    ETA and ODEP, for the Disability Employment Initiative that
    you, Mr. Chairman, have championed. We recognize, also, that
    young people need skills to qualify for the jobs of the future,
    and request additional funds for the YouthBuild Program and the
    Job Corps operations.

                               WORKER PROTECTION

        At the Department of Labor, we take very seriously our
    obligation to both protect workers and to protect those
    businesses that play by the rules and provide their workers a
    safe and fair workplace. No worker should have to worry about
    whether they are going to come home safely at the end of a
    shift or get paid for the work that they do. And no employer
    should have to compete against companies that cut corners on
    safety or evade the law.
        The fiscal year 2012 budget builds on recent gains from our
    worker protection agencies. As an example, the Occupational
    Safety and Health Administration, OSHA, must ensure that all
    employers live up to their obligation to provide a safe
    workplace. Fiscal year 2012 budget provides the enforcement and
    regulatory staff and resources we believe are necessary to meet
    that challenge. It also maintains and expands on our commitment
    on compliance assistance programs, including the Voluntary
    Protection Program and the free Onsite Consultation Program
    that focuses on small businesses.
        Also within OSHA, we include additional funds to respond to
    the challenge of implementing a greatly expanded Whistleblower
    Protection Program that the Congress enacted.
        The Upper Big Branch mine disaster, as you recall, 1 year
    ago, resulted in the needless loss of 29 miners, and the worst
    mining disaster since the creation of the Mine Safety and
    Health Administration. In light of this tragedy, the budget
    request includes additional resources so necessary to ensure
    that the Department has the right tools needed to best protect
    our miners. The request includes funding to continue to reduce
    the backlog of contested citations at the Federal Mine Safety
    and Health Review Commission. And I thank you for your
    attention that you have paid to this problem in the recent
    budget agreement. We must also continue our efforts in this
    area to ensure that we're holding accountable mine operators
    who fail to meet their legal and moral obligation and
    responsibility to provide safe mines.
        I also wanted to highlight a few other priority areas at
    DOL. The budget request contains an increase for EBSA, the
    Employment Benefit Security Administration, that protects
    employee benefits for more than 149 million people by
    safeguarding the integrity of 718,000 pension plans and 2.6
    million health plans. Our recent request also includes
    resources in the Wage and Hour Division and other agency
    partners to prevent misclassification which is often misused by
    employers by classifying workers as independent contractors in
    order to avoid their legal obligation to pay taxes or follow
    employment laws.
        One of my goals as Secretary has been to build upon a
    balanced pattern of global trade. Unless workers' rights,
    wages, and working conditions are respected in countries abroad
    that we trade with, workers will be at a disadvantage in the
    global economy, particularly U.S. workers. The budget includes
    an increase of this work by our Bureau of International Labor
    Affairs while maintaining resources in ILAB's effort to combat
    child labor. Again, I want to thank the chairman for his
    tireless effort on our behalf and those many millions of
    children.
        Before closing, I want to emphasize our commitment to
    improving how we deliver services. We're constantly
    scrutinizing ourselves and looking for opportunities to improve
    and to do things much smarter. I'm particularly proud of our
    adoption of a rigorous self-evaluation program. We have a new
    chief evaluation officer who is helping us measure our impact
    of our programs to find out what works and what does not work.
    And I welcome the opportunity for her to have a discussion with
    each of you.
        And I also want to note that the budget includes a proposal
    to strengthen the integrity of unemployment insurance. And we
    look forward to working with Congress on that matter.
        Again, I want to thank you for the opportunity to present
    our budget. I look forward to working with all of you. And I
    hope that we'll continue to make headway in the coming year.
        Thank you for the opportunity to be here.
        [The statement follows:]
                      Prepared Statement of Hilda L. Solis
        Chairman Harkin, Ranking Member Shelby, and members of the
    Subcommittee, thank you for the invitation to testify today. I
    appreciate the opportunity to discuss the fiscal year 2012 budget
    request for the Department of Labor.
        There is broad agreement that the Federal Government has to start
    living within its means. Now that our economic recovery is gaining
    strength, we must come together, reduce our deficit, and get back on a
    path that will allow us to pay down our debt. But we must do it in a
    way that protects the recovery, protects the investments we need to
    grow, create jobs, and helps us win the future. Building on the 2012
    budget and borrowing from the recommendations of the bipartisan Fiscal
    Commission, the President recently proposed a balanced approach to
    achieve $4 trillion in deficit reduction over 12 years. Part of this
    plan is to keep annual domestic spending low by building on the savings
    reflected in our 2011 budget agreement. That step alone will save us
    about $750 billion over 12 years. The administration is committed to
    making the tough cuts necessary to achieve these savings--including to
    programs we care about--but will not sacrifice the core investments we
    need to grow and create jobs.
        The 2012 budget request for the Department of Labor includes a
    number of these difficult cuts, but it also includes key investments
    that would allow us to win the future by out-innovating, out-educating,
    and out-building our global competitors. Getting America back to work
    is a top administration priority as we seek to spur growth in the U.S.
    economy. It is important to promote the creation of ``good jobs,'' and
    the Department of Labor plays a vital role in this goal by helping
    workers find and prepare for new jobs, helping employers find skilled
    workers, and enforcing statutory obligations that keep workers safe and
    help them keep what they earn.
                            investing in the future
        The Department of Labor fiscal year 2012 budget invests in the
    future by working toward my vision, Good Jobs for Everyone. The
    Department's budget focuses on this vision in a fiscally responsible
    manner by:
      --Getting America Back to Work;
      --Keeping Workers Safe; and
      --Helping Workers Provide for Their Families and Keep What They Earn.
                          getting america back to work
        To get America back to work and win the future, the Department will
    prepare workers with the tools they need to succeed in the 21st century
    economy, help workers and firms find each other, and support innovative
    strategies to promote economic recovery. The budget documents have been
    provided to the Committee and are available on our website, but for
    now, I want to share the key investments with you:
      --Workforce Innovation Fund.--The public workforce investment system
            is more important now than ever, but we need to make it more
            efficient, streamlined, and targeted to serve our growing
            customer base. To ensure that our investments in employment and
            training are focused on reform, the Departments of Labor and
            Education will invest in a Workforce Innovation Fund that will
            drive innovation and reinvigorate America's workforce
            development system. The Fund represents a small but crucial
            investment in innovative, evidence-based, and cost-saving
            workforce investment strategies that will significantly impact
            formula-funded activities well into the future. We were pleased
            that the final 2011 budget agreement included funding for the
            Fund. Our commitment to innovation is also reflected in
            requests for green jobs innovation activities and, of course,
            for evaluation so that we can improve our knowledge of what
            works.
      --YouthBuild.--Developing the skills of our Nation's youth is
            critical to ensuring that our workforce is ready to succeed in
            the future. The 2012 budget requests additional funds for the
            YouthBuild program, which provides disadvantaged youth,
            including youth with disabilities, with a pathway to employment
            or post-secondary education. In fiscal year 2012, we will
            continue to implement the YouthBuild random assignment
            evaluation--the first rigorous impact evaluation ever conducted
            of the program--to measure the program's impacts on
            participants' post-program employment and earnings and to build
            knowledge of what works.
      --Unemployment Insurance Solvency and Integrity.--This administration
            is committed to protecting the financial integrity of the UI
            system and helping unemployed workers return to work as swiftly
            as possible. Two major legislative proposals would strengthen
            the unemployment insurance safety net. One would help States
            improve the solvency of their unemployment accounts in the
            Unemployment Trust Fund (UTF), while providing temporary tax
            relief for employers. The other would create incentives for
            States to adopt Short-Time Compensation programs and expand
            their use nationally through implementation grants and a
            temporary Federal program in order to help avert layoffs.
            Another legislative proposal would focus on reducing UI
            improper payments by giving the States new tools and resources
            that will strengthen the fiscal integrity of the UI system
      --Job Corps.--Our Job Corps program has a long history of preparing
            disadvantaged youth for a successful transition into the
            workforce. The 2012 budget would request additional funds for
            the program, and continues an ambitious agenda to improve the
            program's performance.
      --Veterans' Employment and Training Service.--We know returning
            veterans can contribute greatly to our economy. The request for
            the Department's Veterans' Employment and Training Service
            includes additional funds for the Homeless Veterans
            Reintegration Program to provide employment and training
            assistance to almost 27,000 homeless veterans, including
            continuing our outreach to homeless women veterans. In
            addition, the budget request funds the Transition Assistance
            Program for service members and their spouses, including
            expansion of services to retiring Reserve and National Guard
            members. Transition Assistance Program workshops play a key
            role in helping service members transition swiftly and
            successfully to civilian employment.
      --Disability Employment Initiative.--It is also important to continue
            our efforts to ensure that our workforce system effectively
            serves persons with disabilities. To accomplish this, the
            Department's budget includes funding for the Employment and
            Training Administration and the Office of Disability Employment
            Policy to continue the Disability Employment Initiative begun
            in fiscal year 2010. This initiative works to build the
            capacity of the WIA One-Stop Career Center system to serve job
            seekers with disabilities by improving coordination across
            programs, leveraging resources, and prioritizing the provision
            of service to job seekers with disabilities (adults and youth)
            through the Social Security Administration's Ticket to Work
            program.
                              keeping workers safe
        Winning the future requires a successful competitive market where
    all firms are playing by the rules to keep workers safe. Workers should
    be safe in their jobs and we need to ensure that our worker protection
    efforts keep up with the changing economy. The fiscal year 2012 budget
    builds on recent gains for our Worker Protection agencies. Some of the
    highlights of our worker protection request include:
      --Occupational Safety and Health Administration.--The Occupational
            Safety and Health Administration (OSHA) must ensure that all
            employers are able to provide safe workplaces to their
            employees. The request would expand OSHA's commitment to
            preventing injuries, illnesses and fatalities by deterring
            employers in the most hazardous workplaces who exhibit a
            profound disregard for worker safety and health. The fiscal
            year 2012 budget also includes funds to support OSHA's work
            with the 21 whistleblower programs it administers in order to
            reduce the backlog in whistleblower claims, expedite the
            handling of received complaints, and prepare for a high volume
            of complex cases resulting from recently passed laws.
      --Mine Safety.--The Upper Big Branch mine disaster just over 1 year
            ago resulted in the needless loss of 29 miners' lives and was
            the worst mining disaster in the last 40 years. To prevent
            future such tragedies, the budget request includes additional
            resources for the Mine Safety and Health Administration (MSHA)
            to ensure that the Department has the tools we need to best
            protect miners. The Budget also requests funding for the Office
            of the Solicitor (SOL) to reduce the enforcement backlog of
            contested citations at the Federal Mine Safety and Health
            Review Commission (FMSHRC). Funds would also support
            Administrative Law Judges processing Mine Safety and Health
            citation cases at FMSHRC. We must continue our efforts in this
            area to ensure that we are holding accountable mine operators
            who fail to meet their legal and moral responsibility to
            operate safe mines.
       helping workers provide for their families and keep what they earn
        Employee Benefits Security Administration.--The Department's
    Employee Benefits Security Administration (EBSA) protects the employee
    benefits for more than 149 million people by safeguarding the integrity
    of 718,000 pension plans, including 401(k) plans, 2.6 million health
    plans, and a similar number of other employee benefit plans. The
    additional requested resources will support the significant increase in
    congressional action aimed at strengthening benefit security for
    working Americans and their families. The Department's efforts will
    make plans more secure and help ensure that workers and their families
    receive the benefits to which they are entitled from their plan and
    under the law.
        Pension Benefit Guaranty Corporation.--The Budget proposes to
    strengthen the defined benefit pension system for the millions of
    Americans who rely on it by giving the PBGC Board the authority to
    adjust premiums and directing PBGC to take into account the risks that
    different sponsors pose to their retirees and to the pension insurance
    program. In order to ensure that these reforms are undertaken
    responsibly, the budget would require 2 years of study and public
    comment before any implementation and the gradual phasing-in of any
    increases.
        Employee Misclassification Prevention and Detection Initiative.--
    The budget re-proposes a multi-agency Misclassification Initiative that
    would coordinate Federal and State efforts to remedy violations that
    may result from the misclassification of employees as ``independent
    contractors'' and mitigate future violations.
        Other priorities from the budget submitted by the President in
    February include additional funds for the Bureau of International Labor
    Affairs. The fiscal year 2012 budget includes funds to allow ILAB to
    collect additional information for its responsibilities for reporting
    on labor rights in countries that have free trade agreements and trade
    preference programs with the United States. The budget will also
    continue the Bureau's longstanding commitment to combating child labor
    internationally and to building international relationships that
    improve global working conditions and strengthen labor standards around
    the world.
                                   conclusion
        To summarize, the 2012 budget provides targeted investments to help
    workers and firms better find each other, prepare Americans with the
    skills needed for the jobs of today and the jobs of the future, and
    ensure that we have a fair and equitable labor market for firms and
    workers. Our efforts will help to get America back to work, foster safe
    workplaces that respect workers' rights, provide a level-playing field
    for all businesses, and help American workers provide for their
    families and keep the pay and benefits they earn. I am committed to
    achieving the goal of Good Jobs for Everyone while the administration
    focuses on our shared long-term goal of reducing the Federal deficit. I
    believe it is possible to do both and stand ready to work with you in
    the weeks and months ahead on a responsible way forward.
        Mr. Chairman, thank you for inviting me today. I am happy to
    respond to any questions that you may have.

        Senator Harkin. Thank you very much, Madam Secretary.
        We'll start a round of 5-minute questions.

                     EMPLOYMENT OF PEOPLE WITH DISABILITIES

        Madam Secretary, I know you share my deep concern about
    what happened in a situation in Iowa a couple of years ago. It
    was uncovered in April 2009. Again, for your benefit, and
    others, here's what happened. We found people with
    disabilities, 21 men, were working in a turkey processing
    plant. They had been employed by Henry's Turkey Service, out of
    Goldthwaite, Texas--shipped up to Iowa--and had been working in
    this turkey processing plant, some for as long as almost 20
    years. They were living in an old bunkhouse, an old
    schoolhouse--106-year-old schoolhouse--where the boilers didn't
    work. It was cold. Cockroaches were everywhere. And these men
    were bused from there to the workplace and back again. They
    were making 41 cents an hour--subminimum wage--41 cents an
    hour. And they were working right next to people making $12 an
    hour, doing the same job. I mean, it's not that they were
    picking up after them, they were doing the exact same work. And
    so, this was uncovered. It became quite a scandal.
        I have since visited--now, those men have been taken out of
    there. I've since visited with some of those employees in
    Waterloo, but some went back to Texas. Some are still in Iowa,
    and they're working. And they're working not at subminimum wage
    jobs, but at regular integrated employment. In fact, one even
    started his own business, which is a lawn care business in
    Waterloo.

                               WAGE HOUR DIVISION

        Now, why do I raise this issue? I raise it because, from
    2000 to 2008, the Wage and Hour Division lost 20 percent of its
    staff. John McKeon, Deputy Administrator of the Department of
    Labor's Wage and Hour Division, told me, before I held the
    hearing that we held on this subject in the HELP Committee,
    that there are many employers in the United States who pay less
    than the minimum wage and, ``have never seen a Wage and Hour
    investigator.'' And that's sort of what happened in Iowa.
        As I understand it, they were visited, years ago, and then,
    every year, all they have to do is just send in a piece of
    paper. They just send in a piece of paper saying that, ``We're
    complying,'' and that's the end of it. The turkey place was
    called Atalissa--Atalissa. And so, we refer to it as the
    Atalissa case, which raises, in my mind, if that happens in
    Iowa, how many more Atalissas are there out there? And as you
    know, I am taking the opportunity in the HELP Committee and
    with the Workforce Investment Act, to take a look at this area
    of subminimum wage, and how people with disabilities are
    funneled into subminimum wage jobs. They're never given any
    training, never any upgrading of skills, never tested to see,
    can they do something else? Obviously, if these men were doing
    the same job as nondisabled people, they should have been paid
    the same rates. There should have been integrated employment.
        So, I guess I just wanted to bring that to your mind and to
    your attention and just ask you, again, what actions your
    Department's taking to prevent this sort of situation from
    happening again, and to find out how many other places like
    this exist in our country?
        Secretary Solis. Mr. Chairman, I also am appalled by this
    particular case. And I know the last time that I came before
    this subcommittee, I think you brought it up at that time, as
    well. Since that time, I'm happy to report that our Wage and
    Hour Division, because of the support that we received, we're
    able to bring back the enforcement capability that we lost in
    the last 10 years.
        And what we have done, in this particular case, is to look
    at those individuals that are working with the 14(c) program,
    particularly identifying this population, and looking through a
    survey, a compliance survey, to see where we have gaps, where
    we have found problems. And I can tell you that I will make
    sure that you get the results of our survey that will be due to
    us in about 4 to 6 weeks.
        And with that, I would say that we have made sure--and this
    one particular case that you're talking about--at the time,
    they were not certified under the 14(c) program, but we did
    have our Wage and Hour personnel take action, as well as our
    solicitor. That particular situation is being litigated in
    courts right now. And we're finding that there were some major,
    major violations of the Fair Labor Standards Act. And these
    individuals, I believe----
        Senator Harkin. Yeah.
        Secretary Solis [continuing]. Will find justice.
        And I would tell that we're going to continue to look at
    these kinds of abuses, because we know that if it happened
    there, it could very well be happening somewhere else. And we
    want to get to the bottom of that.
        Senator Harkin. I thank you for that. And I also--I just
    might say, they got initial summary judgment for $1.76 million.
    But, then again, that doesn't--that helps, but that doesn't
    take care of the losses they've had in Social Security, for
    example, payments that they're going to need when they get
    older. And some are on the verge of retirement right now. So,
    thank you.
        Secretary Solis. I'd be happy to work with you on that----
        Senator Harkin. I appreciate it.
        Secretary Solis [continuing]. On strengthening----
        Senator Harkin. I appreciate it.
        Secretary Solis [continuing]. This program.
        Senator Harkin. This case just shocks the conscience. Just
    shocks the conscience. Thank you very much, Madam Secretary.
        Senator Shelby.

                          RECOVERY EFFORTS IN ALABAMA

        Senator Shelby. Thank you, Mr. Chairman.
        Madam Secretary, last week, tornados devastated my home
    State of Alabama. It was the worst that we've experienced in my
    lifetime, and probably in most people's lifetime in the whole
    South. I toured the damage, last Friday, with the President.
    And we've had a number of Cabinet Secretaries who were down
    there Saturday and Sunday. I'm going back down there next week
    with the HUD Secretary, who's already been there.
        Could you tell me what the Department of Labor is doing to
    assist the people of Alabama in their recovery efforts? I know
    you're doing some things. But, you know, we're facing dire
    circumstances.
        Secretary Solis. Right. Senator, also I want to convey my
    condolences to the families there, as well as to the other
    States that are affected, and tell you that this is a constant
    reminder of my role at the Department of Labor, because we have
    a special funding that is made available. Fortunately, we have
    some funds for them. In fact, this morning, before I came to
    this hearing, I signed off on what we call the National
    Emergency Grant, the NEG, that will be going to Alabama, to
    those, I believe, 67 counties that are eligible, under FEMA----
        Senator Shelby. That's fine.
        Secretary Solis [continuing]. To receive funding. The
    amount is for about $10 million to help provide temporary jobs
    for those individuals, whether they work for private or public
    sector, if they've lost their homes. They'll be hired. They can
    help provide with cleanup. They'll also be able to help provide
    with any repair, renovation, reconstruction for low-income
    housing, as well as provide assistance for weatherization. And
    particularly, people that are eligible for other types of
    Federal aid, they will be able to help those individual
    households repair.
        I know this is a small amount, given the catastrophe there.
    And I would imagine that the Governor and yourself will be
    working with my staff, my Assistant Secretary----
        Senator Shelby. Sure.
        Secretary Solis [continuing]. Jane Oates, who was contacted
    very early on, and had our staff out in the field. In this
    tornado, unfortunately, we lost some State staff from----
        Senator Shelby. We did.
        Secretary Solis [continuing]. Various WIA programs, that
    lost their homes and lost their lives, as well.
        So, we know this is tragic. And I am also prepared, once we
    have more notification from the other States that have not yet
    completed their applications, to make a visit out there myself,
    as I did a year ago, when we heard about the BP oilspill. We
    have a necessity to be on top of safety and protection for
    workers, as well.
        Thank you.

                         NATIONAL LABOR RELATIONS BOARD

        Senator Shelby. Well, thank you very much. And I know there
    are other States, including the State of Mississippi that
    Senator Cochran represents, that were affected here.
        I want to turn to another area. On April 20 of this year,
    the acting General Counsel of the National Labor Relations
    Board issued a complaint against the Boeing Company, alleging
    that it violated Federal law by deciding to transfer a second
    airplane production line from a union facility in the State of
    Washington to a nonunion facility in the State of South
    Carolina. The complaint said this was discrimination. It's
    interesting that the National Labor Relations Board used the
    word ``transfer,'' as its production line does not, and never
    did, exist in Washington State. I make this point because, if
    the production line never existed in Washington and was not
    planned or committed there, there were no jobs lost there.
        Madam Secretary, I understand that the National Labor
    Relations Board is an independent agency. But, I'd like to hear
    your thoughts on the underlying issue here, that private U.S.
    business cannot freely open new facilities in right-to-work
    States without fear of retaliation by the U.S. Government and
    this administration. Is that the policy of this administration?
        Secretary Solis. Senator, I would just say to you--and you
    just emphasized that--that this in an independent agency, the
    NLRB. And while they are currently going through their decision
    or--I can't really comment on what they are--on what the
    counsel there is----
        Senator Shelby. I know it's not directly under you. You
    have an opinion on it, or you'd just rather not----
        Secretary Solis. No. No, I don't have, other than to tell
    you that this administration strongly supports the efforts of
    those that want to associate with unions and collectively
    bargain.
        Senator Shelby. And what if they don't want to associate
    with them?
        Secretary Solis. They have those rights, as well.
        Senator Shelby. Do they support that, too?
        Secretary Solis. I believe so.
        Senator Shelby. I hope so.
        Secretary Solis. I believe so. Yes.

                               JOB CORPS PROGRAM

        Senator Shelby. I want to get into the Job Corps, if I
    could, in my limited time. Job Corps is the Nation's largest
    vocationally focused education and training program for
    disadvantaged youths. For the year 2012, the administration
    included $1.7 billion for Job Corps. I'm concerned about the
    lack of clear metrics within the Department for evaluating Job
    Corps. It's my understanding the Job Corps Program has not had
    a rigorous evaluation since the Mathematica administrative data
    study concluded in 2003, 8 years ago. And that study concluded
    that the program's cost exceed its benefits.
        Further, according to a study published in the American
    Economic Review in 2008 entitled, ``Does Job Corps Work?'', Job
    Corps participants were less likely to earn high school
    diplomas, according to this study, and earned an average of
    only 22 cents more an hour than nonparticipants. The study even
    showed that the program had no effect on college attendance or
    completion.
        These are disturbing statistics, given that the Federal
    Government spends an average of $27,000 per Job Corps
    participant over a 9-month period. As we all know, for $27,000,
    a person could earn their associate's degree or attend several
    years at a university somewhere in America.
        Madam Secretary, what are your thoughts on the
    justification for spending $1.7 billion on a workforce training
    program that has few, that I see, published results, and clear
    problems with management of taxpayer funds? What's your defense
    of that?
        Secretary Solis. Senator, first of all, I'd like to tell
    you that I am a strong believer of the Job Corps Program. And
    since I have been in charge of the program in the last 2 years,
    we have made, I think, some tremendous strides in trying to
    make sure that we do provide the metrics and evaluation. And I
    would tell you that, yes, that last review that you talk about
    that was done in 2001, it's unfortunate that, in the past 10
    years, or so, that there wasn't a closer look at what the
    metrics are.
        But, I would tell you that what we are doing now is
    instituting more evaluation from within our own program. And I
    would tell you that, in program year 2009 through June 2010,
    20,000 students attained high school diplomas in--and their
    general equivalency diploma (GED), 30,000 students completed
    career and technical training in 11 high-growth areas.
        Senator Shelby. What's the percentage of that? That's good,
    but----
        Secretary Solis. Seventy-six percent of--in 2009, were--
    graduates were placed in employment, or some chose to go in the
    military.
        Senator Shelby. Okay.
        Secretary Solis. So, we are doing a better job. But, I
    realize that one of the goals that we have to look at here is,
    What career are these folks going into?--not just a job, not
    just a part time, or not just a minimum wage job, but also a
    career. So, we've instituted, I think, a whole platform to have
    them look at renewable energy--green jobs. We can transition
    from construction into a new hybrid technological area.
        And it's hard, because these students are the ones that--
    our society, or maybe their families, have failed them. And I
    would tell you that, in many instances--and I know Senator
    Cochran might agree--that these students--young people--not all
    of them are young, some of them are 21, 24 years old--have
    stepped up, in many ways, when there's disasters. When Katrina
    happened, I know some of them were out there helping to rebuild
    homes----
        Senator Shelby. Yeah.
        Secretary Solis [continuing]. For even people who were less
    fortunate than themselves. And I look to these students as our
    future leaders, many who have transformed their lives, many who
    have served--even in my own office, have come and have shared
    their talent and skills with us. And I think that, in many
    cases, it's a well-kept secret. Yes, we could make improvement
    with Job Corps. But, we should not somehow push aside the
    enormous resource that we have with these young people. We only
    have 124 centers. And, at best, there hasn't been sufficient
    funding to help make them more effective and more, how could I
    say, directed toward those good careers that we all know that
    they can be a part of.
        Senator Shelby. Well, I want to--I'm not proposing we
    abolish Job Corps. I'm thinking, in trying to work with you and
    Senator Cochran and others, to improve it. Because, I know it
    does do some good. And I know, for a lot of people, it's their
    last hope. But, we can always improve it.
        Secretary Solis. Absolutely.
        Senator Shelby. I hope you're committed to that.
        Secretary Solis. I am. I am, sir. And I would love to be
    able to visit with you----
        Senator Shelby. Absolutely.
        Secretary Solis [continuing]. And one of our Jobs Corps
    centers----
        Senator Shelby. Thank you.
        Secretary Solis [continuing]. So that we can look at those
    things together.
        Senator Shelby. Thank you, Mr. Chairman.
        Secretary Solis. Thank you.
        Senator Harkin. Thanks, Senator Shelby.
        Senator Cochran.
        Senator Cochran. Mr. Chairman, thank you.
        Madam Secretary, welcome to our subcommittee. We appreciate
    your being here to discuss the budget request for the programs
    under the jurisdiction of your Department.

                    JOB CORPS CENTER, GULFPORT, MISSISSIPPI

        Mentioning the Job Corps center reminds me that, in
    Hurricane Katrina, we had a devastating hurricane, as you
    recall, and everybody does, that struck the gulf coast area of
    the country. And our Job Corps center in Gulfport, Mississippi,
    was totally destroyed. And so, we had a lot of displaced people
    who had been working there and living there. Progress has been
    made, but I wonder whether or not you can give us some idea
    about when the construction, or reconstruction, of that center
    might be completed. We had heard 2012. Now we're hearing it
    might be delayed well over into 2013 or 2014. What is the
    latest information you can provide the subcommittee with on
    that subject?
        Secretary Solis. Yes, thank you, Senator Cochran. I would
    just say that, at the Gulfport center, students, as you know,
    have already been enrolled. So, we have about one-half the
    number of students that we could handle there. That's about, I
    believe, 145 that are currently there and enrolled. We know
    that we have to continue to build out the rest of the facility,
    which is going to take us some time. We believe that we're
    making progress on the permanent construction. That's what
    you're talking about. And I can see--possibly by mid-August of
    this year, we should be able to see that permanent dormitory
    established there that I know you're concerned about. The rest
    of the center, the design will probably be complete in another
    2 years--2 to 3 years, unfortunately. But, it remains a focus
    of what our efforts are there. And believe me, I will keep you
    up to date, and my staff will. And I'm just excited that we're
    able to serve with those 145 students that are currently on
    campus.
        Senator Cochran. We appreciate your personal attention to
    that and the leadership that the Department is providing to get
    that back into operation as soon as possible. Thank you.

                               YOUTHBUILD PROGRAM

        There's another program, that I was curious about your
    assessment of it, called ``YouthBuild.'' And it's targeted to
    younger workers. It's a training program but a workforce
    development program all at the same time. It gives high-risk
    youth opportunities to develop occupational skills with
    vocational training as they work. Could you tell us what the
    program is achieving, if it's working? Do we continue to
    support it under your budget request?
        Secretary Solis. Thank you, Senator Cochran. I am delighted
    that, through the YouthBuild Program, and especially the
    funding that we received in the last two cycles, have been able
    to help us focus better on providing better certificates and
    measurements for student success. And one of the highlights, I
    think, of our effort has been to really infuse technology. So,
    whether it's healthcare, IT, or whether it's renewable energy,
    changing the focus, in some ways, from construction to
    renewable energies. And I've actually been able to see this on
    the ground, where young men and women--and I'm delighted to say
    ``women''--are getting enrolled in these programs and really
    learning the crafts, the crafts that will help provide them
    with better training, better skills, and giving them a job. And
    most students that enroll in the program are tied in, typically
    with either an apprenticeship program, in some cases, and in
    some cases, with a business developer in construction, that
    will hire those individuals up as rapidly as they're trained.
        So, I would say to you that the program--actually, I would
    love to see it expanded, because I think it is well worth our
    investment there. And I know that many people, again, that come
    into that program sometimes are the hardest ones to serve,
    because they may not have completed their high school
    education. Some may not be as motivated as others. And once
    they find collegiality amongst their other peers, they then
    become competitive with themselves. And I've seen them develop
    leadership skills and actually work in new industries that are
    actually going to help to bring back our economy, especially
    when it comes to conservation and restructuring and
    retrofitting of some of our aged housing and commercial
    buildings. I see a lot of them that are very enthusiastic about
    the program.
        Senator Cochran. Thank you. I'm also advised there's other
    good news from my State. One program, in particular, the on-
    the-job training provided under the Workforce Investment Act,
    has been particularly successful in Mississippi. And I wanted
    to pass that assessment from my staff on to you, and thank you
    for the leadership on that.

                     OFFICE OF DISABILITY EMPLOYMENT POLICY

        And Disability Employment Service is another area where I
    think the Department is making important contributions. That's
    a well coordinated effort, I'm told, providing those with
    disabilities rehabilitation services, encouraging them,
    monitoring their progress. Some of the highest rates of
    rehabilitation in the country, at over 70 percent, are being
    observed under that program. It's the Disability Employment
    Initiative.
        Secretary Solis. Yes.
        Senator Cochran. And I thank you for your leadership in
    that area, as well. Are you familiar with those reports?
        Secretary Solis. Yes, I am. Yes, I am. And I want to thank
    the chairman and this subcommittee for supporting the funding
    for that program. And it continues, I think, to be something
    that really is refreshing, because it helps to shine a light on
    the fact that the disabled community has been underrated. In
    fact, what we're finding, from our own assessments, is that
    they tend to perform better in the workplace. And we are losing
    out, as a country, if we don't utilize the skills and talents
    that they have.
        So, we know that good models exist in Iowa and other
    States, and we want to continue to build that out. Under the
    leadership of my Director for ODEP, Kathy Martinez, she has
    been tremendous. You know, she is--I call her one my Charlie's
    Angels, who's been out there, really helping to fight, and
    really parlay the importance of providing the disabled
    community with the tools that they need. They're not asking for
    a handout. They're asking for a hand up, an ability to be able
    to work in different employment situations. And when we find
    employers that are willing to do that, they are going to make
    those businesses shine. And we've seen it already evidence. And
    I'm very delighted that, through the leadership of this
    chairman, that we're looking at expanding this effort, also, to
    include our one stops. So, there are one-stop centers. We have
    3,000 of them. We'll also start looking at how we can better
    serve that population and address their issues, up front.
        Senator Cochran. Thank you.
        Thanks, Mr. Chairman.
        Senator Harkin. Thanks.
        Senator Brown.
        Senator Brown. Yeah. Thanks, Mr. Chairman.
        Welcome, Madam Secretary.

                         AFRICAN-AMERICAN UNEMPLOYMENT

        Talk to me about African-American unemployment. African-
    American unemployment is 16 percent--official unemployment. We
    know it's higher than that, almost twice the white unemployment
    rate of 8.7 percent. What is DOL doing specifically to address
    the endemic, long-term very serious problem of black
    unemployment?
        Secretary Solis. It's a very serious problem, Senator. And
    I know it's one that we care a lot about.
        I recently visited Ohio and several States there, and met
    with several faith-based leaders to talk about how we can
    begin, in a better way, to target our funding and our
    proposals. One thing I will tell you is that we, under the ARRA
    Program, were able to target about $150 million in career
    pathways out of poverty, targeting communities that have
    unemployment rates above, say, 50 percent. Those went into
    particular communities of color. We continue to also provide
    reintegration programs for ex-offenders. It's something very
    important. And with our YouthBuild Program and our Job Corps
    Program, I think it's safe to say that about 40 percent to 60
    percent are African-American.
        We need to do more, obviously. And we do need to have
    assistance, in terms of providing them with the job training
    opportunities that will put them into good careers that won't
    just lead to a paycheck, but a career. And I think that's what
    we're trying to do in some of our new rollout of programs.
        We just announced, for example, in the H1B Program, through
    fees that we received, $240 million in grants that will go out
    to help dislocated workers, but also working with industry to
    help provide new technical training to their current incumbent
    workers, hopefully open up that slot to allow for a dislocated
    worker. Hopefully, it will be those in those communities most
    distressed. So, that is going to be our focus for that
    particular program.
        But, we continue to work with our community colleges, our
    workforce investment boards, and with the faith-based community
    to see how we can better improve the status of African-
    Americans.
        But, again, one of the things I have to tell you--and you
    know this better than I--is that one of the things we have to
    do is aspire for higher education. That's why the President has
    talked a lot about providing opportunities for Pell grants, for
    assistance, for financial aid, so that individuals can receive
    a community college degree and hopefully get better training,
    because it is a more competitive workforce.

                     2012 BUDGET RESOLUTION PASSED BY HOUSE

        Senator Brown. Thank you. You mentioned Federal job
    training programs, WIA, and other things. The--I'm concerned,
    with the 2012 budget resolution that passed the House, the
    consolidation of multiple programs serving a range of
    populations--minorities, veterans, individuals with
    disabilities, dislocated workers, at-risk youth--into a single,
    one-size-fits-all voucher program, and squeezing those programs
    to the point of tens of billions of dollars, over the next 10
    years. Does the administration share the view approved by the
    House, that now is the time to significantly reduce investments
    in workforce training? Is that something that you oppose? Would
    you talk to us about, you know, sort of a critique of that, and
    what direction you think we should go in, if you disagree?
        Secretary Solis. Well, Senator, as you know, the President
    and the debate right now is about working within our means. And
    that obviously is something that we do take serious. And we did
    take that step in this budget.
        And I would say to you that we have attempted to keep the
    integrity of our programs in place. As the President said, we
    don't want to hurt the innovation, the ability to not be able
    to compete, and the fact that we have to keep our vulnerable
    communities front and center.
        So, I would say to you that my personal commitment is to
    try to keep the integrity of these programs in place. I
    realize, as a former member, like yourself, that we don't have
    the luxury of being able to cut back on these very vital
    programs that help provide people the ability to get back to
    work. There are so many people that are, how could I say,
    feeling let down, that they don't have an opportunity to get a
    job right away. And those are the very folks that we have to
    keep in place. Those are the very folks that we have to make
    sure that they receive training, that they go to our one-stop
    centers and they keep engaged. Because, the farther they are
    away from that ability, an employer, chances are, will not want
    to hire them up. And we've seen that evidenced already in the
    workplace, where actually employers are saying, if someone's
    been out of work more than 6 months or 1 year, they may not be
    the first person that they're going to look at, in terms of
    their resume. So, I'm very concerned about this.
        Senator Brown. My last--thank you--my last question, Mr.
    Chair.

                    EXPANSION OF TRADE ADJUSTMENT ASSISTANCE

        Madam Secretary, the administration did something very
    important, many things very important, in the Recovery Act.
    Specifically what I want to talk about, just for a moment, is
    the expansion of trade adjustment assistance to expand it, not
    just to the service industry, but to--I mean, not just to
    manufacturing, but service and those job layoffs and retraining
    in--where not only--not exclusively with countries with whom we
    had a free trade agreement. That--you know, we were able--it
    was in effect til the end of December of this past year; we
    were able to get a 6-week extension with--you know, the--late
    in December, as you know. And you helped us with that. But,
    this--the expanded TAA eligibility lapse for service workers
    and workers who lost their jobs in--as a result of----
        Secretary Solis. Right.
        Senator Brown [continuing]. Of job loss in countries with
    whom we didn't have a free trade agreement, that--so, what's
    the Department doing? Is the Department, now that that's
    lapsed--I--number one, I'd like the administration to take a
    stronger position on TAA. You know, some people have called TAA
    ``funeral expenses'' for these trade agreements, frankly. But,
    at least TAA is something. And now we don't even have TAA for
    these workers that have lost their jobs because of trade
    agreements that were wrong-headed. I remember your work in the
    House against some of them--CAFTA and some others. What--is the
    administration going to speak more forcibly--forcefully on the
    extending of TAA and extending of the health credit--the HCTC,
    health care tax credit? And what are you doing, in terms of
    processing these applications, when the program--the expansion
    of the program is expired on TAA?
        Secretary Solis. Well, Senator, we are very concerned that
    there was not a decision to extend the TAA Program. And it is
    of great concern. And it is affecting many dislocated workers
    at this time. And I do believe that the program is worthy of
    being reinstituted, because I know it does make a difference,
    especially for people from the Midwest, in your case, your
    State, and other places where we've seen industries leave our
    country and go to other places, where it has made a difference
    to help provide as a safety net for people to transition into
    new jobs. I saw it happening, time and time again, these last 2
    years, especially in the automobile industry. We saw a lot of
    dislocated workers that received this assistance and were able
    to make the transition quickly to get higher skills or
    healthcare coverage and be able to make that transition.
        And as you know, that story, I think, is a good story,
    especially with the automobile recovery, where we've seen that
    now GM, Chrysler, and those folks have been able to put back
    some lines of assembly and also put people back, and they've
    paid back their loans.
        But, TAA is very important. That discussion has to go on. I
    understand there are individuals that still have questions
    about it and are trying to tie that in with other trade
    agreements. I would hope that the--that this body would do the
    right thing and extend it on its own, if possible. But again,
    that is not something that I can determine.
        Senator Brown. Well, but we----
        Secretary Solis. But, I wholeheartedly support it.
        Senator Brown. Thank you. But, we need the administration
    to speak much more forcefully than they have on the importance
    of TAA. You weren't absent, as an administration--and I know
    your personal feelings on this--you weren't absent, last
    December, on this, but you weren't nearly as vocal as an
    administration that stands for workers and stands for
    retraining and stands for an industrial moving forward that we
    have not done so well, in the last few years, on. So, that's a
    plea to you.
        Thank you, Madam Secretary.
        Senator Harkin. Thank you very much, Senator Brown.
        Senator Shelby.
        Senator Shelby. Mr. Chairman, I have a couple of questions,
    and then I have a number for the record. If I can ask the rest
    of them, after I ask these two, for the record, I'd appreciate
    it very much.

                                   GAO REPORT

        Madam Secretary, I want to go back into some of the GAO
    reports. In January, the GAO released a report on multiple
    employment and training programs, and the report stated, and
    I'll quote, ``Little is known about the effectiveness of the
    employment and training programs we identified because only
    five reported demonstrating whether outcomes can be attributed
    to the program through an impact study, and about one-half of
    all the programs have not had a performance review since
    2004.'' That was the GAO.
        Despite unemployment being at 8.8 percent, officially, the
    Department of Labor, it's my understanding, has not taken
    action to address its ineffective programs. In fact, based on
    the GAO survey of Department of Labor officials, only 5 of 47
    programs have studies that assess whether the program is
    improving employment outcomes.
        Madam Secretary, how do you respond to these troubling
    issues identified in the GAO report? And, if you want to, you
    can answer that for the record.
        Secretary Solis. Thank you, Senator. I would just say to
    you, as I mentioned earlier, that the report that was--that
    you're citing was done in the previous administration, was
    supposed to be completed, I believe, at that time. That's why I
    signed a contract so that we could continue to do our own
    evaluation and have that done, which began in 2009.
        [The information follows:]

                   Department of Labor's Performance Measures

        Nearly all of the Department of Labor's two dozen
    employment and training programs include strong accountability
    features and performance metrics on employment, retention and
    earnings measures. We are strengthening our accountability
    further, as demonstrated by the Departmental 2011-2016
    strategic plan, which places an increased focus on performance-
    based management. Performance measures are being reassessed for
    consistency across programs throughout the workforce system to
    promote better outcomes for individuals of all skill and need
    levels, particularly those who are not yet ready and able to
    move quickly into a good job. We believe that workers and
    employers should have ease of access to information about past
    participants' outcomes, to make informed decisions about which
    programs are most likely to meet their needs.
        In addition to the annual employment and training
    performance reviews conducted at the Federal, State, local and
    training provider levels, the Department has been working
    diligently over the past 2 years to restore the rigor of our
    evaluation studies. Specifically, I established the Chief
    Evaluation Office (CEO), which was staffed in May 2010. The
    purpose of this office is to coordinate the Department's
    research and evaluation agenda in order to increase its
    capacity to conduct high quality, rigorous evaluations.
        Further, the GAO has noted in a recent March 2011 report
    the marked improvement in the dissemination of research reports
    by the Employment and Training Administration under my
    leadership at the Department of Labor. The GAO noted that,
    ``The 34 research reports published by ETA in 2008 took, on
    average, 804 days from the time the report was submitted to ETA
    until the time it was posted to ETA's research database. By
    contrast, from 2009 through the first quarter of 2010, the
    average time between submission and public release was 76 days,
    which represents a more than 90 percent improvement in
    dissemination time compared with 2008.'' \1\
    ---------------------------------------------------------------------------
        \1\ U.S. Government Accountability Office, ``Employment and
    Training Administration: More Actions Needed to Improve Transparency
    and Accountability of Its Research Program,'' March 2011, p. 26.
    ---------------------------------------------------------------------------
        Also, since 2009, approximately half the evaluations the
    Employment and Training Administration (ETA) has funded have
    been rigorous, random assignment impact evaluations. These
    include the Workforce Investment Act (WIA) Gold Standard
    Evaluation of the Adult and Dislocated Worker Programs (WGSE),
    the YouthBuild Impact Evaluation, the Reintegrating of Ex-
    Offenders Random Assignment Evaluation, the Impact Evaluation
    of Green Jobs, Health Care and High Growth Training Grants and
    the Transitional Jobs Impact Evaluation, all of which will
    examine net impacts on employment, retention and earnings, and
    include benefit-cost analyses. ETA was able to fund these
    evaluations through an increase in fiscal year 2010
    appropriations and the large one-time infusion of funds made
    available to the Department through the American Recovery and
    Reinvestment Act of 2009.
        While rigorous random assignment impact studies, such as
    the WGSE, provide the most credible information on program
    effectiveness, these are also highly resource intensive and
    take a range of 3 to 7 years to implement and complete. Mindful
    of the statutory responsibility for evaluation, and to address
    the knowledge gap until the WGSE results are available, in 2009
    the ETA released the results of a quasi-experimental net impact
    evaluation of the WIA Adult and Dislocated Worker programs.\2\
    This study uses the next-best methodology when random
    assignment is not available. This evaluation found positive
    long-term earnings impact for both programs, though the impacts
    were more substantial for the Adult program than for Dislocated
    Workers. ETA plans to publish interim findings of the WGSE in
    2013, and the final report will be available in 2016, although
    this schedule is dependent upon continued appropriations for
    the evaluation of WIA programs.
    ---------------------------------------------------------------------------
        \2\ The Workforce Investment Act Non-Experimental Net Impact
    Evaluation: Final Report may be found at ETA's Research Publication
    Database Web site.

        Secretary Solis. The results of that study----
        Senator Shelby. Is this ongoing?
        Secretary Solis. Yes. And that will become available in
    2013. It does take time, because----
        Senator Shelby. It does.
        Secretary Solis [continuing]. You're looking at different
    factors. But, nevertheless, since I've been here, we have begun
    this evaluation.
        Senator Shelby. Have you seen some of the preliminary work?
        Secretary Solis. Not necessarily----
        Senator Shelby. Not yet?
        Secretary Solis. No. But, as I said earlier, that some of
    the results that we have seen from our own evaluation, our in-
    house, shows that during the program year June 2009 to June
    2010, 76 percent of our workers exiting the WIA dislocated
    program, and 69 percent of the workers exiting the adult worker
    training, found a job within 3 months. And after that--and
    that--and I think those are good statistics----
        Senator Shelby. That's good.
        Secretary Solis [continuing]. Considering a bad economy,
    when you're finding four----
        Senator Shelby. It's tough.
        Secretary Solis [continuing]. To five people are competing
    for one----
        Senator Shelby. It's tough out there with skills, right
    now.
        Secretary Solis. Yes.
        Senator Shelby. We understand that. But, my interest is
    probably--coincides with yours, that we want these programs to
    work. And we have to measure them. And if they don't work, we
    figure out something that will work. Because, the end game is
    to get people back to in the employment. Is that right?
        Secretary Solis. Yes. And, Senator, I would say that one of
    the things that we need to focus on is reauthorizing WIA,
    because that's really going to help us. What I've heard, time
    and time again, is that this is an old system that has to be
    restructured. It has to look at new segments, regional issues,
    and really look from the bottom up, not from the top down.
        Senator Shelby. I think we know somebody that deals with
    authorization close to us today.

                         TRANSITION ASSISTANCE PROGRAM

        If I could, I'd like to get into another program, the
    Transition Assistance Program. The unemployment rate for
    veterans of the wars in Iraq and Afghanistan rose to 15.2
    percent in January 2011 which is well above the official
    national rate of 8.8 percent. This is the highest rate recorded
    since the Bureau of Labor Statistics began tracking this data
    in 2006. And these are our veterans, recent veterans.
        Madam Secretary, are we doing all we can to assist our
    veterans, particularly as they attend the Transition Assistance
    Program classes prior to discharge from the military service?
    It's my understanding that the Transition Assistance Program,
    which the Labor Department administers for the Department of
    Defense, was recently revised; its first substantive revision
    since the first gulf war. Is there data or any information yet
    on whether the revised program is actually helping veterans
    find jobs, particularly 21st century jobs that will sustain
    them--in information technology, health-related professions,
    and the energy industry--jobs that are meaningful?
        I believe we owe our veterans a lot. And I'm sure you'd
    share this.
        Secretary Solis. I couldn't agree with you more, Senator.
    And, as a former House member, this was one area--while I
    didn't sit on that committee--I was very concerned with the
    training and the TAP program. That's why I asked my Assistant
    Secretary, Ray Jefferson, who runs that division, to take a
    keen look at what was going on there. And what we found was
    that, yes, there hadn't been evaluations. There weren't any
    metrics to really identify the people that went through the
    process, if they really found employment.
        We're doing a better job. We're investing money. We have a
    whole evaluation and a request for proposal to look at how we
    can improve the program. We have new partners. And I'm happy to
    report that we even have engaged outside entities like the U.S.
    Chamber of Commerce, who has agreed to help us identify
    opportunities for employment, something that should have
    happened 10 years ago. This program was neglected for the last
    8 years. I admit that. I wasn't here----
        Senator Shelby. I know you weren't.
        Secretary Solis [continuing]. For all that time. But, I can
    tell you that one of the concerns that this administration has
    is making sure that we don't just help that soldier, male or
    female, but we also help the family. Because, the family can
    also help provide assistance----
        Senator Shelby. Absolutely.
        Secretary Solis [continuing]. If they're given the right
    tools and information. Training, especially for wounded
    warriors--very important. I've seen some tremendous programs
    that have come out of efforts, that identify good careers. For
    example, helmets to hardhats, where actually an individual can
    go in through a training and apprenticeship program, and then,
    after they leave and are discharged, can actually continue in
    that program in their State, and then be hired up almost
    immediately, making a six-figure salary. And that, to me, is
    something that we ought to be expanding and looking more at.
        I'm looking forward to working with the Department of
    Defense (DOD)--and we have, with the Veterans Administration
    (VA)--to improve upon these services. This couldn't be one of
    the most, if not one of the most important areas that I often
    look at.

                                   WOMEN VETS

        And I'm particularly concerned about returning women vets.
    We've had a number of women, young women who've gone in, who
    are also faced with a lot of challenges, one that isn't easily
    identified when they come back home. Many have been through
    different posttraumatic stress and also need our help. Many are
    not apt to identify, in many cases, that they are veterans, as
    well. Because, when you find them, in some cases, homeless or
    in a shelter, they won't say that they were a vet, because they
    feel ashamed. And we have to remedy that. And we have to let
    everyone know that----
        Senator Shelby. They should be proud.
        Secretary Solis [continuing]. They're needed, that they're
    needed.
        Senator Shelby. They should be proud of what they've done.
    And you're absolutely right that if we can get them back in the
    workforce, it will help them readjust to civilian life, because
    they've gone through a heck of a lot.
        Secretary Solis. Absolutely.
        Senator Shelby. Thank you, Mr. Chairman.
        Senator Harkin. Thank you, Senator Shelby.

                              JOB CORPS EVALUATION

        Madam Secretary, I don't have any other questions, just,
    again, a follow up on what Senator Cochran talked about
    earlier. You had an exchange with him on the Job Corps, I
    believe. And I think Senator Shelby asked a question about the
    efficiency and effectiveness of Job Corps. Yes, it does cost
    $27,000 per person. But, let me give you one example of a young
    woman that I know that was in our Job Corps center in Dennison,
    Iowa.
        Our Job Corps center in Dennison, Iowa, was the first in
    the Nation, by the way--oh, this has been 20-some years ago--
    that actually added a facility whereby young single mothers
    could come and bring one or two children with them, and be
    housed there in a safe environment. They have a Head Start
    program right there for these kids, plus the healthcare
    benefits and things like that, that accrue to them.
        You take a young single mother who dropped out of high
    school when she was about a sophomore, had some unfortunate
    things happen to her, is now 18, 19 years old, two children and
    no hope, no family, no structure, and headed toward a life of
    drugs and crime. She gets sent to the Job Corps center. Her
    kids have a great place to stay. They're in a Head Start
    program and she's in a program where she's going to get her
    GED, and then she's being trained for a career. She sees a
    future ahead of her now. She has all the hope and all of the
    kind of internal support mechanisms she needs to go out there
    and do something.
        Does that cost $27,000 a year? You bet it does. But, the
    cost to society of not doing that, I submit to you, will be 10,
    20, 30 times that much--the cost to society--if we don't do
    that.

                              RETURN ON INVESTMENT

        So, I know Job Corps. You look at it and you wonder about
    the rate of return on investment, as they say, and things like
    that. But, I don't mind an indepth look. I think we should have
    it evaluated. I agree with you on that. If there's places that
    can be tightened up, it should be done. But, in certain cases,
    this is just going to be--it's not a quick fix. Some of these
    young people are just not a quick fix. And it takes some time.
        But, it's been my experience, with the Job Corps centers
    over the last 30 years, as a Congressman before this, that
    sure, there are obviously those that don't make it. There are
    those that drop out, and don't make it. But, I would say, the
    success rate that I have been able to see has been tremendous.
    And what they do in the local community and the local
    businesses and the synergism, the inner workings with these
    kids and young people in the Job Corps centers with the local
    business community, and how they work things out, it's just
    been for a rural area, it's been quite a thing to see.
        So, I just--again, count me as a great supporter of Job
    Corps. I don't want to turn a blind eye to things that need to
    be done to make it more effective. And I hope we can work
    together, and work in a bipartisan----
        Senator Shelby. Absolutely.
        Senator Harkin [continuing]. Fashion to do that.
        Senator Shelby. We want the end result, don't we?
        Senator Harkin. And we want the end result. Exactly right.
    Exactly right.
        So, Madam Chairman, thank--or, Madam Secretary, thank you.
        Secretary Solis. Thank you both. Thank you. I thank the
    subcommittee.
        And I do want to work with you on evaluation. I think that,
    yes, we are in hard budget times. We realize that. But, I
    think, again, if we can preserve the quality of the intent of
    these services, and help those people that really deserve the
    help, I think----
        Senator Harkin. Yeah.
        Secretary Solis [continuing]. We're on the same page.
        Senator Harkin. I'll just add one other thing to my good
    friend--and he is a great friend of mine--Senator Shelby--is
    that we are working on WIA. We've been working on it for a long
    time, even before I was chairman. And hopefully, we're going to
    have a bill this year.
        Secretary Solis. Good.
        Senator Shelby. If I could, Mr. Chairman, I just want to
    reemphasize that we all--Senator Harkin was relating some
    examples of where Job Corps really works with people and
    everything--that's what we all want. We want to help these
    people, because if we don't help them, as he's pointed out,
    they will be--a lot of them will be in trouble. They will be on
    welfare for most of their life, if not in prison. I won't say
    everybody, but so many of them. And this is a chance to help
    them. We just want to make sure that the programs are working.
    Let's pump them up. If they're not working, let's find out why
    they're not working.
        Secretary Solis. Right.
        Senator Shelby. Because, the need for people--and the help
    is going to be there--we just want the program to work.
        Senator Harkin. Absolutely.
        Secretary Solis. Thank you.
        Senator Shelby. Okay.
        Senator Harkin. Amen.

                         ADDITIONAL COMMITTEE QUESTIONS

        Secretary Solis. Thank you both. Thank you. It's a
    pleasure. Thank you.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                   Questions Submitted by Senator Tom Harkin
                   employee benefits security administration
        Question. Since fiscal year 2009, the Employee Benefits Security
    Administration has created efficiencies in its programs, eliminated
    lower-priority spending and realized other cost savings. What
    additional steps will EBSA complete in fiscal year 2011? What is
    proposed in the fiscal year 2012 budget request?
        Answer. Our new paperless participant complaint intake system is
    scheduled to become fully operational by the end of fiscal year 2011.
    Currently 92 percent of inquiries and complaints handled by our Benefit
    Advisors (BAs) are received by phone. We will encourage the use of our
    new electronic intake process which will be more efficient for the BAs
    and will be more user friendly for the public. When the paperless
    system is operational, all participant inquiries/complaints regardless
    of how they are received will be managed electronically. Currently,
    participants can submit inquiries electronically; however, the
    submission does not auto-populate the inquiry database and make
    assignments to the appropriate office for handling. The new system will
    more efficiently direct electronic inquires to a Benefit Advisor in the
    appropriate office and transmit the response for electronic approval
    and clearance. The system will provide basic contact information for
    the participant and the subject of the inquiry/complaint that will
    auto-populate our tracking system. The new paperless system will
    include standard language paragraphs to be used in correspondence when
    responding to all types of participant inquiries and will include an e-
    mail wizard that will allow us to more efficiently contact the
    participants and plan sponsors to resolve complaints. This will
    substantially improve the efficiency of the overall Participant
    Assistance Program.
        By the end of fiscal year 2011, EBSA will have implemented a new
    call management system and web-based reporting tool throughout its
    regional offices. This system helps EBSA to achieve performance measure
    targets through more efficient workload management. Also, it allows
    EBSA to handle more live calls, reduces hold times and dropped calls,
    and provides managers with real time performance data in order to
    adjust duty roster schedules. Answering calls live ensures contact with
    the participant and is more efficient by eliminating call-backs, voice
    mail messages, and customer service complaints to Congressional
    offices, DOL managers and other officials.
        The EBSA reporting compliance program is continuing to adapt to the
    new EFAST2, wholly electronic, Form 5500 processing system which became
    operational in fiscal year 2010. The new EFAST2 makes Form 5500 data
    available faster--within 24 hours of a filing being made. Consequently,
    EBSA is able to analyze and review data on a ``real time'' basis and
    then apply a customized approach in targeting filings with significant
    errors.
        Question. What will the Employee Benefits Security Administration
    achieve in terms of workload and performance in fiscal year 2011?
        Answer. The fiscal year 2011 information and data provided in the
    fiscal year 2012 congressional budget justification was based on an
    annualized continuing resolution at fiscal year 2010 enacted
    appropriations. While the final fiscal year 2011 appropriation
    approximated these funding levels, the delay in appropriations creates
    challenges in achieving workload and performance goals. At this point,
    we expect the performance for the Employee Benefits Security
    Administration (EBSA) to differ from the fiscal year 2011 information
    in the fiscal year 2012 congressional budget justification as follows:

    ----------------------------------------------------------------------------------------------------------------
                                                                         Original
                                                                        fiscal year
                            Workload measure                           2011 workload    Fiscal year     Difference
                                                                      in fiscal year   2011 revised
                                                                         2012 CBJ
    ----------------------------------------------------------------------------------------------------------------
    Civil Investigations Processed..................................           3,282           2,900            -382
    Criminal Cases Processed........................................             247             200             -47
    Participant Inquiries (Field)...................................         246,000         233,000         -13,000
    Participant Inquiries (NO)......................................          10,000          12,000          +2,000
    Indictments.....................................................              84              82              -2
    Compliance Seminars.............................................              10               6              -4
    Regulatory Projects.............................................             237             250             +13
    Individual Exemptions...........................................             122             130              +8
    Section 502(I) Waivers..........................................              15               6              -9
    Exemption Processing Time.......................................             301             430            +129
    ----------------------------------------------------------------------------------------------------------------

        All remaining fiscal year 2011 workload estimates remain as
    presented in the fiscal year 2012 CBJ.
        Question. The Department has proposed a new regulation defining
    ``fiduciary'' under the Employee Retirement Income Security Act of
    1974. What benefits would the proposed regulation have for employers--
    especially small employers--that sponsor retirement plans?
        Answer. Investment advisers have assumed an increasingly important
    role in helping employers, especially small employers, choose an
    appropriate menu of investments choices for 401(k) plans and in
    advising employees and IRA holders on how to allocate their individual
    account balances. Although ERISA specifically provides that investment
    advisers may be fiduciaries, and employers and employees often rely
    heavily on their advice, advisers often have no accountability for
    their recommendations because the Department's current regulation
    stipulates a five-part test which makes it easy for these advisers to
    avoid fiduciary status.
        The Department's proposal would address this problem by providing
    that those who purport to give impartial investment advice for a fee
    will be held to ERISA's fiduciary standards of prudence and loyalty,
    and preventing them from using compensation arrangements that conflict
    with these duties. Small business owners, in particular, are often not
    equipped to make plan investment decisions on their own. In selecting
    appropriate plan investments and investment options for their
    employees, small businesses depend on impartial expert advice. The
    Department's proposed regulation will give these employers recourse
    against advisers who fail to uphold the standards of a plan fiduciary.
                          wage and hour division (whd)
        Question. The fiscal year 2012 budget identifies savings related to
    the operation of a toll-free employer compliance assistance call
    center. Please describe how this proposal will achieve the identified
    savings with at least the same level of services currently provided.
        What steps will WHD complete in fiscal year 2011 that create
    efficiencies and realize other cost savings?
        Answer. In order to improve the ability to provide timely and
    accurate customer service at each of the more than 200 offices
    nationwide, the Wage and Hour Division (WHD) is in the process of
    implementing a telephone system with automated call distribution and
    integrated voice response technology. Once all new hardware and
    software are fully deployed in fiscal year 2011, WHD will be better
    able to route calls for more efficient transfers and referrals, manage
    staffing needs to be more responsive to callers, record and monitor
    calls for quality and training purposes, and collect and analyze
    telephone usage statistics.
        With the full implementation of the new computer telephony system,
    WHD will be able to provide better and timelier service to the public,
    and at lower cost than it did with the call center.
        Question. What additional cost savings are proposed in the fiscal
    year 2012 budget request?
        Answer. The fiscal year 2012 budget request indicates program
    decreases for Employment Compliance Assistance and the Call Center of
    $2,290,000 and 12 FTE. Over the last 2 years WHD has hired additional
    in-house technicians who can answer calls more effectively and
    accurately and as noted above, WHD is already in the process of
    upgrading its own telephone infrastructure in order to improve the
    ability to provide timely and accurate customer service at each of the
    more than 200 offices nationwide.
        Question. What will the WHD achieve in terms of workload and
    performance in fiscal year 2011?
        Answer. The fiscal year 2011 information and data provided in the
    fiscal year 2012 congressional budget justification was based on an
    annualized continuing resolution at fiscal year 2010 enacted
    appropriations. At this point, we expect the performance for the Wage
    and Hour Division (WHD) to be consistent with the fiscal year 2011
    information in the fiscal year 2012 congressional budget justification.
        With the additional investigative resources added to the agency
    over the past 2 years, the WHD expects an increase in the number of
    compliance actions that it is able to complete in a fiscal year. For
    example, WHD estimated a 20 percent increase in the number of concluded
    compliance actions for fiscal year 2011, or approximately 5,400
    additional cases above the 26,500 completed in fiscal year 2010. The
    newly hired investigators have now completed much of their basic
    training requirements, and as a result, are contributing to the
    agency's investigation production numbers.
        WHD also expects to see an increase in the number of directed
    investigations that it completes in fiscal year 2011--particularly in
    high risk industries, i.e., those industries with high minimum wage and
    overtime violations and among vulnerable worker populations where
    complaints are not common. WHD's fiscal year 2011 directed
    investigations are being concentrated in the agricultural,
    construction, and hotel/motel industries and in specific program areas.
    The program areas include the FLSA Section 14(c) program in which
    employers are certified to employ disabled workers at wages below the
    Federal minimum wage and the Davis-Bacon and related Acts and Service
    Contract Act government contract programs. WHD offices are also
    conducting directed investigations in industries in which young workers
    are employed and at risk of injury. In fiscal year 2011, WHD will
    complete a pilot study related to H-2B compliance in the resort segment
    of the hotel/motel industry. The agency will also examine compliance in
    the residential construction sector.
        Finally, WHD has revised its Davis-Bacon wage survey processes to
    improve the quality and timeliness of wage determinations published by
    the agency. WHD, for example, is now utilizing State prevailing wage
    determinations as the basis for issuing more current highway wage
    rates. This change, coupled with improvements to the survey process,
    has positioned the agency to complete during fiscal year 2011 all 26
    surveys that were initiated in 2010.
        Question. According to the preliminary results from the WHD's 2010
    review of the authority established under 14(c) of the Fair Labor
    Standards Act, 23 percent of Section 14(c) certificate holders were
    found in compliance with only 57 percent of consumers paid in
    compliance with this section of the law. What specific steps will WHD
    take in fiscal year 2011 and under the fiscal year 2012 budget request
    to improve these unacceptably low compliance rates?
        Answer. We agree that the 2010 evaluation of employer compliance
    with Section 14(c) of the Fair Labor Standards Act produced
    disappointing results. In response to the evaluation findings, WHD
    conducted investigation-based evaluations of a randomly selected sample
    of 154 community rehabilitation programs (CRPs) that were certified to
    employ individuals with disabilities at less than the minimum wage. The
    agency conducted full investigations of randomly selected CRPs from
    three employer groups: all certified CRPs, CRPs with prior violations,
    and CRPs that had conducted a self audit as part of the certification
    process.
        In the baseline evaluation, 65 percent of the cases, which
    represent approximately 3 percent of the nationwide population of
    community rehabilitation programs (CRP), were randomly selected for
    investigation. Twenty-three percent of the investigated CRP's were in
    compliance with all laws enforced by Wage and Hour for both Section
    14(c) workers and other staff workers. Seventy-two percent had monetary
    violations.
        With respect to the evaluation of prior violators, 42 cases
    representing 49 percent of the nationwide population of CRP's with
    prior investigations were selected. Nineteen percent of the
    investigated CRP's were in compliance with all laws enforced by WHD for
    both Section 14(c) workers and other staff workers, and 69 percent had
    monetary violations.
        For CRPs that conducted a self-audit as part of the certification
    process, 47 cases, representing 24 percent of the CRP's with prior
    self-audits, were randomly selected for investigation. Fifteen percent
    of the investigated CRP's were in compliance with all laws enforced by
    WHD for both Section 14(c) workers and other staff workers, and 83
    percent had monetary violations.
        Despite the low compliance rates found in all three evaluations,
    the data appear to be more nuanced than the rates suggest. The majority
    of the violations resulted from incorrect or untimely prevailing wage
    and commensurate wage determinations. Other violations were caused by
    confusion about the appropriate minimum wage, owing to the fact that
    between 2007 and 2010, the Federal minimum wage increased three times
    followed by further minimum wage increases at the State level. Keeping
    pace with these minimum wage adjustments produced many of the
    violations during the survey period.
        WHD has identified a number of internal and external strategies to
    address these types of violations, including changes to the
    certification process. Given the high turnover among CRP staff who
    conduct these wage determinations, WHD is considering additional
    training requirements for CRPs. WHD is also analyzing the certification
    process as a potential means for routinely and broadly disseminating
    information on making wage determinations and other compliance issues
    to certification applicants. Given the geographic distribution of CRPs,
    along with their staffing and resource constraints, Web-based training
    could reach a wider audience with less investment for both WHD and
    CRPs. Exploring the use of technology in training and maintaining the
    emphasis on improving wage determinations may address many of the
    violations found.
                 office of federal contract compliance programs
        Question. OFCCP recently secured a contract to conduct a program
    level organizational assessment. What were the findings and related
    costs savings implemented or planned to be implemented? What additional
    steps will OFCCP complete in fiscal year 2011 that create efficiencies
    and realize other cost savings? What additional actions are proposed in
    the fiscal year 2012 budget request?
        Answer. To ensure that it is appropriately staffed and resourced to
    implement its enhanced enforcement, compliance, regulatory and outreach
    efforts, OFCCP undertook an independent management and organizational
    assessment. The goal of the organizational assessment was to evaluate
    the agency's current structure, staff capabilities, resource
    allocation, and business process efficiency. The assessment was broken
    into two distinct parts; the former focusing on the National Office and
    the latter focusing on the regions. In response to the findings of the
    first part of the assessment, OFCCP reorganized its National Office and
    created a Governance Board to address systemic issues and break down
    organizational barriers. OFCCP is still in the process of evaluating
    the findings of the regional assessment.
        The reorganization involved making the following changes to the
    structure of the National Office, which were aimed at improving
    organizational effectiveness and efficiency: (1) create a
    Communications Team within the Office of the Director; (2) make the
    Division of Statistical Analysis a unit reporting to the Division of
    Program Operations; (3) create a separate Testing Unit within the
    Division of Program Operations; (4) create a separate Data Integrity
    Team within the Division of Program Operations; and divide the Branch
    of Budget, Finance and Administrative Services into three specialized
    parts (the Branch of Budget and Finance, the Branch of Human Resources
    Liaison and Information Management, and the Administrative Services
    Unit).
        The purpose of the OFCCP Governance Board is to transform the way
    the agency addresses select operational issues. The independent
    organizational assessment found that too often, identification and
    development of solutions to operational issues occurs among functional
    groups on an ad-hoc basis. This approach is not systematic; nor does it
    provide a consistent mechanism for divisions and regions to work across
    organizational boundaries. It encourages stove piping and thus limits
    the agency's ability to achieve desired outcomes. Additionally, it was
    suggested that many projects would benefit from broader input from the
    various segments of the OFCCP workforce.
        The OFCCP Governance Board will provide a transparent and
    sustainable means to address appropriate operational issues across
    organizational boundaries. Once fully implemented, the OFCCP Governance
    Board will improve vertical and horizontal communication within OFCCP,
    strengthen the workforce, create a healthier work environment, and
    provide better ways to identify issues and solve problems, as well as
    enable the agency to more effectively achieve output targets, outcome
    goals as described in the Department's Strategic Plan, as well as other
    organizational goals. In addition, the OFCCP Governance Board will
    improve employee morale by sending a message to staff that we are
    committed to including them in the decisionmaking process.
        The Governance Board is designed to augment existing approaches. To
    ensure success, the process will be developed carefully, beginning with
    a few high priority projects and expanded over time.
        In addition to improvements made as a result of the organizational
    assessment, OFCCP expects to realize significant savings from its new
    IT system, the Federal Contractor Compliance System (FCCS), a modern
    cloud-computing based integrated case and content management
    information technology solution, which is slated to replace the
    agency's 20 year old case tracking system, the OFCCP Information System
    (OFIS), in fiscal year 2012. In fiscal year 2011, OFCCP devoted $3.815
    million to the development of system requirements for FCCS. The agency
    plans to allocate an additional $2 million to the project in fiscal
    year 2012.
        At present, the compliance review process is completely manual. The
    FCCS will significantly increase the agency's productivity by fully
    automating this process. Concurrently, FCCS will eliminate
    inconsistencies across OFCCP's regions by imbedding business rules in
    the automated environment, thereby preventing deviations from standard
    operating procedures. Stand alone functionalities such as word
    processing, spread sheets, statistical software, and e-mail will be
    integrated into the FCCS, eliminating the need to exit one system to
    invoke the other. This will create additional efficiencies in
    completing and tracking cases. For example, compliance officers must
    enter case related status updates manually into OFIS. This leads to
    delays and input errors, and is extremely inefficient. By eliminating
    the need to manually enter status updates and providing the capability
    to capture, store, search, retrieve and reference case file
    documentation, the FCCS will save time spent in reconciling
    information.
        The FCCS will also improve information security. Currently, OFCCP
    case files are in hard copy and lack advanced safeguards to protect the
    personally identifiable information and commercial data provided to
    OFCCP by Federal contractors. The FCCS will enable the agency to
    create, analyze, generate, schedule, and track cases in a secure
    electronic environment.
        We estimate the FCCS will cost about $23 million over a 10 year
    period, in contrast to a benefit of about $39 million for that same
    period. The system is designed to allow the agency to add enhancements
    and improvements over time. Under OFIS, the agency would not be able to
    add value in the upcoming years. On the contrary, OFIS would become
    more obsolete every year, and more expensive to maintain over the same
    time period. In fact, the overall cost to operate the OFIS system for
    the next 10 years is estimated to be greater than for FCCS, even when
    the FCCS acquisition and planning cost, front loaded in the first 2\1/
    2\ years, is factored in. For years 3 to 10, we estimate it would cost
    twice as much for OFIS to operate as it would for FCCS. Thus,
    implementing the FCCS will enable OFCCP to realize significant savings
    over time in addition to large gains in productivity.
        Question. What will the OFCCP achieve in terms of workload and
    performance in fiscal year 2011?
        Answer. In fiscal year 2011, OFCCP is implementing the following
    strategic goals to achieve the Secretary's vision of good jobs for
    everyone: (1) prepare workers for good jobs and ensure fair
    compensation by increasing workers' incomes and narrowing wage and
    income inequality, and assisting low wage and the unemployed with
    gaining access into the labor market and the middle income bracket; and
    (2) assure fair and high quality work-life environments by eliminating
    barriers to a fair and diverse workforce. OFCCP has also developed new
    outcome measures that are being baselined in fiscal year 2011. These
    measures will be used to target OFCCP's performance in fiscal year 2012
    and beyond. The measures are: Compliance rate for Federal contractors;
    discrimination rate for Federal contractors; and impact of an OFCCP
    evaluation on future contractor compliance.
        To measure and assess workload enforcement efforts, OFCCP has
    several workload measures that are assessed quarterly. These include
    completion of 3,500 compliance evaluations in fiscal year 2011, which
    includes a target of 3,225 supply and service reviews and 275
    construction reviews. The agency exceeded its compliance review goals
    by 18 percent through the first and second quarters of fiscal year
    2011. OFCCP also has workload measures for its outreach and compliance
    assistance work, and has also implemented a new quality control measure
    that will look at the quality of cases worked on by compliance
    officers.
        To further enhance the effectiveness of the compliance review
    process, OFCCP focuses its investigative efforts on enforcement
    priorities once desk audits are completed. The objective is to modify
    how and where case investigation decisions are determined to ensure
    efficient use of resources. Specifically, the agency identifies cases
    for priority review based on the potential and type indicators of
    discrimination and uses a new concept called Triaging of Cases, to
    identify similar issues and patterns among corporate-wide
    establishments and within industries. The agency's focus centers on
    compensation cases, hiring investigations, veterans and disability
    investigations, and other investigations including promotions,
    terminations, and good faith efforts. This concept allows the agency to
    focus enforcement efforts toward complex investigations, which renders
    more in-depth, detailed and thorough investigations, including
    additional onsite verifications.
        In addition, OFCCP is using performance accountability measures
    that assist the agency's enforcement efforts, as well as provide the
    agency with the ability to make proactive adjustments that will ensure
    the agency reaches its goal. The performance accountability efforts
    include: (1) ongoing monitoring and reporting of field enforcement
    operations by national and regional office activities; (2) quality
    assurance and quality Investigations of contractors that assist the
    agency in achieving its goal to conduct more comprehensive audits; (3)
    improving the identification of adverse impact indicators in the audit
    process; (4) identifying compensation disparities; and (5) bringing
    more Federal contractors into compliance. The agency will also enhance
    the training of its Compliance Officers with an objective to expand and
    increase the effectiveness of the agency's enforcement. The training
    will provide staff with introductory, intermediate, and advanced level
    training in line with national priorities.
        Question. Secretary Solis, as you know, I am supportive of your
    efforts to strengthen the affirmative action requirements of 41 CFR
    part 60-741, the regulations implementing Section 503 of the
    Rehabilitation Act of 1973, as amended (Section 503). You issued an
    Advance Notice of Proposed Rulemaking (ANPRM) last July with a
    September deadline for comments. Can you please provide an update on
    where things stand with that proposed rule, and when we can expect to
    see a final rule? I strongly believe that Federal contractors can play
    a big role in helping to improve employment outcomes for qualified
    workers with disabilities, and I am eager to see the Section 503
    regulations strengthened as part of a broader effort to increase the
    number of people with disabilities participating in the U.S. labor
    force.
        Answer. I share your belief that strengthening the Section 503
    regulations is an important part of the broader effort to increase the
    number of people with disabilities in the U.S. labor force. The ANPRM
    we published last year resulted in 127 comments from disability and
    veteran advocacy organizations, trade and professional associations,
    employers, and other interested groups and individuals. All comments we
    received were considered as we drafted a Notice of Proposed Rulemaking
    (NPRM), which was submitted to OMB for interagency review under
    Executive Orders 12866 and 13563 on May 24.
                  office of labor-management standards (olms)
        Question. In fiscal year 2011, OLMS will eliminate a unit dedicated
    to audits of international unions. OLMS has determined that these
    expenses will be better used in core mission work. Please provide
    supporting data for this conclusion, including how OLMS will enforce
    relevant laws with respect to international unions.
        What additional steps will OLMS complete in fiscal year 2011 that
    create efficiencies and realize other cost savings?
        Answer. In fiscal year 2011, OLMS plans to eliminate the
    International Compliance Audit Program (I-CAP), which on average,
    resulted in seven or eight audits per year. Savings will be applied to
    maintaining FTE levels in OLMS' core mission, compliance assistance and
    enforcement of employer/consultant reporting. It is important to note
    that OLMS is continuing to conduct criminal investigations involving
    international unions based on information of financial improprieties.
    Criminal investigations are part of OLMS' core mission work and OLMS
    projects to have sufficient resources to conduct approximately 300
    criminal investigations in fiscal year 2011. OLMS is also continuing to
    conduct union officer election investigations (over 130 cases
    projected) including investigations of international union officer
    elections. OLMS will also continue to conduct audits of intermediate
    body and local unions under the compliance audit program (CAP). OLMS
    will create efficiencies in the CAP program by improving its audit
    targeting methods to more effectively identify fraud and embezzlement
    while conducting fewer audits. Despite fewer audits, OLMS' enforcement
    program will remain viable and effective. OLMS will also realize
    efficiencies and cost savings in the election program by working to
    reduce the number of days it takes to resolve union officer election
    complaints and, in the reports and disclosure program, by increasing
    the number of LMRDA reports filed electronically.
        Question. What additional actions are proposed in the fiscal year
    2012 budget request?
        Answer. OLMS proposed the following initiatives in the fiscal year
    2012 budget request:
      --Increase effectiveness of audits by focusing resources on labor
            unions most likely to be in violation of the law.
      --Improve timeliness in resolving union member election complaints.
      --Improve the Internet public disclosure service and public access to
            information reported by unions, union officers, union
            employees, employers, labor consultants and surety companies
            under the Act.
      --Increase provision of compliance assistance to national and
            international labor organizations to increase their affiliates'
            LMRDA compliance by developing, implementing, and extending the
            number of voluntary compliance agreements (VCA) to establish
            goals, baselines, and measures for improving recordkeeping,
            reporting, and internal controls.
      --Improve compliance with minimum bonding requirements of local and
            intermediate union affiliates by working closely with their
            parent national and international unions, including those who
            are not party to a VCA.
      --Increase the number of national and international unions whose
            affiliates conduct audits of their own financial records in
            accordance with a partnership that develops, delivers, and
            evaluates a customized local union audit training curriculum
            for each parent union.
      --Increase the number of reports filed by employer-consultant
            persuaders.
      --Reduce delinquency rate of filers of Labor Organization Annual
            Financial Reports.
      --Reduce delinquency rate of chronically delinquent filers of Labor
            Organization Annual Financial Reports.
        Question. What will the OLMS achieve in terms of workload and
    performance in fiscal year 2011?
        Answer. The fiscal year 2011 workload and performance data provided
    in the fiscal year 2012 congressional budget justification was based on
    an annualized continuing resolution at the fiscal year 2010 enacted
    level. At this point, however, we expect the performance for the Office
    of Labor-Management Standards to differ from the fiscal year 2011
    information in the fiscal year 2012 congressional budget justification
    as follows:
        OLMS expects that the number of election cases will exceed the
    projected total of 130. Election cases are predicated on member
    complaints and during fiscal year 2011, OLMS has received an inordinate
    number of these cases.
        OLMS projects fewer supervised elections (projected 35). The number
    of supervised elections is a demand-driven measure in that OLMS cannot
    predict changes in annual numbers, and historically the number of
    supervised elections has fluctuated greatly (based upon the number of
    election investigations, ability to reach voluntary agreements, etc.)
        OLMS expects to exceed the predicted number of 200 compliance
    audits and complete at least 350 during fiscal year 2011.
        As noted above (SSEC10), OLMS expects to continue to seek increased
    program efficiencies for the remainder of fiscal year 2011 and into
    fiscal year 2012.
                office of workers' compensation programs (owcp)
        Question. Since fiscal year 2009, the OWCP has created efficiencies
    in its programs, eliminated lower-priority spending and realized other
    cost savings. What additional steps will OWCP complete in fiscal year
    2011?
        Answer. OWCP continues to modernize its technology systems to
    automate claims processing and provide greater accessibility and
    services to customers. Expanded use of teleconferencing has reduced
    travel costs to conduct informal hearings and conferences and training
    costs. Technology tools also enable centralization of functions and
    increases flexibility in workforce assignments and workload
    organization and management. In fiscal year 2011, OWCP will:
        Consolidate Division of Federal Employees' Compensation (DFEC)
    claims intake and case creation activities from 12 District Office
    locations to two central sites. Consolidation will improve consistency
    in the quality of case creation as well as provide operational
    efficiencies such as reduced contract staff and equipment requirements.
        Deploy the Employees' Compensation Operations and Management Portal
    (ECOMP) to allow electronic filing of Federal Employees' Compensation
    Act (FECA) claim forms, submission of other documents, and the
    uploading of documents directly through a secure web-based application.
        Deploy DFEC's new interactive voice response (IVR) system that will
    offer self-help features to callers, greatly improve call routing, and
    provide greater access to information and assistance services.
        DEEOIC continues to actively look for ways to improve customer
    service and speed benefit delivery. In response to a customer service
    satisfaction survey conducted last year, new pamphlets and brochures
    are being developed to be posted online and given out at the Resource
    Centers. These informational pamphlets will provide clear guidance to
    the claimant population concerning key benefit and program issues.
        Continue, on a monthly basis, the Black Lung program assessment of
    each district office's workload and the rebalancing of caseloads so as
    to prioritize the adjudication of new claims filed under the Patient
    Protection and Affordable Care Act (PPACA).
        Question. What is proposed in the fiscal year 2012 budget request?
        Answer. Requests for additional resources in fiscal year 2012,
    through which OWCP will continue to create efficiencies in its
    programs, eliminate lower-priority spending, and realize other cost
    savings include:
      --$1,200,000 in Special Benefits (FECA) to provide for policy review
            and conversion of the iFECS Case Management System to the new
            HIPPA International Classification of Diseases standard, ICD-10
            mandated by the Department of Health and Human Services. The
            ICD coding scheme is used by OWCP to identify medical
            conditions accepted in workers' compensation claims and by the
            healthcare industry for delivery of services to our claimants.
      --$3,200,000 and 9 FTE in Longshore Salaries & Expenses for resources
            to address the numbers and complexity of Defense Base Act (DBA)
            claims and reduce processing timeframes. DBA injury and death
            cases in connection with the wars in Iraq and Afghanistan have
            increased dramatically, rising from 347 cases in fiscal year
            2002 to nearly 15,000 cases in fiscal year 2010, while
            Longshore resources have remained static.
        In addition, OWCP continues to pursue legislative reform of the
    Federal Employees' Compensation Act (FECA). We estimate that our reform
    proposal will save the Government (conservatively) between $400 and
    $500 million in its first 10 years. In addition, the proposal contains
    several provisions that will improve administration of FECA operations.
    These include creating a lower benefit level, or ``conversion''
    benefit, once an injured employee reaches Social Security Retirement
    age or after 1 year of FECA compensation (whichever is later);
    establishing a uniform compensation rate of 70 percent for all
    claimants, including schedule awards, and removing benefit augmentation
    for dependents; moving the 3-day waiting period for benefits from after
    the 45-day continuation of pay period to the first 3 days following the
    filing of a traumatic claim; and authority to match Social Security
    records with FECA claims records without prior claimant approval to
    ensure continued FECA benefit eligibility.
        Fiscal year 2012 funding will enable OWCP to introduce additional
    customer service improvements and business process and organizational
    design enhancements, as well as workload management innovations such as
    Telework and Flexiplace expansion.
        Question. The congressional budget justification indicates that the
    Division of Federal Employees' Compensation will take a series of steps
    related to the recruitment, placement, and accommodations of workers
    with disabilities. Please provide more specifics on current and
    proposed actions under existing law.
        Answer. Subsequent to last year's kick-off of the new Federal
    workplace safety and return-to-work (RTW) initiative--``Protecting Our
    Workers and Ensuring Reemployment'' (POWER)--DFEC met with the 14
    larger agencies to discuss their current performance levels and actions
    they will take to meet their POWER targets. The meetings also included
    discussions about those agencies' organizational and other RTW
    challenges, opportunities for DFEC to provide assistance, and the
    agencies' potential for improvement.
        Extending those latter topics, DFEC and DOL's Office of Disability
    Employment Policy (ODEP) are developing a research project to be
    completed by the end of fiscal year 2012 to document the obstacles that
    exist in Federal agencies relating to return to work, job
    accommodations, and placement and the best practices used by agencies
    to reduce or eliminate these obstacles and increase opportunities for
    success. This research project also supports the objectives of
    Executive Order 13548, Increasing Federal Employment of Individuals
    with Disabilities, which specifically directs the Secretary of Labor to
    take steps that will foster improved return-to-work outcomes. DFEC and
    ODEP will utilize the results to offer tailored technical assistance to
    Federal agencies regarding the adoption and implementation of
    successful return-to-work practices and related disability employment
    practices.
        To provide an incentive to Federal employers to reemploy injured
    Federal workers with permanent disabilities, DFEC has begun a program
    to identify and certify FECA claimants for job placement using Office
    of Personnel Management (OPM) Schedule A hiring authority.
    Qualification for Schedule A authority, found at 5 CFR
    Sec. 213.3102(u), provides an avenue to enhance and expedite hiring of
    individuals with disabilities (as well as other categories of
    individuals) for Federal service by removing barriers and increasing
    employment opportunities. Participation in the program is voluntary on
    the part of the claimant; however, if they volunteer they must self-
    identify the nature of their disability. With Schedule A, qualified
    candidates who meet the OPM guidelines can be hired non-competitively:
    without the typical recruitment headaches; without posting and
    publicizing the position; and without going through the certificate
    process.
        Question. What will the OWCP achieve in terms of workload and
    performance in fiscal year 2011?
        Answer. Following enactment of the fiscal year 2011 appropriation,
    OWCP reprioritized workload and activities to support the targets and
    goals addressed in the fiscal year 2011 congressional budget
    justification. It is expected that the Federal Employees' Compensation
    Division, the Coal Mine Workers' Compensation Division, and the Energy
    Employees Occupational Illness Compensation Division achievements will
    be close to the established targets. The possible exception is the
    Longshore and Harbor Workers' Compensation Division which is currently
    not achieving the GPRA goal of 58 percent of First Payment of
    Compensation Issued Within 30 days for Defense Base Act cases. The
    performance for the DBA First Payment measure through the second
    quarter is 54 percent. The performance targets were based on requested
    additional funding for nine additional FTE and information technology
    investments that was not enacted. Longshore's resources have been
    severely taxed by both the numbers and the complexity of Defense Base
    Act claims arising from increased activity by civilian contractors
    supporting the military overseas.
              occupational safety and health administration (osha)
        Question. What steps will OSHA complete in fiscal year 2011 and
    does it propose in fiscal year 2012 to create efficiencies and realize
    other cost savings in pursuing the agency's mission?
        Answer. OSHA has been carefully controlling its Full-Time
    Equivalent (FTE) ceiling and hiring in fiscal year 2011 to ensure that
    priority, mission-critical positions are filled. The agency has also
    been granted Voluntary Early Retirement Authority (VERA) by the Office
    of Personnel Management for the remainder of fiscal year 2011, which
    extends to agency operations outside of Washington, DC for the first
    time in well over a decade. In addition, the agency has reduced funding
    for discretionary purchases, including travel, contracts and printing.
    As an example, the agency is starting to utilize video conferencing
    technology for training, meetings and screening of egregious cases to
    reduce travel expenses. OSHA is also pursuing technology efficiencies,
    including the elimination of outdated and redundant equipment, to
    realize cost savings.
        Question. How will the modest increase available to OSHA be
    targeted to carrying out the highest priority activities in fiscal year
    2011 and achieving the core mission of the agency?
        Answer. OSHA did not receive an increase to its budget in fiscal
    year 2011. The continuing resolution provided the Department with the
    authority to move funds from the Departmental Management appropriation
    to other accounts for the purposes of program evaluation, initiatives
    related to the identification and prevention of worker
    misclassification, and other worker protection activities. With this
    authority, funding was restored to OSHA in the amount of the 0.2
    percent rescission for standards development, State program enforcement
    efforts, and training on identifying worker misclassification.
        Question. What will the OSHA achieve in terms of workload and
    performance in fiscal year 2011?
        Answer. The fiscal year 2011 information and data provided in the
    fiscal year 2012 congressional budget justification was based on an
    annualized continuing resolution at fiscal year 2010 enacted
    appropriations. At this point, we expect the performance for OSHA to
    not differ significantly from the information in the fiscal year 2012
    congressional budget justification.
                  mine safety and health administration (msha)
        Question. What steps will MSHA complete in fiscal year 2011 to
    create efficiencies and realize other cost savings in pursuing the
    agency's mission?
        The fiscal year 2012 budget identifies savings related to the
    elimination of the small mines office and the SAVE proposal related to
    the use of postcards reminders for certain information requests.
        Answer. With respect to the Small Mines Office, MSHA is not going
    to close or eliminate it, but will transfer and integrate the function
    into the Metal and Nonmetal program. MSHA intended to replace the
    narrative in the justification during the drafting phase to reflect
    this, but unfortunately that did not occur.
        MSHA will begin mailing the first post card reminders in lieu of
    the multi-part 7000-2 forms for the CY 2011 second quarter reporting
    period (April-June). This transition will reflect the beginning of the
    savings outlined in the SAVE proposal.
        Question. Please describe how this proposal will achieve the
    identified savings with at least the same level of services currently
    provided.
        Answer. Implementing the SAVE proposals to move to the mailing of
    post cards will significantly reduce MSHA's printing and postage costs.
    MSHA will continue to mail the multi-part form when requested; however,
    MSHA is encouraging stakeholders to take advantage of the on-line
    filing capability.
        MSHA believes the transfer of the Small Mines Office function will
    increase the effectiveness of the program by allowing the managers to
    focus on areas where their expertise is needed. This will provide more
    meaningful compliance assistance, leading to lower overall fatality and
    accident rates at all mines.
        Question. What additional cost savings are proposed in the fiscal
    year 2012 budget request?
        Answer. The fiscal year 2012 request includes two reductions
    totaling $3,250,000 reflecting the elimination of a project previously
    funded through an earmark.
        Question. How will the modest increase available to MSHA be
    targeted to carrying out the highest priority activities in fiscal year
    2011, including those previously addressed in MSHA reports to the
    Committee on Appropriations and Office of Accountability reports, and
    achieving the core mission of the agency?
        Answer. In the Department of Defense and Full-Year Continuing
    Appropriations Act, 2011, Congress appropriated to MSHA an additional
    $7.27 million (post rescission) above the revised fiscal year 2010
    continuing resolution (CR) level. MSHA allocated this funding to
    address critical projects and needs within its core programs and comply
    with known congressional interest. Below is a summary of the
    allocations:
    Federal Mine Safety and Health Review Commission (FMSHRC) Backlog
            Reduction (SOL): $2,000,000
        Transfer of funds necessary to continue the backlog reduction
    project for the last 2 months of the fiscal year.
    Federal Mine Safety and Health Review Commission (FMSHRC) Backlog
            Reduction (MSHA): $750,000
        Funds necessary to continue the backlog reduction project for the
    last 2 months of the fiscal year.
    Metal and Non/Metal Inspections: $1,300,000
        Funds for overtime and travel to ensure the Metal and Nonmetal
    enforcement program have the necessary resources to complete its
    mandated inspections.
    Upper Big Branch Investigation Costs: $550,000
        Funds to offset costs associated with MSHA's investigations into
    the Upper Big Branch mine disaster above those that were supported
    through the 2010 supplemental appropriation.
    Coal District 4 Split: $250,000
        In response to concern about the sheer size and responsibility of
    the District 4 office, whose area of jurisdiction in southwest West
    Virginia encompassed nearly 400 mines and mine facilities or roughly 20
    percent of the Nation's coal mines, MSHA is splitting the District into
    two more manageable organizations, creating a new District office, D12.
    This action will better serve MSHA and the mining industry. The
    creation of two districts to cover southern West Virginia will provide
    for more effective enforcement oversight and improved management of
    this significant portion of MSHA's workload. The allocation reflects
    funding to support the infrastructure of a temporary space while GSA
    secures a permanent location for the new District 12 office. All items
    purchased or leased will convey to the permanent location.
    Brookwood-Sago Grants Increase: $500,000
        Increase the Miner Act-established Brookwood-Sago Grants program by
    $500,000. The program provides funding for the development of
    educational and training programs and training materials for mine
    emergency preparedness by providing funding for education and training
    programs to help identify, avoid, and prevent unsafe working conditions
    in and around underground mines, and focuses on training materials and
    training programs for mine rescue and mine emergency preparedness in
    underground coal mines.
    Enforcement Programs Computer IT support: $1,100,000
        Funding to provide replacement laptop and desktop computer
    equipment for enforcement staff. Current laptops and desktops are 3-4
    years old and only have one-half GB of memory which causes all programs
    to run very slowly. Some machines are taking as long as 8 minutes to
    start up. This substantially and negatively impacts productivity by
    reducing mine site time for the inspectors. These machines will not be
    able to support Office 2010 if and when DOL/MSHA upgrades to this
    version. Additionally, Windows 7 would not be able to be supported as
    the operating system due to inadequate hardware and memory on current
    machines. MSHA and DOL have already begun migrating to Windows 7 where
    the hardware is able to support the move.
    Health Samples Reengineering: $900,000
        Funding to replace MSHA's current obsolete 31-year old COBOL system
    and provide an application that is fully integrated with MSHA's
    enterprise database. The new system will significantly reduce
    maintenance costs and improve processing speed. Reengineering the
    system will allow for:
      --Consistent management of samples data.
      --Establish consistent integration of samples monitoring with
            enforcement activities.
      --Provide consistent reporting mechanisms.
      --Maintain the ability to perform unique validations based on sample
            type.
      --Provide a consistent mechanism for tracking sample history.
      --Provide the capability to create a consistent advisory mechanism
            for reporting violations to MSHA enforcement personnel.
    Mine Emergency Equipment: $750,000
        Provides funding for the purchase of Mine Emergency Operations
    (MEO) response equipment. MSHA will purchase:
      --Communications vehicle, wireless mesh points and supporting
            equipment.
      --Satellite dish for improved communications.
      --Engineering vehicle, trailer and equipment.
    Base Funding Reallocations: -$1,080,000
        MSHA will re-direct lapsed compensation funding to offset increases
    in the Metal and NonMetal enforcement, which will allow MSHA to ensure
    that Metal and Nonmetal completes 100 percent of its mandated
    inspections. Additionally, MSHA is reallocating resources to increase
    the Brookwood-Sago Mine Safety Grants programs, transfer management of
    the Mount Hope Lab from Technical Support to the Coal activity, and
    support MSHA's expanded regulatory program.
        Question. What will MSHA achieve in terms of workload and
    performance in fiscal year 2011?
        Answer. We expect MSHA to continue its enhanced enforcement
    efforts, i.e. impact inspections, maintain 100 percent of the mandated
    inspections, and conduct other inspections/investigations. Although the
    delay in fiscal year 2011 appropriations created some challenges in
    achieving workload and performance goals, MSHA expects its workload and
    performance levels to coincide very closely with the fiscal year 2011
    information in the fiscal year 2012 congressional budget justification.
    The fiscal year 2011 information and data provided in the fiscal year
    2012 congressional budget justification was based on an annualized
    continuing resolution at the fiscal year 2010 enacted appropriation
    level.
                        bureau of labor statistics (bls)
        Question. BLS has taken steps in recent years to reduce travel
    costs by expanding the use of videoconferencing and web-based services.
    What additional steps will BLS complete in fiscal year 2011 to create
    efficiencies and realize other cost savings in pursuing the agency's
    mission?
        Answer. The Bureau of Labor Statistics (BLS) has continued to
    increase the use of its videoconferencing system, web-based services,
    and telephone and Internet data collection to mitigate travel costs.
    The videoconferencing system provides high-quality audio and video for
    meetings between the BLS national office and its regional locations. In
    addition, the BLS uses videoconferencing to meet with organizations
    located outside the United States, where international travel would
    have been required previously. The BLS has increased its use of WebEx,
    a web-based service that combines real-time desktop sharing with phone
    conferencing to conduct some work activities with State and regional
    staff, rather than traveling to conduct business on site. The BLS has
    also increased its use of telephone and Internet data collection,
    thereby reducing the travel costs associated with collecting data. In
    addition to reducing travel costs, the BLS has been working to identify
    and, where possible, reallocate unused/unneeded IT equipment
    (computers, servers, printers, and cellphones) using the Asset
    Management Application (AMA). The AMA enables the BLS to transfer
    surplus IT equipment that is still serviceable to offices where it will
    be used. These strategies have proven to be an effective means to avoid
    rising costs. The BLS is committed to continuing such practices.
        Question. In addition to the elongating of the fielding schedules
    for National Longitudinal Surveys and the elimination of the
    International Labor Comparisons program, what additional cost savings
    and efficiencies are proposed in the fiscal year 2012 budget request?
        Answer. In 2012, the BLS will continue efforts to implement online
    forms within the Producer Prices and Price Indexes (PPI) program, a
    survey that currently collects monthly price data by mail and fax. In
    fiscal year 2011, PPI began work with the centralized Internet Data
    Collection Facility within the BLS to offer online data collection to
    select respondents. By the end of fiscal year 2012, the BLS will
    realize cost savings of approximately $10,000. Offering modern,
    electronic options to respondents, including use of online data
    collection, will improve the accuracy, timeliness, and efficiency of
    data collection for both respondents and the BLS and be more
    environmentally friendly.
        Question. BLS also has taken steps to change the relationship with
    State labor market information agencies, most recently with the
    centralization of the current employment statistics (CES) program. The
    Nation requires current, accurate, detailed labor statistics for
    Federal and non-Federal data users. Please comment on the accuracy of
    the data being produced through the centralized CES program.
        How are DOL agencies and State labor market information agencies
    interacting with each other and with other Federal and non-Federal
    entities to address the goals of relevant Federal legislation and the
    Federal-State cooperative statistics system?
        Answer. In March 2011, the BLS assumed responsibility for producing
    CES State and metropolitan area estimates. The transition went smoothly
    and, as of early June, the BLS has produced 2 months of estimates under
    the new protocol. State agencies have cooperated fully with the BLS
    during the transition. States continue to relay information to the BLS
    about any local events not captured by the CES sample, and provide
    analysis and dissemination of the estimates to local data users. Data
    accuracy remains high as the sample size remains unchanged and is
    supplemented by local information provided by States. In addition, the
    centralization will permit the BLS to implement program enhancements in
    the CES program to improve survey response rates, thereby reducing the
    statistical error on the estimates. Centralizing operations at the BLS
    also improves the consistency and transparency of the estimation
    process, which are important dimensions of quality.
        In terms of the overall Federal-State cooperative system for
    producing Labor Market Information (LMI), the BLS and States continue
    to work together through the annual cooperative agreement process to
    produce, analyze, and disseminate data from the CES, Local Area
    Unemployment Statistics, Occupational Employment Statistics, Mass
    Layoff Statistics, and Quarterly Census of Employment and Wages
    programs. Consistent with Section 309 of the Workforce Investment Act
    of 1998, BLS senior management and 10 State LMI Directors elected by
    their peers continue to hold regular formal consultations.
    Representatives of other Federal agencies involved in producing labor
    market information regularly participate in these consultations as
    well.
        Question. Last, the National Research Council held a workshop last
    year on facilitating innovation in the Federal statistical system.
    Please comment on DOL agencies' innovation activities and plans.
        Answer. To foster innovation at the agency and program level, the
    BLS has included a number of budget initiatives in the President's
    budget in recent years. For example, in 2010, the BLS received
    resources to provide new series on ``green'' jobs, addressing the need
    for detailed data on these rapidly evolving industries and occupations.
    As another example, in 2012, the BLS is requesting resources to
    modernize its Consumer Expenditure (CE) survey. The CE survey is a
    critical input for the Consumer Price Index. This initiative will allow
    for continuous research to incorporate multiple data collection modes
    to take advantage of new technologies, use new sample and statistical
    modeling methods to increase cost effectiveness, and assess the
    feasibility of implementing further improvements.
        The BLS also continuously improves its current data products to the
    extent possible within existing resource levels. For example, in 2010,
    the BLS released official all-employee hours and earnings data, which
    provide more comprehensive information for the Bureau of Economic
    Analysis' National Income Accounts and for analyzing economic trends.
    Also in 2010, the BLS began publishing, for the first time, national
    estimates of workplace injuries and illnesses incurred by State and
    local government workers.
        In addition, the National Research Council report highlighted the
    importance of interagency work in fostering innovation within the
    Federal statistical system. One current example is the Joint Program in
    Survey Methodology, which is intended to address the critical and
    growing need of Federal agencies for highly trained personnel in
    mathematical statistics and survey methodology.
        Question. What will the BLS achieve in terms of workload and
    performance in fiscal year 2011?
        Answer. The BLS does not expect the workload and performance goals
    to differ from the fiscal year 2011 information in the fiscal year 2012
    congressional budget justification.
                         office of the solicitor (sol)
        Question. What steps will the Office of the Solicitor (SOL)
    complete in fiscal year 2011 to create efficiencies and realize other
    cost savings in pursuing the agency's mission?
        Answer. In fiscal year 2011, SOL continues to develop critically
    needed Legal Technology infrastructure improvements. This initiative
    began with an evaluation in fiscal year 2009. In fiscal year 2011, we
    are projected to complete the first of three phases of development.
    SOL's IT modernization initiative addresses important improvements in
    SOL's IT/Litigation Support infrastructure, including: replacing SOL's
    failing case management and time reporting systems (SOLAR/TD), as well
    as developing capacities in the critical areas of legal document
    management, document review tools, transcript and evidence management,
    trial presentation and case analysis. In addition, in fiscal year 2011,
    SOL continues to build its FTE-related program support capacity,
    including its professional development and training necessary to ensure
    that SOL's legal skills are competitive with those of its adversaries
    and other stakeholders that influence the working conditions and
    security of America's working women and men.
        Question. The fiscal year 2012 budget identifies savings related to
    the elimination of resources for compliance assistance and outreach,
    longshore litigation, and review of Uniformed Services Employment and
    Reemployment Rights Act case referrals to the Department of Justice.
    Please describe how these proposals will achieve the identified savings
    without compromising SOL's core mission.
        Answer. SOL's budget request for fiscal year 2012 was constructed
    in close coordination with the budget priorities for its DOL client
    agencies, enabling SOL to forcefully and decisively support the
    Secretary's vision of ``good jobs for everyone.'' The fiscal year 2012
    budget includes three program reductions as follows.
        Eliminate SOL's Compliance Assistance and Public Outreach
    Activities.--SOL proposes to cease performing the wide variety of
    compliance assistance and public outreach activities in which it
    currently engages, including speeches, presentations, responding to
    inquiries from and providing training to the public, and supporting the
    clients' compliance assistance activities.
        Eliminate SOL review of the Veterans Employment and Training
    Service's (VETS) USERRA case referrals to DOJ.--The Department of
    Justice bears the primary authority for litigating cases in this
    program and engages in a de novo review of the merits of each case.
    This proposal eliminates SOL's review of the recommendations to DOJ
    from VETS.
        Eliminate Non-participation memos.--DOL should discontinue its
    practice of drafting legal memos to support its decision not to
    participate in cases under the Longshore and Harbor Workers
    Compensation Act and Mine Act in the courts of appeals, and should
    communicate those recommendations orally to OWCP and MSHA.
        Question. What additional cost savings are proposed in the fiscal
    year 2012 budget request?
        Answer. As described in the response to SSEC24, SOL is in the midst
    of an IT Modernization initiative that began in fiscal year 2009 and
    the fiscal year 2012 budget request includes funding to continue this
    project in fiscal year 2012.
        Question. What will the SOL achieve in terms of workload and
    performance in fiscal year 2011?
        Answer. The fiscal year 2011 information and data provided in the
    fiscal year 2012 congressional budget justification (CBJ) were based on
    an assumed annualized funding level based on the continuing resolution
    at fiscal year 2010 enacted appropriations. While the final fiscal year
    2011 full year continuing resolution approximated these funding levels,
    the delay in appropriations has created challenges in achieving
    workload and performance goals. Consistent with the performance and
    workload information in SOL's fiscal year 2012 CBJ, SOL expects its
    fiscal year 2011 workload and performance projections to be consistent
    with fiscal year 2011 information in the fiscal year 2012 CBJ, with the
    increased production from the temporary and term FTE funded by the
    fiscal year 2010 supplemental appropriation (and the $2 million
    transfer from MSHA's fiscal year 2011 appropriations to SOL) to reduce
    the backlog of mine safety and health cases pending before the Federal
    Mine Safety and Health Review Commission. At this point, we expect the
    performance for SOL to differ from the fiscal year 2011 information in
    the fiscal year 2012 CBJ as follows:
        Historically, including in the fiscal year 2012 CBJ, SOL aggregated
    its Pre-Litigation Matters and Litigation Matters together as
    ``Litigation Matters'' when reporting. Now that SOL has revised its
    production measures to separate out Pre-Litigation Matters from
    Litigation Matters, we have revised targets and results for Litigation
    Matters Opened (formerly referred to as Litigation Matters Received)
    and Litigation Matters Concluded to exclude Pre-Litigation Matters from
    the tabulations, and we have included separate figures for Pre-
    Litigation.
        The projected number of Mine Safety and Health litigation backlog
    matters to be concluded in fiscal year 2011 projection for Litigation
    Matters Concluded, as reflected in SOL's workload projects, has been
    revised. The original target was based on a projection from the MSH
    litigation matters concluded in the first quarter of the backlog
    project, but based on current trending, that rate is not sustainable as
    a constant rate over the full project. While we expect this SOL
    workload measure to trend downward, the MSH litigation backlog project
    remains on track to exceed our expectations for disposition of cases
    and citations. It is important to note that the SOL workload
    projections are not directly comparable to data and projections
    reported in the Quarterly Reports to Congress for the Targeted Caseload
    Backlog Reduction Project. This is because SOL's projections are based
    on SOLAR, which tracks only Litigation Matters Concluded by SOL, and
    the reports to Congress are based on data provided by the Federal Mine
    Safety and Health Review Commission, including matters handled by
    MSHA's CLRs (and not SOL) as well. In addition, these two data sets are
    based on different time periods.
                     bureau of international affairs (ilab)
        Question. What actions will the Bureau of International Affairs
    take in fiscal year 2011 to create efficiencies and realize other cost
    savings in pursuing the agency's mission?
        Answer. The President's fiscal year 2011 budget request included
    additional resources for ILAB to improve its monitoring and enforcement
    of trade agreements and expand its worker rights technical assistance
    program. The United States has trade agreements with 13 developing
    countries and provides trade preferences to approximately 140 other
    developing countries. These agreements and programs include labor
    rights obligations. Without the additional requested resources, ILAB
    has shifted staff from lower priority activities, such as participation
    in inter-agency processes, to higher priority activities such as labor
    monitoring and the enforcement. However, we anticipate that monitoring
    activities will increase as the U.S. negotiates additional trade
    agreements and ILAB continues to strive for the robust enforcement of
    trade agreements.
        ILAB will continue to coordinate its efforts to address the root
    causes of child labor and forced labor with those of the International
    Labor Organization (ILO). ILAB will also continue to search for ways to
    improve the effectiveness of its programs to advance its goal of
    improving the livelihoods of exploited laborers and at-risk youth.
        ILAB is using research and technology to improve the efficiency of
    ILAB's operations. Systematic research and analysis on the status of
    labor rights in trade partner countries allows ILAB to coherently
    target policy engagement--including trade enforcement actions and
    technical cooperation activities--to specific countries and issues
    where the maximum impact may be achieved. ILAB has made substantial
    progress on developing a system for tracking and sharing information
    internally and with other agencies. This helps utilize scarce resources
    as efficiently as possible.
        Question. What additional steps are proposed in the fiscal year
    2012 budget?
        Answer. The ILAB budget proposal for fiscal year 2012 included
    expanded resources (1) for additional staff in the area of monitoring
    and enforcement of the labor provisions of trade agreements and (2) for
    expanded worker rights grants. The budget proposal did not call for
    specific additional steps to create efficiencies and realize other cost
    savings in pursuing the agency's mission beyond those proposed in the
    fiscal year 2010 budget and cost savings realized to comply with the
    constraints of the continuing resolutions covering fiscal year 2011.
        However ILAB intends to continue to pursue efficiencies and cost
    savings from measures that have been put in place during the current
    fiscal year, including prioritization of activities, targeted
    engagement with those governments that offer greatest promise of
    progress, limitations on staff travel and cautious hiring and
    replacement policies.
        In addition, in fiscal year 2012 ILAB intends to undertake more
    assignment of staff across its offices in order to accomplish all high
    priority and mandated work without addition staff resources, in case
    the fiscal year 2012 budget does not allow additional hiring. ILAB will
    also identify and eliminate additional lower priority activities,
    beyond those curtailed in fiscal year 2011, as needed to accomplish its
    mission with constrained resources. ILAB has started to identify such
    lower priority activities for possible elimination in fiscal year 2012.
    These measures will mean that ILAB is not able to sustain the current
    level of effort on all programs.
        Question. Please describe the impact of not receiving the increase
    proposed in the fiscal year 2011 budget, particularly on activities
    related monitoring and enforcement of labor provisions of trade
    agreements.
        Answer. Not receiving the increase proposed in the fiscal year 2011
    budget has significantly reduced ILAB's intended impact on improving
    worker rights around the world. Without the fiscal year 2011 request
    for resources to monitor and enforce labor provisions of trade
    agreements, ILAB will be unable to increase its monitoring efforts. In
    fiscal year 2011, ILAB has been monitoring less than half the number of
    trade partner countries it would have monitored under the requested
    level of funding. It has also been impossible to establish and expand
    high priority trade related worker rights technical assistance,
    especially Better Work programs. A lower level of resources will lead
    to a reduction in ILAB's planned activities, particularly monitoring
    and enforcement, in the following specific ways:
        Monitoring.--ILAB will not have the resources to systematically
    review, analyze and track labor problems in all FTA countries. ILAB has
    developed a set of standards and a systematized method for tracking
    progress on labor issues, but has only been able to apply this in-
    depth, systematic monitoring to six FTA countries. For the other 11 FTA
    partners, ILAB has been conducting ad hoc monitoring as problems arise.
    ILAB's responsibilities related to the labor provisions of FTAs are
    expected to rise significantly in the next year. The recently
    negotiated Colombia Action Plan Related to Labor Rights will require
    significant ILAB resources to monitor in the near future. In addition,
    the United States is currently negotiating the Trans-Pacific
    Partnership FTA (TPP) with seven countries. ILAB has not been able to
    invest the staff resources to engage the developing countries that are
    party to the TPP negotiations on labor issues to the extent we consider
    desirable. Negotiating new FTAs offers the best leverage for the
    necessary changes in labor regimes and institutions. Without the
    additional resources, ILAB's capacity to bring current and detailed
    knowledge to the negotiating process will be seriously constrained. TPP
    countries include Vietnam, Malaysia, and Brunei Darussalam, which have
    significant labor challenges.
        Enforcement.--ILAB will not have the resources to expand
    enforcement beyond 2010 levels of the labor obligations of countries
    that benefit from U.S. trade agreements and preference programs. ILAB
    monitors and engages countries on labor rights law and practice if a
    labor petition is filed under GSP, free trade agreements, or as part of
    the annual review process of AGOA. ILAB had planned to expand its
    engagement to additional countries of concern to address areas where
    there were concerns they had not met their obligations. While ILAB has
    identified potential labor rights issues in trade partner countries, it
    has been unable to proactively initiate new labor consultations or
    reviews under trade agreements and preference programs because of the
    significant staff resources they would entail.
        ILAB must divert resources from other functions. ILAB has already
    been compelled to re-assign staff from technical assistance and
    research functions to mandated monitoring and enforcement of FTA labor
    provisions. If monitoring activities increase, we will have to draw
    resources from other priorities.
        ILAB also has not received requested resources to expand its worker
    rights technical assistance programs. These programs aim to create a
    level playing field for U.S. workers in the global economy and improve
    worker rights in U.S. trade partner countries. As part of this
    initiative, ILAB has established Better Work programs in Haiti, Lesotho
    and Nicaragua, and provided initial funding in fiscal year 2010 to
    establish a program in Bangladesh and support modest expansions in
    Vietnam and Cambodia. In fiscal year 2011, we plan to initiate a
    program in Egypt modeled on Better Work. However, without additional
    resources, these programs will not be able to be fully scaled up.
        Question. What will the ILAB achieve in terms of workload and
    performance in fiscal year 2011?
        Answer. The fiscal year 2011 information and data provided in the
    fiscal year 2012 congressional budget justification was based on an
    annualized continuing resolution at fiscal year 2010 enacted
    appropriations. While the final fiscal year 2011 appropriation
    approximated these funding levels, the delay in appropriations creates
    challenges in achieving workload and performance goals. At this point,
    we do not expect the performance for ILAB to differ from the fiscal
    year 2011 information in the fiscal year 2012 congressional budget
    justification.
                              women's bureau (wb)
        Question. What actions will the Women's Bureau take in fiscal year
    2011 to create efficiencies and realize other cost savings in pursuing
    the agency's mission, beyond replacing staff with lower-paid employees?
        Answer. The Women's Bureau works diligently to make the most
    effective use of its resources. Over 85 percent of the Bureau's budget
    is spent on salaries and benefits, rent and working capital fund,
    leaving very little discretionary funding. However, the Bureau
    continues to look for ways to create efficiencies in the way it does
    business. One way is by utilizing the Federal Strategic Sourcing
    Initiative to lower cost for supplies. Both the national and regional
    offices use this initiative to purchase supplies whenever possible.
        In addition, the Bureau is attempting to reduce copying and
    printing costs and find ``greener'' alternatives when disseminating
    outreach and technical assistance materials. As part of our strategic
    outreach activities, the Bureau provides attendees with research
    papers, guides, manuals, and other materials. At meetings or events
    that require such extensive resource material, the Bureau has moved
    away from printing the documents to providing them on flash drives. The
    use of flash drives also allows the Bureau to include additional
    Departmental and governmental information and resources to the attendee
    at no additional cost. These flash drives also serve as a
    communications tool, as they are imprinted with Bureau's name and
    website.
        Question. What additional steps are proposed in the fiscal year
    2012 budget?
        Answer. The Bureau will continue to look for efficiencies including
    use of technology to reduce travel costs. The Bureau is working with
    the Department for cost effective ways to implement video conferencing
    with our regional offices, which will reduce travel costs over the near
    future. Additionally we are looking to use social media tools to
    promote our message, products and programs and increase the turnout and
    impact of our initiatives.
        Question. The budget proposes appropriations language to enable the
    Women's Bureau to make grants. How much funding and what purposes would
    this authority be used to support?
        Answer. The Bureau anticipates that approximately $500,000 to
    $750,000 of funds currently spent on contracts will be spent on grants.
    The Bureau typically works closely with nonprofits, community and
    faith-based organizations, and educational institutions to meet its
    mission of helping women achieve economic security, providing them with
    the necessary tools to ensure their advancement in the labor force, and
    promoting fair and high-quality work-life environments. These informal
    partnerships have been productive, but grants and cooperative
    agreements would give the Bureau the tools to better achieve its public
    policy and programmatic goals and objectives. This authorization would
    allow the Bureau to fund research, publications, and educational
    efforts that will directly contribute to the Bureau's mission.
        Question. What will the Women's Bureau achieve in terms of workload
    and performance in fiscal year 2011?
        Answer. The fiscal year 2011 information and data provided in the
    fiscal year 2012 congressional budget justification was based on an
    annualized continuing resolution at fiscal year 2010 enacted
    appropriations. While the final fiscal year 2011 appropriation
    approximated these funding levels, the delay in appropriations creates
    challenges in achieving workload and performance goals. At this point,
    we expect the performance for the Women's Bureau to differ only
    slightly from the fiscal year 2011 information in the fiscal year 2012
    congressional budget.
                 office of disability employment policy (odep)
        Question. What actions will the Office of Disability Employment
    Policy (ODEP) take in fiscal year 2011 to create efficiencies and
    realize other cost savings in pursuing the agency's mission? What
    additional steps are proposed in the fiscal year 2012 budget?
        Answer. In fiscal year 2011 ODEP will create efficiencies and
    realize costs savings by focusing on the priority activities that we
    believe will yield the greatest impact on low labor force participation
    and high unemployment rates. This will allow ODEP to shift resources to
    key problem areas and, in some cases, increase resources to conduct
    policy development and expand technical assistance and dissemination
    efforts. For example, we plan to transition some programs and
    initiatives to other Federal agencies who are better positioned to
    administer them. For example, ODEP efforts related to two initiatives--
    United We Ride and America's Heroes at Work--will be reduced as other
    agencies assume greater responsibility for these.
        ODEP is proposing additional steps in fiscal year 2012 to
    concentrate its efforts on those key factors most likely to yield
    significant results. By utilizing proven strategies focused on our
    priority areas, ODEP will direct and redirect its resources to maximize
    impact. Also, in fiscal year 2012, ODEP intends to increase its
    reliance on the National Employer Technical Assistance Center (NETAC)
    which has knowledge of ODEP's policy products and utilizes a consortium
    approach to leverage access of national organizations to employers and
    stakeholders. By relying on NETAC and its partners, ODEP can extend its
    reach and ability to rapidly disseminate information and provide
    technical assistance. ODEP expects to realize operational efficiency
    and cost savings by tapping into NETAC's existing knowledge,
    infrastructure and capacity to reach more than 4,000 employers
    (including the Federal Government and its contractors), service
    providers, and other stakeholders likely to adopt and implement
    effective practices.
                        dol's civil rights center (crc)
        Question. Please provide information on the findings from the new
    review process of State Methods of Administration and the assistance
    that will be provided to help States and the One Stop System meet the
    needs of all customers or potential customers, including individuals
    with disabilities.
        Answer. The WIA nondiscrimination regulations require each Governor
    (or his/her designee) to prepare and submit to DOL's Civil Rights
    Center (CRC) a document known as a Methods of Administration (MOA) plan
    for ensuring that all WIA Title I financially assisted State programs
    comply with the civil rights laws enforced by CRC, including the laws
    protecting individuals with disabilities. Additionally, every 2 years,
    the Governor is required to review the MOA to determine whether it
    needs to be updated in order for the State to be in full compliance. If
    updates are necessary, the Governor must make and submit them; if no
    updates are necessary, the Governor must certify in writing that the
    previous MOA remains in effect.
        Until recently, review of the MOA documents was CRC's primary
    method of assessing whether each Governor was satisfying his/her
    oversight responsibilities. Within the past 2 years, CRC has shifted
    the emphasis of its reviews to determining whether the actions
    described in the plans are actually being implemented.
        CRC offers recipients a number of different types of technical
    assistance and training. The agency's website, which underwent a major
    reorganization in fiscal year 2010, contains compliance assistance
    tools and training courses on a number of nondiscrimination-related
    topics, including disability issues. CRC staff members provide
    individualized compliance assistance and information, upon request, to
    congressional staff, State- and local-level Equal Opportunity Officers,
    Disability Program Navigators, Job Corps administrators and staff,
    other DOL managers and employees, representatives from other Federal
    departments and agencies, members of the public seeking information
    about civil rights laws, and a host of other persons from CRC's
    internal and external customer base. This assistance and information is
    generally provided by phone or e-mail, and occasionally in person.
    (Note: The majority of technical assistance requests CRC receives are
    with regard to disability issues, such as the lawfulness of disability-
    related inquiries.)
        With regard to training, CRC continues its policy of delivering
    training courses and workshops at State- or Local Area-sponsored
    training events, tailored to the specific issues of concern to the
    audience. In recent months, the agency has leveraged limited resources
    by providing these courses and workshops remotely, via webinar and
    audio conference; live delivery will take place as budgets permit. In
    addition, CRC will offer its 22nd Annual National Equal Opportunity
    Training Symposium from August 30 through September 2 in Crystal City,
    Virginia. The 2010 event drew approximately 350 State- and local-level
    EO Officers and staff, as well as administrators and staff of the One-
    Stop workforce development system; Job Corps staff and contractors; and
    other stakeholders.
        Question. What will the ODEP achieve in terms of workload and
    performance in fiscal year 2011?
        Answer. The fiscal year 2011 information and data provided in the
    fiscal year 2012 congressional budget justification was based on an
    annualized continuing resolution at fiscal year 2010 enacted
    appropriations. Since the final fiscal year 2011 appropriation closely
    approximated these funding levels, the delay in appropriations is not
    expected to create any significant challenges in achieving workload and
    performance goals. At this point, we do not expect the performance for
    the Office of Disability Employment Policy (ODEP) to differ
    significantly from the fiscal year 2011 information in the fiscal year
    2012 congressional budget justification.
                emerging industries and high growth occupations
        Question. The prediction of emerging industries and high growth
    occupations is essential to effective workforce development. What are
    the current ways that ETA is using labor market information to improve
    workforce services such as job search, career counseling and training?
        Answer. We agree that labor market information (LMI) including
    information about emerging industries and high growth occupations is
    necessary to ensure that job seekers, career changers, and strategic
    planners have the labor market intelligence they need to make sound
    training, education, and economic development investments. This past
    year, ETA launched two new creative and useful electronic tools:
    mynextmove.org which is a career exploration site for individuals
    entering the labor market and myskillsmyfuture.org which quickly shows
    unemployed workers what other jobs need their skill sets.
        ETA takes several actions to assure that State and local workforce
    investment boards, One-Stop Career Centers, partner agencies, job
    seekers, and businesses have a wide variety of reliable and comparable
    labor market data and information. ETA provides annual funding from the
    Workforce Information-National E-Tools and Capacity Building budget
    line to the States and territories and consortia of States to support
    the collection and dissemination of state and local labor market
    information, including:
      --Production at the State and local levels of 2- and 10-year industry
            and occupational employment projections;
      --Population of the Workforce Information Database that facilitates
            the sharing among the States of comparable data sets on wages,
            licenses, credentials, military to civilian occupational cross
            walks, employer location and contact information, etc.;
      --Maintenance and expansion of the occupational information network
            (O*NET) that documents occupational skills, competencies, and
            detailed work activities including new, emerging, or evolving
            occupations such as green jobs; and
      --Universal access to the LMI data described above and a variety of
            other data through state LMI web sites and via national
            electronic tools including the Career One Stop portal at
            www.CareerOneStop.org and ONET Online at http://
            www.onetonline.org/. These websites and portals receive more
            than 38,000,000 customer visits per year.
        In addition, in 2009, ETA provided nearly $50,000,000 in ARRA
    competitive grants for State LMI Improvement grants to 24 States and
    six consortia. While most projects continue to operate, to date the
    States have:
      --Conducted numerous State- and local-level surveys to measure green
            jobs and the impact green jobs are having on their States'
            economies, and to identify education and training programs that
            support skills acquisition for emerging industries and
            occupations;
      --Researched the use of ``Real Time'' LMI (job openings data
            collected daily and aggregated from the Internet job banks and
            corporate websites) to enhance 2-year and 10-year projections
            and to make more job opportunity data available to job seekers;
      --Conducted research on green jobs skills with the goal of aiding
            dislocated workers' transition from declining to transforming
            and emerging industries; and
      --Developed new tools and improved access to workforce and LMI data
            in the labor exchange operations within the One-Stop Career
            Centers.
        Question. How is the Department working to improve the use or
    availability of this information to make quality and timely
    predictions?
        Answer. One of the State LMI Improvement grants, noted in the
    response to SSEC 37, was awarded to the Projections Managing
    Partnership consortia of States to re-write and enhance the State and
    local industry and occupational short-term (2 years) and long-term (10
    years) software suite that States use to inform training, education,
    and economic development investment decisionmaking. This is now
    available to all States to produce the occupational projections. In
    addition, the consortia made enhancements to add the skills that will
    be in demand by combining the projected occupational growth and O*NET-
    defined skills.
        In September 2010, the Department released a new skill
    transferability tool specifically designed for direct use by dislocated
    workers who have skills and work experience but need to change jobs to
    adapt to the changes in their local economy. Called
    myskillsmyfuture.org, this site uses simplified navigation, language,
    and integrated information resources to provide a seamless experience
    for dislocated workers. Similarly, for individuals who are exploring
    careers, the Department released a site in February 2011 with
    simplified language, and an online 60-question interest assessment tool
    that makes the O*NET occupational profiles easier to access and use,
    while ultimately still linking to the additional detail available
    through O*NET OnLine. This tool is found at mynextmove.org.
                    adult employment and training activities
        Question. The fiscal year 2012 budget request indicates that the
    Department will increase the rate of industry-recognized credential
    attainment among customers receiving training. What is the strategy for
    increasing credential attainment and how will the Department measure
    its progress on this goal?
        Answer. The Secretary of Labor has set a high priority performance
    goal of increasing by 10 percent the number of workforce program
    participants who attain industry-recognized credentials. To support
    this goal, the Employment and Training Administration has issued
    guidance to the system (Training and Employment Guidance Letter 15-10),
    provided technical assistance through webinars and other means, and
    invested in promising program models. A summary of this activity
    follows:
        ETA, with its partner agencies in Education and Health and Human
    Services, supports the increase of credential attainment through the
    development of career pathway systems. Through strong alignment of
    education, training and employment services among public agencies and
    with employers, career pathway approaches better enable low-skilled
    adults and other hard-to-serve populations, students, and workers, to
    succeed in postsecondary education and earn in-demand, industry-
    recognized credentials that place them on a career ladder. Through
    discretionary grants and technical assistance efforts, ETA is working
    with community colleges, State workforce systems and others to develop
    career pathway models that link education and training to advancement
    along a specific track. For example, one career pathway includes bridge
    programs to assist Certified Nursing Assistants to become Licensed
    Practical Nurses.
        ETA also focuses on strengthening programs like Job Corps and
    YouthBuild that help young people earn valuable occupational
    credentials while completing high school and Registered Apprenticeship
    programs that provide participants a valuable credential while earning
    wages on the job.
        Through the Trade Adjustment Assistance Community College and
    Career Training Initiative, the Department of Labor will make a large
    investment in building the capacity of community colleges and other
    eligible higher education institutions to design programs that meet the
    needs of trade-impacted workers. These programs will be designed to
    meet the needs of non-traditional, eligible students for flexible
    scheduling, easy entry and exit from programs, accelerated remediation
    through contextualization, integrated academic and occupational
    training, on-line courses, and more. They will reflect evidence-based
    strategies that have proven effective, or test strategies that have
    promise.
              dislocated worker employment and training activities
        Question. Dislocated Worker National Emergency Grants (NEGs) are
    sometimes used to create employment opportunities for dislocated
    workers to assist with clean up from natural disasters. What portion of
    fiscal year 2010 NEGs was used for these purposes and how many
    dislocated workers received employment opportunities through these
    grants?
        Has the use of NEGs for this function increased over time?
        Answer. As fiscal year 2010 appropriations fund Program Year (PY)
    2010 activity for National Emergency Grants (NEGs), we are providing
    responses based on disaster NEG activity thus far in PY 2010 (PY 2010
    began July 1, 2010 and ends June 30, 2011).
        Within the National Reserve, the fiscal year 2010 appropriation
    provided $190,919,666 for NEGs. As the table below shows, the
    Department has awarded 18 disaster NEGs and funded two increments for
    prior year disaster NEGs, for a total $79,893,327. Of the amount
    awarded, $69,041,816 was funded, which is about 36 percent of the
    almost $191 million available for NEGs in PY 2010 and 55 percent of the
    $126,544,605 awarded to date. An estimated 6,180 individuals will
    receive temporary employment opportunities and reemployment services
    through these NEGs. A number of these NEGs are too recent to have
    completed their final planning/hiring, so we have presented their
    participant estimates in italics.
        Disaster NEG funds provide funding to create temporary jobs to
    support clean-up and recovery efforts. These efforts can fluctuate
    widely depending on the number, severity, and type of natural disasters
    that occur in any given year. Activity in PY 2010 is slightly above
    average. However, it doesn't compare to Hurricane Katrina/Rita efforts,
    where Louisiana alone spent $43,599,160 to provide 7,502 disaster
    affected workers temporary employment and reemployment services.
        As indicated, we are still within the program year, and it is
    customary for State applications to come in late in the program year as
    formula funds are depleted. As a result of this practice, together with
    recent weather emergencies, the Department currently has applications
    that exceed the remaining funds for NEGs and we expect the entire
    appropriation to be awarded.

    --------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                  Amount
    State                        Project                         New or incremental        Approval date       approved (up    Amount funded   Participants
                                                                       funding                                   to award)
    --------------------------------------------------------------------------------------------------------------------------------------------------------
       KYKY-Severe Storms, Tornadoes, and Flooding           New...................  6/6/2011.............      $4,276,514      $4,276,514             317
       OKOklahoma Severe Storms and Tornadoes                New...................  6/1/2011.............        $471,150        $471,150              26
       MOMO Severe Storms, Tornadoes and Flooding 2011       New...................  5/27/2011............      $5,822,352      $5,822,352             404
       ARSevere Storms, Tornadoes and Associated Flooding    New...................  5/26/2011............      $3,758,327      $3,758,327             249
       TNTN-Disaster-Storms, Tornadoes, Flooding             New...................  5/23/2011............      $3,589,704      $3,589,704             480
       CACalifornia Tsunami Waves                            New...................  5/11/2011............      $6,498,100      $6,498,100             271
       GAGeorgia Tornado and Storm Disaster                  New...................  5/11/2011............      $5,000,000      $5,000,000             300
       MSMS-Disaster-Severe Storms, Tornadoes, Straight-     New...................  5/9/2011.............      $7,000,000      $7,000,000             525
          line Winds, and Associated Flooding
       ALSevere Storms, Tornadoes, Winds, & Flooding         New...................  5/4/2011.............     $10,000,000     $10,000,000             800
          Disaster
       OROregon Tsunami Wave Surge 2011                      New...................  4/15/2011............        $284,023         $94,674              15
       ORSTORMS 2011                                         New...................  3/18/2011............        $176,904        $176,904              10
       CA2010 California Severe Storms                       New...................  2/23/2011............     $11,267,940      $3,755,980             252
       ARStorms October 2009                                 Increment.............  12/10/2010...........  ..............          $8,494             119
       PRTropical Storm Otto                                 New...................  11/23/2010...........      $4,000,000      $4,000,000             607
       MNSouthern MN 2010 Flood                              New...................  11/8/2010............      $1,160,391        $580,195              29
       IASevere Storms/Flooding/Tornadoes 2010               New...................  9/22/2010............      $5,800,000      $2,000,000             126
       TNSevere Storms and Flooding                          Increment.............  9/14/2010............  ..............      $2,921,500             670
       TXHurricane Alex Flooding                             New...................  9/14/2010............      $5,849,481      $5,849,481             416
       KYEastern Kentucky Severe Storms, Flooding and        New...................  8/27/2010............        $938,441        $938,441              57
          Mudslides
       PRSevere Storms and Flooding                          New...................  7/22/2010............      $4,000,000      $2,300,000             507
                                                            ------------------------------------------------------------------------------------------------
               Totals                                        ......................  .....................     $79,893,327     $69,041,816           6,180
    --------------------------------------------------------------------------------------------------------------------------------------------------------

                                   youthbuild
        Question. As you know, as a result of the significant funding
    constraints on the fiscal year 2011 continuing resolution, the 2011
    funding level for YouthBuild represents a significant reduction to the
    program. Specifically, the program was funded at $80 million--a $23
    million or 22 percent reduction. On May 17, 2011, the Department
    announced 74 grantees that will receive funding under the fiscal year
    2011 appropriation for YouthBuild. How many existing YouthBuild
    grantees have lost funding as a result of the reduction and how many of
    the 74 awards are going to new grantees not previously funded by the
    Department?
        Answer. With fiscal year 2009 and American Recovery and
    Reinvestment Act Funds (ARRA), a total of 183 grants were funded by the
    Department of Labor (DOL). In fiscal year 2011, a total of 74 grants
    were awarded, of which two went to organizations not previously awarded
    grants by DOL. This means that 72 previously funded grantees were
    refunded through the 2011 competition. Therefore, 111 grantees were not
    refunded in the most recent competition.
        Question. In the past the Department has tended to fund YouthBuild
    grants on a 2-year basis. Has that approach changed as a result of the
    lower funding level in fiscal year 2011?
        Answer. With fiscal year 2011 funds, the Department of Labor (DOL)
    awarded 74 YouthBuild grants that are for 2 full years of program
    services. These grants were provided the full amount from the fiscal
    year 2011 funds. This plan was outlined in Solicitation for Grant
    Application announced in October, 2010 and was not a result of the
    lower funding level.
                                   job corps
        Question. The fiscal year 2011 continuing resolution included a $75
    million rescission to Job Corps construction and renovation funds. How
    will Job Corps implement that rescission?
        What projects will it impact and will Job Corps go forward with the
    planned construction of centers in Wyoming and New Hampshire?
        Answer. Job Corps had preliminarily identified $75 million from
    previously budgeted, but not obligated, projects. These projects have
    now been placed on hold, subject to available resources, and may be
    designated to receive funding in future Program Years. These projects
    are in one of three categories: (1) projects in which the budgeted
    amount includes the construction phase of the project, (2) projects in
    which the budgeted amount includes the design phase of the project, and
    (3) projects in which the budgeted amount was only partially rescinded.
        The new centers in Wyoming and New Hampshire are still under
    consideration in light of the available funding. Final decisions will
    be made after the Department thoroughly assesses the impact of the
    rescission and concludes a re-evaluation of Job Corps' inventory of
    construction projects.
                           workforce innovation fund
        Question. The fiscal year 2011 continuing resolution included $125
    million for a new Workforce Innovation Fund to support innovative new
    strategies or expand evidence-based strategies that align programs and
    strengthen the workforce development system to improve the education
    and employment outcomes for job seekers and workers, youth, and
    employers. What are the Department's plans for these awards in terms of
    the timing of the solicitation and awards and the likely number of
    awards?
        What benefits do you see these grants having for the workforce
    investment system and how would these initial grants tie to the
    President's fiscal year 2012 request for Workforce Innovation Funds?
        Answer. While the precise timeline is still being discussed, ETA is
    pursuing an aggressive timeline to prepare for publication of the first
    Workforce Innovation Fund (WIF) Solicitation for Grant Applications. To
    ensure that our final product draws fully on the experience and
    knowledge of stakeholders and is capturing the most innovative and
    promising approaches, the Department has commenced an intensive
    stakeholder engagement strategy which includes outreach to Federal
    partners, including the Departments of Education and Health and Human
    Services and the Office of Management and Budget; State and local
    workforce organizations; intergovernmental organizations and
    associations; Senate and House Committees (Authorizing and
    Appropriations); and foundations and the research community. ETA is
    using a mix of face-to-face discussions and webinars to encourage broad
    participation; it has established a general e-mail account
    (workforce.innovation@dol.gov) where stakeholders can post ideas and
    feedback. ETA will determine the size and scope of grants after
    analyzing information from the consultations.
        The WIF offers a unique opportunity to test innovative workforce
    strategies that lead to system change. While the fiscal year 2011
    budget provides only a brief description of the WIF, the fiscal year
    2012 budget request provides additional information and outlines the
    intent and purpose. Specifically, the administration intends that the
    Fund:
      --invest in projects that deliver services more efficiently and
            achieve better outcomes, particularly for vulnerable
            populations and dislocated workers;
      --support both structural reforms and the delivery of services;
      --emphasize building knowledge about effective practices through
            evaluation;
      --translate into improved labor market outcomes and increased cost
            efficiency and other measures in the regular formula programs;
            and
      --facilitate the use of waivers where necessary to achieve better
            outcomes and facilitate cooperation across programs and funding
            streams.
        In fiscal year 2011, the Department is the sole contributor to the
    fiscal year 2011 Workforce Innovation Fund. Therefore, the first year
    of funding on innovation strategies will directly benefit Title I and
    III (Workforce Investment System and Wagner-Peyser Employment Service)
    programs, although proposals to improve coordination with Title II and
    IV, and other Federal programs would be in line with goals for system
    reform. If joint funding with the Department of Education is achieved
    in fiscal year 2012, the Department will have a solid framework from
    which to expand to the other WIA title programs.
            community service employment for older americans (cseoa)
        Question. The President's fiscal year 2012 budget proposes the
    transfer of CSEOA to the Department of Health and Human Services'
    Administration on Aging. What has been the reaction to this proposal of
    the national nonprofit agencies who administer the majority of these
    grant funds?
        Have you received a lot of comments from those entities, what are
    their concerns and how are you addressing their concerns in your
    transition planning?
        Answer. The Department has received very few direct comments from
    grantees. However, we have arranged two conference calls for the
    Assistant Secretaries of the Department of Health and Human Services
    (HHS) Administration on Aging (AoA) and the Department of Labor
    Employment and Training Administration to speak with the national
    grantee directors and with all grantees to address any concerns.
    Questions in advance of and during the calls largely centered on how
    the program would work if it went to AoA, and what kind of changes AoA
    anticipated making in how the program is structured and funds are
    allocated. Both Assistant Secretaries assured grantees that the
    Departments would work collaboratively to ensure that the proposed
    transfer would be as seamless as possible, with collaboration and
    consultation at the staff level already underway. This would include
    coordination on the statutorily required national grantee competition
    planned for late 2011, with operations under these new grants effective
    in 2012.
        Question. Also, as the budget notes, the majority of State CSEOA
    programs are housed within offices on aging, senior services or health
    and human services departments. What will the transfer of this program
    mean for the 17 States where that is not the case, where CSEOA programs
    are housed in labor departments and how will DOL and HHS ensure a
    smooth transition for those grantees?
        Answer. Under the Older Americans Act, Governors have complete
    discretion on where within the State bureaucracy the CSEOA program is
    housed. Program services, performance goals, program structure,
    coordination requirements, etc., are not dependent on whether the
    program is administered at the State level by either a Labor or HHS
    State agency. Because CSEOA has a dual focus on job training and
    community service, it can be effectively run by either the Labor or HHS
    State agency.
                                     ______

                Questions Submitted by Chairman Daniel K. Inouye
            workforce investment act (wia) workforce innovation fund
        Question. Are the innovation grants proposed in the fiscal year
    2012 budget intended to inform the Employment and Training
    Administration's (ETA's) reauthorization efforts or are they a
    component of ETA's ongoing efforts to improve program functioning?
        Answer. This Fund represents a small but crucial investment in
    innovative, evidence-based and cost-saving workforce strategies to
    strengthen outcomes for both workers and employers. This Fund will
    benefit future WIA formula-funded activities by moving the public
    workforce system toward better results and more cost effective delivery
    that can be replicated broadly across the workforce system. In
    addition, while evidence developed over the next few years may not be
    available in time to inform an imminent WIA reauthorization, it would
    inform future WIA reauthorizations and administrative guidance issued
    by the Department.
        Question. Are the proposed innovation grants multi-year grants and
    would they require funding in subsequent years? If these proposed
    innovation grants are intended as multi-year grants, what are the
    proposed periods (e.g., 3 years, 5 years)?
        Answer. Grant funds are available for Federal obligation through
    September 30, 2012; the appropriation remains available for recording,
    adjusting, and liquidating obligations properly chargeable to the WIF
    account until September 30, 2017. Assuming a 1 year close out period,
    grants could be provided for a period of up to 5 years. Senators Harkin
    and Murray have recommended a 2-3 year period of performance. While
    this aligns with our typical grant award period, and will adequately
    accommodate front-line service delivery reforms, such a time period may
    not be sufficient for a State or regional partnership to make
    structural or systemic changes at the State or local level and observe
    how those changes increase efficiency or quality in service delivery.
    Currently, the Department is engaged in intensive stakeholder
    consultations for the WIF which will provide more information around a
    practical timeframe of grant availability.
        Question. Will the proposed reduction in the Governors Reserve from
    15 percent to 7.5 percent of State formula grant allocations affect the
    ability of Governors to carry out required statewide activities within
    the WIA system?
        Answer. It is possible that the reduction in the Governor's Reserve
    will cause States to scale back on some statewide activities, including
    performance incentives to local areas. The fiscal year 2011 Full-Year
    Continuing Appropriations Act reduced the Governor's Reserve from 15
    percent to 5 percent, which will provide a test case to determine how
    States prioritize their statewide activities with fewer available
    resources. For the fiscal year 2011 funds, the Department has advised
    States to consider investments in statewide activities central to State
    management such as reporting or those that provide direct services to
    participants ahead of other required activities. States that are unable
    to carry out all required activities due to a lack of funds may apply
    for a waiver to allow for a temporary exemption from the requirement to
    carry out some of the required statewide activities, such as
    performance incentives and evaluations.
                         unemployment compensation (uc)
        Question. What has DOL done to discourage States from reducing the
    number of weeks that unemployed workers can receive regular
    unemployment compensation (UC) benefits?
        Answer. The Federal-State UC program is a cooperative arrangement
    between the Federal Government and the States providing income support
    to individuals who meet the eligibility requirements of State law.
    Federal UC law establishes broad requirements that State laws must
    meet. Otherwise, States are free to establish the requirements of their
    own UC laws. Federal law has never included any requirements concerning
    weeks of benefits payable. Thus, DOL has no official role in mandating
    the number of weeks of benefits that States provide; we implement laws
    passed by Congress. Additionally, we note that until the American
    Recovery and Reinvestment Act, Federal law had never included any
    requirements concerning weekly benefit amounts. Currently States that
    have agreed to operate the Emergency Unemployment Compensation (EUC)
    program on behalf of the Federal Government (and all States currently
    do) are prohibited from reducing their weekly benefit amounts. The EUC
    program is currently set to expire December 31, 2011, with phase out
    completed by June 9, 2012.
        There are potential consequences if States reduce the number of
    weeks of benefits available. Specifically, the benefit amounts
    available under the permanent extended benefits (EB) program and the
    temporary emergency unemployment compensation (EUC) program are reduced
    if individuals received fewer than 26 weeks of regular UC. DOL has
    informed States considering such benefit reductions of the impact on
    EUC and EB benefit amounts that would be available to eligible
    individuals in their States.
        Question. Will the administration support the reauthorization of
    the Emergency Unemployment Compensation (EUC08) program before it
    expires in January 2012? Would the administration support an extension
    of 100 percent Federal financing for Extended Benefits (EB) beyond
    January 4, 2012?
        Answer. When people lose their jobs our Unemployment Insurance
    system provides crucial support for both the recipients and their
    communities. We've seen in every recession how important these benefits
    are not just in helping to keep food on the table and roofs over
    peoples' heads, but they provide an automatic stabilizer for our
    economy. Each dollar paid out in UI benefits generates $2 in economic
    activity, which means that helping the jobless prevents joblessness.
        The extension of Emergency Unemployment Compensation (EUC) and 100
    percent Federal financing of Extended Benefits--that we pushed for and
    passed as part of the broadly supported tax agreement in December--have
    been very important for our economy. They are helping 7 million
    Americans support themselves while looking for work who would otherwise
    have seen their benefits expire and supporting the businesses in their
    community. The Council of Economic Advisers estimates that these
    extensions of Federal support for unemployment insurance will create
    600,000 jobs this year.
        As we continue to work every day to put Americans back to work, we
    are looking at a wide variety of options. The extension of Unemployment
    Insurance benefits is also one of the ideas that should be analyzed
    economically and discussed with all Members of Congress as we go
    forward.
        Question. Does the administration favor adding another Tier of
    emergency UC benefits to the Emergency Unemployment Compensation
    program (EUC08)?
        Answer. Whether Unemployment Insurance benefits should be expanded
    is worth both analyzing economically and discussing with all members of
    Congress as we go forward.
                                davis-bacon act
        Question. What are Department of Labor's plans to improve
    implementation of the Davis-Bacon Act?
        Answer. In fiscal year 2010, the Wage and Hour Division (WHD) re-
    engineered its Davis-Bacon wage survey processes to improve the quality
    and timeliness of wage determinations published by the agency. For
    example, we are now utilizing State prevailing wage determinations as
    the basis for issuing more current highway wage rates. This change,
    coupled with improvements to the survey process, has positioned the
    agency to complete during fiscal year 2011 all surveys that are
    currently in the pipeline.
        WHD continues to improve the IT system used for Davis-Bacon wage
    determinations and to re-engineer its wage determinations processes in
    order to improve the timeliness and accuracy of wage determinations. We
    are also building upon previous efforts to revamp and enhance
    performance measures and goals, as well as increase our numbers of
    trained and experienced survey staff. We believe all these efforts will
    produce more responsive and representative survey results that will
    lead to more accurate and timely wage determinations.
        Question. What resources would DOL need to ensure that Davis-Bacon
    wage determinations are accurate and up-to-date?
        Answer. The Department's budget does not include a request for
    additional resources for Davis-Bacon wage determinations. Process
    changes in conducting wage surveys are currently being implemented.
    These changes should enable the Wage and Hour Division to update and to
    keep current wage determinations nationwide.
        Question. How will the administration's proposed cut to the
    Community Service Employment for Older Americans program affect
    services to older, low-income Americans?
        Answer. The fiscal year 2011 budget allocation has already reduced
    program funding to the level proposed in the fiscal year 2012 budget.
    It will mean an approximate 25 percent reduction in funding and
    services to unemployed, low-income seniors starting in PY 2011, as
    compared to PY 2010 regular funding. However, grantees are already
    implementing management strategies to help ensure that the impact of
    the severe funding reductions on current CSEOA participants is
    minimized in so far as possible. Grantee strategies include eliminating
    new enrollments, cutting back on hours of paid community service
    training for individual participants, and restricting any time
    extensions for current participants beyond the new statutory 48 month
    participation limit that starts on July 1, 2011.
                                     ______

                  Questions Submitted by Senator Patty Murray
                          evaluations and performance
        Question. Duplicity and ineffectiveness are two claims that have
    been levied against Federal job training programs recently, mostly in
    response to the release of a GAO report earlier this year. However,
    most of the inquiries I've heard into these claims never got to the
    heart of the matter. I believe that accountability and performance are
    too important not to address the issue fully.
        I'd like to ask about the evaluation required under Sec. 172 of the
    law. To your knowledge, why, under the Bush administration, didn't the
    Department complete the multisite control group evaluation of WIA
    formula programs by fiscal year 2005 as required by statute?
        Has the Obama administration made such an evaluation a priority?
        Answer. While rigorous random assignment impact studies provide the
    most credible information on program effectiveness, these also are
    highly resource intensive and take a minimum of 5 years to implement
    and complete. The Bush administration had several policy proposals to
    change WIA, and while we cannot answer with certainty why decisions
    were made, it is our understanding that the Bush administration viewed
    the WIA program as a program undergoing a transition. It generally is
    advisable not to conduct an evaluation of a program undergoing
    transition, as it could result in incorrect conclusions.
        While it is unfortunate that we do not have evaluation results from
    that period in time, in 2008, the Department commissioned the rigorous
    WIA Gold Standard Evaluation of the Adult and Dislocated Worker
    Programs (WGSE). This study will use a control group to measure the
    impact of the WIA adult and dislocated worker formula programs at
    nearly 30 randomly selected sites. The study's results will be
    available in 2016, although this schedule is dependent upon continued
    appropriations for the evaluation of WIA programs.
        Question. I'd like to ask about the other evaluations that the
    Department has undertaken under the authority of Sec. 172. Another
    recently released GAO report noted that ETA released 34 reports to the
    public in 2008, 20 of which had waited between 2 and 5 years to be
    approved for public release. GAO goes on to note that several of those
    reports would have been useful for the workforce system.
        To your knowledge, why didn't the Bush administration release those
    findings and reports earlier?
        How has the Obama administration worked to address the criticisms
    leveled by GAO concerning it research and evaluation activities for WIA
    programs?
        Answer. As I understand it, the Bush administration argued that
    those studies were flawed. What I can tell you is that the GAO's March
    2011 report discussed the marked improvement in the dissemination of
    research reports by the Employment and Training Administration under my
    leadership at the Department of Labor. The GAO noted that, ``The 34
    research reports published by ETA in 2008 took, on average, 804 days
    from the time the report was submitted to ETA until the time it was
    posted to ETA's research database. By, contrast, from 2009 through the
    first quarter of 2010, the average time between submission and public
    release was 76 days, which represents a more than 90 percent
    improvement in dissemination time compared with 2008.''
        The Department has also worked diligently over the past 2 years to
    increase the rigor of its evaluation studies. For example, I created
    the Chief Evaluation Office (CEO), which was staffed in May 2010. The
    purpose of this office is to coordinate the Department's research and
    evaluation agenda in order to increase its capacity to conduct high
    quality, rigorous evaluations.
        In addition, since 2009, about half the evaluations the Employment
    and Training Administration (ETA) has funded have been rigorous, random
    assignment impact evaluations. These include: (a) the Workforce
    Investment Act (WIA) Gold Standard Evaluation of the Adult and
    Dislocated Worker Programs (WGSE); (b) the YouthBuild Impact
    Evaluation; (c) the Reintegrating of Ex-Offenders Random Assignment
    Evaluation; (d) the Impact Evaluation of Green Jobs, Health Care and
    High Growth Training Grants; and (e) the Transitional Jobs Impact
    Evaluation. Each of these evaluations will examine net impacts on
    employment, retention and earnings, and include benefit-cost analyses.
    ETA was able to fund these evaluations through an increase in fiscal
    year 2010 appropriations and the large one-time infusion of funds made
    available to the Department through the American Recovery and
    Reinvestment Act of 2009.
        While rigorous random assignment impact studies, such as the WGSE,
    provide the most credible information on program effectiveness, they
    also are highly resource intensive. Mindful of the statutory
    responsibility and to address the knowledge gap until the WGSE results
    are available, in 2009 the ETA released the results of a quasi-
    experimental net impact evaluation of the WIA Adult and Dislocated
    Worker programs.\1\ This study uses the next-best methodology when
    random assignment is not available. This evaluation found positive
    long-term earnings impact for both programs. ETA plans to publish
    interim findings of the WGSE in 2013, and the final report will be
    available in 2016.
    ---------------------------------------------------------------------------
        \1\ The Workforce Investment Act Non-Experimental Net Impact
    Evaluation: Final Report may be found at ETA's Research Publication
    Database Web site.
    ---------------------------------------------------------------------------
        In addition, random assignment evaluations may not always be
    possible when the law requires that people receive services as is the
    case in many entitlement programs such as the Unemployment Insurance
    (UI) program. In November 2010, ETA released a study which used
    nationally representative tax and benefit data in a prominent
    macroeconomic model, which provided new evidence reaffirming the value
    of UI as an automatic economic stabilizer during the latest
    recession.\2\
    ---------------------------------------------------------------------------
        \2\ The Role of Unemployment Insurance As an Automatic Stabilizer
    During a Recession may be found at ETA's Research Publication Database
    Web site.
    ---------------------------------------------------------------------------
        Question. I'd like to address the lack of performance information
    argument. Does the Department collect performance data on WIA formula
    programs? If so, how long has such data been collected and what does it
    reveal about the value of WIA programs?
        Answer. The Department has collected performance information on WIA
    formula programs since its inception. The principal data set, known as
    the Workforce Investment Act Standardized Record Data (WIASRD), records
    a wide range of information about individual program participants,
    including program outcomes for participants after they have exited from
    the program. The outcomes recorded include employment, job retention,
    and earnings, as well as attainment of education, credentials, and
    skills.
        Other information collected includes individual demographic
    information and data about participation in and services or other
    assistance received through WIA or partner programs. The full list of
    data elements collected by WIASRD is posted on-line at http://
    www.doleta.gov/performance/guidance/WIA/Appendix-A-WIASRD-
    Specifications-Expires-02282009.xls.
        Since WIA's inception, the Department has used this information to
    produce and disseminate quarterly and annual performance reports. These
    reports provide aggregate summary information on program exiters and
    their outcomes with respect to the given time periods. These reports
    are available to the public on-line at http://www.doleta.gov/
    performance/results/Reports.cfm?#etaqr.
        While this information is highly useful for monitoring program
    performance, it cannot directly provide information regarding the value
    of the programs. However, this information is the primary source of
    data on which program evaluations, cost-benefit analyses and/or impact
    studies are based. On the whole, these studies have provided evidence
    that WIA programs enhance both the employment prospects and future
    earnings of WIA participants.
        As with any performance accountability system, WIA data systems and
    performance metrics could always be improved or expanded. However, WIA
    is certainly not lacking performance information as the WIASRD is a
    rich dataset.
                          investment compared to need
        Question. A recent GAO report noted $18 billion was invested in
    Federal employment and training programs in fiscal year 2009, an
    increase of $5 billion since an analysis in 2003. The same report goes
    on to note that after adjusting for inflation, the increase in funds
    equals $2 billion, which is approximately the same amount Congress
    invested in these programs in the American Recovery and Reinvestment
    Act to help address the impact of the Great Recession. I've seen some
    reports that public financing for our workforce development programs
    has actually fallen by 90 percent since the 1970s while our workforce
    has grown by 50 percent.
        However, just looking at recent years, it's my understanding that
    the one-stop delivery system saw a marked increase in use over the last
    several years due to the downturn in the economy. In fact, it
    experienced nearly 234 percent increase in participants. Do you believe
    that Federal investments have matched the increasing need for services
    since 2003?
        Answer. In calendar year 2010, ETA programs served more than 39.1
    million people. The Wagner-Peyser Employment Services (ES) and
    Unemployment Insurance (UI) served 74.6 percent of this total, and 63
    percent of those receiving Unemployment Insurance also received Wagner-
    Peyser funded Employment Services. ETA's other programs provided more
    comprehensive services to over 9.9 million people in 2010. The high
    level of participants reflects the continued demand for temporary
    income support, training and employment services including job search
    assistance, and the impact of the American Recovery Act and
    Reinvestment Act funding.
        While many of ETA's current workforce programs existed in 2003, we
    are not able to make a direct comparison between the number of
    individuals served in 2010 with those served in 2003 due to a changing
    number of workforce investment programs authorized and appropriated by
    the Congress. It also is important to note that the $18 billion
    invested in Federal employment and training cited by the Government
    Accountability Office includes the one-time $2 billion infusion of
    funding from the American Recovery and Reinvestment Act. Without these
    funds, there will be a significant decrease in individuals who receive
    WIA services.
        Adequate funding is important; there are many individuals eligible
    for WIA services that the system could serve with additional funding.
    In addition, increasing the number of participants who acquire
    industry-recognized credentials through longer-term training means
    higher cost services; and funding evaluations to assess the
    effectiveness of alternative approaches requires significant resources.
    However, these needs must be balanced with the current economic
    environment, and the acknowledgment that the Federal Government must
    live within its means. This requires that investments be strategic and
    focus on increasing efficiency and alignment with existing Federal
    resources. For example, the new Workforce Innovation Fund supports the
    identification and replication of innovative, evidence-based and cost-
    saving workforce strategies.
        The range of such investments can build on technological advances
    (e.g., using online resources to reach more people), system flexibility
    measures such as waivers, partnerships, and guidance on aligning or
    leveraging resources to help State and local workforce investment
    programs deliver cost effective and high quality services to job
    seekers and worker and employers.
                           administrative structures
        Question. Another claim we often hear about job training programs
    is multiple administrative structures and lack of strategic approach to
    planning at the State level. To help address this issue, we've heard
    about the value of unified planning and common performance measures as
    ways to reduce administrative burden while promoting a better
    understanding about the value of these programs. How does the
    Department propose to address these concerns?
        What value do you see in unified planning and the use of common
    measures?
        Answer. The Workforce Investment Act of 1998, Section 501 allows
    States to submit a single Unified Plan to satisfy the planning
    requirements of multiple employment and training programs. ETA
    currently is redesigning and streamlining the Unified State Plan
    requirements in order to improve strategy-focused planning and promote
    improved alignment and integration of workforce and other relevant
    programs. ETA is working with States to gather ideas and feedback on
    how the current State planning process could be improved without any
    changes in law. We hope that encouraging more strategic and joint
    planning among States will prepare the states for any reauthorized WIA
    that enhances planning provisions. ETA will encourage more States to
    engage in unified planning leading to improved outcomes across programs
    (as captured by the common measures) and resource utilization. Common
    measures and unified planning are complementary tools that can support
    State and Federal efforts to better align planning with performance
    measurement and make each process more effective and efficient.
        ETA anticipates sending revised planning guidance to States in
    December 2011 that will facilitate the inclusion of multiple partners
    in the planning process and in the State plan submitted to the
    Department.
        The goals of the effort to redesign State plans are to:
      --Focus State planning on strategy instead of operations and
            compliance;
      --Better align and integrate workforce programs and strategies with
            each other and other relevant programs (e.g., training
            providers, education, and economic development);
      --Streamline various paperwork processes;
      --Encourage strategic thinking and creating workforce strategies that
            focus on skills training and credential attainment; and
      --Use current labor market information and economic indicators to
            place newly trained individuals into career pathway employment
            opportunities and track retention through wage record
            information.
                                     ______

                Questions Submitted by Senator Mary L. Landrieu
        Question. Your testimony this morning reflects the administration's
    commitment to keep annual domestic spending low by building on the
    recently enacted continuing resolution that defined spending levels for
    the remainder of fiscal year 2011 and to make the tough cuts necessary
    to achieve these savings. Can you identify the additional cuts that
    would be needed to make the fiscal year 2012 DOL budget request before
    us consistent with the deficit reduction framework President Obama
    announced last month?
        Answer. The President's fiscal year 2012 budget was transmitted
    before enactment of the final fiscal year 2011 appropriations bill. I
    am aware that there are ongoing bicameral, bipartisan discussions
    between the administration and congressional leadership on the Nation's
    long-term fiscal picture. These conversations, along with the enacted
    fiscal year 2011 appropriations, could impact eventual funding levels.
    The implications of both on the fiscal year 2012 request will be
    evaluated. Nonetheless, the fiscal year 2012 budget request reflects
    the administration's policy priorities and remains a good starting
    point for developing funding levels. We look forward to working closely
    with you as the process moves forward.
        But while the administration is committed to making the tough cuts
    necessary to achieve these savings--including to programs we care
    about--we will not sacrifice the core investments we need to grow and
    create jobs and protect our workforce. We still believe that the fiscal
    year 2012 budget request is a disciplined approach, representing
    responsible spending that supports the most critical investments
    necessary to keep our workforce system moving forward to assist our
    country's businesses and workers. The budget includes key investments
    that are an essential part of the President's commitment to out-
    innovate, out-educate and out-build our global competitors, and to
    assure that our workplaces are safe and fair. In short, getting America
    back to work is a top administration priority. As you formulate your
    appropriations bill, I hope we can work together to ensure adequate
    funding for the programs that help us reach that goal.
                      voluntary protection programs (vpp)
        Question. Currently, there are approximately 96 Voluntary
    Protection Programs (VPP) sites in the State of Louisiana that are
    actively pursuing VPP status in the State of Louisiana. Collectively,
    these sites employ approximately 28,871 workers. The fiscal year 2012
    budget request includes $4 million for Department of Labor's
    Occupational Safety and Health Administration (OSHA) to administer the
    VPP for 2012. How will President Obama's proposed deficit reduction
    framework impact the resources terms of their ability to administer the
    VPP?
        Answer. The fiscal year 2012 request level includes sufficient
    resources to maintain the VPP program, which is included in the Federal
    Compliance Assistance budget activity.
        Question. According to Government Accountability Office report on
    the VPP published in May 2009, approximately 80 percent of VPP
    worksites have fewer than 500 employees. Has OSHA studied and concluded
    separately on the impact on small businesses?
        Answer. The 80 percent figure does not accurately capture the true
    number of actual small businesses because GAO was looking at the size
    of the worksite and not the size of the company owning the worksite.
    For example, many participating U.S. Postal Service worksites have been
    classified as small businesses because they employ 250 or fewer
    employees.
        OSHA has not concluded a separate analysis of the impact of VPP on
    small business because only 99 out of the 1,644 Federal VPP sites (6
    percent) of the total number of VPP sites meet the small business
    definition (250 or fewer employees and are not part of a corporation/
    organization with 500 or more employees.)
        Question. What are OSHA's plans to review the impact on small
    businesses that participate in the VPP?
        Answer. While at this time, there are no plans to review the impact
    on small businesses that participate in the VPP, OSHA has formed a VPP
    Workgroup to conduct a comprehensive evaluation of OSHA's VPP in
    response to the May 2009 GAO report. Comprised of Regional and National
    Office VPP personnel, the Workgroup will review such subject areas as
    consistency in VPP administration, response to fatalities and
    documentation following fatalities, effective use of limited resources,
    recertification of current VPP sites, and training, communication, and
    cost of administering the VPP. The review process will involve
    interviews of OSHA VPP staff (Region and National Office), VPP
    stakeholders (e.g., VPPPA, labor unions, VPP corporate participants,
    and congressional staff), and review of policy and procedure manuals. A
    first draft of the Workgroup's evaluation/report is to be completed by
    the end of September 2011. Small business participation in VPP will be
    addressed as part of this comprehensive VPP evaluation.
        Small businesses with exemplary safety and health management
    systems are more likely to be recognized under OSHA's Safety and Health
    Recognition Program (SHARP). These small employers have had a full On-
    site Consultation visit and meet other requirements. Upon receiving
    SHARP recognition, OSHA exempts worksites from OSHA programmed
    inspections during the period that the SHARP certification is valid.
        Question. What is the current status of implementing the
    recommendations from the GAO report for assessing the performance of
    the VPP?
        Answer. OSHA is continuing to evaluate and develop ways to improve
    internal controls and measurement of program performance and
    effectiveness as part of the ongoing VPP continuous improvement
    process. The Assistant Secretary's series of VPP policy memoranda (five
    to date, the earliest signed August 3, 2009, and the most recent, April
    22, 2011) include instructions to strengthen nationwide consistency in
    OSHA's administration of VPP; improve the quality and documentation of
    OSHA actions following a fatality at a VPP site; strengthen internal
    controls, audit procedures, tracking, and proper documentation of OSHA
    actions; and improve annual data submissions required of all VPP
    participants and OSHA's review of the submissions and follow-up
    actions. And as mentioned above, in order to ensure successful
    implementation of these improvements, OSHA has formed a VPP Workgroup
    to conduct a comprehensive evaluation of OSHA's VPP.
        Question. Some of my constituents have contacted me regarding the
    Department of Labor's (DOL) proposed rule for expanding the definition
    of the term ``fiduciary'' to include Employee Stock Ownership Plan
    (ESOP) annual appraisers. See 75 Fed. Reg. 65263 (Oct. 22, 2011).
    According to testimony submitted by the American Society of Appraisers
    at a hearing on this proposed fiduciary rule held last month, the
    proposed rule would impose ``significant financial burdens'' on ESOP
    appraisers because it would require ESOP appraisers to purchase special
    high-cost fiduciary insurance in addition to the standard errors and
    omissions insurance required under current law. These increased
    insurance costs will result in increases to the cost of ESOP
    valuations--costs that would be then transferred to the ESOP and
    inevitably to the customer. Has the DOL made a determination as to
    whether it will exempt annual ESOP appraisals from the new fiduciary
    rules?
        Answer. Some stakeholders have asserted that the proposal would
    cause some appraisers to discontinue ESOP valuations and would
    significantly increase costs of appraisals for small businesses that
    sponsor ESOPs. The Department is carefully reviewing these and other
    comments with a view to avoiding unwarranted costs for ESOPs. In so
    doing, we must also keep in mind that ESOPs often use annual appraisals
    to calculate the dollar amount that participants who are leaving the
    employer will receive for their shares. Thus, such appraisals should be
    conducted in a prudent and impartial manner.
        Question. Some constituents have also raised questions as to how
    the above-referenced proposed fiduciary duty rule will impact broker-
    dealers servicing individual retirement accounts. Constituents have
    expressed concern about the proposed rule having the effect of
    restricting affordable access to services for initiating and managing
    IRAs. Recent studies have illustrated that IRAs are the fastest growing
    accounts holding retirement savings. Specifically, IRAs are widely held
    by small investors. Small investors prefer brokerage relationships over
    advisory relationships. Ninety-eight percent of investor accounts with
    less than $25,000 are in brokerage relationships. The proposed rule
    would practically make every investment-related conversation with a
    client subject to fiduciary duty. Consequently, under this proposed
    rule firms and their associated representatives may not receive
    different levels of compensation based on the investment choices made
    by retail investors in protected IRA accounts. The current fee
    structure accommodates the needs of small investors by allowing firms
    to provide them with affordable investment services commensurate with
    their risk profile. Under the proposed rule, brokerage firms would be
    forced to offer investment services and guidance to IRA investors
    through fee based advisory accounts--which frequently require much
    higher fees. These higher fees make it uneconomical and unaffordable
    for the majority of IRA investors. What is DOL going to do to ensure
    small IRA accounts can continue to be served by broker-dealers in the
    same way they are being served now?
        Answer. Today, the advice provided to workers, employers, and
    retirees about their retirement plans is too often tainted by conflicts
    of interest and therefore potentially harmful. There is strong evidence
    that unmitigated conflicts of interest cause substantial harm, and
    therefore the Department is confident that amending the fiduciary
    regulation to combat such conflicts will deliver significant benefits
    to plan participants and IRA holders. This evidence is found in
    academic research, IRA underperformance, SEC examinations, and EBSA's
    own enforcement experience. Taken together, the available evidence more
    than establishes that such negative impacts are present and often times
    large. When the fiduciary proposal is finalized, plans, plan
    participants and IRA holders will be able to more readily access and
    benefit from impartial advice that puts their interests first.
        The Department has received comments that the proposed fiduciary
    regulation would force brokers to convert their existing commission-
    based accounts into fee based advisory accounts, which would result in
    higher fees and widespread distributions from smaller account, as these
    advisory accounts would require higher minimum balances. The Department
    is carefully considering these comments. To be clear however, the
    proposal does not, by its terms, require brokers to restructure their
    compensation as wrap fees or to convert brokerage accounts to advisory
    accounts. Moreover, under already existing administrative exemptions
    broker-dealers that are fiduciaries can receive commissions for trading
    securities, insurance products, and mutual funds--which are the types
    of investments that make up the large majority of IRA assets today.
    These and other existing exemptions already create substantial space
    for brokers to provide fiduciary advice as fiduciaries under ERISA and
    the tax code while continuing to operate as brokers under the 1934
    Securities Exchange Act. In addition, we have ample authority to grant
    additional exemptions if there are legitimate concerns that beneficial
    practices would be needlessly prohibited. We will attempt to provide
    this clarification in a more formal manner as we proceed in this
    process.
        Further, the tax code itself treats IRAs differently from other
    retail accounts, bestowing favorable tax treatment, and prohibiting
    self-dealing by persons providing investment advice for a fee. In these
    respects, and in terms of societal purpose, IRAs are more like plans
    than like other retail accounts. Most IRA assets today are attributable
    to rollovers from plans.\3\ The statutory definition of fiduciary
    investment advice is the same for IRAs and plans. It therefore makes
    sense to establish a single consistent definition for both by
    regulation, and then deal with the practical differences between the
    two by tailoring exemptions accordingly. In addition, while IRA holders
    have more choice, they may nonetheless require more protection. Unlike
    plan participants, IRA holders do not have the benefit of a plan
    fiduciary to represent their interests in selecting or compensating
    investment advisers. Compared to those with plan accounts, IRA holders
    have larger account balances and are more likely to be elderly. For all
    of these reasons, combating conflicts among advisers to IRAs is at
    least as important as combating those among advisers to plans.
    ---------------------------------------------------------------------------
        \3\ Peter Brady, Sarah Holden, and Erin Shon, The U.S. Retirement
    Market, 2009, Investment Company Institute, Research Fundamentals, Vol.
    19, No. 3, May 2010, at http://www.ici.org/pdf/fm-v19n3.pdf.
    ---------------------------------------------------------------------------
                                     ______

                    Questions Submitted by Senator Jack Reed
                                   workshare
        Question. As you know, I introduced legislation last year to expand
    work sharing, which just over 20 States have adopted or implemented. I
    was pleased to see the administration include a work sharing proposal
    in its budget this year that builds off of my legislation. What can we
    do to encourage the remaining States to adopt work sharing and for more
    businesses to participate in work sharing as a means to avoid layoffs
    and help workers stay attached to the workforce?
        Answer. The Department currently is limited in what it can do to
    actively encourage the adoption of worksharing or short-time
    compensation (STC) programs. Current legislative authority for STC does
    not authorize certain State practices, such as making the payment of
    STC contingent on the employer entering into a plan with its employees
    and making such plan subject to approval by the State UC agency.
    Amending Federal law would address these issues and allow the
    Department to more actively promote STC. The Department's Unemployment
    Compensation Integrity Act of 2011 that was recently sent to the
    Congress includes language that would provide the necessary legislative
    authority for the Department to more actively promote STC. The
    Department welcomes the opportunity to work with the Congress to
    develop additional strategies to encourage more states to adopt STC and
    more businesses to participate.
                    workforce investment act reauthorization
        Question. Public libraries are key access points in the workforce
    investment system. How can we strengthen these linkages in the
    Workforce Investment Act? Do you see the Innovation Fund that was
    included in the fiscal year 2011 CR as an avenue for supporting
    library-workforce partnerships?
        Answer. We agree that public libraries are an important access
    point for all jobseekers to access workforce services. Under current
    law, libraries may serve as affiliate One-Stop Career Centers and this
    feature should be preserved in a reauthorized Workforce Investment Act.
    The Department has an agreement with the Institute of Museum and
    Library Services (IMLS) to support strong linkages between public
    libraries and the workforce investment system. Under this agreement,
    the Department has provided technical assistance and guidance
    specifically targeted to library workers on how to use the workforce
    electronic tools such as career exploration, resume writer, job banks,
    etc. The Workforce Innovation Fund will test and support innovative
    practices and strategies in the workforce system and will contribute to
    the ongoing work of the Department to disseminate and replicate
    innovative, successful, and proven practices, which may include those
    supported by partnerships between the workforce system and other
    partners such as libraries. The Department has launched a broad
    consultation process regarding the WIF with the public workforce system
    and its stakeholders and partners, such as libraries, and this input
    will help shape the grant solicitation.
                                     ______

                  Questions Submitted by Senator Sherrod Brown
                    unemployment rate for african americans
        Question. In 2010, the overall unemployment rate in the United
    States was 9.6 percent. However, the unemployment rate for African-
    Americans was 16 percent, which is nearly twice as much as the 8.7
    percent unemployment rate for white Americans. We also know African-
    Americans are among highest of the long-term unemployed.
        The numbers we use only include people who the Bureau of Labor
    Statistics considers officially unemployed; still more Americans want
    jobs and can't find one, yet they aren't considered unemployed. Many of
    these Americans, like discouraged workers, have likely been unemployed
    for a very long period of time as well.
        Please explain what DOL is doing to address the especially high
    long-term unemployment rates among African-Americans?
        Are there any programs geared specifically toward lowering the high
    unemployment rates among African-Americans?
        Answer. DOL recently released a comprehensive report looking at the
    labor market situation for African-Americans since the 2007-2009
    recession. Although most of the Department's programs are not
    specifically targeted to any one demographic, our programs are serving
    African-Americans who are unemployed and underemployed in significant
    numbers. The following provides an overview of how these programs have
    benefitted millions of African-Americans during these challenging
    economic times:
      --Ensuring that training and employment services are serving African
            Americans and are providing a host of support services to hard-
            to-place workers.
        --Between October 2009 and September 2010, more than 4.3 million
                participants served by the Department's Wagner-Peyser
                program, employment services administered by the
                Department, were African-American. This figure represents
                over 19 percent of total participants served by this
                program.
      --The Workforce Investment Act (WIA) served 570,000 self-indentified
            African-American Adult and Dislocated Worker participants who
            received staff-assisted services from July 2009 to June 2010.
            For PY 2009 (July 2009-June 2010), after receiving counseling
            or counseling and training services, over 330,000 Adult and
            Dislocated African-American workers exited their respective
            programs. In addition, of those being served by WIA, over
            140,000 African-Americans found jobs during the corresponding
            timeframe.
        --As of September 30, 2010, 28,392 African-Americans have been
                served by the Department's Community Based Job Training
                grants and 13,060 African-Americans have been served
                through the Department's High Growth and Emerging Industry
                grants.
        --Between October 2009 and September 2010, 11,835 African-American
                workers impacted by trade were served by the Department's
                Trade Adjustment Assistance program.
        --In January 2011, the Department of Labor announced the
                availability of approximately $500 million for the first
                round of Trade Adjustment Assistance Community College and
                Career Training Grants. The program will enable eligible
                institutions of higher education, including but not limited
                to community colleges, to expand their capacity to provide
                quality education and training services suitable for Trade
                Adjustment Assistance program participants and other
                individuals. The overarching goals of these grants are to
                increase attainment of degrees, certificates, and other
                industry-recognized credentials and better prepare workers,
                for high-wage, high-skill employment.
      --The National Farm-Worker Jobs Program provides funding to
            community-based organizations and public agencies to assist
            migrant and seasonal farm-workers and their families attain
            greater economic stability. Between October 2009 and September
            2010, nearly 1,000 individuals who exited the program after
            receiving core, intensive, and training services were African-
            American.
        --Since its inception in spring 2006, the Reintegration of Ex-
                Offenders programs have assisted over 26,000 participants.
                Of these, 15,530 (60 percent) are African-Americans.
        --The Federal-State Unemployment Insurance system (UI) served over
                2,377,000 African-Americans from October 2009 to September
                2010.
      --Providing training opportunities for African-American workers to be
            involved in the clean energy economy. In 2010, DOL funded the
            following Recovery Act grant competitions designed to advance
            training and employment in these industries.
      --``Pathways Out of Poverty'' grants provided $150 million to support
            programs that help disadvantaged populations find ways out of
            poverty and into economic self-sufficiency through employment
            in energy efficiency and renewable energy industries.
        --Among the awardees was the East Harlem Employment Services, which
                will work with foundations, unions, educational
                institutions, and minority contractors to provide education
                and training to 1,819 people and unsubsidized employment to
                881 people in Flint, Michigan and Baltimore, Maryland.
        --MDC, Inc. was awarded funds to train more than 700 persons,
                including 400 who will be placed into employment, in
                Orangeburg, Calhoun and Bamberg Counties in South Carolina.
                The Los Angeles Community College District will use funds
                to provide training to more than 925 persons, including 667
                who will receive on the job training.
      --``Energy Training Partnership'' grants provided $100 million for
            job training in energy efficiency and clean energy industries,
            of which approximately $50 million reached communities of
            color. The grants support job training programs to help
            dislocated workers and other target populations, including
            communities of color, find jobs in expanding green industries
            and related occupations.
        --Transitioning more African-American youth to employment through
                programs targeting individuals affected by high poverty and
                high unemployment.
    Job Cops and Youthbuild
      --Programs such as Job Cops and YouthBuild provide job training and
            educational opportunities for low-income or at-risk youth aged
            16 to 24. As of September 2010, there are 8,380 African-
            American youth enrolled in YouthBuild, representing nearly 60
            percent of the participants served in the program.
        --African-American youth represented approximately 50 percent of
                Job Corps students. In addition, VETS and ETA recently
                announced a pilot for 300 veterans to participate in Job
                Corps.
    ``Skills for America's Future'' Initiative
      --Increasing college attendance and graduation rates among African-
            American youth and encouraging more African-American students
            to pursue careers in science, engineering and technology. The
            President's ``Skills for America's Future'' initiative seeks to
            increase the number of college graduates in science,
            technology, engineering, and mathematics (STEM), as well as
            improve industry partnerships with community colleges and other
            training providers by matching classroom curricula with
            industry standards and employer needs.
      --Assisting workers interested in starting their own businesses.
            Entrepreneurship training is available to dislocated workers
            and other adults and youth through the public workforce system
            overseen by DOL. DOL is also currently conducting an
            experimental training program called Growing America Through
            Entrepreneurship (GATE). Project GATE connects individuals with
            entrepreneurship training and education to help them realize
            their dreams of business ownership. Project GATE, which is now
            in its second phase, has been shown to increase the number of
            hours of business training participants receive, the speed of
            business opening among participants, and the longevity of their
            businesses.
        --In eight States--Delaware, Maine, Maryland, New Jersey, New York,
                Oregon, Pennsylvania, and Washington--certain unemployed
                workers who participate in entrepreneurship training or
                business counseling but would otherwise be eligible for
                unemployment insurance can obtain weekly benefits through a
                program called Self Employment Assistance.
    Supporting Family-Friendly Workplace Policies
      --Examples of such policies include flexible work schedules and on-
            site child care, along with the Department's Wage and Hour
            Division's implementation of the break time for the nursing
            mothers' law, which became effective when the Patient
            Protection and Affordable Care Act was signed by the President
            in March 2010. This new law requires employers to provide
            reasonable break time and a place--other than a bathroom that
            is shielded from view and free from intrusion by coworkers or
            the public--to express breast milk while at work. The
            Department's role in this effort will undoubtedly help nursing
            moms achieve balance between their job and care for their
            children.
      --Additionally, the Department has taken steps to ensure more workers
            can take advantage of the Family and Medical Leave Act (FMLA)
            by issuing an Administrator Interpretation clarifying that the
            definition of son and daughter includes someone who stands or
            stood ``in loco parentis'' to the child. This interpretation
            ensures that an employee who assumes the role of caring for a
            child receives parental rights to family leave regardless of
            the legal or biological relationship.
      --Protecting workers through enhancing the Department's Wage and Hour
            Division and Office of Federal Contract Compliance Programs
            enforcement
        --The WHD is working to prevent employee misclassification.
                Misclassification often results in the failure of employers
                to pay employees the proper minimum wage or overtime pay.
                Employers may also evade payroll taxes and often do not pay
                for workers' compensation or other employment benefits. As
                a result of misclassification, employees are denied the
                protections and benefits of this Nation's most important
                employment laws--protections to which they are legally
                entitled. Misclassification tends to be a pervasive problem
                in industries that employ a large number of vulnerable
                workers, such as construction, janitorial, staffing firms,
                restaurants, and trucking. The President requested funding
                in fiscal year 2012 for DOL to lead a multi-agency
                initiative to strengthen and coordinate Federal and State
                efforts to enforce statutory protections, and identify and
                deter employee misclassification. This initiative will help
                provide employees with their rightful pay and benefits.
        --The Department recovered more than $176 million in African-
                American wages for nearly 210,000 workers in fiscal year
                2010. Through the direct leadership of Secretary Solis, the
                Wage and Hour Division hired more than 300 new
                investigators--a staff increase of more than one-third.
                These increased staffing levels will help improve complaint
                investigations and more targeted enforcement.
        --In 2010, the Office of Federal Contract Compliance Programs
                (OFCCP) completed 80 compliance evaluations where it
                identified discriminatory practices under Executive Order
                11246, which bars race, gender, religious, and national
                origin discrimination by Federal contractors impacting
                minorities, which included African-Americans. One case of
                compensation discrimination against an African-American
                male resulted in an award of $24,894 in back pay. Overall,
                OFCCP also entered into more than 96 Conciliation
                Agreements with discrimination findings on behalf of more
                than 12,000 affected workers, resulting in back pay awards
                of more than $9 million, and more than 1,400 potential job
                offers to provide relief for affected workers who have been
                discriminated against under the Executive Order. Of these,
                14 discrimination cases impacted 1,414 African-Americans.
                         workforce training strategies
        Question. As we've discussed on several occasions, I've been
    working on sector partnership workforce training strategies for 4
    years, along with Senator Olympia Snowe. This is the strategy of
    bringing multiple industry players together, along with labor,
    community colleges, and WIBs, to design a training curriculum and
    pipeline for future workers within that industry. It's a proven
    strategy many Governors have taken up, and we're seeing success in
    Ohio, especially in biosciences and healthcare.
        I've introduced legislation--the SECTORS Act--that would amend WIA
    to create dedicated capacity for sector partnerships, and many States
    have used their 15 percent set-aside for statewide activities under WIA
    to support these strategies.
        The fiscal year 2011 CR created a new Workforce Innovation Fund
    that will be used to support demonstration and replication projects
    that test innovative workforce service delivery strategies, and the
    fiscal year 2012 budget request proposed $380 million for the Fund.
        Given the reduction in State-level funding under the recent CR, and
    while Congress continues to consider WIA reauthorization, can you
    assure me that new and existing sector partnerships will be eligible to
    receive support from the new Workforce Innovation Fund?
        Answer. Eligible applicants for these competitive grants are
    States, State agencies eligible for assistance under Title I and III of
    the Workforce Investment Act, consortia of States, or partnerships,
    including regional partnerships (which ETA interprets to include
    partnerships of local Workforce Investment Boards). Applications
    submitted by an eligible entity should demonstrate appropriate and
    engaged partnerships that support the proposed innovation that leads to
    better employment outcomes for individuals, meets the skill needs of
    employers, accelerates learning and credential attainment, and
    increases efficiencies in the delivery of services. Depending on the
    relationship and types of activity, sector partners may be eligible to
    receive funding in support of the overall goals of the proposed
    innovation.
        ETA is engaged in a consultation process with key stakeholders
    including the Federal partners, Congress, intergovernmental
    organizations, and the public workforce system in support of the SGA
    development. Your comment and others received through both formal and
    informal discussions will be taken under advisement as the Department
    refines the WIF.
                          payroll fraud prevention act
        Question. I recently introduced, with Senators Harkin, Blumenthal,
    and Franken, the Payroll Fraud Prevention Act (S. 770) which would
    protect workers from being misclassified as independent contractors,
    thereby ensuring access to fair labor standards, health and safety
    protections, and workers compensation. The President's budget includes
    $46 million to combat worker misclassification.
        What is DOL's plan for cracking down on worker misclassification
    and payroll fraud? How does making misclassification a violation of the
    Fair Labor Standards Act (FLSA) helpful to your efforts?
        Answer. The administration recognizes that misclassification is a
    serious problem--it often deprives workers of rights and benefits to
    which they are entitled under the law; it results in a loss to Federal
    and State revenue, and underfunded unemployment insurance and workers
    compensation funds; and it creates an uneven playing field for those
    employers who obey the law. This is why the Department is participating
    in a multi-agency Misclassification Initiative, headed by the Vice
    President's Middle Class Task Force, that aims to coordinate the
    administration's efforts to enforce statutory protections, identify and
    deter employee misclassification, and mitigate future violations.
        Internally, the Department's Initiative is headed by the Wage and
    Hour Division (WHD), which is working with the Department's Solicitor's
    Office to increase information sharing and coordination between DOL
    agencies, with other Federal agencies, and with State agencies that
    also enforce laws where employee misclassification is a significant
    issue. When WHD finds cases where misclassification has occurred, it
    will be referring those cases to the appropriate Federal and State
    agencies, such as the IRS and State agencies that oversee Unemployment
    Insurance and Workers Compensation programs.
        WHD is also focusing its enforcement and compliance assistance
    resources on those industries with large numbers of vulnerable and low
    wage workers where misclassification is particularly prevalent. WHD is
    working on ensuring that employers, employees, and the public fully
    understand that misclassification, whether deliberate or as an
    unintended consequence of a business practice that seeks to reduce
    labor costs, frequently leads to violations of the laws we enforce, and
    effectively communicating to employers the risks of being found in
    violation. As part of this effort, WHD is actively seeking to work with
    local and national businesses and trade associations to make sure that
    our compliance assistance reaches their members.
        Currently, misclassification is not a violation of any Federal
    labor or employment law, but the practice often leads to violations of
    those laws. We believe that, by making misclassification a violation of
    the FLSA, requiring notice to workers informing them whether they are
    classified as employees or not, and providing civil money penalties for
    violating the act's recordkeeping provision, the Payroll Fraud
    Prevention Act would provide employers with important additional
    incentives to make the correct call when determining whether a worker
    is an employee and keep accurate records of how they treat those
    employees, which could reduce the number of violations that occur
    without WHD having to get involved.
        Question. The administration is soon likely to submit to Congress
    the pending trade agreements with South Korea, Colombia, and Panama.
    The administration recently announced a ``labor action plan'' with
    Colombia.
        The Colombian government, however, continues to fail at effectively
    prosecuting those responsible for anti-union violence. The United
    Steelworkers claim the Colombian government has prosecuted only 4 to
    5.6 percent of the nearly 2,800 killings of trade unionists since 1986.
    And, it has not initiated investigations into more than two-thirds of
    these killings. What is your view of the labor action plan with
    Colombia? Has Colombia so far met obligations set forth in the labor
    action plan, including its April 22 commitments? How is the Bureau of
    International Labor Affairs at DOL involved in the implementation of
    the action plan?
        Answer. The Colombian Action Plan Related to Labor Rights (Action
    Plan) and our partnership with the new administration of President
    Santos provide a concrete way forward to address the problems of
    violence and impunity as a matter of urgency and to improve protections
    for internationally recognized labor rights in Colombia.
        Yes, Colombia has met the April 22 commitments and is on track to
    meet the additional commitments in the Action Plan. We are continuing
    to work with the Government of Colombia to ensure that Colombia
    continues to make the needed progress.
        For example, the Action Plan includes strong and specific steps to
    increase investigation and prosecution of the perpetrators of earlier
    violence against union activists because the Santos administration
    recognizes that ending impunity is a major factor in deterring future
    crimes. In accordance with the Action Plan, President Santos has issued
    a directive to the National Police, which has already assigned 100
    additional full-time judicial police investigators to support the
    investigation of violence against trade unionists. The Prosecutor
    General's office has issued directives, consistent with the Action
    Plan, to improve the investigation and prosecution of labor cases. It
    is also undertaking an analysis of past homicide cases of union members
    and activists, in order to extract lessons that can help improve the
    investigation and prosecution of future cases. Moreover, the Prosecutor
    General's office has analyzed its needs for additional investigators
    and prosecutors and submitted its plan and 2012 budget request to the
    Santos administration, which has committed to provide funding for the
    expanded staffing, including to strengthen capacity in regional
    offices. In addition, the Prosecutor General's office is working with
    the Colombian labor unions and the National Labor School (ENS) to
    reconcile the Government's and ENS' lists of union homicides since 1986
    with that of the unions.
        DOL's Bureau of International Labor Affairs (ILAB) has been closely
    involved in both the negotiation and implementation of the Action Plan.
    An interagency team comprised of DOL, the Office of the United States
    Trade Representative, and the Departments of State and Justice are
    working closely with the Colombian government to ensure that each
    commitment under the Action Plan is fulfilled.
                       national longitudinal youth survey
        Question. For the past 32 years, the Center for Human Resource
    Research at the Ohio State University has been tasked with conducting
    the National Longitudinal Youth Survey. This survey measures an array
    of important issues ranging from how families handle their financial
    affairs, the impact of training and education programs for reentry into
    the workforce, and what Federal programs are most effective over
    multiple decades.
        As the Nation continues to recover from the 2008 economic downturn,
    this survey can help us better understand how long unemployment, high
    rates of youth unemployment term and foreclosure can impact youth in
    future decades.
        How does the Department of Labor plan to utilize the National
    Longitudinal Youth Survey to best gauge the impact of the current
    recession?
        Answer. The NLS records the labor force experiences of two cohorts
    of American men and women. The older cohort is the 1979 National
    Longitudinal Survey of Youth (NLSY79) that provides information on the
    ``baby boomer'' generation. The younger 1997 cohort is composed of
    individuals currently in their late 20s and early 30s. The NLS captures
    long-run changes in individual labor force behavior by interviewing the
    same individuals over extended time periods. As a result, it is
    uniquely designed to enable researchers and policymakers to examine how
    changing economic conditions, such as a recession, affect labor force
    experiences.
        Policymakers can utilize information from past recessions to
    understand the effect of the recent recession. For example, a study
    using the NLSY79 measured the wage effects for people who graduated
    from college in a recession (Kahn, 2010). Another study used the NLSY79
    from the years 1978 to 2006 to examine how State and national
    unemployment rates affected the likelihood of divorce (Arkes and Shen,
    2010).
        Another use of these data can be to study the recent recession and
    recovery. As the recession began, the nearly 10,000 members of the
    NLSY79 were aged 43 to 51 and had been followed for almost 30 years.
    Analysts will be able to examine how the recession affected this
    generation's retirement plans, health, ability to pay for their
    children's college education, and many other aspects of their lives.
    The 9,000 members of the NLSY97 were 23 to 28 when the recent recession
    started and had been reporting about their lives for over 10 years.
    This survey includes many veterans of the wars in Iraq and Afghanistan,
    and the Department's Veterans' Employment and Training Service already
    has used the survey to examine the challenges these young veterans have
    faced as they transition back to civilian life. Analysts will continue
    to use the NLSY97 to examine how the recession affected the career
    trajectories, educational attainment, health, families, and other
    aspects of the lives of veterans and nonveterans, both in the short-
    term and across the rest of their working lives.
                     international labor comparisons (ilc)
        Question. I was pleased that Congress saw fit in the fiscal year
    2011 continuing resolution to maintain the International Labor
    Comparisons (ILC) office of the Bureau of Labor Statistics. I'm
    concerned, however, by the administration's proposal to eliminate this
    important office in its fiscal year 2012 budget.
        As you know, the ILC program provides the only systematic data
    comparing labor costs in the United States with major trading partners,
    including China. As the volume of trade expands, particularly with
    developing countries, having reliable information on the
    competitiveness of our workers with those overseas is more important
    than ever before. While other agencies produce international data, none
    has the mission and expertise like the ILC to compare data across key
    countries on labor costs, GDP, unemployment, wages, and inflation.
    Therefore, it is disturbing that the administration would seek to
    eliminate this source of information.
        If, as the President and you have stated, we are going to out-
    educate, out-innovate, out-compete in the global economy, it is
    imperative we do not sacrifice this source for effective policy making
    and analysis. I request that you share with me your views on
    maintaining the ILC in the fiscal year 2012 budget, and beyond.
        Answer. The 2012 President's budget carries forward the proposal
    from the 2011 budget to eliminate the International Labor Comparisons
    (ILC) program. The BLS proposes to eliminate this program to fund
    other, more critical needs. In developing the 2012 budget, the
    administration committed to make tough choices that prioritize our
    Nation's most pressing needs during its economic recovery. As a result,
    programs that were funded in the 2011 budget were identified for
    reduction in the 2012 President's budget. The proposal to redirect ILC
    funding does not reflect on the quality and usefulness of the ILC data,
    but rather the administration's commitment to maintaining the quality
    and quantity of some of our Nation's most important economic
    indicators.
                                     ______

                Questions Submitted by Senator Richard C. Shelby
                              dol fiduciary rules
        Question. The Department of Labor's recent proposal to amend its
    fiduciary duty rule has raised many questions about potential
    unintended consequences of the rule. For example, a recent study by
    Oliver Wyman found that ``the proposed rule will disproportionately
    negatively affect small balance IRA investors.'' What types of economic
    analyses does the Department intend to conduct to shed more light on
    how the proposal would affect small and large entities, including
    retirement plans, their sponsors and service providers, and individual
    retirement accountholders?
        Answer. The proposed regulation included a regulatory impact
    analysis (RIA) that assessed the potential costs and benefits
    associated with the proposal. The Department's RIA satisfied applicable
    requirements and provided an appropriate economic basis for the
    proposal. The Department acknowledged in the RIA that its assessment
    was subject to uncertainty and solicited public comment to help it
    address areas of uncertainty. As we move forward with finalizing the
    proposed rule and developing an expanded RIA, the Department will take
    into account input received from stakeholders and consultations with
    other Federal agencies. The economic impact of the final rule on both
    ERISA plans and IRAs will be carefully considered during this process.
        Some private studies--including several have been commissioned by
    organizations opposed to the proposal--purport to demonstrate that the
    Department's proposal will hurt the very investors and workers that the
    Department is seeking to help. However, these studies are predicated on
    several deeply flawed assumptions. For example, one widely cited study
    builds its entire cost analysis on the assumption that commission-based
    compensation for servicing IRA's would no longer be allowed even though
    there are exemptions already in place that allow broker-dealers acting
    as fiduciaries to receive commissions for the sale of securities,
    mutual funds and insurance products.
        The Department is always mindful of the impact its regulatory
    actions may have on the availability of investment products and
    services to employee benefit plans, IRAs, and to workers and retirees
    covered by those plans. For example, some commenter's have suggested
    that we consider the possible exercise of the Department's authority to
    issue additional administrative exemptions from certain prohibited
    transaction provisions of ERISA as a way of ensuring the continued
    availability of certain types of transactions that they say clearly
    benefit plan participants, beneficiaries, and IRA owners. Other
    commenter's urged that the effective date of the final regulation allow
    service providers transition time to adjust their business practices
    and systems for compliance. We will also be considering these comments
    and suggestions.
                                      cftc
        Question. The CFTC has proposed rules under the Dodd-Frank Act
    that, when read together with the Department's proposed rule on
    fiduciary duty, may make it impossible for pension plans to find
    counterparties willing to engage in swap transactions with them. Does
    the Department of Labor plan to weigh in on the CFTC rulemaking or take
    steps in its own rules to ensure that pension plans are able to
    continue to use swaps in managing plan risks?
        Answer. The Department has recently weighed in with the CFTC on the
    interaction between the fiduciary proposal and the CFTC rules proposed
    under Dodd-Frank by sending a letter from EBSA Assistant Secretary
    Phyllis Borzi to CFTC Chair Gary Gensler. As this letter says, it is
    the Department's view that ``a swap dealer or major swap participant
    acting as a plan's counterparty in an arm's length bilateral
    transaction with a plan represented by a knowledgeable independent
    fiduciary would not fail to meet the terms of the proposed regulation's
    counterparty exceptions solely because it complied with the business
    conduct standards set forth in the CFTC's proposed regulation.'' The
    Department does not seek to impose ERISA fiduciary obligations on
    persons who are merely counterparties to plans in arm's length
    commercial transactions. Parties to such transactions routinely make
    representations to their counterparties about the value and benefits of
    proposed deals, without purporting to be impartial investment advisers
    or giving their counterparties a reasonable expectation of a
    relationship of trust. Accordingly, the Department's proposed
    regulation provides that a counterparty will not be treated as a
    fiduciary if it can demonstrate that the recipient of advice knows or
    should know that the counterparty is providing recommendations in its
    capacity as a purchaser or seller.
        As we evaluate the comments we have received, we will continue to
    evaluate the particular terms used to define the scope of any exception
    to ensure that the regulation is as clear and effective as possible,
    and to avoid any unintended consequences.
        Finally, the Department and the CFTC are actively consulting with
    each other and coordinating our efforts relating to the DOL fiduciary
    regulation and the CFTC business conduct standard. Our shared joint
    goal is to harmonize these initiatives to ensure that the regulated
    community has clear and sensible pathways to compliance. We are
    confident that this goal will be achieved.
        Question. The Department of Labor is considering issuing a
    transparency rule under ERISA that would require service providers to
    disclose detailed financial information to health plans. If so,
    pharmacy benefit managers (PBMs) may be required to provide detailed
    disclosure of their proprietary cost structures (e.g., pharmacy
    discounts and drug manufacturer rebates) to thousands of PBM clients
    without sufficient confidentiality protections to safeguard against the
    anti-competitive effects repeatedly pointed out by the Federal Trade
    Commission in the context of state PBM transparency laws. As the
    Department is undertaking rule promulgation to require the disclosure
    of proprietary data of service providers of ERISA plans, what has the
    Department done to reconcile its proposal with the FTC's seemingly
    contrary position? Has the Department had high level, in-depth
    discussions with the FTC's Bureau of Competition?
        Answer. Yes, the Department has met with senior policymakers at the
    FTC and had very productive and informative discussions. We will
    continue to work closely with our colleagues at the FTC on this
    regulatory initiative.
        In March, the FTC's decided in a 5-0 vote to write Mississippi
    lawmakers about the anticompetitive effects of competitors learning
    each other's pricing information:

        ``These provisions could result in sharing competitively sensitive
    cost information among competing pharmacies and pharmaceutical
    manufacturers. In particular, such information sharing could undermine
    competition between pharmacies to be included in PBM networks and
    between pharmaceutical manufacturers to offer discounts to PBMs. Both
    outcomes could raise prescription drug prices for consumers. We note,
    however, that if there are appropriate confidentiality safeguards in
    place, health plan sponsors (and their consultants) may find specific
    cost information helpful as they seek to select among PBMs, understand
    their enrollees' prescription drug use, and ensure that they are
    receiving appropriate rebates from PBMs.''

        Question. How has the Labor Department calculated the additional
    costs of service provider disclosure in the absence of confidentiality?
        Answer. The Department is aware of the FTC's March 2011 letter. We
    are still gathering information in advance of considering policy
    options for this rulemaking at this time and have not yet calculated
    the potential costs and benefits of service provider disclosure in the
    absence of confidentiality. The Department will take into account the
    FTC's concerns regarding competition, collusion, and appropriate
    confidentiality safeguards in developing the regulatory impact analysis
    for any rule that is promulgated in this area.
        The FTC's March, 2011, letter also noted how certain disclosure
    could increase collusion.

        ``In some circumstances, sharing information among competitors may
    increase the likelihood of collusion or coordination on matters such as
    price or output. The antitrust agencies have explained how coordinated
    interaction harms consumers: coordinated interaction `can blunt a
    firm's incentive to offer customers better deals by undercutting the
    extent to which such a move would win business away from rivals' and
    `also can enhance a firm's incentive to raise prices by assuaging the
    fear that such a move would lose customers to rivals.' ''

        Question. What action is the Labor Department pursuing to mitigate
    collusion or price coordination among corporations?
        Answer. The Department's objective in this area is to ensure that
    ERISA plan fiduciaries have sufficient information to fulfill their
    fiduciary responsibility of determining whether their contracts or
    arrangements with service providers, such as PBMs, are reasonable. We
    will consult closely with the FTC as we develop a regulatory framework
    that addresses concerns regarding collusion or price coordination.
         trade adjustment assistance community college training grants
        Question. Could you explain why the Trade Adjustment Assistance
    Community College Training Grants program (TAACCCT) calls for the
    development of Open Education Resources to meet the immediate training
    needs of students?
        The National Center for Academic Transformation indicates that
    ``high-quality course materials [are already available] at a reasonable
    cost,'' ``reasonably priced software . . . is a non-problem,'' and that
    available software enables ``faculty to focus on pedagogy rather than
    materials creation.'' Therefore, why do you believe the Federal
    Government should spend develop materials that appear to already exist
    in the marketplace?
        Answer. The Department expects the Federal funding from the Trade
    Adjustment Assistance Community College and Career Training (TAACCCT)
    grant program to provide quality education and training services to
    Trade Adjustment Assistance (TAA) for Workers program participants as
    well as other individuals to improve their knowledge and skills,
    enabling them to obtain good, sustaining jobs. The program allows for
    development of materials, and it also can improve on existing courses
    that can be completed in 2 years or less. Ultimately, the goal of
    adoption and adaptation of courses is to increase industry-recognized
    credential or degree completion rates of participants through four key
    priorities and strategies including: (1) accelerating progress for low-
    skilled and other workers, (2) improving retention and achievement
    rates to reduce time to completion, (3) building programs that meet
    industry needs including the development of career pathways, and, (4)
    strengthening online and technology-enabled learning.
        Across these strategies, DOL recognizes that grantees may use
    existing courses or programs when they are well suited to meet the
    project's objective. However, training and education needs vary by
    region and can change quickly. The marketplace does not support courses
    that meet every project need. In some cases courses may need to be
    tailored or augmented, and in other cases new materials altogether, not
    currently supported by the marketplace, may be developed.
        As one of four strategies, community colleges and other education
    organizations have an opportunity to harness technology in their
    classrooms and modernize their curriculum. These projects are
    encouraged to improve or develop online or technology-enabled learning
    programs and courses that can be taken to scale beyond a community
    level to reach a national audience of diverse students over a larger
    geographic area. The programs and courses developed with these funds,
    particularly those developed by consortia of eligible institutions,
    will be produced to maximize interoperability and exchange, and made
    freely available for reuse and improvement by others. Online and
    technology-enabled learning courses not only ensure widespread usage
    but encourage continuous improvement of courses and learning materials.
    Most importantly, online learning allows for rapid deployment and the
    ability to meet employers' skilled workforce needs as they arise.
                                 budget deficit
        Question. Unemployment in our Nation is 8.8 percent. Madam
    Secretary, what is your Department doing to ensure that we are
    providing our workers with the type of assistance necessary to help our
    small businesses and entrepreneurs create well paying jobs?
        Answer. While the Department's resources do not directly create
    jobs, they can help ensure workers acquire the skills that employers
    need to successfully compete in the global economy. The public
    workforce system focuses workforce development resources on the
    expressed needs of employers, both small and large, in the following
    ways:
        Local and State workforce boards oversee WIA programs; they are
    required to be business-led and have majority business membership to
    connect the One-Stop service delivery system directly to the local
    employers to ensure workers and training providers are knowledgeable
    about what jobs/skills are needed in the regional or local economy.
        The Department has strengthened connections between the public
    workforce system and local employers through initiatives such as:
        Awarding $75,000,000 in competitive On-the-Job Training (OJT) where
    small businesses can be reimbursed up to 90 percent of the trainees'
    wages for up to 6 months to cover the extraordinary costs of training;
        Requiring many of ETA's competitive grants to focus on employers'
    skill needs or require a partnership with employers, for example, H-1B
    technical skills training grants that may be competitively awarded to
    partnerships of private and public sector entities that may include
    business-related nonprofit organizations, such as trade associations;
        Providing technical assistance such as training Business Service
    Representatives from the One-Stop Career Centers and Workforce
    Investment Boards to better address business needs and issuing guidance
    about Entrepreneurship (TEGL No.12-10).
        The Department worked closely with businesses and trade
    associations to develop 19 competency models in such industry sectors
    as energy, advanced manufacturing, allied health and long-term care and
    supports, and entrepreneurship. These competency models document the
    foundational and technical skills and competencies required for
    workplace success in economically important industries and are
    available at www.careeronestop.org/competencymodel. Industry competency
    models provide a resource for the development of curricula,
    certifications, and the tests that assess work-related competencies.
    Most importantly, competency models support worker progression along
    career pathways.
                            workforce investment act
        Question. Under the Workforce Investment Act (WIA--pronounced WEE-
    a), all WIA funded initiatives were to be evaluated in 2005. It is now
    2011 and we do not have any significant, concrete updates on WIA
    programs. Given the fiscal restraints in the fiscal year 2012 budget,
    unless we know that workforce programs are working, I do not think we
    should continue to fund them. It is my understanding the Department has
    started a comprehensive evaluation of WIA funded programs and interim
    results will be available in 2013. Secretary Solis, in the meantime,
    can you address ways this subcommittee can effectively evaluate these
    programs?
        Answer. The value of training is illustrated by the entered
    employment rate, or how many individuals found jobs. For the 12-month
    period ending June 30, 2010, individuals receiving WIA Dislocated
    Worker program training found employment 1.6 times faster than those
    who did not receive training. Adults at program exit who participated
    in On-the-Job Training (OJT) found employment at a rate of 86 percent,
    while dislocated workers receiving OJT found jobs at 90.3 percent
    rate.\4\ In the 6-month period after finding jobs, individuals who
    completed the WIA Adult program and Dislocated Worker program, and who
    were unemployed at program entry, helped stimulate the economy by
    earning just under $7.2 billion.\5\
    ---------------------------------------------------------------------------
        \4\ Workforce Investment Act Standardized Record Data (WIASRD)
    records from Program Year 2009 (July 1, 2009-June 30, 2010).
        \5\ Workforce Investment Act Standardized Record Data (WIASRD)
    records from April 1, 2008 to March 31, 2009.
    ---------------------------------------------------------------------------
        However, such outcome data do not take into account what
    participants could accomplish without WIA. To do so, in 2008 the
    Department released the WIA Non-Experimental Study.\6\ This study found
    that, although differences across States are substantial, participation
    in the WIA Adult program is associated with an increase in quarterly
    earnings of several hundred dollars. The analysis of participants who
    receive only core and intensive services suggests that their benefits
    may be as great as $100 or $200 per quarter over the period of study,
    which is substantial compared to the small costs of those services. The
    marginal benefits of training may exceed $400 in earnings each quarter.
    ---------------------------------------------------------------------------
        \6\ http://wdr.doleta.gov/research/FullText_Documents/
    Workforce%20Investment%20Act%
    20Non%2DExperimental%20Net%20Impact%20Evaluation%20%2D%
    20Final%20Report%2Epdf.
    ---------------------------------------------------------------------------
        The study also found that following entry into WIA, Dislocated
    Workers experience several quarters for which earnings are depressed
    relative to comparison group workers. However, their earnings do
    ultimately overtake the comparison group. The return they experience
    from training appears to be smaller than that obtained by Adult program
    participants. The study further found that women appear to obtain
    greater benefits than men for participation in both the Adult and
    Dislocated Worker programs.
        The estimated effects for various subgroups examined--nonwhite non-
    Hispanics, Hispanics, those under 26 years of age, those 50 years of
    age or above, and veterans--are similar to the estimated effects for
    all WIA participants. In other words, there is essentially no evidence
    that any of the subgroups considered have experiences that differ from
    the average in important ways.
        Because of serious concerns about the limitations of the
    methodology and data used in the non-experimental study, in 2008 the
    Department commissioned the WIA Gold Standard Evaluation (WGSE). This
    study will address the limitations of the 2008 study as shown in the
    table below and includes a cost-benefit component. The study's results
    will be available in 2016, although this schedule is dependent upon
    continued appropriations for the evaluation of WIA programs.

    --------------------------------------------------------------------------------------------------------------------------------------------------------
                                     WIA Non-Experimental Impact Study (aka 2008 Impact Study)                   WIA gold standard evaluation
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    Evaluation Methodology........  Quasi-experimental methods (propensity score matching).....  Random assignment
    Sample........................  Consisted of 12 purposively selected States................  Will use a nationally representative sample of
                                                                                                  approximately 30 randomly-selected local workforce
                                                                                                  investment areas
    Comparison Groups.............  Drawn from Unemployment Insurance claimants and Wagner-      Will randomly assign from WIA applicants
                                     Peyser participants.
    Data Sources..................  Used administrative data (UI wage records) which limited     In addition to administrative data, will use survey data
                                     the outcomes looked at to quarterly earnings and             which will allow a full range of educational, employment,
                                     employment.                                                  earnings, and self-sufficiency outcomes to be examined
    Services Examined.............  Looked at three levels of services: Core, Intensive, and     Will look only at Intensive and Training compared to Core
                                     Training compared to persons not receiving WIA services.
    Study Dates...................  Looked at participants who entered WIA between July 2003     Will look at entrants between approximately September 2011
                                     and June 2005.                                               and December 2012
    --------------------------------------------------------------------------------------------------------------------------------------------------------

                             program effectiveness
        Question. In March, GAO stated that the Employment and Training
    Administration's research and evaluation programs have ``failed to
    conduct research that can answer urgent workforce policy questions and
    lead to an understanding of what works and what does not.'' What are
    the Department of Labor's plans to improve the efficiency and
    effectiveness of programs administered by the Department?
        Answer. The Department of Labor is taking action in virtually all
    aspects of its operations to ensure that our programs will operate at
    the optimal levels of effectiveness and efficiency. We strongly believe
    in the importance of Federal fiscal responsibility and that part of
    this responsibility is identifying which programs and strategies
    efficiently provide the greatest benefit to participants.
        The Department recently undertook a significant strategic planning
    process, publishing the U.S. Department of Labor Strategic Plan Fiscal
    Years 2011-2016 on September 30, 2010. The strategic planning process
    was highly inclusive, including formal opportunities for public
    comment. Further, each agency, including ETA, has formal Operating
    Plans that are used to guide and monitor its performance. Together,
    these plans harness and direct the Department's resources toward
    achieving five goals, which include: (1) preparing workers for good
    jobs and fair compensation, and (2) for those not working, provide
    income security. These planning processes are designed to maximize the
    use of evidence and results.
        The Department relies on performance data and evaluations. In
    addition to our efforts to reassess performance measures to promote
    better outcomes for individuals of all skill and need levels, we
    believe that workers and employers should have easy access to
    information about program outcomes for past participants, so they can
    make informed decisions about which programs are most likely to meet
    their needs.
        The Department has worked diligently over the past 2 years to
    increase the rigor of its evaluations. I established the Chief
    Evaluation Office (CEO) to coordinate the Department's research and
    evaluation agenda and increase its capacity to conduct high quality,
    rigorous evaluations. The CEO is working closely with all Departmental
    agencies, including ETA, to ensure that Departmental evaluations are
    appropriately rigorous and designed to yield clear and actionable
    information for policymaking purposes.
        Since 2009, about half the evaluations the ETA has funded have been
    rigorous, random assignment impact evaluations. These include: (1) the
    Workforce Investment Act (WIA) Gold Standard Evaluation of the Adult
    and Dislocated Worker Programs (WGSE); (2) the YouthBuild Impact
    Evaluation; (3) the Reintegration of Ex-Offenders Random Assignment
    Evaluation; (4) the Impact Evaluation of Green Jobs, Health Care and
    High Growth Training Grants; and (5) the Transitional Jobs
    Demonstration Impact Evaluation. Each of these evaluations examines net
    impacts on employment, retention and earnings, and include benefit-cost
    analyses. ETA was able to fund these evaluations through an increase in
    fiscal year 2010 appropriations for evaluations and the funds made
    available to DOL by the American Recovery and Reinvestment Act of 2009.
    Random assignment evaluations are highly resource intensive and
    typically take a range of 3 to 7 years to implement. In addition,
    random assignment evaluations of our programs may not always be
    possible when the law requires that people receive services. Therefore,
    it is necessary at times to conduct other types of evaluations to gain
    as much information as possible with available resources.
        Another key investment that the Department will maximize is the
    Workforce Innovation Fund (Fund). The Full-Year Continuing
    Appropriations Act of 2011 provides $124.7 (post rescission) for the
    Workforce Innovation Fund that will support competitively awarded
    grants to States; State agencies that are eligible for assistance under
    any program authorized under WIA; consortia of States; or partnerships,
    including regional partnerships. This Fund represents a small but
    crucial investment in innovative, evidence-based and cost-saving
    workforce strategies. This Fund will significantly benefit WIA formula-
    funded activities well into the future by obtaining results that can be
    replicated broadly throughout the workforce system. These results will
    inform administrative guidance issued by the Department and future
    workforce related legislative initiatives.
        In addition, the Department has developed effective partnerships
    with other Federal agencies that encourage State and local synergies to
    improve the delivery of quality, cost effective services across
    programs and evaluate their performance. Finally, we look forward to
    continuing to work with Congress in support of a WIA reauthorization
    bill that meets the administration goals of streamlined service
    delivery, better meeting the needs of employers and regional economies,
    improving accountability, and promoting innovation.

                              SUBCOMMITTEE RECESS

        Senator Harkin. The subcommittee will stand recessed.
        [Whereupon, at 11:03 a.m., Wednesday, May 4, the
    subcommittee was recessed, to reconvene subject to the call of
    the Chair.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2012

                                  ----------

                            WEDNESDAY, MAY 11, 2011

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 9:59 a.m., in room SD-124, Dirksen
    Senate Office Building, Hon. Tom Harkin (chairman) presiding.
        Present: Senators Harkin, Reed, Mikulski, Brown, Shelby,
    Kirk and Moran.

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                         National Institutes of Health

    STATEMENT OF DR. FRANCIS S. COLLINS, DIRECTOR
    ACCOMPANIED BY:
            HAROLD VARMUS, M.D., DIRECTOR, NATIONAL CANCER INSTITUTE
            ANTHONY S. FAUCI, M.D., DIRECTOR, NATIONAL INSTITUTE OF ALLERGY
                AND INFECTIOUS DISEASES
            SUSAN B. SHURIN, M.D., ACTING DIRECTOR, NATIONAL HEART, LUNG,
                AND BLOOD INSTITUTE
            DR. GRIFFIN RODGERS, DIRECTOR, NATIONAL INSTITUTE OF DIABETES,
                DIGESTIVE AND KIDNEY DISEASES

                    OPENING STATEMENT OF SENATOR TOM HARKIN

        Senator Harkin. The Senate Subcommittee on Labor, Health
    and Human Services, and Education will now come to order.
        First of all, Dr. Collins, welcome back to the
    subcommittee. We welcome also Dr. Harold Varmus, Director of
    the National Cancer Institute; Dr. Tony Fauci, Director of the
    National Institute of Allergy and Infectious Diseases; Dr.
    Griffin Rodgers, Director of the National Institute of
    Diabetes, Digestive and Kidney Diseases; and Dr. Susan Shurin,
    Director of the National Heart, Lung, and Blood Institute.
        This subcommittee holds an appropriations hearing on the
    NIH budget every year, and every year I am both inspired by the
    dedication of the scientists who testify before us and proud
    that their accomplishments have made America the world leader
    in biomedical research. But in recent years, our Nation's
    status in that regard has been threatened. While China and
    Singapore make massive investments in research, here in the
    United States we're pulling back.
        The fiscal year 2011 appropriations bill that Congress
    passed last month cut NIH funding by $322 million below the
    fiscal year 2010 level. When you consider how much funding was
    needed to keep up with inflation, the cut was more like $1.3
    billion, taking inflation into account.
        We should be thankful that the result wasn't significantly
    worse. H.R. 1, the spending bill passed by the House majority,
    would have cut NIH funding by $1.6 billion or $2.6 billion if
    you counted inflation. Fortunately, the Senate rejected that
    plan.
        But even the compromise bill that was ultimately signed in
    law will result in a success rate for NIH research grants, I'm
    told, of just 17 or 18 percent, meaning just one out of every
    six peer-reviewed application will be approved. And, again, I
    am informed that that is the lowest success rate on record for
    NIH.
        What a dismal downturn from what Senator Specter and I, and
    others did back in the late 1900s and early 2000 when we
    doubled the funding of NIH and we got the success rate up, I
    think--if I'm not mistaken. You correct me, Dr. Collins--up in
    the 20-30 percent range, somewhere in there. And we thought we
    were on a path to continue that kind of a success rate. Now,
    it's down lowest on record.
        And there is cause to fear even bigger cuts next year. The
    budget plan approved by the House last month would cut health
    funding by 9 percent in fiscal year 2012. If that plan were
    approved, severe reductions to NIH research would be
    unavoidable.
        That doesn't make sense. Let's set aside for a moment any
    thoughts about the moral value of trying to improve people's
    health, and just look at the issue from a purely economic
    standpoint. NIH research is one of the best investments this
    country can make.
        A study released yesterday by United for Medical Research
    concluded that in fiscal year 2010, NIH funding supported
    almost 500,000 jobs across country. And I always have to remind
    people that only a small percentage of that goes to NIH in
    Bethesda, Maryland. I want Senator Mikulski to know that. Most
    is awarded to researchers at academic institutions all over the
    United States.
        Another study by Battelle examined the specific impact of
    the Human Genome Project, which was overseen, again, by Dr.
    Collins and completed in 2003. The Federal Government spent a
    total of $3.8 billion on this historic initiative. A lot of
    money, but the return on the investment is staggering.
    According to the Battelle study that $3.8 billion translated
    into an economic output of $796 billion between 1988 and 2010.
    And, of course, we'll be seeing benefits from the Human Genome
    Project for many more decades to come. In fact, when I was
    reading all of your testimonies last night, what struck me in
    each one of them there were references made back to genomic
    research in every single case of the institutes who are
    represented here.
        So the lesson is clear. Biomedical research is one of the
    engines that drive our economy. If we want our economy to grow,
    both immediately and in the long term, that engine needs fuel.
    Drastically cutting NIH, as the House budget would force us to
    do, would be a classic case of penny wise and pound foolish
    thinking. That, again, is just on the economic side.
        On the human side, though, the great advances that have
    been made in cancer research and what we have done to lessen
    the threat of cancer--young kids now with leukemia are being
    cured at an almost 100 percent rate. Maybe that's not quite
    right, but pretty darn close, things that were unheard of just
    a few years ago. The advances that we're making in infectious
    diseases, unheard of 20 years ago when I first came on this
    subcommittee. Well, that's been 25 years ago, but great
    advances have been made. Just stark.
        So, from the human standpoint, in helping people have
    better lives and overcoming some of the dreaded diseases that
    have plagued mankind for so long, on both fronts, biomedical
    research is the place to go and we ought not to be penny wise
    and pound foolish on that.
        And so now I'll recognize my ranking member, Senator
    Shelby, for an opening statement.

                     STATEMENT OF SENATOR RICHARD C. SHELBY

        Senator Shelby. Thank you, Mr. Chairman. I appreciate you
    holding this hearing today to discuss the vital mission carried
    out by the National Institutes of Health.
        We live in a world where there are thousands of
    debilitating and life-threatening diseases, all that could use
    additional funding for research and clinical trials.
        I support Federal investment in basic biomedical research
    and development. Research carried out by the NIH and its
    network of 325,000 researchers at 3,000 institutions across the
    country serves the Nation with the goal of improving human
    health. As research becomes more expensive and private capital
    dries up, I believe it's critical to ensure support for
    translational research; that is, research that moves a
    potential therapy from development to the market.
        The NIH has developed an interesting proposal with the
    establishment of the National Center for Advancing
    Translational Sciences, NCATS. NCATS is intended to fill the
    gap between advances in scientific understanding of disease and
    the process to turn new scientific insights into products. I
    believe the need for an entity to straddle the world's research
    and industry is clear.
        In the private market, pharmaceutical companies will
    abandon drug development projects that are not initially
    successful, become too complex or do not provide a lucrative
    path forward.
        For example, since 1949, there have only been two major
    drug discoveries in mental health--lithium and Thorazine. Sixty
    years later, researchers still do not know why these drugs
    actually work. Hundreds of genes have been shown to play roles
    in mental illness, too many for focused efforts by drug
    developers.
        Therefore, many drug manufacturers have dropped out of the
    mental-health field. In particular, pharmaceuticals for rare
    and neglected disease are often ignored because private
    companies avoid this small market with little profit appeal
    leaving patients with no treatment options.
        Even promising new drugs discovered through basic research
    often struggle during the translational stage of the process
    because it's expensive, time consuming and prone to failure.
    These barriers inhibit both the scientists dedicated to
    improving health and the patients who ultimately need improved
    cures and care.
        The question remains, however, as to whether NCATS is the
    right approach to solving the issue. Will NCATS be the right
    mechanism for taking valuable discoveries that the taxpayer has
    funded and giving it a greater opportunity to make it in the
    marketplace? As we review this proposal, we need to consider
    the fact that NIH is not a drug developer or an expert in the
    therapeutics world.
        Dr. Collins, I would like to continue to work with you to
    make a thoughtful, informed decision regarding the NCATS.
    Unfortunately, the fiscal year 2012 budget request, I believe,
    does not provide adequate details on the reorganization.
        It is May 11 and we've not received a budget amendment or
    specific structural details of an NCATS, a program NIH wants to
    implement by October 1. How can the subcommittee be expected to
    support a program that does not yet exist in budget documents?
        I understand that the transition from basic research to
    clinical application requires interdisciplinary and
    multidisciplinary expertise. Research that aims to transform
    science is inherently difficult. If it were easy, the need for
    transformation would not exist.
        NCATS may be the answer to solve this complex issue, but it
    also may not be. We don't know. Dr. Collins, I believe that
    NCATS is a matter that we should contemplate, but we must
    ensure that the steps forward are measured and in the best
    interests of all stakeholders, especially those who are in need
    of treatment and care.
        I look forward to working with you and the chairman on this
    very important issue. Thank you.

                            INTRODUCTION OF WITNESS

        Senator Harkin. Thank you very much, Senator Shelby.
        Now, welcome back to Dr. Collins.
        Francis Collins was sworn in as the 16th Director of the
    National Institutes of Health in August 2009 after being
    unanimously confirmed by the Senate.
        He is a physician geneticist noted for his discoveries of
    diseased genes and leadership, of course, of the Human Genome
    Project. Prior to becoming Director, he served as Director of
    the National Human Genome Research Institute at NIH.
        Dr. Collins received his bachelor's degree from the
    University of Virginia, his Ph.D. from Yale and his M.D. from
    the University of North Carolina at Chapel Hill.
        Dr. Collins, again, welcome, and first I want to say that
    your testimony, and all of the testimony of the Directors who
    are here, will be made a part of the record in their entirety.
        Again, due to time, Dr. Collins, we ask you to make a
    fairly comprehensive statement. I'm not going to get the clock
    going here, but if it goes too long and people start looking at
    me funny, then I'll probably ask you to close it out. But
    please take whatever time you need to give us an update on NIH
    and a concise summation of your written testimony.

                  SUMMARY STATEMENT OF DR. FRANCIS S. COLLINS

        Dr. Collins. Well, thank you, Senator, and, Mr. Chairman,
    and distinguished members of the subcommittee, it's an honor to
    appear before you this morning, together with my colleagues, on
    behalf of NIH.
        And I'll try not to talk so long that people start looking
    at you or looking at me, but I do have some things I really
    wanted to put in front of this distinguished subcommittee,
    because this is a very exciting time for biomedical research.
        NIH is the largest supporter of biomedical research in the
    world, and we're here to present the President's budget request
    of $31.987 billion for fiscal year 2012.

                       NIH--Turning Discovery Into Health
     Global Competitiveness--The Importance of U.S. Leadership in Science
          and Innovation for the Future of Our Economy and Our Health
        The National Science Board's 2010 Key Science and Engineering
    Indicators, provide insight into how crucial decisions on R&D funding
    may affect our Nation's ability to thrive in an increasingly
    competitive and knowledge-driven global economy. While these trends
    apply not just to bimoedical reserch, but also to research in
    chemistry, physics, engineering, computer science, and many other
    fields, the conclusion of most observers is that the 21st century will
    be dominated by the life sciences, and the country that leads in this
    area will have much to gain. Unfortunatley, the United States,
    traditionally the dominant Nation in scientific resarch, has been
    slipping in leadership recently.
        Losing Ground.--R&D investment growth rates are rising sharply in
    Asia.

        For example, China's growth rate is 4 times higher than the U.S.
    rate.
        While the U.S. remains among the nations with the highest actual
    R&D expenditures, Asia is rapidly closing the gap.

        Employment Impact: The number of people engaged in scientific
    research in China has increased dramatically. In 2007, China had 1.42
    million researchers, while the US had 1.47 million. In 2010, it is
    likely that China has surpassed the U.S. research workforce.

        Knowledge Generation: The number of scientific articles published
    is a common measure of scientific productivity. The average increase in
    U.S. publications is significantly lower than for other key countries
    and also below the world average. Meanwhile, China, Thailand, South
    Korea, and others show impressive growth rates.

        As a result of the previously mentioned trends, it is not
    surprising that the U.S. share of world publications has significantly
    decreased, and that China's share has grown.

    ------------------------------------------------------------------------
                                                Share of world
                                              articles (Percent)    Percent
                 Country/Region             ----------------------   Change
                                                1998       2008
    ------------------------------------------------------------------------
    United States..........................       34         28.9       -5.1
    EU.....................................       34.6       33.1       -1.5
    China..................................        1.6        5.9        4.3
    Japan..................................        8.5        7.8       -0.7
    Asia-8.................................        3.6        6.8        3.2
    ------------------------------------------------------------------------
    Source: SEI 2010

        The number of times a scientific article is cited indicates its
    scientific impact. One could argue that emerging countries are
    publishing articles with limited impact. While this may be the case
    from certain perspectives, the aggregate number of citations indicates
    a worrisome plunge in the U.S. share of worldwide citations, which fell
    8.6 percent from 1998 to 2008. In contrast, China and Asia-8 countries
    displayed a noticeable increase in their share of citations, rising 3.7
    percent and 3.1 percent respectively over the same time period.
        Economic consequences: Reducing R&D investments when other nations
    are rapidly increasing them has already had significant consequences on
    exports, which are an important component of the U.S. economy and well
    being of Americans.

                            IMPACTS ON U.S. ECONOMY
        NIH is the largest funder and conductor of biomedical research in
    the world.
        The NIH fiscal year 2011 budget is $31 billion--84 percent of which
    is awarded to the Nation's finest universities, institutes, and small
    businesses through a rigorous peer review process. Every State, along
    with almost every Congressional district, benefits.
        NIH extramural program supports more than 40,000 competitive
    research grants and 325,000 research personnel at more than 3,000
    universities, medical schools, and other research institutions in all
    50 states, U.S. territories, and around the world.
        Approximately 10 percent of the NIH budget funds nearly 6,000
    scientists working at the NIH campus in Bethesda, in laboratories in
    Rockville and Frederick, Maryland, at Research Triangle Park in
    Raleigh, North Carolina, and at the Rocky Mountain Laboratories in
    Hamilton, Montana.
        NIH spending increases business activity directly and indirectly:
    According to Families USA, each dollar of NIH award money generates
    about $2.21 of new business activity within 1 year, while each grant
    awarded by NIH generates about 7 jobs.
        NIH-driven advances have not only had profound effects on the
    health and quality of life for all Americans, but also yielded economic
    gains. The percentage of elderly with chronic disabilities has declined
    (from 27 percent in 1982 to 19 percent in 2005). Since 1970, life
    expectancy in the United States has risen from 71 to 78 years.
    Economists estimate that these gains in life expectancy have been worth
    approximately $95 trillion.
        The economic potential of NIH-fueled advances in improved
    treatments for disease is also clear in this projection: a reduction in
    cancer deaths by one percent has a present value to current and future
    generations of Americans of nearly $500 billion. A full cure would be
    worth approximately $50 trillion--more than three times today's GDP.
        Advances in disease diagnosis also illustrate the health-related
    and economic benefits of NIH research: approximately $100 million in
    health care costs annually are being saved through the use of a genomic
    test that determines whether a particular type of breast cancer is
    likely to be cured by surgery and radiation or by chemotherapy. As a
    result of this test, thousands of women are being spared needless
    exposure to toxic therapies--and millions of dollars are being saved.
        NIH is an engine of innovation--and a crucial support for the
    global competitive stature of the United States. In fiscal year 2010,
    NIH filed 289 U.S. patent applications (of which 141 were new
    applications). These are now included in a total of 3,186 NIH patent
    applications in the United States and abroad that were pending
    approval.
    Key Facts on U.S. Competitiveness in the Global Research Arena
        The United States still is the world leader in science and
    engineering research. But that leadership role is being challenged by
    China, India, and other nations as they recognize the economic, health,
    and social benefits of investing in R&D.
        Over the past decade, R&D intensity has grown in Asia, but remained
    flat in the United States.
        Growth of R&D expenditures in the United States averaged 5-6
    percent annually from 1996-2007, lagging behind the worldwide average
    of 7 percent per year. In contrast, growth in most Asian nations
    exceeded the worldwide average, and China's R&D expenditures grew more
    than 20 percent annually from 1996-2007.
        The United States share of high technology exports fell by one-
    third from 1996-2007. China's share more than tripled.
        India exported $8.3 billion in pharmaceutical products and services
    in fiscal year 2009, up 25 percent from the previous year.
        About 277,000 people, ranging from scientists and to production
    workers, are currently employed by pharmaceutical companies in the
    United States, a decline of 5 percent from 2008. More than 340,000
    people work in India's pharmaceutical manufacturing industry in 2009--
    and the industry is projected to grow by 13 percent in 2010.
        Between 1995 and 2007, the worldwide share of researchers working
    in China, Singapore, South Korea, or Taiwan rose from 16 percent to 31
    percent.
        In 2007, the United States had 1.47 million people engaged in
    scientific research; China had 1.42 million--and it was generating R&D
    jobs at three times the rate of the U.S.
        In the United States, the percentage of undergraduate students who
    major in science and engineering is 15 percent; in China, it is 50
    percent.
        In 1995, China ranked 14th in the world in the production of
    research publications. In 2008, it ranked second.
        China's leading genome sequencing institute, BGI, is on track to
    sequence more than 10,000 human genomes a year. That would surpass the
    entire DNA sequencing output of the United States.
        For more on how shifts in global research capacity are challenging
    the United States to actively focus on maintaining its competitive
    strength, go to http://www.nsf.gov/statistics/nsb1003/.

                              Health Improvements
        In the last 25 years, NIH-supported biomedical research has
    directly led to human health benefits that both extend lifespan and
    reduce illnesses:
      --Prolonging Life and Reducing Disability.--Our Nation has gained
            about 1 year of longevity every 6 years since 1990. A baby born
            today can look forward to an average lifespan of nearly 78
            years--nearly three decades longer than a baby born in 1900.
            Not only are people living longer, they are staying active
            longer. From 1982 through 2005, the proportion of older people
            with chronic disabilities dropped by almost a third.
      --Heart Disease.--NIH research has generated new techniques for heart
            attack prevention, effective drugs for lowering cholesterol and
            controlling blood pressure, and strategies for dissolving blood
            clots. As a result, the death rate for coronary disease is 60
            percent lower--and for stroke, more than 70 percent lower--than
            during the era of World War II. Better treatment of acute
            conditions, better medications, and improved health-related
            behaviors--all made possible by NIH research--account for as
            much as two-thirds of this reduction.
      --Chronic Disability.--From 1982-2004, the reported chronic
            disability among American seniors dropped nearly 30 percent.
            Health improvements from NIH research played a major role in
            this, including better prevention and treatment of heart
            attacks and strokes, advances in treatment of arthritis, and
            improved technologies for cataract surgery.
      --Age-Related Macular Degeneration (AMD).--Forty years ago there was
            little or nothing one could do to prevent or treat advanced AMD
            and blindness. Because of new treatments and procedures based
            on NIH research, 750,000 Americans who would have gone blind
            over the next 5 years instead will continue to have useful
            vision.
      --Breast Cancer.--The 5-year survival rate for women diagnosed with
            breast cancer was 75 percent in the mid-1970s. Because of NIH-
            supported research, the 5-year survival rate has risen to over
            90 percent.
      --Cervical Cancer.--Cervical cancer is a deadly cancer in women. Due
            to groundbreaking NIH research, an FDA-approved vaccine
            (Gardasil) now is available to prevent the development of
            cervical cancer.
      --Colon Cancer.--From 1974-1976, in an NIH-sponsored study, the 5-
            year survival for patients with colon cancer was 50 percent. In
            2009, based on NIH-supported clinical trials using new
            diagnostics and treatments, a comparable patient group has a 5-
            year survival rate of over 70 percent.
      --Cochlear Implants.--Because of NIH-supported research, children who
            are profoundly deaf but receive a cochlear implant within the
            first 2 years of life now have the same skills, opportunities,
            and potential as their normal-hearing classmates.
      --Type 1 Diabetes.--Thirty to forty years ago, 30 percent of patients
            died within 25 years of a diagnosis of type 1 diabetes. Today,
            due to tight blood glucose control, heart disease and stroke in
            patient with type 1 diabetes have been reduced by over 50
            percent.
      --Hepatitis B.--In the mid-1980s, hepatitis B infection caused
            untreatable and fatal illness. Due to intensive vaccination
            programs based on NIH research, the rate of acute hepatitis B
            has fallen by more than 80 percent.
      --HIV/AIDS.--In the 1980s, the diagnosis of HIV infection was a
            virtual death sentence. Due to antiviral drugs developed by
            NIH, today an HIV-positive 20-year-old can be expected to reach
            the age of 70.
      --Infant Health.--In 1976, the infant mortality rate was 15.2 infant
            deaths per 1,000 live births. By 2006, that rate had fallen to
            6.7 deaths per 1,000 live births. Much of this progress can be
            attributed to NIH research in the areas of neonatal care unit
            procedures and new drugs administered to women at risk for
            premature birth.
      --Childhood Leukemia.--Survival rates for children with the most
            common childhood leukemia (acute lymphocytic leukemia) is now
            90 percent.
                             Advances In Knowledge
        NIH-funded research leads to thousands of new findings every year.
    These incremental advances and technological developments are the
    building blocks that ultimately yield significant improvements in
    health. Highlighted below are just a few of the many recent advances
    from NIH-supported research:
      --Studies find possible new genetic risk factors for Alzheimer's
            disease.--Scientists have confirmed one gene variant and have
            identified several others that may be risk factors for late-
            onset Alzheimer's disease, the most common form of the
            disorder. In the largest genome-wide study, or GWAS, ever
            conducted in Alzheimer's research, NIH-supported investigators
            studied DNA samples from more than 56,000 study participants
            and analyzed shared data sets to detect gene variations that
            may have subtle effects on the risk for developing Alzheimer's.
            Until recently, only one gene variant, Apolipoprotein E-e4
            (APOE-e4), had been confirmed as a significant risk factor gene
            for the common form of late-onset Alzheimer's disease, which
            typically occurs after age 60. In 2009 and 2010, researchers
            confirmed additional gene variants of CR1, CLU, and PICALM as
            possible risk factors for late-onset Alzheimer's. This newest
            GWAS confirms the fifth gene variant, BIN1, affects development
            of late-onset Alzheimer's. The genes identified by this study
            may implicate pathways involved in inflammation, movement of
            proteins within cells, and lipid transport as being important
            in the disease process.
      --NIH scientist advance universal flu vaccine.--Significant progress
            was made toward the development of a universal flu vaccine that
            would confer longer term protection against multiple influenza
            virus strains. NIH-supported researchers have identified the
            regions of influenza viral proteins that remain unchanged among
            seasonal and pandemic strains. These findings will inform the
            development of influenza vaccines that might one day provide
            universal protection against the broad range of influenza
            strains. Such a universal influenza vaccine would provide
            broader protection against multiple flu strains and make yearly
            flu shots a thing of the past.
      --Early detection of cancer is critical to provide effective
            therapy.--NIH-supported investigators recently reported the
            detection of a single metastatic cell from lung cancer in one
            billion normal blood cells. These circulating tumor cells
            (CTCs) may also be released into the bloodstream of patients
            with invasive but localized cancers. The presence of CTCs may
            be an early indicator of tumor invasion into the bloodstream
            long before distant metastases are detected. Identifying CTCs
            may be viewed as performing liquid biopsies, which can be
            especially advantageous for prostate cancer. Researchers plan
            to extend their work to develop a point-of-care microchip that
            would allow non-invasive isolation of CTCs from patients with
            many different types of cancer, to improve the management and
            treatment of this devastating disease.
      --Prenatal surgery reduces complications of spina bifida.--NIH-
            supported scientists reported that a surgical procedure to
            repair a common birth defect of the spine, if undertaken while
            a baby is still in the uterus, greatly reduces the need to
            divert, or shunt, fluid away from the brain. The fetal surgical
            procedure also increases the chances that a child will be able
            to walk without crutches or other devices. The birth defect,
            myelomeningocele, is the most serious form of spina bifida, a
            condition in which the spinal column fails to close around the
            cord. The study, the Management of Myelomeningocele Study
            (MOMS), was stopped after the enrollment of 183 women, because
            of the benefits demonstrated in the children who underwent
            prenatal surgery. In spite of an increased risk for preterm
            birth, children who underwent surgery while in the uterus did
            much better, on balance, than those who had surgery after
            birth.
      --Progesterone reduces rate of early preterm birth in at risk
            women.--Preterm infants are at high risk of early death and
            long term health and developmental problems including,
            breathing difficulties, cerebral palsy, learning disabilities,
            blindness and deafness. An NIH study found that progesterone
            gel reduces the rate of preterm birth before the 33rd week of
            pregnancy by 45 percent among women with a short cervix, which
            is known to increase the risk of preterm birth. Women with a
            short cervix can be identified through routine ultrasound
            screening, and once identified could be offered treatment with
            progesterone. In addition, infants born to women who received
            progesterone had a lower rate of respiratory distress syndrome
            than those in the placebo group.
      --Daily dose of HIV drug reduces risk of HIV infection.--A daily dose
            of an oral antiretroviral drug, currently approved to treat HIV
            infection, was shown to reduce the risk of acquiring HIV
            infection by 43.8 percent among men who have sex with men. The
            findings, a major advance in HIV prevention research, came from
            a large international clinical trial supported by NIH. The
            study, titled ``Chemoprophylaxis for HIV Prevention in Men''
            found even higher rates of effectiveness, up to 72.8 percent,
            among those participants who adhered most closely to the daily
            drug regimen. These new findings provide strong evidence that
            pre-exposure prophylaxis with an antiretroviral drug, a
            strategy widely referred to as PrEP, can reduce the risk of HIV
            acquisition among men who have sex with men, a segment of the
            population disproportionately affected by HIV/AIDS.
            Prophylactic antiretroviral therapy has already been proven to
            significantly reduce the transmission of HIV from a mother to a
            child during childbirth through breastfeeding.
      --Pocket-sized device makes medical ultrasound more accessible.--NIH-
            supported research at General Electric supported the
            development of a low-cost, portable, high-quality ultrasonic
            imager. In the last year, this advance was extended even
            further with GE's production of ``Vscan.'' This pocket-sized
            device makes medical ultrasound even more accessible and has
            enabled wireless imaging, patient monitoring, and prenatal care
            applications.

      --Lung cancer screening with CT scan reduces deaths.--The National
            Lung Screening Trial found that screening with low-dose
            computed tomography (CT) can decrease lung-cancer deaths among
            current and former heavy smokers by 20 percent. Because of
            earlier identification of cancerous tumors, screening was found
            to reduce mortality from lung cancer, the most common cause of
            cancer deaths.
      --Nicotine vaccine shows promise in preventing tobacco addiction.--
            Vaccines developed to combat drug addictions work by generating
            drug-specific antibodies that bind the drug while in the
            bloodstream and prevent its entry into the brain. A nicotine
            vaccine recently found to improve smoking quit rates is now in
            phase III trials to evaluate continued abstinence at 12 months.
      --Nanotechnology demonstrates advances in the realm of materials
            technologies.--Carbon nanotubes have been used to deliver
            chemotherapeutic agents specifically to head and neck cancer
            cells, causing rapid death of the cancer cells, but leaving
            non-cancerous cells unharmed.
      --Certain lipid molecules that show promise in controlling pain could
            result in new treatments.--Researchers have demonstrated in
            animal models that certain lipids called resolvins, which shut
            down inflammation, are more potent than morphine in controlling
            pain. Since these resolvins are normally found in the body,
            they are likely to be safe and non-addictive when used
            therapeutically. Additional research is under way to explore
            these compounds further and translate into new analgesics for
            pain management.
      --Combined treatment improves vision in patients with diabetic
            macular edema.--A comparative effectiveness study for diabetic
            macular edema found that combined treatment with the drug
            ranibizumab and laser therapy was substantially better at
            improving vision in patients with diabetes than laser therapy
            alone, and better than laser therapy with a different drug
            (triamcinolone).
      --Scientists develop a system for making functional hair cells from
            stem cells, offering possible new treatment of deafness.--In
            mammals, mechanically-sensitive ``hair cells'' in the inner
            ear, which are essential for both hearing and balance cannot
            regenerate when they die or are damaged. NIH supported
            scientists have used mouse embryonic stem cells as well as
            induced pluripotent stem cells and generated hair cells that
            respond to mechanical stimulation, offering a new avenue for
            the treatment of deafness.
      --Experimental medication lifts depression symptoms in people with
            bipolar disorder.--NIH intramural researchers discovered that
            ketamine, an anesthetic medication, provides rapid and
            effective treatment for depressive symptoms among patients with
            bipolar disorders. While ketamine's side effects make it
            impractical for long-term use, this class of drugs may be
            invaluable for treating severe depressive symptoms in these
            patients during the weeks it usually takes for typical
            antidepressants to take full effect.
         Proposed National Center for Advancing Translational Sciences
                         National Institutes of Health
    Rationale
        The development of new diagnostics and therapeutics is widely
    recognized as a complex, costly, and risk-laden endeavor. Only a few of
    the thousands of compounds that enter the drug development pipeline
    will ultimately make it into the medicine chest.

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

                                    Mission
        To advance the discipline of translational science and catalyze
    development and testing of novel diagnostics and therapeutics across a
    wide range of human diseases and conditions.

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

        In recent years, there has been a deluge of new discoveries of
    potential drug targets, yet we still lack effective therapeutics for
    many conditions, especially rare and neglected diseases. A major
    problem is that the drug development pipeline is full of bottlenecks
    that slow the speed of development and add expense to the process. To
    address these challenges, the National Institutes of Health (NIH) has
    proposed establishing the National Center for Advancing Translational
    Sciences (NCATS).

        NCATS will study various steps in the drug development pipeline,
    identify bottlenecks amenable to re-engineering, and experiment with
    innovative methods to streamline the process. Promising therapeutic
    projects will be used to evaluate pipeline innovations.
        NCATS will complement--not compete with-- translational research
    being carried out elsewhere at NIH and in the private sector. In fact,
    through its mission to use the power of science to advance the entire
    discipline, NCATS will benefit all stakeholders, including academia,
    biotechnology firms, pharmaceutical companies, the Food and Drug
    Administration, and--most importantly--patients and their families.
    Functions
        NCATS will aim to improve the processes in the drug development
    pipeline by:
      --experimenting with innovative approaches in an open-access model;
      --choosing therapeutic projects to evaluate these innovative
            approaches; and
      --promoting interactions to advance the field of regulatory science.
        NCATS also will strive to catalyze the development of new drugs and
    diagnostic tests by:
      --encouraging collaborations across all sectors;
      --providing resources to enable therapeutic development; and
      --enhancing training in relevant disciplines.

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

        NCATS will:
      --facilitate--not duplicate--other translational research activities
            supported by NIH;
      --complement--not compete with--the private sector; and
      --reinforce--not reduce--NIH's commitment to basic research.

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

    Programs
        NCATS will be formed by pulling together these existing NIH
    programs: components of the Molecular Libraries initiative,
    Therapeutics for Rare and Neglected Diseases, Office of Rare Diseases
    Research, Rapid Access to Interventional Development, Clinical and
    Translational Science Awards, and FDANIH Regulatory Science. In
    addition, the Cures Acceleration Network will be part of NCATS if funds
    are appropriated for fiscal year 2012. Relocated programs will have
    their respective budgets transferred to the new center.
        Background
        On May 19, 2010, the NIH Director asked the NIH Scientific
    Management Review Board (SMRB) to:
      --identify the attributes, activities, and functional capabilities of
            a translational medicine program for advancing therapeutics
            development; and
      --broadly assess the NIH landscape for existing programs, networks,
            and centers for inclusion; and recommend their optimal
            organization.

        On Dec. 7, 2010, the SMRB recommended the creation of a new
    translational medicine and therapeutics center. It also urged NIH to
    undertake a detailed analysis, through a transparent process, to
    evaluate the new center's impact on existing NIH programs.
        Informed by the SMRB's recommendations, NIH initiated a planning
    process to establish NCATS. The NIH Director established three panels
    to guide and inform the process: the Institute and Center Directors'
    (ICD) NCATS working group, the Advisory Committee to the Director (ACD)
    NCATS working group, and the NIH Clinical and Translational Science
    Awards (CTSA) Integration working group.
        On Jan. 4, 2011, Dr. Collins charged the ICD working group with
    making recommendations on the mission, functions, and organizational
    design of NCATS. This panel presented its recommendations to Dr.
    Collins on Feb. 17, 2011. The ACD working group, which has been asked
    to provide high-level advice on how NCATS can best engage the private
    sector in translational science, met for the first time on Feb. 4,
    2011. This distinguished panel of outside experts will report its
    findings to the ACD later this year.
        The final working group, composed of leaders from across NIH, was
    formed in mid-March to ensure a smooth transition of the CTSA program
    into NCATS.
    Next Steps
        At every point along the way, NIH has sought input on NCATS from a
    broad and diverse array of stakeholders. In addition, NIH will continue
    to inform all stakeholders on new developments and seek their comments
    through our interactive web site Feedback NIH.
        Pending approval from the Health and Human Services Secretary, the
    Office of Management and Budget, and the Congress, NCATS will be
    included in the fiscal year 2012 budget and be formally established on
    Oct. 1, 2011.

        So in this brief statement today, I'd like to tell you
    about four innovative areas, and I'm going to show some
    pictures up on the screen in which NIH is investing in order to
    carry out its mission of turning discovery into health.
        First, dramatic advances in technologies, including
    imaging, nanotechnology, computational biology, and, yes,
    genomics, have recently made it possible for scientists to
    understand the details of health and disease in breathtaking
    new ways.
        Consider this curve, the cost to sequence a human genome.
    Look at the profound reduction over the past decade. In 2001,
    it cost about $100 million to sequence a single human genome.
    That cost now stands at about $10,000, and we anticipate it
    will be less than $1,000 within the next few years.
        That advance will give many Americans access to far more
    personalized strategies for detecting, treating and preventing
    disease than are now available.
        Those new technologies not only reduce the cost of doing
    science, but open up whole new frontiers in medicine. I'll tell
    you about one of those later in a story about a 6-year-old boy
    named Nic that I think you'll find quite compelling.
        But, first, let's turn to the effects that this technology
    has had on our understanding of cancer. Cancer is a disease of
    the genome, comes about because of mutations in DNA.
        Through a bold initiative, called the Cancer Genome Atlas,
    or TCGA, my colleague, Harold Varmus, and others are analyzing
    the DNA of tumors of hundreds of patients to identify
    comprehensively the genetic mutations associated with the
    specific cancers.
        Brain and ovarian cancers were the first ones selected for
    study through TCGA and the results have been stunning. Knowing
    the molecular drivers of cancer gives us a chance to make much
    more accurate diagnoses, prognoses, and predictions of response
    to therapy. And in the longer run, this approach will lead to
    development of a new generation of targeted therapies, those
    magic bullets so dreamed of to treat this disease.
        The plan for the next few years is ambitious. TCGA will
    sequence, characterize, and understand the genomes of 20
    different types of tumors.
        New treatments are wonderful. Effective prevention can be
    even better. NIH is dedicated to use the latest science to
    improve America's health today by identifying effective new
    strategies for disease prevention. The grave threat of diabetes
    is a compelling example of how we are doing this.
        This map shows the prevalence of diabetes in the United
    States in 1995. As you can see from the color code, in most
    States, less than 5 percent of adults were affected, but watch
    what happened over just 15 years. Prevalence of diabetes has
    gone up rapidly in every State, and it now stands at 9 percent
    or more in many parts of the country.
        The total costs of the disease, including medical care,
    disability and premature death, were an estimated $174 billion
    in the United States in 2007. If current trends continue, one
    in three U.S. adults will have diabetes by 2020, just 9 years
    from now, and the annual cost of care alone will have risen to
    a breathtaking $500 billion.
        But my colleague, Grif Rodgers, and I can offer some hope.
    NIH spearheaded a landmark clinical trial on how to prevent
    type 2 diabetes. The Diabetes Prevention Program, or DPP,
    involved adults with pre-diabetes. That refers to a modest
    elevation of glucose in the blood foreshadowing much worse to
    come if nothing is done, but not yet frank diabetes.
        The study participants were assigned personal coaches who
    encouraged them to exercise about 30 minutes a day and to make
    modest dietary changes resulting in an average weight loss of
    just 7 percent. This simple approach lowered the chance of
    full-blown diabetes by a whopping 58 percent, and that has been
    sustained for more than 10 years.
        Building on these results, NIH has joined with the Centers
    for Disease Control and Prevention (CDC), the YMCA, Walgreens,
    United Health Care and other partners to bring this program to
    communities in 10 States. And we are now working with
    colleagues at CMS to explore how a similar program could be
    used to great advantage in Medicare and Medicaid.
        Now, I'd like to turn your attention to another important
    contribution of NIH research already mentioned by the chairman,
    enhancing the economy and U.S. competitiveness worldwide.
        NIH will be a key engine driving the U.S. economy in the
    21st century. Many call this the century of biology. As
    mentioned, just yesterday, a new economic impact study
    published by United for Medical Research suggests that in
    fiscal year 2010 NIH research funding supported an estimated
    487,900 American jobs at 3,000 institutions and small
    businesses across all 50 States of this Nation.
        More than that, nearly 1 million U.S. citizens are employed
    by the industries and companies that make up this sector of the
    economy, earning $84 billion in wages and salary and exporting
    $90 billion of goods and services annually. But despite this
    impressive track record, our Nation today is at serious risk of
    losing its position as the world's research leader.
        As you can see in this slide, which shows the percent
    growth of R&D expenditures on an annual basis, China and India
    and other countries have been steadily increasing their R&D
    expenditures by 10 percent or more per year, highlighting China
    and India there. Whereas, the United States has been at a
    substantially lower level. China's growth rate is now four
    times greater than ours.
        Let me give you a personal example of what this means. Last
    fall, when I visited the BGI Genome Center in Shenzhen, China,
    I saw an amazing facility built in just 3 years from an
    abandoned shoe factory that is capable of sequencing more than
    10,000 human genomes a year.
        The capacity of that one Chinese institution now surpasses
    the combined capacity of all genome sequencing centers in the
    United States. This critical area of scientific innovation,
    stimulated by the U.S.-led Human Genome Project, is now being
    developed more aggressively in China than it is here, a
    sobering story indeed, and one that I hope would inspire our
    Nation to redouble its efforts on the research front.
        A final area I wish to highlight in which our Nation faces
    exceptional challenges, as well as exceptional opportunities,
    is this field of translational science which Senator Shelby has
    specifically highlighted in his opening statement. As a result
    of years of steadfast support of NIH research by Congress and
    the American people, we find ourselves in a paradoxical
    situation.
        This graph shows we've seen a deluge of discoveries about
    the molecular basis of disease, both rare and common, which
    provide us with the power to identify more therapeutic targets
    than ever before; more than 4,000 diseases now having their
    molecular basis discovered, much of that in the last decade.
        But there's a serious problem. The process of taking those
    basic discoveries to the point of clinical advances, as here
    demonstrated by a diagram showing you what happens in the
    development of new therapeutics, is far too slow--14 years on
    the average--and the failure rate is far too high--more than 98
    percent. We clearly need a new approach to therapeutic
    development and a new partnership with the private sector.
        So to meet this need, NIH is proposing the establishment of
    a new national center for advancing translational sciences or
    NCATS. NCATS will allow us to study the various steps in the
    development of diagnostics, devices and therapeutics, identify
    bottlenecks that might be reengineered and experiment with
    innovative methods to streamline this process.
        Through this new center, we can work in an open-access
    model that will allow stakeholders, including industry and
    academia, to access and apply the innovations that are
    developed. NCATS will also advance the field of regulatory
    science by promoting interactions among the NIH, FDA, patient
    advocates, and pharmaceutical and biotechnology companies.
        Importantly, NCATS will complement, not compete with, the
    private sector. This is not Bethesda Pharm. It will facilitate
    translational research being carried out elsewhere at the NIH,
    extensive translational work already going on by many of the 27
    Institutes, including those represented at this table. And it
    will reinforce, not reduce, NIH's commitment to basic science,
    a foundational part of our mission.
        Most importantly, though, by advancing discipline of
    translational sciences, NCATS will benefit patients and their
    families.
        So, Mr. Chairman, members of the subcommittee, I've spoken
    today about the great promise of new technologies, how we're
    applying science to prevention, NIH's role in maintaining U.S.
    economy--world leadership, and the unique opportunity to pursue
    a new paradigm in translation.
        Let me close by sharing the story of one little boy to show
    you what NIH research advances now allow us to do. So meet Nic
    Volker, a brave boy from Monona, Wisconsin.
        Starting about the age of two, Nic developed a mysterious
    life-threatening disease that ravaged his body, making it
    impossible for him to eat normally and causing unimaginable
    pain and suffering.
        At a loss to explain Nic's terrible affliction, researchers
    at the Medical College of Wisconsin decided to sequence Nic's
    DNA instruction book hoping to find an answer. After exacting
    work over several months, the researchers identified a
    misspelling of just one single letter in a little-studied gene
    called XIAP. Now, glitches in this gene had been associated
    with rare blood disorders, but not with intestinal symptoms.
    Based on this new insight, the research team had an idea that,
    as with the rare blood disorders, Nic's disease might be
    curable with a bone-marrow transplant.
        Transplantation of cord blood cells from--stem cells from a
    matched donor occurred in July of last year. Although Nic is
    still receiving some immunosuppressant drugs to prevent
    rejection of the donated cells, his symptoms have largely
    disappeared, and, today, as you can see here, he can eat
    normally and vigorously.
        What's more, he's now attending kindergarten, enjoying
    outings with his family and friends, signing up for a T-Ball
    team, and, this past Sunday, presenting his mother with a
    flower for Mother's Day. Nic has given us all a glimpse of the
    future.

                              PREPARED STATEMENTS

        Thank you, Mr. Chairman. This concludes my formal remarks.
        [The statements follow:]
             Prepared Statement of Francis S. Collins, M.D., Ph.D.
                                  introduction
        Good morning, Mr. Chairman and distinguished Members of the
    Subcommittee. I am Francis S. Collins, M.D., Ph.D. and I am Director of
    the National Institutes of Health (NIH).
        It is a great honor to appear before you today to present the
    administration's program level request of $31.987 billion for NIH in
    fiscal year 2012, and to discuss the contributions that NIH-funded
    biomedical research has made in improving human health. NIH is the
    largest supporter of biomedical research in the world, providing funds
    for more than 40,000 competitive research grants and more than 325,000
    research personnel at more than 3,000 research institutions and small
    businesses across our Nation's 50 States. I also want to offer a vision
    of how NIH will catalyze innovation in basic and translational
    sciences, and will ensure future U.S. economic strength and global
    competitiveness.
        On behalf of NIH and the biomedical research enterprise, I want to
    thank you as Members of the Senate for sparing NIH from deeper cuts in
    the final fiscal year 2011 continuing resolution (CR). We know that,
    even as Congress and the administration wrestled with cuts of more than
    3 percent to the Labor-HHS portion of the CR, NIH received a 1 percent,
    or $321.7 million, cut from the fiscal year 2010 level, while other
    programs and functions were cut more deeply.
        NIH's mission is to seek fundamental knowledge about the nature and
    behavior of living systems and to apply that knowledge to enhance human
    health, lengthen life, and reduce the burdens of illness and
    disability. I can report to you that NIH continues to believe
    passionately in that mission and works tirelessly to achieve it.
        Due in large measure to NIH research, our Nation has gained about 1
    year of longevity every 6 years since 1990. A child born today can look
    forward to an average lifespan of nearly 78 years--nearly three decades
    longer than a baby born in 1900. And not only are people living longer,
    but their quality of life is improving: in the last 25 years, the
    proportion of older people with chronic disabilities has dropped by
    almost one-third.
        NIH research has enabled new techniques to prevent heart attacks,
    newer and more effective drugs for lowering cholesterol and controlling
    blood pressure, and innovative strategies for dissolving blood clots
    and preventing strokes. As a result, the U.S. death rate for coronary
    disease is 60 percent lower--and for stroke, more than 70 percent
    lower--than three generations ago. Better treatment of acute heart
    disease, better medications, and improved health-related behaviors--all
    underpinned by NIH research--account for as much as two-thirds of these
    reductions.
        In recent years, largely as a result of NIH research, we have
    succeeded in driving down mortality rates for cancer in the United
    States. This progress comes despite the fact that cancer is largely a
    disease of aging and our population is growing older. Over the 15-year
    period from 1992 to 2007, cancer death rates dropped 13.5 percent for
    women and 21.2 percent for men. According to an American Cancer Society
    report released in July 2010, the continued drop in overall mortality
    rates over the last 20 years has saved more than three-quarters of a
    million lives.\1\ And in cancers that strike children we have made
    near-miraculous progress--the 5-year survival rate for children with
    the most common childhood cancer, acute lymphocytic leukemia, is now 90
    percent.\2\
    ---------------------------------------------------------------------------
        \1\ http://pressroom.cancer.org/index.php?s=43&item=252.
        \2\ http://seer.cancer.gov/csr/1975_2008/
    browse_csr.php?section=28&page=sect_28_table.08.html.
    ---------------------------------------------------------------------------
        I would also like to offer a shining example of the Senate's strong
    and consistent support of biomedical research at NIH by note that we
    are celebrating a significant anniversary. This year marks the 10th
    anniversary of the establishment of the Dale and Betty Bumpers Vaccine
    Research Center (VRC) at NIH. Groundbreaking research performed at the
    VRC is making great progress toward developing a universal flu vaccine
    that confers longer-term protection against seasonal and pandemic
    influenza strains.
        Today, scientists have to make an educated guess about the make-up
    of the coming winter's influenza viruses. These educated guesses become
    the basis for the manufacture of each year's flu shot and mean that
    everyone has to be re-immunized in anticipation of next year's strain
    of flu. Recently, NIH scientists have identified pieces of influenza
    viral proteins that consistently appear among seasonal and pandemic flu
    strains. These findings raise the possibility that we might soon
    develop an influenza vaccine that provides near-universal protection
    against a broad range of current and future strains of influenza,\3\ as
    well as make yearly flu shots a thing of the past. Most of this
    exciting work was performed at the VRC. Scientists at that same center
    are making important strides toward the development of the long-hoped-
    for vaccine against the human immunodeficiency virus (HIV), the cause
    of acquired immune deficiency syndrome (AIDS). While after so many
    frustrations, no one would want to predict success just yet, recent
    discoveries of VRC scientists about how to encourage production of
    neutralizing antibodies against HIV have provided renewed hope that
    this pressing problem may ultimately be solved.
    ---------------------------------------------------------------------------
        \3\ http://www.niaid.nih.gov/news/newsreleases/2010/Pages/
    UniversalFluVax.aspx.
    ---------------------------------------------------------------------------
                            nih and economic growth
        Mr. Chairman and Members of the Subcommittee, I recognize that,
    given our Nation's fiscal situation, and the extraordinarily tough
    decisions that you will have to make about our Nation's finances, you
    need to be assured that NIH remains a worthwhile national investment.
    Even as you make these decisions and even as our country recovers from
    financial recession, I want to offer evidence that NIH and its research
    provide two strong and ongoing benefits to our economy.
        First, NIH research spending has an impact on job creation and
    economic growth. A new economic impact study by United for Medical
    Research suggests that in fiscal year 2010, NIH research funding
    supported an estimated 487,900 American jobs, including researchers and
    spin-off employment.
        Second, NIH research funding has a longer term impact in its role
    as the foundation for the medical innovation sector. Nearly 1 million
    U.S. citizens are employed by the industries and companies that make up
    this sector of the economy, earning $84 billion in wages and salary in
    2008, and exporting $90 billion of goods and services in 2010. NIH
    support for biomedical research institutions catalyzes business
    activity in other ways as well. Such institutions constitute reservoirs
    of skilled, knowledgeable individuals and, thereby, attract companies
    that wish to locate their operations within such ``knowledge hubs.''
        For example, in the 1990s, Federal funding through research grants
    and the Small Business Innovation Research (SBIR) and the Small
    Business Technology Transfer (STTR) programs transformed the academic
    research environment and helped to launch new industrial sectors in
    Silicon Valley and elsewhere that are flourishing today. Federal
    funding has been crucial in stimulating the formation of start-up
    companies and collaborations among academia and the private sector in
    the development of innovative technology. A prime example is the
    company Affymetrix.
        In the late 1980s, a team of scientists led by Stephen P.A. Fodor,
    Ph.D., developed methods for fabricating DNA microarrays, called
    GeneChips, using semiconductor manufacturing techniques, melded with
    advances in combinatorial chemistry to capture vast amount of
    biological data on a small glass chip. In 1992, the first of several
    NIH grants was awarded to Affymetrix; with this and an SBIR grant from
    the Department of Energy, Dr. Fodor was able to demonstrate proof of
    principle of using large arrays of DNA probes in genetic analysis.
    Affymetrix and similar companies are building the machine tools of the
    genomic revolution. In 2009, Affymetrix had annual revenue of $327
    million and employed more than 1,100 people.
        Furthermore, NIH research leads to better health outcomes that not
    only ease human suffering, but also produce an economic return. A 2006
    study by Kevin Murphy and Robert Topel of the University of Chicago
    shows that a permanent reduction of 1 percent in cancer deaths has a
    present value to current and future generations of Americans of nearly
    $500 billion. The article states that if we were able to defeat cancer
    completely, such cures would be worth approximately $50 trillion--more
    than three times today's Gross Domestic Product.\4\
    ---------------------------------------------------------------------------
        \4\ Murphy, K.M., & Topel, R.H. (2006), The value of health and
    longevity. Journal of Political Economy, 114(5), 871-904.
    ---------------------------------------------------------------------------
        We face a similar economic threat from diabetes. If current trends
    continue, by 2050 as many as one in three U.S. adults will be diagnosed
    with diabetes.\5\ Total costs of diabetes, including medical care,
    disability, and premature death, reached an estimated $174 billion in
    the United States in 2007.\6\ According to analysis from the
    UnitedHealth Center for Health Reform & Modernization, more than 50
    percent of Americans could have diabetes or pre-diabetes by 2020.\7\
    Furthermore, the center's analysis predicts diabetes and pre-diabetes
    will account for an estimated 10 percent of total healthcare spending
    by the end of this decade, at an annual cost of almost $500 billion.
    ---------------------------------------------------------------------------
        \5\ http://www.cdc.gov/media/pressrel/2010/r101022.html.
        \6\ CDC National Diabetes Fact Sheet. http://www.cdc.gov/diabetes/
    pubs/pdf/ndfs_2011.pdf.
        \7\ http://www.unitedhealthgroup.com/hrm/UNH_WorkingPaper5.pdf.
    ---------------------------------------------------------------------------
        But I can offer some hope. NIH spearheaded a landmark clinical
    trial on type 2 diabetes prevention that showed that people at high-
    risk for diabetes can dramatically reduce their risk of developing type
    2 diabetes through modest exercise and dietary changes that achieve
    modest weight loss. Called the Diabetes Prevention Program (DPP), the
    clinical trial included 3,234 adults at high risk for developing type 2
    diabetes, including those with a family history of diabetes, as well as
    other risk factors. One-third of these individuals participated in a
    lifestyle program that included exercise training and dietary change
    implemented under the guidance of lifestyle coaches. The DPP research
    team found that this approach lowered risk of diabetes by 58
    percent.\8\ The DPP trial also demonstrated that the cost of the
    lifestyle intervention was $3,540 per participant over 3 years, which
    was significantly offset by the lowering of other healthcare costs as
    lifestyle participants became healthier.\9\ The cost effectiveness of
    the DPP has continued to be followed and 10-year results will be
    published in the near future. Building on these critically important
    results, NIH partnered with the Centers for Disease Control and
    Prevention (CDC) and more than 200 private partners, including the
    YMCA, Walgreens, and UnitedHealthcare, to bring these evidence-based
    lifestyle interventions to communities in Ohio, Indiana, Minnesota,
    Arizona, Oklahoma, New Mexico, New York, New Jersey, Connecticut, and
    Georgia. In addition, the DPP Lifestyle Intervention is being used by
    the Indian Health Service in a large demonstration project on many
    American Indian reservations.
    ---------------------------------------------------------------------------
        \8\ Knowler WC, et al. Reduction in the incidence of type 2
    diabetes with lifestyle intervention or metiformin. N. Engl J Med
    346:393-403, 2002.
        \9\ Diabetes Care. 2003 Jan;26(1):36-47.
    ---------------------------------------------------------------------------
                           investing in basic science
        At NIH, we have always put our greatest percentage of our resources
    into basic research. This is because the fundamental observations made
    today become the building blocks of tomorrow's knowledge, therapies,
    and cures. NIH's history has repeatedly demonstrated that significant
    scientific advances occur when new basic research findings, often
    completely unexpected, open up new experimental possibilities and
    therapeutic pathways. Historically, NIH has put more than 50 percent of
    its budget into basic research and the research discoveries that led to
    the 132 Nobel prizes won by our intramural and university scientists
    are evidence of the wisdom of this investment.
        Basic research is precisely the type of work that the private
    sector, which must see a rapid return on invested capital, cannot
    afford to support. NIH provides the fundamental observations that
    pharmaceutical and biotechnology companies can turn into diagnostics,
    therapies, and devices that eventually reach patients. As the
    Congressional Budget Office put it, ``Federal funding of basic research
    directly stimulates the drug industry's spending . . . by making
    scientific discoveries that expand the industry's opportunities for
    research and development.'' \10\
    ---------------------------------------------------------------------------
        \10\ Congressional Budget Office, Research and Development in the
    Pharmaceutical Industry, October, 2006, p. 3.
    ---------------------------------------------------------------------------
        Because we simply cannot predict the next scientific revelation or
    anticipate the next opportunity, our basic research portfolio must be
    diverse. We set scientific priorities by considering a wide array of
    biomedical questions that we might try to answer. It is rather like
    facing a series of doors, some of which lead to vast treasures and
    others to much more modest payouts, without any sure way of knowing
    what lies behind any particular door. To improve our odds of striking
    scientific gold, we need a broad basic research portfolio that enables
    our Nation to open as many doors as our resources allow.
        Not all disease or scientific problems are equally ripe for new
    advances, nor do such advances come at the same rate across the
    portfolio, no matter how pressing today's public health challenges are.
    We can only be sure that without a strong commitment to basic research
    today, the new knowledge of tomorrow will remain hidden behind those
    unopened doors and future therapies and cures will remain out of our
    reach.
        Let me offer a few of the exciting insights that NIH's support of
    basic research have provided. On April 3, 2011, the online issue of
    Nature Genetics presented the findings by a team of NIH-supported
    scientists who had identified five new genetic variants that are risk
    factors for late-onset Alzheimer's disease, which is the most common
    form of the disorder. These findings doubled from 5 to 10 the number of
    gene variants that we know are associated with Alzheimer's disease.\11\
    ---------------------------------------------------------------------------
        \11\ Naj, A.C. et al. Common Variants of MS4A4/MSA6E, CD2AP, CD33
    and EPHA 1 are associated with late-onset Alzheimer's Disease. Nature
    Genetics, EPUB April 3, 2011, and Holligworth, P., et al. Common
    variants at ABCA7, MS4A/MS4A4E, EPHA 1, CD33 and CD2Ap are associated
    with Alzheimer's disease. Nature Genetics. Epub April 3, 2011.S
    ---------------------------------------------------------------------------
        What is even more compelling is that these newly identified genes
    strongly implicate inflammation and high cholesterol as risk factors in
    the development of Alzheimer's disease. Although each of these newly
    identified genes increases a given individual's risk of developing the
    disease by no more than 10 to 15 percent, the unanticipated insight
    that cholesterol and inflammation are contributing factors opens up new
    research avenues to understand the disease process, and increases the
    likelihood that we can glimpse potential preventions or therapies.
        NIH's commitment to basic research has also provided us with one of
    the most promising therapeutic strategies we have seen to date for the
    deadliest form of skin cancer, melanoma. Since 2002, we have known that
    many melanoma tumors exhibit a mutation in the BRAF gene and that this
    mutation might provide a target for therapeutic intervention. A team
    that included NIH-supported investigators used high-throughput
    screening in combination with structural biology, to identify compounds
    that inhibit the activity of the mutant form of the BRAF gene found in
    most melanomas, but have little effect on the BRAF gene found in normal
    cells. This basic cancer research supported by NIH contributed to the
    development of the drug PLX4032, a drug designed to inhibit the
    activity of a mutant form of the protein called BRAF. This is a
    powerful example of how support for basic research can be translated
    into therapeutic potential. In August 2010, Plexxikon, a small drug
    development company, announced that PLX4032, had elicited a positive
    response in more than 80 percent of melanoma patients in early phase
    clinical trials. PLX4032 caused the tumors in 24 of the 30 trial
    participants to shrink by at least 30 percent, while the tumors of two
    patients disappeared. Another clinical trial involving hundreds of
    participants across many institutions demonstrated that metastatic
    melanoma patients treated with PLX4032 lived 6 to 8 months longer than
    those who had been given the chemotherapy drug dacarbazine, which is
    the current standard of care.
        Whether it is with the hope of finding new ways to treat cancer,
    prevent Alzheimer's disease, or help people suffering from countless
    other rare and common conditions, we at NIH invest in basic research
    because of our conviction that it will benefit our Nation in the long
    term.
                        advancing translational science
        NIH also has a longstanding commitment to translating fundamental
    knowledge into cures and therapies for human disease. It should not be
    surprising that NIH-supported science underpins many of the most
    transformative drugs and therapies that have benefited millions of
    Americans and people around the world, including statins to lower
    cholesterol and drugs to treat depression. In 2010, we conducted a
    trans-NIH inventory of therapeutics development activities and found
    more than 550 such projects, of which approximately 65 percent were
    pre-clinical and 35 percent were clinical research.
        An analysis published in the February 10, 2011 issue of the New
    England Journal of Medicine (NEJM) underscores the depth and breadth of
    NIH's support for translational science that benefits patients.\12\ The
    article's authors describe a new emphasis on ``public sector research''
    that is almost exclusively supported or conducted by NIH, noting ``the
    boundaries between the roles of the public and private sectors have
    shifted substantially since the dawn of the biotechnology era, and the
    public sector now has a much more direct role in the applied-research
    phase of drug discovery.''
    ---------------------------------------------------------------------------
        \12\ Stevens, Ashley J. et al. The role of public-sector research
    in the discovery of drugs and vaccines. New England Journal of
    Medicine, 364,:6, February 10, 2011.
    ---------------------------------------------------------------------------
        Drugs that represent a major advance in treatment or offer
    treatments for diseases for which no adequate therapy currently exists
    are granted ``priority review'' by FDA. According to the NEJM article,
    between 1990 and 2007, 20 percent of the FDA approvals of novel
    compounds granted priority review were given to drugs discovered by
    NIH. Examples include AZT for HIV/AIDS and the targeted leukemia
    therapy Gleevec. Over the past 40 years, 153 new FDA-approved drugs,
    vaccines, or new indications for existing drugs were discovered through
    work carried out by NIH-supported biomedical research institutions.
        Despite NIH's historic and growing commitment to translational
    sciences, far more remains to be done. Millions of people still suffer
    from diseases, such as cancers and diabetes, for which we have no
    adequate treatments. There are nearly 7,000 rare diseases, yet we have
    therapies for fewer than 200 of them. This staggering public health
    need and attendant human suffering continues even as the pharmaceutical
    industry, beset by economic stress, is investing less in research and
    development, and the pool of venture capital needed by the biotech
    industry is drying up.
        At the same time, a deluge of discoveries about the molecular basis
    of disease has been made possible by the sequencing of the human and
    many other genomes, as well as breathtaking advances in research
    technologies, such as high-throughput screening and bioinformatics.
    These discoveries reveal hundreds of tantalizing potential therapeutic
    targets. As the result of years of steadfast support of NIH research by
    Congress and the American people, we find ourselves in a paradoxical
    situation: we can uncover the molecular basis of common and rare
    diseases better than ever before and we can more readily identify
    therapeutic opportunities than at any point in history, but the
    pipeline through which these new therapeutic agents must pass is
    crimped and, in some places completely blocked.
        Consequently, a new approach to therapeutic development, and a new
    partnership with the private sector, is needed. That is why we have
    proposed the establishment of NIH's new National Center for Advancing
    Translational Sciences beginning in fiscal year 2012.
              national center for advancing translational sciences
        As previously noted, NIH has a long and rich history of significant
    contributions to therapeutic development. In particular, the National
    Cancer Institute (NCI) and the National Institute for Allergy and
    Infectious Diseases (NIAID) have made major contributions over many
    years to the discovery of new treatments. However, now is the time to
    consider the therapeutic development process itself as a scientific
    problem that is ripe for innovation. The mission of the National Center
    for Advancing Translational Sciences (NCATS) will be to advance the
    discipline of translational science and catalyze the development and
    testing of novel diagnostics and therapeutics across a wide range of
    human diseases and conditions. NIH has no intention of entering the
    drug development arena that is rightly the province of private sector
    companies. Indeed, given that it costs in the range of $ 1.3 billion to
    $1.8 billion to bring one drug to market, it is clear that it would be
    impossible for NIH to compete with private industry.\13\ What NCATS
    intends to do is advance the science of therapeutic development and
    determine if there are ways we can re-engineer the drug development
    pipeline; creating new approaches and methods that will benefit
    everyone interested in speeding the delivery of new medicines.
    ---------------------------------------------------------------------------
        \13\ DiMasi, JA, Hansen RW, Grabowski HG. Extraordinary claims
    require extraordinary evidence. Journal of Health Economics
    2005;24(5):1034-1044. Tonkens, R. An Overview of the Drug Development
    Process. The Physician Executive May-June 2005.
    ---------------------------------------------------------------------------
        Today, the development of new diagnostics and therapeutics is a
    complex, costly, and risky endeavor. Only a few of the thousands of
    compounds that enter the drug development pipeline will ultimately make
    it into the medicine chest or to the patient's bedside. NCATS will
    study the various steps in the drug development pipeline, consult with
    the private sector to identify bottlenecks amenable to re-engineering,
    and experiment with innovative methods to streamline the process.
        To offer one example of the kind of pipeline challenge we might
    address, new ideas about assessing the toxic potential of drug
    candidates using sophisticated cell-based methods, instead of animal
    toxicology testing, hold out the promise of revolutionizing this step
    in validating a new therapeutic agent--and such research can be
    catalyzed by NIH in ways that might otherwise not be possible.
        NCATS will attack the bottlenecks in the drug development pipeline
    by experimenting with innovative approaches in an open-access model so
    that all stakeholders, ranging from industry to patients, will be able
    to access and apply its innovations. NCATS's open access operating
    framework will also advance the field of regulatory science by
    promoting interactions among the Food and Drug Administration (FDA),
    NIH, patient advocates, and pharmaceutical and biotechnology companies.
    NCATS will encourage collaboration across all sectors, provide
    resources to enable therapeutic development, and support and enhance
    training in the relevant translational science disciplines.
        NCATS will complement--not compete with--translational research
    being carried out elsewhere at NIH and in the private sector. In fact,
    in pursuing its mission of using the power of science to advance the
    entire discipline of translational science, NCATS will benefit all
    stakeholders, including academia, biotechnology firms, pharmaceutical
    companies, the FDA, and--most importantly--patients and their families.
        NCATS will pull together existing NIH programs such as the
    Therapeutics for Rare and Neglected Diseases program, the Office of
    Rare Diseases Research, the Rapid Access to Interventional Development
    program, the Clinical and Translational Science Awards, the FDA-NIH
    Regulatory Science grants program, and components of the Molecular
    Libraries initiative. These relocated programs will have their
    respective budgets transferred to or implemented by the new center. In
    addition, we are hopeful that funding for the new Cures Acceleration
    Network will be provided within the NCATS appropriation in fiscal year
    2012. The intent of this innovative program and its exceptional DARPA-
    like flexibilities for supporting projects are a natural fit with
    NCATS.
        Aside from the new funding requested in fiscal year 2012 for the
    Cures Acceleration Network, resources for NCATS will come from the
    combination of already existing and appropriated programs and so be
    budget neutral.
        NCATS will bring the scientific method to bear on today's drug
    development process and aim to improve and speed the therapeutic
    development process of tomorrow.
                                   conclusion
        This statement has provided you with a brief overview of NIH's past
    successes and future commitment to basic and translational sciences,
    along with a quick look at the important role that NIH plays in our
    domestic economy and U.S. global economic and scientific leadership.
        But I would like to close my testimony today with an example that
    demonstrates the benefits to be reaped from our continuing pursuit of
    ``personalized medicine.'' It is the story of one individual, 6-year-
    old Nic Volker of Monona, Wisconsin. Starting about the age of 2, Nic
    developed a mysterious, life-threatening disease that ravaged his
    intestines, making it impossible for him to eat normally and causing
    unimaginable pain and suffering. At a loss to explain this terrible,
    inflammatory condition, researchers and clinicians at the Medical
    College of Wisconsin decided to sequence Nic's entire exome, that is,
    all the parts of the genome that code for the proteins that become
    life's building blocks. After exhaustive work over a period of months,
    the researchers identified a mutation in Nic's XIAP gene. Such
    mutations had been associated with rare blood disorders, but not with
    bowel symptoms. Based on this new insight, the research team had an
    idea that, as with the rare blood disorders, Nic's disease might be
    curable with a bone marrow transplant.
        NIH investment over the years in the sequencing of genomes--and the
    technologies associated with such sequencing--has put us at the
    threshold of ``personalized medicine.'' Young Nic Volker is one of a
    handful of individuals who has crossed that threshold, and it was made
    possible because of years of research and development supported and
    performed by NIH.
        Transplantation of cord-blood stem cells from a matched donor
    occurred in July of last year and, although Nic is still on
    immunosuppressant drugs to prevent rejection of the donated cells, his
    symptoms have largely disappeared and today he can eat normally. Hot
    dogs are his favorite!
        The local newspaper, the Milwaukee Journal Sentinel, was so struck
    by the saga of Nic and his family that they devoted a series of
    articles to the little boy's struggles and therapy, coverage that
    included posting photos, videos, blogs, and many other resources to the
    web. The five Journal Sentinel journalists did such a good job that
    they were awarded the Pulitzer Prize for Explanatory Reporting on April
    18. Now, that is truly putting a face on the promise of today's
    biomedical research, tomorrow's personalized medicine, and NIH's role
    in making this promise possible.
        Thank you Mr. Chairman. This concludes my formal remarks.
                                     ______

                   Prepared Statement of Harold Varmus, M.D.
        Mr. Chairman and Members of the Committee: I am pleased to present
    the President's fiscal year 2012 budget request for the National Cancer
    Institute (NCI) of the National Institutes of Health (NIH). The fiscal
    year 2012 request includes $5,196,136,000 for NCI, which reflects an
    increase of $141,899,000 over the comparable fiscal year 2011 level of
    $5,054,237,000.
        We now know that cancer is a collection of diseases reflecting
    changes in a cell's genetic makeup and thus its programmed behavior.
    Sometimes the genetic changes occur spontaneously or are inherited;
    sometimes they are caused by environmental triggers, such as chemicals
    in tobacco smoke, ultraviolet radiation from sunlight, or viruses.
    While cancers constitute an incredibly diverse and bewilderingly
    complex set of diseases, we have at hand the methods to identify
    essentially all of the genetic changes in a cell and to use that
    knowledge to rework the landscape of cancer research and cancer care,
    from basic science to prevention, diagnosis, and treatment. The funds
    in the President's budget for NCI represent a bold investment strategy
    critical for realizing that goal.
        The emerging scientific landscape offers the promise of significant
    advances for current and future cancer patients, and for preventing
    cancer so that many never become cancer patients. And it offers
    scientists at the National Cancer Institute--and in the thousands of
    laboratories across the United States that receive NCI support--the
    opportunity to increase the pace of lifesaving discoveries
    dramatically.
        In the past year alone, we have seen powerful examples of how
    research dollars have translated into concrete advances against cancer
    through basic science, prevention and early detection, and treatment.
        Basic science.--In collaboration with NHGRI, the NCI is leading The
    Cancer Genome Atlas (TCGA), the largest and most comprehensive analysis
    of the molecular basis of cancer ever undertaken. TCGA aims to identify
    and catalog all of the relevant genetic alterations in many types of
    cancer. For instance, building on their recent reclassification of
    glioblastoma multiforme (GBM), an aggressive form of brain cancer, this
    year TCGA investigators discovered that about 10 percent of patients
    with one of the four subtypes of GBM are younger at diagnosis and live
    longer than patients with other subtypes of the disease, but their
    tumors are unresponsive to current intensive therapies. The molecular
    profile of this subtype offers new targets for developing drugs to
    treat this form of the disease more effectively. TCGA scientists are
    also preparing to publish similarly important findings about the major
    form of ovarian cancer in mid-2011 and are in the midst of analyzing
    nearly 20 other types of cancer.
        Prevention and early detection.--NCI's intensive efforts to study
    and reduce the use of tobacco products have contributed to a sustained
    annual reduction in age-adjusted cancer mortality rates over the past
    decade and more. But current and former heavy smokers remain at high
    risk of developing lethal lung cancers, which are the leading cause of
    cancer mortality. In late 2010, NCI announced initial results from the
    National Lung Screening Trial, a large, multi-year randomized trial
    that enrolled more than 53,000 subjects. Because early detection
    provides the potential to intervene at the earliest, most treatable
    stages of disease, thus reducing potentially difficult to treat
    outcomes seen in more advanced disease, current and former smokers who
    were screened with low-dose helical computed tomography were 20 percent
    less likely to die of lung cancer than were peers who received standard
    chest x-rays. These results provide the first clear demonstration that
    a screening procedure can be effective in reducing mortality from lung
    cancer--a finding that could save many lives among those at greatest
    risk. Over the course of the $240 million study, NLST investigators
    collected samples of early and advanced lung cancers from enrolled
    subjects, and these specimens will be invaluable for determining
    genetic alterations that may be used to predict which tumors are likely
    to progress to an advanced stage.
        Cancer treatment.--The potential therapeutic impact of basic
    discoveries made by TCGA and other efforts in cancer genomics has been
    dramatically illustrated this year by the development of effective
    drugs against the most deadly form of skin cancer, melanoma. Almost a
    decade ago, studies of cancer genomes first uncovered a common mutation
    in a gene that encodes an enzyme called BRAF. Last year, early stage
    clinical trials at NCI-designated Cancer Centers of drugs targeted
    against the mutant BRAF enzyme showed that most melanomas with the
    relevant mutation regressed dramatically. Although tumor regression
    generally lasted less than a year, NCI-supported investigators have
    already pinpointed some causes of resistance to BRAF inhibitors,
    outlining a pathway to more sustained control of this lethal disease.
        Another benefit of a prolonged and broad-based investment in cancer
    research has also been realized in the context of malignant melanoma
    this year, with the recent approval by the FDA of an antibody,
    ipilimumab, which extends the lives of patients with metastatic
    melanoma. Ipilimumab stimulates the immune system to act against cancer
    by blocking natural inhibitors of the immune response, an approach that
    would not be possible without a profound understanding of the immune
    system and one that promises to harness immunological tools against
    other cancers.
        These examples of NCI's progress in understanding, treating, and
    detecting different forms of cancer illustrate what can be achieved at
    an accelerated pace with sustained investments across the cancer
    research spectrum, such as proposed under the President's budget. While
    those perspectives are only beginning to inform the American public's
    perception about cancer and its treatment, the downward trajectory of
    cancer deaths--reported by NCI and its partners in March--reflects real
    and sustained reductions over more than a decade for numerous cancers,
    including the four most common: breast, colorectal, lung, and prostate.
    We have identified proteins and pathways that different cancers may
    have in common and represent targets for new drugs for these and many
    other cancers--since so often research in one cancer creates potential
    benefits across others.
        Additional progress against cancer also will require building these
    research advances into clinical treatments and diagnostic tools for
    better patient care and by our many connections with public and private
    sector partners. The Institute's investments in translational research
    are broad and deep, and will receive NCI's full energies, recognizing
    that the publicly announced proposal for reorganizing services that
    support translational science in general could give NIH additional
    focus in this important area.
                 revitalizing the cancer clinical trials system
        For today's new understandings of cancer biology to benefit cancer
    patients on a broad scale, they must be coupled with a modernized
    system for conducting cancer clinical trials. This system must enable
    clinical researchers across the Nation to acquire tumor specimens and
    conduct genetic tests on each patient, to efficiently analyze molecular
    changes in those samples, to manage and secure vast quantities of
    genetic and clinical data, and to identify subsets of patients with
    tumors that demonstrate changes in specific molecular pathways--
    pathways that can be targeted by a new generation of cancer therapies.
        As part of its effort to transform the cancer clinical trials
    system, NCI asked the Institute of Medicine (IOM) in 2009 to review the
    Clinical Trials Cooperative Group Program. This program involves a
    national network of 14,000 investigators currently organized into nine
    U.S. adult Cooperative Groups and one pediatric cooperative group that
    conduct large-scale cancer clinical trials at 3,100 sites across the
    United States. The IOM report, issued in April 2010, noted that the
    current trials system--established a half-century ago--is inefficient,
    cumbersome, underfunded, and overly complex. Among a series of
    recommendations, the report urged that the existing adult cooperative
    groups be consolidated into a smaller number of groups, each with
    greater individual capabilities and with new means to function with the
    others in a more integrated manner.
        In December 2010, NCI announced its intent to begin consolidating
    the current nine adult cooperative groups into four state-of-the-art
    entities that will design and perform improved trials of cancer
    treatments, as well as explore methods of cancer prevention and early
    detection, enhance the ability of the cooperative groups to assess the
    molecular characteristics of individual patients' tumors, and study
    quality-of-life issues and rehabilitation during and after treatment.
    The sole pediatric cooperative group was created by consolidating four
    pediatric cooperative groups almost a decade ago, and that group will
    not be affected by the current consolidation effort.
                             provocative questions
        This has been a challenging and hopeful time for NCI to lead the
    Nation's cancer research program. Over the past two decades researchers
    have unraveled some of the damage that occurs in the genome of a cancer
    cell and how a cancer cell behaves in its local environment as a result
    of those changes. With this better understanding of cancer and recent
    technological advances in many fields, such as genomics, molecular
    biology, biochemistry, and computational sciences, progress has been
    made on many fronts, and a portrait has emerged for several cancers.
    With sustained and accelerated funding, and NCI's strong leadership in
    defining cancer research priorities, we can build upon today's cancer
    advances with provocative thinking by asking better questions.
        To that end, NCI is asking researchers in various disciplines to
    pose and articulate ``provocative questions'' that can help guide the
    Nation's investment in cancer. Provocative questions may be built on
    older, neglected observations that have never been adequately explored,
    or on recent findings that are perplexing, or on problems that were
    traditionally thought to be intractable but now might be vulnerable to
    attack with new methods.
        Many of these provocative questions are being asked--and answered--
    by young scientists who are early in their careers. The 2012 budget
    will support NCI's commitment to ensuring that an equitable share of
    our research grants will go to the young men and women, who are at the
    forefront of understanding cancer.
        We are now reaping the rewards of investments in cancer research
    made over the past 40 years or more, even as we stake out an investment
    strategy to realize the potential we see so clearly for the future. The
    public has benefitted from past generous congressional stewardship of
    biomedical research funding; cancer research over the past four decades
    has provided the evidence required to lower the incidence and mortality
    of many kinds of cancer, to improve the care of cancer patients, and to
    establish the new understanding of cancer that is now beginning to
    revolutionize control of cancer throughout the world.
        No matter what the fiscal climate, NCI will strive to commit the
    resources necessary to bring about a new era of cancer research,
    diagnosis, prevention, treatment, and survivorship.
        Thank you for the opportunity to provide you this testimony, and I
    would be pleased to answer any questions you might have.
                                     ______

                  Prepared Statement of Susan B. Shurin, M.D.
        Mr. Chairman and Members of the Committee: I am pleased to present
    the President's budget request for the National Heart, Lung, and Blood
    Institute (NHLBI) of the National Institutes of Health (NIH). The
    fiscal year 2012 budget of $3,147,992,000 includes an increase of
    $80,903,000 over the comparable fiscal year 2011 level of
    $3,067,089,000.
        The NHLBI provides global leadership for a research and education
    program to promote prevention and treatment of heart, lung, and blood
    diseases. Our vision is to enhance the health of all individuals and
    thereby enable them to enjoy longer and more productive lives. The
    Institute advances its objectives through an innovative program of
    excellent science that addresses urgent public health needs,
    capitalizes upon extraordinary opportunities, leverages strategic
    assets, balances and integrates basic and clinical research approaches,
    and calls upon the creativity, expertise, and dedication of thousands
    of scientists here and abroad. The American people have generously
    supported this work for many years, and tremendous progress has
    resulted.
        This testimony highlights three areas of particular current
    emphasis: (1) genetics and genomics; (2) regenerative medicine; and (3)
    translational medicine.
                             genetics and genomics
        NHLBI-funded gene-sequencing projects and genome-wide association
    studies have been extraordinarily productive. Scanning the genomes of
    more than 100,000 people from all over the world, scientists recently
    reported the largest set of genes yet discovered that underlie blood
    lipid variations known to be major risk factors for coronary heart
    disease. Altogether, the gene variants explain between one-quarter and
    one-third of the inherited portions of cholesterol and triglyceride
    measured in the blood. Of the variants, 59 had not been previously
    identified and thus provide new clues for developing effective
    medicines to combat heart disease. This exciting discovery follows upon
    similar research, reported in 2009, regarding another heart disease
    risk factor--hypertension. Using genomic analysis of over 29,000
    participants from the Framingham Heart Study and other cohorts, an
    international research team identified a number of unsuspected genetic
    variants associated with systolic and diastolic blood pressure.
    Although hypertension has long been known to run in families and have a
    substantial genetic component, previous attempts to identify genes
    associated with blood pressure had met with only limited success. The
    new findings from both the lipid and the blood pressure studies
    illustrate the potential of large-scale genome-wide scans to identify
    genes that play roles in a complex disease of widespread public health
    importance.
        Smaller-scale genome-wide scans are also providing valuable new
    information about less common disorders, such as thoracic aortic
    aneurysm and dissection--a condition that is often asymptomatic until
    an unpredictable catastrophic cardiovascular event occurs. Researchers
    comparing 418 patients with non-familial thoracic aneurysms to normal
    controls identified a number of genetic variants that appeared more
    frequently in the patients. Many of the variants exist in genes that
    are in some manner involved in contraction of smooth-muscle cells,
    suggesting that genetic variants governing smooth-muscle cell function
    are a potential target of predictive tests that could be developed in
    the future.
        Although genome-wide scans and sequencing have identified many
    genetic variations that contribute to disease risk, much more research
    is needed to understand the mechanisms underlying gene disease
    associations. NHLBI is advancing this area by supporting a new program,
    Next Generation Genetic Association Studies, to investigate cells that
    have been reprogrammed into induced pluripotent stem cells to model
    heart, lung, and blood diseases and explore the functional consequences
    of genetic variation.
        Another initiative, Getting from Genes to Function in Lung Disease,
    will support characterization of the function of lung-disease
    associated genes and their variants that have been identified through
    GWAS or other genetic approaches. Multidisciplinary teams will use a
    variety of experimental methods and tools to elucidate the mechanisms
    that contribute to diseases such as asthma, chronic obstructive
    pulmonary disease (COPD), sarcoidosis, and idiopathic pulmonary
    fibrosis and thereby generate knowledge that may lead to more effective
    ways to prevent and treat them. In fiscal year 2012, the Institute
    plans to solicit research projects to study two severe and poorly
    understood conditions that affect the lungs: The Genomic Research in
    Alpha-1 Antitrypsin Deficiency and Sarcoidosis program will conduct
    state-of-the-art genomic, microbiomic, and phenotypic studies with the
    goals of understanding the molecular and cellular bases of the
    diseases, facilitating classification of sub-types, and developing new
    drug therapies.
        Because genome-wide scans are not well suited to discovery of
    extremely uncommon genetic variants, the Institute is pursuing other
    avenues to explore the contributions of infrequent variants to both
    common and rare diseases. A program planned for fiscal year 2012 in
    collaboration with the National Human Genome Research Institute, Life
    After Linkage: The Future of Family Studies, will use data from
    existing family studies to identify and characterize genes, including
    rare variants, that influence complex diseases. The potential success
    of such an approach is illustrated by a recent breakthrough resulting
    from a collaboration between the NHLBI intramural program and the NIH
    Undiagnosed Diseases Program. Researchers identified the genetic cause
    of a rare and debilitating vascular disorder, not previously explained
    in the medical literature, that involves severe arterial calcification.
    Analysis of DNA from members of three affected families revealed that
    the variant is in a gene responsible for a product that protects
    arteries from calcifying. It is hoped that this understanding of the
    underlying defect will enable discovery of improved treatment for the
    patients.
                             regenerative medicine
        Body components can malfunction because of inherent defects,
    catastrophic or accumulated damage, or senescence, and chronic disease
    is often the result. Restoring healthy function via delivery of
    ``replacement parts'' and helping organs repair injury with functional
    tissue instead of scarring are high priorities of NHLBI. Recent
    progress gives much reason for optimism. For example, heart attacks
    cause permanent damage to heart muscle cells (cardiomyocytes) that
    renders them useless for pumping blood. Although cardiomyocytes cannot
    themselves be rejuvenated, NHLBI-supported scientists were able to
    induce other heart cells (fibroblasts) to become pluripotent stem cells
    that, in turn, were induced to become cells that looked and behaved
    much like cardiomyocytes. The finding suggests the possibility that
    fibroblasts--cells widely available throughout the body--could be
    directly reprogrammed into functional cells to treat or prevent heart
    failure and other adverse consequences of cell damage. Other NHLBI-
    supported researchers recently reported progress toward engineering
    lung tissue in a rat model, creating a scaffold populated with
    multipotent neonatal rat cells to produce a transplantable organ
    capable performing the fundamental lung function of gas exchange. The
    success of this study and others using cadaveric human lung tissue and
    immortalized cell lines suggests that such an approach might one day be
    beneficial for patients who are awaiting lung transplant.
        NHLBI is making considerable investments to advance regenerative
    medicine research for cardiovascular, lung, and blood diseases. A
    collaborative solicitation with the National Institute of Biomedical
    Imaging and Bioengineering, New Strategies for Growing 3D Tissues, will
    support highly integrated, multidisciplinary research to improve
    understanding of how cells respond to their environment and how cell-
    communication systems that enable blood-vessel and organ development
    can be used to engineer 3D human cellular aggregates. Translation of
    Pluripotent Stem Cell Therapy for Blood Diseases will promote the
    development of technologies for translation of recent stem cell
    advances into treatments for sickle cell disease and other blood
    disorders. This new program will build upon the expertise, resources,
    and infrastructure of the ongoing NHLBI Progenitor Cell Biology
    Consortium, and it will encourage collaboration with two other
    Institute initiatives--Production Assistance for Cellular Therapies and
    the Gene Therapy Resource Program, which is slated for renewal in
    fiscal year 2012.
        A major initiative planned for fiscal year 2012, Consortium of Lung
    Repair and Regeneration: Building the Foundation, will establish an
    interactive group of multidisciplinary teams to formulate and test
    innovative hypotheses about the mechanisms that control lung repair and
    regeneration. The program will seek to leverage innovative technologies
    such as tissue engineering, biomaterials and scaffolds, induced
    pluripotent stem-cell technology, cell-directed therapy, and humanized
    animal models that are not used widely in lung-regeneration research
    but are being applied to investigate regeneration and repair in other
    organ systems.
                             translational medicine
        NHLBI continues to place strong emphasis on translating basic
    science findings into better diagnostic, therapeutic, and preventive
    approaches and fostering their use in real-world clinical practice. A
    number of initiatives are supporting these efforts. For example, a
    program called Science Moving Towards Research Translation and Therapy
    (SMARTT) has been launched to facilitate transition of potential new
    therapies for heart, lung, and blood diseases from discovery in the lab
    to the testing needed to establish their safety and effectiveness in
    people. Pre-clinical development--that is, readying products for
    testing in humans--is the first step in turning discoveries into cures,
    but the processes involved can be expensive and baffling to academic
    scientists. Connecting academic researchers with industry, the SMARTT
    program will offer help with manufacturing, pharmacology and toxicology
    testing, pre-clinical and early-phase clinical study design, and
    administrative and regulatory matters.
        The Translational Research Implementation Program, or TRIP, is
    intended to facilitate well-designed clinical trials in heart, lung, or
    blood diseases to demonstrate the safety and efficacy of promising
    interventions that have emerged from fundamental studies. Its initial
    phase, which began in fiscal year 2010, supported the planning of
    trials; the second phase will fund the most promising of them beginning
    in fiscal year 2012. A second new program will provide planning grants
    to establish the feasibility of pivotal clinical trials with a major
    focus on hemoglobinopathies such as sickle cell disease and
    thalassemia. Another solicitation, planned for fiscal year 2012, would
    provide an innovative mechanism for the development of clinical trials
    for hemostatic and thrombotic disorders, including access to expertise
    in clinical trial methodology and design through existing institutional
    resources.
        Several exceptionally promising new translational efforts in lung
    diseases are also under way. Research Education in Sleep and Circadian
    Biology is promoting the use of innovative educational tools and
    programs to accelerate the transfer of recent scientific advances and
    health knowledge in sleep and circadian biology into clinical and
    public-health practice. Renewal of a solicitation titled Utilization of
    a Human Lung Tissue Resource for Vascular Research will advance
    translational efforts in lung vascular disease, using previously
    collected biospecimens from patients with pulmonary hypertension. An
    initiative slated for fiscal year 2012 would support dosing and
    efficacy trials of promising but untested therapies for lung diseases,
    including agents that have already been approved for use in treating
    other diseases and combinations of common drugs with low toxicities,
    neither of which would be likely candidates for testing by industry.
    Such small proof-of-concept trials are vitally important for
    translating basic research advances into clinical research, providing a
    foundation for larger efficacy trials, and advancing understanding of
    disease processes.
                                     ______

            Prepared Statement of Griffin P. Rodgers, M.D., M.A.C.P.
        I am pleased to present the President's fiscal year 2012 budget
    request for the National Institute of Diabetes and Digestive and Kidney
    Diseases (NIDDK) of the National Institutes of Health (NIH). The fiscal
    year 2012 budget includes $1,837,957,000, which is $47,272,000 more
    than the comparable fiscal year 2011 level. Complementing these funds
    is an additional $150,000,000 also available in fiscal year 2012 from
    the Special Statutory Funding Program for Type 1 Diabetes Research. The
    NIDDK supports research on a wide range of common, chronic, costly, and
    consequential diseases and health problems that affect millions of
    Americans. These include diabetes and other endocrine and metabolic
    diseases; digestive and liver diseases; kidney and urologic diseases;
    blood diseases; obesity; and nutrition disorders.
     uncovering the genetic and environmental causes of disease to inform
                             therapy and prevention
        Unprecedented discoveries in genetics continue to lead the way
    toward the development of personalized treatments and prevention of
    devastating diseases and disorders. Scientists revealed that certain
    variants in the APOL1 gene may be responsible for the differential risk
    of developing kidney disease for African Americans. These variants also
    provide a degree of protection against African sleeping sickness, a
    degenerative and potentially fatal condition caused by a parasite that
    is endemic to Africa. This could explain why these variants are more
    commonly found in individuals of African descent, despite the increased
    risk of kidney disease they confer.
        Many of the diseases within the NIDDK research mission result from
    the interaction between multiple genetic and environmental factors.
    Research on the human microbiome--the microorganisms associated with
    the body--has demonstrated that the composition of bacterial
    communities is determined mostly by their location on or in the body
    and varied between people. In a separate study, scientists reported
    that bacteria in the mouse gut contributed to changes in appetite and
    metabolism. Therefore, excess calorie composition and obesity may be
    affected by these bacterial populations. Researchers in The
    Environmental Determinants of Diabetes in Youth are using newly
    developed technologies to study the microbiome of children at high risk
    for developing type 1 diabetes and explore whether viral or bacterial-
    based treatments could be used to prevent or treat the disease. NIDDK
    will continue to capitalize on recent genetics and environment
    discoveries to transform prediction, prevention, diagnosis, and
    treatment of diseases within the Institute's mission.
                    improving patient care through research
        Obesity is a major health epidemic in the United States, and it
    increases the risk for type 2 diabetes; kidney, heart, and liver
    disease; and other health issues. Therefore, efforts to curb this
    rising trend are vitally important. The NIDDK's HEALTHY study revealed
    that while a middle school-based intervention did not reduce obesity
    school-wide, it lowered the obesity rate in students with the highest
    risk for type 2 diabetes. This important result will inform future
    school-based efforts to reduce overweight and obesity in children.
    Research also shows that weight loss can improve the health of people
    with diabetes. NIDDK's Look AHEAD study showed that weight loss in
    overweight and obese people with type 2 diabetes can lead, with lower
    medication requirements, to long-term favorable effects on diabetes
    control and cardiovascular risk factors.
        NIDDK continues to support efforts to test potential treatments for
    NIDDK-related diseases and disorders. Investigators demonstrated in a
    preliminary trial that salsalate, an anti-inflammatory drug used for
    years to manage arthritis pain, can help people with type 2 diabetes
    control blood glucose levels. If the expanded trial is successful, it
    could lead to a safe and inexpensive way to treat the disease. Non-
    alcoholic steatohepatitis (NASH) is a form of fatty liver disease
    associated with overweight and can lead to liver cirrhosis and liver
    failure requiring a transplant. Currently, there are no specific, FDA-
    approved treatments for NASH. NIDDK scientists compared vitamin E, the
    insulin-sensitizing drug pioglitazone, and placebo for treatment of
    adult NASH, and reported promising improvements in response to 2-year
    therapy, especially for vitamin E.
        It is important to compare available, effective treatments and
    combine this knowledge with a patient's history to identify the best
    option for treating an individual. A recent NIDDK study demonstrated
    that, on average, a lower blood pressure goal was no better than the
    standard goal at slowing progression of kidney disease among African
    Americans who had chronic kidney disease resulting from high blood
    pressure. However, the lower blood pressure goal did benefit patients
    who had protein in their urine, a sign of kidney damage. In light of
    the APOL1 results I described earlier, this and other findings suggest
    that genetic traits more common in African Americans may subtly alter
    the pathogenesis of kidney disease in this population, and new classes
    of drugs that target these pathways might be more effective in
    preventing the onset and progression of chronic kidney disease in these
    patients.
        Millions of American women suffer from stress urinary incontinence,
    an underdiagnosed public health problem that is associated with
    diminished quality of life. An NIDDK trial demonstrated that two
    different surgical approaches were equally effective--although they had
    different side effects--in treatment for stress urinary incontinence, a
    major milestone in treatment for this condition. This information will
    enable women and their doctors to weigh more accurately the benefits
    and risks of available treatment options. In concert with identifying
    the best treatment options, NIDDK research aims to ensure that patients
    are able to take advantage of these results to improve their health and
    care.
            disseminating research results to improve public health
        It is critical that the results of research reach the American
    public quickly and clearly to translate to real improvements in health.
    NIDDK supports a number of public health campaigns such as the National
    Kidney Disease Education Program, the Weight-control Information
    Network, a Celiac Disease Awareness Campaign, and the National Diabetes
    Education Program (NDEP).
        Diabetes continues to be a growing worldwide public health concern;
    rising rates of obesity and an aging populance are driving the
    increasing prevalence of type 2 diabetes. There is hope, however:
    research has shown that it is possible to delay--or even prevent--the
    disease. The NIDDK's landmark Diabetes Prevention Program (DPP) was a
    tremendous success, demonstrating that loss of 5-7 percent of an
    individual's body weight--or treatment with the drug metformin--can
    delay type 2 diabetes. By eating less fat and fewer calories and doing
    moderate exercise, such as brisk walking, DPP participants were able to
    lose body weight and maintain the loss. These lifestyle changes worked
    particularly well for participants age 60 and older, and were equally
    effective for all participating ethnic groups and for both men and
    women.
        To transfer the lessons of the DPP to the community level, NIDDK
    supports translational research, which included a trial of less costly
    delivery of the DPP intervention in YMCAs in group settings. The
    results have led CDC and private organizations to fund the intervention
    at more Ys and United Health Group to cover the cost for plan
    participants to use the intervention at Ys. Additionally, the NDEP is
    disseminating the good news from the DPP follow-up study that
    development of type 2 diabetes continued to be reduced 10 years after
    the intensive lifestyle change or treatment with metformin. NDEP has
    partnered with NIH's Office of Research on Women's Health to also raise
    awareness of the increased risk of type 2 diabetes for women who have a
    history of gestational diabetes.
                       generating research opportunities
        The future of public health depends critically on the development
    of the next generation of scientists and the pursuit of scientific
    opportunities. NIDDK continues to vigorously support new investigators,
    and training and mentorship in biomedical research. NIDDK held its
    second annual New Investigators' meeting to enhance their ongoing
    research and spur future success. NIDDK also held its eighth annual
    workshop for the Network of Minority Research Investigators to
    encourage and facilitate participation of members of underrepresented
    racial and ethnic minority groups in the conduct of biomedical research
    in NIDDK-relevant fields. These new investigators will be poised to
    take advantage of a wealth of opportunities to improve the health of
    Americans; such opportunities have been identified by a number of
    recent strategic planning efforts undertaken by the NIDDK.
        The development and application of new technologies will also
    improve patient care. Through support for small business innovation
    research grants and other efforts, NIDDK will foster cutting-edge
    research in this area. New technologies could facilitate analysis of
    organs, tissues and biological molecules, and, with mobile
    communication, help convey critical information quickly to patients and
    healthcare providers. This research would enhance our ability to
    monitor disease progression or how a therapy is working and would
    improve diagnosis of disease or risk, to enable earlier intervention.
        In closing, Mr. Chairman, NIDDK will continue to emphasize my
    guiding principles: support a robust portfolio of investigator-
    initiated research; vigorously support clinical trials to identify
    better ways to prevent and treat disease; preserve a stable pool of new
    investigators; disseminate science-based knowledge from research
    through education programs; and foster research training and mentoring.
        Thank you Mr. Chairman and members of the Committee for the
    opportunity to share with you a few highlights of NIDDK's research and
    outreach efforts to improve the health of Americans. I will be pleased
    to answer any questions you may have.
                                     ______

                  Prepared Statement of Anthony S. Fauci, M.D.
        Mr. Chairman and Members of the Committee: I am pleased to present
    the President's fiscal year 2012 budget request for the National
    Institute of Allergy and Infectious Diseases (NIAID), a component of
    the National Institutes of Health (NIH). The fiscal year 2012 budget
    includes $4,915,970,000, which is $144,100,000 more than the comparable
    fiscal year 2011 level of $4,771,870,000.
        NIAID conducts and supports biomedical research to understand,
    treat, and prevent infectious and immune-mediated diseases, including
    HIV/AIDS; tuberculosis; malaria; influenza; emerging and re-emerging
    infectious diseases; asthma and allergies; autoimmune diseases; and the
    rejection of transplanted organs. NIAID makes a major investment in
    translational research, which seeks to accelerate the findings from
    basic research into healthcare practice. This decades-long commitment,
    together with NIAID's multidisciplinary collaborations with experienced
    as well as new investigators at academic centers, the private sector,
    and other governmental and non-governmental partners, continues to help
    improve domestic and global health through the development of
    diagnostics, therapeutics, and vaccines for infectious and immune-
    mediated diseases. I appreciate the opportunity to highlight just a few
    of our research successes and to describe some of our most promising
    research programs aimed at improving public health and quality of life.
                                 global health
        NIAID has been a leader in both basic and clinical HIV/AIDS
    research ever since the disease emerged as a devastating public health
    crisis 30 years ago. In 2010, NIAID support for HIV/AIDS research
    resulted in landmark scientific advances in HIV prevention. The NIAID-
    supported iPrEx study demonstrated that a daily dose of an oral
    antiretroviral medication, a strategy known as pre-exposure prophylaxis
    or PrEP, was effective at reducing the risk of HIV acquisition among
    men who have sex with men. This finding was selected by the prestigious
    journal The Lancet as one of the top six medical discoveries in the
    world in 2010 and was named by Time magazine as the number one medical
    breakthrough in 2010. A second important study, and another of The
    Lancet's selections, CAPRISA 004, showed that a vaginal microbicide gel
    of an antiretroviral drug could give women a measure of protection
    against HIV infection. This important trial was funded by the U.S.
    Agency for International Development and carried out using a research
    infrastructure developed with NIAID support. In the area of HIV vaccine
    development, researchers in NIAID's intramural Vaccine Research Center
    and NIAID-funded extramural investigators discovered human antibodies
    that can block a wide range of HIV strains from infecting human cells
    in the laboratory and are now zeroing in on their precise mechanisms of
    action. Coupled with last year's success from the RV 144 HIV vaccine
    clinical trial conducted in Thailand, which found a ``prime-boost''
    vaccine candidate to be safe and modestly effective in preventing HIV
    infection, NIAID is making important strides in developing a robust
    package of prevention modalities that can be used in combination. In
    addition, research supported under NIAID's new initiative, the Martin
    Delaney Collaboratory: Towards an HIV Cure, will provide insights into
    how HIV hiding places in the body--so-called ``reservoirs''--are
    formed, where they are located, how they are maintained despite
    effective antiretroviral therapy, and how they might be eliminated.
        NIAID makes a significant investment in research on the co-
    infections and co-morbidities that often accompany HIV infection.
    Tuberculosis (TB) occurs in about one-third of HIV-infected individuals
    and is the leading cause of death in this group. The NIAID-sponsored
    CAMELIA study demonstrated that survival of untreated HIV-infected
    adults with weak immune systems and newly diagnosed TB can be prolonged
    by starting antiretroviral therapy 2 weeks after beginning TB
    treatment, rather than waiting the standard 8 weeks. This finding will
    help to optimize treatment strategies for people co-infected with HIV
    and TB and promises to save many lives in the developing world. A
    significant number of adults at risk for HIV infection are also at risk
    for hepatitis B and C infection. NIAID supports a robust research
    program to understand the pathogenesis of and immune response to
    hepatitis viruses and to develop novel therapeutics and vaccines
    against the diseases caused by these viruses.
        In 2009, there were approximately 9.4 million TB cases and 1.7
    million TB deaths globally according to the World Health Organization
    (WHO). NIAID has accelerated its TB research activities and is applying
    21st century technology to a field that has lagged behind the study of
    other infectious diseases. NIAID supports the development of several
    promising TB vaccine candidates, and basic and clinical research has
    contributed to both new and repurposed therapeutic approaches and
    candidates. With NIAID support, researchers also have developed a tool
    for diagnosing TB that provides more specific, sensitive, and rapid
    results than currently available diagnostics.
        In 2009, approximately 225 million cases of malaria resulted in
    more than 780,000 deaths, 90 percent of which occurred in Africa,
    according to WHO. More than a decade has passed since the newest class
    of antimalarial drugs, artemisinins, entered widespread use worldwide;
    unfortunately, malaria parasites are becoming increasingly resistant to
    these medications. There is a pressing need for new malaria therapies
    due to the constant threat of the emergence of drug resistance, which
    NIAID is addressing by supporting domestic and international research.
    For example, NIAID-supported researchers identified NITD609 as a
    promising antimalarial drug with a mode of action that differs from the
    current drugs used to treat malaria. NIAID-supported scientists also
    discovered a novel metabolic pathway of the malaria parasite Plasmodium
    falciparum that could lead to new drug targets. In 2010, NIAID
    established ten International Centers of Excellence for Malaria
    Research in malaria-endemic regions. In addition to research on HIV/
    AIDS, TB, and malaria, NIAID supports research devoted to better
    understanding, preventing, and treating other important diseases that
    cause a significant burden of illness and death globally, including
    neglected tropical diseases such as lymphatic filariasis, trachoma, and
    leishmaniasis.
                  emerging and re-emerging infectious diseases
        NIAID continues its critical focus on advancing drugs, vaccines,
    and diagnostics from concept to product development to fight emerging
    and re-emerging infectious diseases. In response to the 2009 H1N1
    influenza pandemic, NIAID played a key role in developing and testing
    the 2009 H1N1 influenza vaccines, and in assessing their safety and
    potential effectiveness in a variety of populations. NIAID researchers
    also made important strides in the development of broadly protective
    influenza vaccines. NIH intramural researchers in the Vaccine Research
    Center demonstrated that a ``prime-boost'' vaccine strategy could
    protect animals from infection with multiple strains of influenza.
    NIAID-supported scientists also determined that individuals infected
    with pandemic 2009 H1N1 influenza generated antibodies that neutralized
    many different influenza virus strains. This adds to the evidence base
    that a universal influenza vaccine may be possible, which would obviate
    the need to modify the influenza vaccine each season. NIAID-supported
    investigators also showed that vaccinating children against influenza
    protects the wider community, underscoring the public health importance
    of widespread vaccination with current and improved vaccines. The
    Lancet chose this study as its top scientific advance of 2010.
        Building on the experience and challenges of the 2009 H1N1
    influenza pandemic, the Department of Health and Human Services
    conducted a review of the Federal Government's efforts to develop
    medical countermeasures (MCMs) such as drugs and vaccines for public
    health emergencies, including bioterror attacks, culminating in a new
    vision for MCM development. As part of this vision, NIAID--in
    coordination with the Biomedical Advanced Research and Development
    Authority and the Department of Defense--will lead the Concept
    Acceleration Program to stimulate the translation of new scientific
    concepts and discoveries to the development of MCMs for biodefense and
    emerging infectious diseases.
        The dengue epidemic in Puerto Rico and dengue cases in Florida and
    Hawaii, as well as the cholera outbreak in earthquake-ravaged Haiti,
    demonstrate the importance of understanding the factors that contribute
    to disease emergence and re-emergence. NIAID dengue research includes
    basic research, vector biology, translational research, as well as the
    development of research tools, resources, and services. With NIAID
    support, scientists are developing several vaccine approaches for
    dengue. NIAID research on cholera spans basic research, genomics,
    studies of environmental and climactic factors, and the development of
    vaccines and therapeutics. An NIAID-supported study pinpointed the
    genetic lineage of the cholera microbe that is causing the epidemic in
    Haiti.
        NIAID continues to support a robust basic, translational, and
    clinical research portfolio to address the public health issue of
    antibiotic resistance for key pathogens, including methicillin-
    resistant Staphylococcus aureus (MRSA) and Gram-negative bacteria. For
    example, NIAID scientists recently identified a toxin from a community-
    acquired strain of MRSA that could be a factor in the severity of MRSA
    infections. NIAID also supports research to preserve the effectiveness
    of currently used antibiotics, including studies to examine optimal
    treatment of community-acquired pneumonia and infections caused by
    Gram-negative bacteria such as Pseudomonas and Acinetobacter. NIAID-
    supported researchers settled a medical controversy by recently showing
    that antibiotics clearly reduce the severity and duration of acute
    middle-ear infections in toddlers that were diagnosed using consistent
    criteria.
                           immune-mediated disorders
        NIAID is committed to furthering our understanding of the
    immunologic mechanisms underlying autoimmune diseases, asthma and
    allergic diseases, rejection of transplanted organs, and other immune-
    mediated disorders; and to translating this knowledge into new
    approaches for diagnosis, prevention, and treatment. In 2010, an NIAID-
    sponsored expert panel produced much-needed comprehensive guidelines
    for medical practitioners for the diagnosis and management of food
    allergy that will be helpful to clinicians across a range of medical
    specialties. NIAID also launched the Human Immunology Project
    Consortium to better understand the human immune system and how it
    reacts to infection or vaccination. The information gained from this
    effort will provide insights into the development of safer and more
    effective vaccines, including those for young children and the elderly.
    In addition, researchers in the NIAID Immune Tolerance Network
    demonstrated that Rituxan is a safe and effective therapy for two
    forms of severe vasculitis, a rare and devastating disease of the blood
    vessels. These data were instrumental in the recent Food and Drug
    Administration-approval of Rituxan for this indication, representing
    the first licensed treatment for this disorder in 40 years. Also, the
    NIAID Inner-City Asthma Consortium determined that the addition of
    Xolair to NIH guidelines-based asthma therapy for young children and
    adolescents resulted in fewer asthma symptoms and severe asthma
    attacks.
                                   conclusion
        For more than 60 years, NIAID has conducted and supported basic and
    clinical research on infectious and immune-mediated diseases leading to
    the development of vaccines, therapeutics, and diagnostics that have
    significantly improved the health and saved the lives of millions
    around the world. NIAID will continue to support the highest quality
    research with the aim of translating fundamental discoveries into
    improved public health.
                                     ______

      Prepared Statement of Josephine P. Briggs, M.D., Director, National
               Center for Complementary and Alternative Medicine
        Mr. Chairman and Members of the Committee: I am pleased to present
    the President's fiscal year 2012 budget request for the National Center
    for Complementary and Alternative Medicine (NCCAM) of the National
    Institutes of Health. The fiscal year 2012 budget includes
    $131,002,000, which is $3,399,000 more than the comparable fiscal year
    2011 appropriation of $127,603,000.
        The National Center for Complementary and Alternative Medicine
    (NCCAM) is the Federal Government's lead agency for scientific research
    on complementary and alternative medicine (CAM). CAM includes a group
    of diverse medical and healthcare interventions, practices, products,
    or disciplines that are not generally considered part of conventional
    medicine (sometimes called Western or allopathic medicine). The
    boundaries between CAM and conventional medicine are not absolute;
    instead, they are constantly evolving: interventions such as hospice
    care or relaxation and breathing techniques in childbirth that were
    once considered unconventional are now widely accepted. Furthermore,
    there is growing interest in more integrative approaches that use both
    CAM and conventional interventions. For example, both the Departments
    of Defense \1\ and Veterans Affairs are integrating select CAM
    modalities into treatments for pain, stress, and sleep disorders.
    ---------------------------------------------------------------------------
        \1\ Pain Management Task Force Final Report: Providing a
    Standardized DOD and VHA Vision and Approach to Pain Management to
    Optimize the Care for Warriors and Their Families, Office of the Army
    Surgeon General, Department of Defense, May 2010.
    ---------------------------------------------------------------------------
        CAM is used by many in the United States, both in treating health
    problems and in promoting better health and well-being. Data from the
    2007 National Health Interview Survey \2\ (NHIS), developed under NCCAM
    leadership in collaboration with the National Center for Health
    Statistics at the Centers for Disease Control and Prevention (CDC),
    show that nearly 40 percent of adult Americans and 12 percent of
    children are using some form of CAM. The data also show that in 2007
    out-of-pocket expenditures for CAM totaled $33.9 billion. While this
    amount accounted for only 1.5 percent of total healthcare expenditures,
    it was more than 11 percent of out-of-pocket expenditures. Finally,
    NHIS data indicate that a large portion of CAM use is best described as
    ``self-care'' in that it occurs outside of the framework of a
    relationship with a healthcare professional. The scope, associated
    costs, and self-care nature of CAM use in the United States reinforce
    the need to develop reliable, objective scientific evidence concerning
    the usefulness and safety--or lack thereof--of CAM interventions, and
    to ensure the public has access to accurate and timely evidence-based
    information.
    ---------------------------------------------------------------------------
        \2\ Nahin RL, Barnes PM, Stussman BA, et al. Costs of complementary
    and alternative medicine (CAM) and frequency of visits to CAM
    practitioners: United States, 2007. CDC National Health Statistics
    Report #18. 2009.
    ---------------------------------------------------------------------------
        NCCAM is shaping its research directions through our third
    strategic plan, which was developed with considerable input from our
    diverse stakeholder community and released in February 2011. The
    strategic plan, Exploring the Science of Complementary and Alternative
    Medicine (available at www.nccam.nih.gov), was built around three long-
    range goals aimed at improving the state and use of scientific evidence
    regarding the two major reasons for use of CAM in the United States--
    treating health problems and supporting or promoting better health and
    well-being. The three goals are to (1) advance the science and practice
    of symptom management; (2) develop effective, practical, personalized
    strategies for promoting health and well-being; and (3) enable better
    evidence-based decisionmaking regarding CAM use and its integration
    into healthcare and health promotion.
                           pain and symptom mangement
        CAM approaches, as treatments for health problems, are used most
    often to manage symptoms such back or neck pain, arthritic or other
    musculoskeletal pain, headache, and insomnia. These are all difficult
    problems and there is broad agreement that existing options are less
    than fully satisfactory for many patients. For example, chronic back
    pain is, by far, the most frequent health problem for which Americans
    turn to CAM. They might try CAM approaches after exhausting other
    options such as opioids, injections, surgery, or physical therapy. More
    often, however, they pursue CAM treatment options, including spinal
    manipulation, yoga, acupuncture, and massage, in conjunction with
    conventional approaches. Individuals suffering from chronic pain
    conditions, their healthcare providers, and health policymakers all
    need better evidence regarding the value and safety of these
    complementary and integrative approaches in alleviating pain, and in
    improving quality of life.
        To address this critical need, NCCAM is intensifying its focus on
    determining whether and how CAM interventions add value to existing
    approaches and on understanding their biological mechanisms. In order
    to advance the science and practice of symptom management, NCCAM plans
    to support Centers of Excellence for Research on CAM for Pain in fiscal
    year 2011. NCCAM is also working with our colleagues at the Department
    of Defense to explore ways that CAM mind and body approaches can be
    used in integrative approaches to treat pain, stress disorders, and
    other symptoms. For example, we recently sponsored a joint workshop on
    acupuncture for the treatment of acute pain. We are also investigating
    potential collaborations with the Department of Veterans Affairs to
    advance CAM research and to maximize our investments in bringing relief
    to our wounded warriors.
                 strategies for promoting health and well-being
        It is generally accepted and well established that sustaining
    healthy behaviors (e.g., good eating habits and regular physical
    exercise) and modifying unhealthy behaviors (e.g., smoking) reduce
    risks of major chronic diseases. Many CAM and integrative medicine
    practitioners and disciplines employ various interventions (e.g.,
    meditation or yoga) to help motivate people to adopt and sustain
    health-seeking behaviors, or to encourage dietary practices (sometimes
    grounded in traditional medical systems) that incorporate a healthy
    food philosophy. Newly emerging evidence suggests that CAM use may be
    associated with greater degrees of health-seeking behavior. While
    causal relationships between CAM use and healthy behavior have not been
    established, the claims and preliminary data deserve investigation
    given the formidable public health challenges in motivating behavior
    change. Research is needed to explore, clarify, and examine the
    hypothesis that certain CAM approaches or practices can, in fact, be
    useful in encouraging better self-care, an improved personal sense of
    well-being, and a greater commitment to a healthy lifestyle.
                            cam research challenges
        Given the scope and self-care nature of CAM use by Americans, NCCAM
    remains committed to supporting rigorous research that will address the
    need for scientific evidence to help the public and their healthcare
    providers make better-informed decisions about CAM use. For example,
    herbal medicines, dietary supplements, and other CAM natural products
    are readily available to and purchased by consumers, but evidence
    regarding usefulness of many does not exist. In addition, some people
    believe that herbal medicines, dietary supplements, and other CAM
    natural products are inherently healthier or safer than drugs. In fact,
    there are ongoing concerns about safety, including the presence of
    contaminants or adulterants (e.g., conventional drugs) in some CAM
    natural products, and the potential of toxic interactions with drugs or
    other natural products.
        Clinical research to address these needs will remain a cornerstone
    of the CAM research enterprise, but these studies are complex,
    expensive, and time-consuming. NCCAM's strategic approach is to ensure
    that clinical trials of CAM natural products are based on a
    scientifically sound hypotheses and methods that are grounded in basic
    mechanistic and translational research. This foundation facilitates
    design of maximally informative clinical trials that include measures
    of biological effect relevant to the hypothesis (e.g., biomarkers or
    surrogate markers), as well as measures of clinical outcomes.
        Investigators studying mind and body interventions face other
    scientific challenges in designing rigorous research that will address
    the questions of greatest importance to consumers, providers, and
    healthcare policymakers. These include identifying relevant study
    endpoints and defining appropriate experimental designs to test
    interventions. To address such challenges, NCCAM recently collaborated
    with several NIH ICs to sponsor a workshop on control and comparison
    groups for studies of non-pharmacological interventions.\3\
    ---------------------------------------------------------------------------
        \3\ NCCAM Workshop on Control/Comparison Groups for Trials of Non-
    Pharmacologic Interventions, April 26, 2010.
    ---------------------------------------------------------------------------
                                   conclusion
        As established in its third strategic plan, NCCAM is focusing the
    Center's efforts and resources on two compelling areas of public health
    need: better strategies for managing symptoms such as chronic pain, and
    better strategies for promoting health and well-being. In both areas
    there exist promising scientific opportunities for research on CAM
    interventions to contribute to real and meaningful progress in
    addressing common and vexing individual and social problems, and in
    developing more integrative approaches to healthcare and the support of
    healthy behaviors and lifestyles.
        Finally, NCCAM's plan looks to a vision in which scientific
    evidence informs decisionmaking by the public, by healthcare
    professionals, and by health policymakers regarding CAM use. NCCAM will
    continue its multi-pronged efforts to provide world-class information
    about the safety and usefulness of CAM interventions to consumers, and
    to foster dialogue about CAM use between patients and their healthcare
    providers. In addition, a new online resource, tailored to the needs of
    healthcare professionals, is being launched on the NCCAM website. It
    includes information on the safety and efficacy of a range of CAM
    practices, and was developed in response to providers' needs for an
    evidence-based, one-stop resource to help answer their patients'
    questions on CAM.
                                     ______

       Prepared Statement of Barbara M. Alving, M.D., Director, National
                         Center for Research Resources
        Mr. Chairman and Members of the Committee: It is a privilege to
    present to you the President's budget request for the National Center
    for Research Resources (NCRR) programs for fiscal year 2012. The fiscal
    year 2012 budget of $1,297,900,000 includes an increase of $41,225,000
    over the comparable fiscal year 2011 level of $1,256,675,000. Funding
    priorities for fiscal year 2012 include the continued support and
    refinement of the Clinical and Translational Science Award program,
    which will reach its targeted number of 60 consortium members later
    this year. Funds will also sustain the range of activities supported by
    the Center's other major programs, including the Research Centers in
    Minority Institutions, the Institutional Development Awards, the
    National Primate Research Centers, and the Biomedical Technology
    Research Centers.
        By uniting innovative research teams with the power of shared
    resources across the Nation, NCRR programs provide laboratory
    scientists and clinical researchers with the tools and training they
    need to understand, detect, treat, and prevent a wide range of diseases
    through clinical and translational research. NCRR's diverse yet
    interconnected NCRR programs enable the research of more than 30,000
    NIH-funded investigators nationwide by providing the resources, tools,
    and networking connections.
        This statement is submitted with the recognition of a publically
    announced proposal for reorganization that would result in dissolution
    of NCRR and the transfer of programs to other NIH ICs and Offices.
           building clinical and translational research capabilities
        NCRR's Clinical and Translational Science Award (CTSA) program is
    transforming biomedical research by building national clinical and
    translational research capacity to speed the translation of laboratory
    discoveries into better treatments for patients. Launched in 2006, the
    CTSA program is a national clinical and translational research
    consortium which now includes 55 medical research institutions in 28
    States and the District of Columbia. The consortium supports research
    by disseminating clinical research informatics tools, forging new
    partnerships with healthcare organizations, and expanding outreach to
    minority and medically underserved communities. The first cohort of
    CTSAs, now re-competing for their next 5 years of funding, have pushed
    scientific discoveries toward novel and promising treatments that
    enable healthcare reform and more cost-effective treatments. For
    instance, research conducted at the University of California, San
    Francisco's CTSA found that reducing salt intake by just a half
    teaspoon per day could help Americans significantly improve their heart
    health, reduce a number of heart-related deaths and potentially save
    millions in healthcare costs. The findings influenced the Food and Drug
    Administration's decision to limit the amount of salt in prepared foods
    and helped support the CDC's salt reduction campaign.
        Importantly, the CTSA consortium serves as a communications hub
    that ensures sharing among sites and accelerates adoption of best
    practices for clinical and translational research. The CTSAs are
    building biomedical research capability by generating new tools and
    resources, such as ResearchMatch.org, a Web-based national recruitment
    registry which matches volunteers with clinical studies seeking
    participants, and the CTSA Pharmaceutical Assets Portal, a public-
    private collaboration enabling scientists to learn more about existing
    compounds that are not being actively developed and might be repurposed
    to treat other types of diseases.
                        energizing research communities
        NCRR programs support new investigators and promote new ideas
    through innovative networking collaborations, partnerships, training,
    and career development for clinical and translational scientists.
    Members of the Institutional Development Award (IDeA) program, which
    supports rural and underserved communities, developed the Network of
    IDeA-funded Core Laboratories (NICL) to address common challenges of
    NCRR-funded core laboratories. NICL addresses, develops and
    disseminates sustainable business models for efficient core operations
    and expands access to advanced core resources and expertise. Now
    extended to other NCRR programs, NICL supports, encourages, and
    facilitates resource sharing and collaboration among NCRR-funded cores
    and shared-resource facilities. NCRR programs are also energizing the
    research community with the world's first physician-scholar training
    program on wireless healthcare research, launched through a partnership
    between The Scripps Translational Science Institute (STSI) CTSA and the
    wireless telecommunications company Qualcomm. STSI is positioned to
    become an invaluable resource for this emerging, high-impact field of
    research.
                  advancing innovative biomedical technologies
        The Biomedical Technology Research Centers (BTRCs) program is
    producing leading edge technologies to accelerate discoveries that help
    researchers who are studying virtually every human disease. At the
    Resource for Magnetic Resonance and Optical Imaging at the University
    of Pennsylvania, researchers are working closely with clinicians to
    improve patient care by developing and promoting ready access to
    imaging tools with the goal of translating novel approaches for imaging
    blood flow through brain tissue and other organs.
                new and better treatments through animal models
        The National Primate Research Center (NPRC) program advances
    research and knowledge in HIV and AIDS, as well as in numerous other
    diseases. The NPRCs have a close relationship with the CTSAs; one
    example is the collaboration between the New England NPRC and the
    Harvard CTSA. The two are jointly examining the observation that
    insulin resistance appears to be a predictor of dementia utilizing a
    monkey model of insulin resistance and an analysis of high-field MRI
    scans in the monkey model conducted by the Harvard CTSA investigators
    who have expertise with MRI in humans. NCRR continues to supply the
    research community with animal models and resources. Through the Link
    Animal Models to Human Disease Initiative (LAMHDI), a Web-based
    resource, investigators can identify and locate useful animal models
    that are essential to their research in treatments for human disease.
            expanding research capabilities to address human health
        Through the IDeA and Research Centers in Minority Institutions
    (RCMI) programs, biomedical research capacities across the Nation are
    expanding into States with historically low NIH funding and are having
    a direct impact on human health. One example is from the National
    Center for Genome Resources in New Mexico, home of the DNA sequencing
    and bioinformatics core for the New Mexico IDeA Networks of Biomedical
    Research Excellence (INBRE). Scientists used innovative whole-genome
    sequencing and expression analyses to study Multiple Sclerosis (MS) in
    identical twins resulting in the first published genome sequences of
    female twins or individuals with autoimmune disease. It is also the
    first systematic comparison of genomes in identical twins, including
    epigenetic markers and expression profiles. Another study from the New
    Mexico INBRE used next-generation sequencing methods to develop a pre-
    conception genetic test for 500+ mutations known to increase the risk
    of numerous rare diseases in children of carriers.
        Another illustrative example is a pilot study, initiated by the
    RCMI Translational Research Network, to study the effect of Vitamin D
    on cardiovascular disease risk factors in African Americans. This study
    is important because racial/ethnic minorities, especially African
    Americans, continue to suffer a disproportionate burden of
    cardiovascular disease. African Americans also tend to have low levels
    of Vitamin D and these low levels have been associated with
    cardiovascular disease risk. Supplementation with Vitamin D may be an
    accessible and affordable intervention.
                providing a catalyst for research collaboration
        Grantee institutions are adopting research networking tools as a
    step toward national networking of people, resources, and data on the
    web. The VIVO project, which is an initiative to enable national
    networking of scientists and resource discovery, is driving the network
    with availability of linked open data about scientists and their work.
    The potential will be realized through their commitment to publish data
    on the web so the information is more easily discoverable and
    connections with other open linked data can be made. VIVO is an open
    source semantic web application linking information automatically from
    institutional and public systems of record to provide detailed profiles
    of scholars and researchers. The power of this semantic web approach is
    the ability for creative visualization of connections not previously
    possible between diverse types of information and data.
        This brief overview of NCRR's programs demonstrates our continuing
    commitment to accelerating clinical and translational research. NCRR
    will continue to advance research through partnerships among its
    programs, other Institutes and Centers at the NIH, and with other
    Federal and non-Federal agencies to advance training and translational
    research opportunities.
                                     ______

    Prepared Statement of Paul A. Sieving, M.D., Ph.D., Director, National
                                 Eye Institute
        Mr. Chairman and Members of the Committee:I am pleased to present
    the President's budget request for the National Eye Institute (NEI).
    The fiscal year 2012 budget of $719,059,000 includes an increase of
    $18,832,000 over the fiscal year 2011 appropriation level of
    $700,227,000. As the director of the NEI, it is my privilege to report
    on the many research opportunities that exist to reduce the burden of
    eye disease.
                      technologies to accelerate discovery
        The causes of common diseases are complex in that there are
    potentially many different environmental factors and genetic variants
    that can contribute to disease. New technologies such as genome-wide
    association studies (GWAS) allow investigators to scan the genomes of
    patients to identify genetic risk variants for common diseases.
    Individually, each of these variants may only contribute to a small
    percentage of cases, so GWAS require many subjects to identify low
    frequency risk variants. In the largest GWAS study in vision research
    to date, NEI investigators recently sequenced DNA from over 18,000
    patients and control subjects and identified three new genes associated
    with age-related macular degeneration (AMD), the most common cause of
    vision loss in older Americans. Two of these genes are involved with
    high-density lipoprotein cholesterol metabolism, implicating a new
    biochemical pathway involved in the pathogenesis of AMD. These findings
    will allow researchers to better understand the disease mechanisms
    underlying AMD and develop therapies that address the root cause of
    vision loss. Glaucoma is another heritable blinding disease where the
    genetic underpinnings are poorly understood. The NEI Glaucoma Human
    Genetics Collaboration, a consortium of clinicians and geneticists at
    12 institutions throughout the United States dedicated to identifying
    the genetic factors associated with glaucoma is conducting a large-
    scale GWAS that involves scanning 5,000 DNA samples. The consortium is
    using state-of-the-science technology to sequence the exome, the full
    complement of protein coding regions in the human genome, in a subset
    of patients. The data from these DNA samples are expected to be
    available to the vision research community in 2011.
              translational sciences and therapeutics development
        Positive results of ongoing, pioneering clinical trials of gene
    therapy for Leber congenital amaurosis, a severe, early onset retinal
    disease, have encouraged applications of this approach to many other
    eye diseases. In the past year, NEI investigators demonstrated proof-
    of-concept of gene therapy using animal models of AMD, achromatopsia,
    Leber's hereditary optic neuropathy, retinitis pigmentosa, and red-
    green color blindness. Previous work with animal models established the
    utility of gene therapy in juvenile retinoschisis, optic neuritis, and
    Stargardt disease. These studies now allow investigators to conduct the
    pre-clinical work necessary to pursue regulatory approval for clinical
    trials. In addition, novel gene delivery systems, such as the use of
    nanoparticles, have shown promise in animal models. Such vectors will
    be helpful in expanding the reach of gene therapy to target a variety
    of ocular tissues such as retinal ganglion cells and the light-
    sensitive photoreceptor cells.
             enhancement of evidence-base for health care decisions
        For treating the blinding (``wet'') form of advanced AMD, monthly
    ocular injections of a drug, Lucentis, was approved in 2007 by the FDA.
    This was the first effective treatment that not only stopped
    progression of the disease, but also improved vision for many patients.
    Lucentis blocks formation of new, but abnormal blood vessels that leak
    fluid into the central part of the retina that is responsible for keen
    vision. It was developed from another inhibitor of blood vessels,
    Avastin, which since its approval in 2004, has been used to block new
    vessels that form to nourish growth of some cancers. Even before final
    FDA approval of Lucentis, ophthalmologists began using Avastin ``off-
    label'' for treating AMD, and today, most AMD patients receive Avastin.
    Given the lack of data regarding the effectiveness of Avastin for AMD
    treatment, in 2007, the NEI had an obligation to patients and
    clinicians to compare the two drugs and to evaluate whether the drugs
    could be used less frequently as needed--called PRN--rather than
    monthly as originally approved for Lucentis. Visual acuity improvement
    was virtually identical (within one letter difference on an eye chart)
    for either drug when given monthly. When each drug was given PRN, there
    also was no difference between drugs. For PRN dosing, patients required
    four to five fewer injections per year compared to monthly treatment
    and still had substantial gains in vision.
        Lucentis was also studied in a comparative effectiveness trial for
    diabetic macular edema (DME), a common sight-threatening complication
    of diabetes in which fluid from leaky blood vessels causes the retina
    to swell. For the past 25 years, DME has been treated with a laser to
    destroy abnormal blood vessels. Although laser therapy slows disease
    progression, the effects are temporary, and repeated treatments can
    damage healthy retinal tissue and impair vision. In recent years,
    ophthalmologists have been supplementing laser treatment with ocular
    injections of either Lucentis, a drug that prevents blood vessel
    growth, or triamcinolone, a corticosteroid to reduce inflammatory
    complications. An ongoing clinical trial comparing the safety and
    efficacy of these two drugs is being conducted by the Diabetic
    Retinopathy Clinical Research Network (DRCR.net), a public-private
    partnership funded by NEI, the Type 1 Diabetes Funding Program, and
    industry collaborators. After 1 year, Lucentis plus laser treatment was
    superior in both safety and efficacy compared to triamcinolone plus
    laser or to laser alone. This landmark clinical trial identified the
    first new safe and effective treatment regimen for DME in more than two
    decades. In addition, the study demonstrated that intravitreal
    triamcinolone, which had been used in 60 percent of patients with DME,
    had significant side effects (cataract and glaucoma) and was not better
    than laser alone. These results are already being used by community
    ophthalmologists to greatly improve the vision and quality of life for
    people living with diabetes.
        Treatment of cataracts in infants is challenging for pediatric
    ophthalmologists and parents. Replacing the opaque lens with an
    artificial lens is critical to prevent permanent loss of vision in the
    eye. After removing the cataract, contact lenses have been the
    preferred method to overcome the loss of the natural lens. However, it
    is difficult and stressful for parents to insert a contact lens into an
    infant's eye. Removing the cataract and surgically implanting a
    transparent intraocular lens (IOL) in adults is common but had not been
    fully characterized in infants. An NEI-supported clinical trial found
    no difference in visual acuity with contact lenses compared to IOLs 1
    year after cataract removal. However, IOLs caused significant numbers
    of surgical complications. Based on these results, the use of contact
    lenses is considered the safest effective treatment for infants with
    cataract.
                          new investigators, new ideas
        The increasingly quantitative nature of the biomedical sciences and
    the explosive growth of genomic, transcriptomic, proteomic,
    metabolomic, neurophysiological and clinical data require that
    investigators work at the interface of biology and computational
    sciences. The NEI is committed to developing the next generation of
    vision researchers and has expanded its institutional training grant
    program with a program in ocular statistical genetics at several
    universities. This program will partner researchers with expertise in
    mathematics, modeling, and computation, fields that are not usually
    affiliated with ocular research, with researchers in all areas of
    vision science to provide state-of-the-art training for a new breed of
    researchers.
                                     ______

     Prepared Statement of Eric D. Green, M.D., Ph.D., Director, National
                        Human Genome Research Institute
        Mr. Chairman and Members of the Committee: I am pleased to present
    the fiscal year 2012 President's budget request for the National Human
    Genome Research Institute (NHGRI). The proposed fiscal year 2012 budget
    is $524,807,000, an increase of $13,749,000 from the comparable fiscal
    year 2011 level of $511,058,000.
        This is an exciting time for biomedical research in general and for
    genomics research in particular. NHGRI investments in the development
    of genomic technologies and their application are generating innovative
    and powerful approaches to address a diverse array of biological and
    biomedical questions. In early 2011, after 2-plus years of rigorous
    consultation and planning, NHGRI published a new strategic plan for the
    field of genomics in the premiere scientific journal Nature. This
    comprehensive strategic vision describes the next key steps in the
    herculean journey to decipher the secrets within our genetic code and
    to use those discoveries to empower health practitioners and patients
    in a fashion that leads to improved human health. The strategic plan
    also challenges the broader biomedical community to anticipate the
    scientific and non-scientific achievements that will be necessary to
    implement cost-effective and accessible genomics-based medical care
    (i.e., genomic medicine).
                               enabling research
        Basic research lays the foundation for understanding the functional
    features within our genome and how disruptions in them can lead to
    disease. In fact, the knowledge gained from basic genomic
    investigations enables scientists and clinical investigators from other
    disciplines to pursue translational research programs to understand
    particular biological pathways or address disease-specific questions.
    The ENCyclopedia of DNA Elements (ENCODE) project and the related model
    organism ENCODE (modENCODE) project are moving forward effectively
    toward their goals of finding all the functional elements in the human
    genome, as well as in the genomes of organisms that serve as important
    models for human biology.
        To stimulate and accelerate multi-disciplinary research, NHGRI has
    funded several Centers of Excellence in Genomic Science (CEGS). In
    addition to pursuing cutting-edge genomics research questions, these
    centers are associated with rigorous training programs that focus on
    groups under-represented in biomedical research. Such efforts aim to
    reinvigorate the biomedical research community by engaging diverse
    expertise and fostering the development of versatile young scientists.
        The unprecedented decreases in the cost of DNA sequencing resulting
    from the NHGRI-stimulated technology development efforts are moving us
    steadily closer to the reality of using genome sequencing as a routine
    part of clinical care. However, even with the three-to-four orders-of-
    magnitude drop in DNA sequencing costs that has occurred, sequencing an
    entire human genome remains too expensive for the kind of human
    research studies needed to dissect the small genetic differences
    between individuals that contribute to increased risk for common
    diseases, such as cancer, heart disease, and asthma, because such work
    often requires the study of thousands or tens of thousands of
    individuals. To this end, NHGRI continues to push forward technology-
    development initiatives, such as the $1,000 Genome program, to develop
    novel and even more cost-effective DNA sequencing methods.
    Concurrently, the NHGRI-funded large-scale sequencing centers continue
    to use innovative approaches for improving available DNA sequencing
    technologies. These efforts are projected to result in a substantial
    drop in the cost of generating a human genome sequence--to less than
    $25,000 by the end of fiscal year 2011 and less than or equal to
    $15,000 by the end of fiscal year 2012.
        To develop an appropriately broad catalog of information about the
    variation within the genomes of different individuals across the world,
    NHGRI continues to contribute substantially to the international 1000
    Genomes Project. In addition, on behalf of NIH, NHGRI led the effort to
    launch a research partnership with the Wellcome Trust, called the Human
    Heredity and Health in Africa (H\3\Africa) Initiative. This new effort
    seeks to stimulate research within African laboratories to enable
    leading-edge genomic studies to be conducted across the continent. The
    knowledge gained through a deeper understanding of genomic variation in
    African populations will not only lead to improved abilities to study
    genetic diseases in those populations, but will enhance our
    understanding of the complex interplay between environmental and
    genetic factors that influence disease susceptibility and drug
    responses in many diverse populations.
                      building a framework for translation
        Building on the tools and knowledge created by these and other
    basic research programs, the joint NHGRI-National Cancer Institute
    (NCI) project, The Cancer Genome Atlas (TCGA), is providing important
    new insights into some of the most vexing forms of malignancy,
    including brain cancer and, more recently, acute myeloid leukemia and
    ovarian cancer. Results from TCGA and associated cancer genomics
    studies by NHGRI-funded investigators point to new therapeutic targets
    and, as recently reported in the Journal of the American Medical
    Association, demonstrate the potential for more precise modes of cancer
    diagnosis and treatment. As a flagship program for NIH translational
    research activities, TCGA is expanding its efforts and will focus on an
    additional 20 major cancers over the next 5 years.
        Beginning in fiscal year 2012, NHGRI will expand its large-scale
    genome sequencing and analysis portfolio to include centers that target
    the study of rare, single-gene (Mendelian) disorders using cutting-edge
    genomic technologies. Rare disease research already is benefiting from
    the new genomic technologies. For example, the causative genes for a
    pair of developmental disorders were discovered recently: Miller
    syndrome, which affects the development of the face and limbs, and
    Kabuki syndrome, which affects facial and cognitive development. These
    two discoveries represent the ``tip of the iceberg'' with respect to
    the identification of altered genes that result in rare diseases, as
    reports of such discoveries are published in the scientific literature
    almost weekly. Another new NHGRI initiative in fiscal year 2012 will
    pilot the use of genome sequencing in clinical care settings, an
    important step towards implementing genomic medicine.
        Complementing the genome sequencing initiatives, the NIH
    Therapeutics for Rare and Neglected Diseases (TRND) program, which is
    currently administered by NHGRI, aims to innovate and accelerate the
    drug development pathway for rare and neglected diseases. As the TRND
    pilot projects move toward their initial milestones, the first full-
    scale project portfolio will be launched in collaboration with external
    and internal partners. Likewise, the NIH Chemical Genomics Center
    (NCGC) continues to serve as a national resource for the generation of
    novel chemical ``leads'' to spur inventive directions in candidate drug
    and biological assay identification. This statement is submitted with
    the recognition of the Department's notification to the Congress of an
    NIH reorganization that would establish a new National Center for
    Advancing Translational Sciences (NCATS).
                    early opportunities for genomic medicine
        The clinical promise of genomics requires strong foundational
    knowledge about the structure and biology of genomes as well as the
    biology of disease. Increasingly, genomics will be used to advance
    medical science and to improve the practice of medicine.
        Cancer genomics (as previously discussed) and pharmacogenomics (or
    genomically guided medication prescription) are anticipated to be
    leading-edge examples of genomic medicine. Successes of the latter
    include the use of genomic information for making decisions about
    administering the antiretroviral drug abacavir, now the standard of
    care for HIV-infected patients. Other promising examples of
    pharmacogenomics involve the use of patient genomic information to
    target the application and dose of tamoxifen to treat breast cancer,
    clopidogrel to treat cardiovascular disease, and the blood-thinner
    warfarin. For cancer genomics, it is expected that genomic profiling of
    tumors will become increasingly routine for making decisions about
    treatment strategies.
        Major advances in the study of common, genetically complex diseases
    also have been seen recently. Over the past 5 years, more than 4,000
    validated associations have been made between a genomic region and a
    common disease (or another specific trait). Studies that identify and
    provide evidence to support the value-added connections between genetic
    factors and observed phenotype (physical traits, clinical symptoms,
    etc.) require substantial investments in time, funding, and resources,
    but are fundamental to translating genomics investments into clinical
    applications. One such initiative, the Electronic Medical Records and
    Genomics (eMERGE) Network, aims to advance the efficiency of this
    scientific approach. This program will enter its second phase in late
    fiscal year 2011, during which it will not only link patients' DNA to
    their electronic medical record information, but also will explore the
    challenges of using the information to inform clinical care in a
    respectful, responsible manner.
        The new NHGRI strategic plan identified several critical cross-
    cutting elements that are integral to navigating successfully the path
    to genomic medicine: bioinformatics and computational biology,
    education and training, and the continued study of the societal
    implications of genomics. The major bottleneck in genome science is no
    longer data generation; rather, it is the computational analysis of
    data. Beyond the research setting, the public, and especially
    healthcare providers, need to become much more conversant in genomics.
    To help address the needs of healthcare professionals, NHGRI has
    launched online tools to support genetic and genomic training in health
    professional education programs, including bilingual case studies.
        Moving forward, translating basic genomic knowledge to improve
    human health will continue to rely on innovative technology
    development, large-scale collaborative and, increasingly, multi-
    disciplinary efforts, and robust attention to the societal implications
    of genomic advances. Demonstrating utility and feasibility will be
    critical for widespread adoption of genomic medicine; the thresholds
    for defining benefit and harm will vary across stakeholders and
    cultural perspectives. However, overcoming the challenges that
    accompany such a paradigm-changing venture is within reach. The
    research and related programs that NHGRI will pursue over the next year
    will continue to lay the groundwork for an era where individualized
    genomic medicine will become a reality, and the original promise of the
    Human Genome Project will be fulfilled.
                                     ______

    Prepared Statement of Richard Hodes, M.D., Director, National Institute
                                    on Aging
        Mr. Chairman and Members of the Committee: I am pleased to present
    the President's fiscal year 2012 budget request for the National
    Institute on Aging (NIA) of the National Institutes of Health (NIH).
    The fiscal year 2012 budget includes $1,129,987,000 which is
    $30,450,000 more than the comparable fiscal year 2011 appropriation of
    $1,099,537,000.
        The National Institute on Aging leads the national effort to
    understand aging and to identify and develop interventions that will
    help older adults enjoy robust health and independence, remain
    physically active, and continue to make positive contributions to their
    families and communities. We support a comprehensive portfolio of
    genetic, biological, clinical, behavioral, and social research related
    to the aging process, healthy aging, and diseases and conditions that
    often increase with age. We also carry out the crucial task of training
    the next generation of researchers who specialize in understanding and
    addressing the issues of aging and old age.
        Approximately 39 million people age 65 and older live in the United
    States, and data from the Federal Interagency Forum on Aging-Related
    Statistics indicate that their numbers will double within 25 years. In
    less than 50 years, the number of ``oldest old''--people ages 85 and
    older--may quadruple. As record numbers of Americans reach retirement
    age and beyond, profound changes will occur in our economic,
    healthcare, and social systems.
              translational sciences and therapeutics development
        NIA supports a comprehensive portfolio of research that builds upon
    basic discovery to develop new preventive, diagnostic, and therapeutic
    interventions for age-related diseases and conditions. For example,
    investigators with the Alzheimer's Disease Neuroimaging Initiative
    (ADNI) have found that changes in the structure of the hippocampus, a
    brain area important to learning and memory, may reflect disease
    progression and effectiveness of potential treatments, and have
    established biomarker and imaging measures that may predict risk for
    cognitive decline and conversion to dementia. Clinical, imaging, and
    biological data from ADNI are available to qualified investigators
    around the world; over 1,700 researchers have signed up for access to
    the ADNI database, and global collaborations have resulted in over 170
    published scientific papers since 2004.
        NIA-supported research to identify Alzheimer's disease (AD)
    biomarkers and gain a deeper understanding of the disease's pathology
    and clinical course has made possible the first revision of the
    clinical diagnostic criteria for AD in 27 years through a joint effort
    of the NIA and the Alzheimer's Association. Unlike the criteria that
    doctors and researchers have been using since 1984, the updated
    guidelines cover the full spectrum of the disease as it gradually
    changes over many years, from the earliest preclinical stages before
    symptoms are apparent through mild cognitive impairment (MCI) and
    advanced dementia. The new guidelines also address the use of imaging
    and biomarkers to determine whether changes in the brain and body
    fluids are due to AD.
        Even under the new guidelines, however, diagnosis of AD remains
    complex. NIA intramural investigators are working toward development of
    an accurate, noninvasive, inexpensive blood test for AD. Last year,
    they found that the amount of a protein called clusterin in the blood
    of AD patients reflected the severity of disease, predicted the
    progression of memory impairment, and may predict brain amyloid burden
    long before the patient develops memory problems. These findings were
    recently replicated by independent researchers, and research is ongoing
    in this promising area.
        A continuing translational research success story for NIH is the
    ongoing development of the compound exendin-4. NIA intramural
    investigators originally developed exendin-4 as a treatment for type 2
    diabetes, but have since found that exendin-4 may act as a
    neuroprotective agent in animal models, and they are now conducting a
    phase II/III clinical trial of the compound in patients with MCI and
    early AD. NIA also supports over 40 drug discovery and development
    projects through our AD Translational and Drug Discovery Initiative,
    including a number of AD pilot clinical trials.
        Other NIA-supported researchers are pursuing the development of
    interventions that will delay disease and dysfunction and even extend
    lifespan. Investigators with the innovative Interventions Testing
    Program found that the drug rapamycin, used to help prevent rejection
    of transplanted organs in humans, extended life span in middle-aged
    mice, and more recently demonstrated that the drug exerts beneficial
    effects early in life. Rapamycin inhibits the mTOR pathway, which helps
    regulate cell growth and proliferation. Building upon these findings,
    in 2010 NIA began soliciting research to identify and characterize
    molecular targets within the mTOR pathway with potential to impact
    health span and lifespan.
        NIA also partners with other agencies and organizations on
    translational initiatives. For example, with the Administration on
    Aging, NIA has established an initiative to support development of
    evidence-based interventions, programs, policies, practices, and tools
    that can be used by community-based organizations to help elderly
    individuals remain healthy and independent in their own homes and
    communities. NIA is also joining ``ambassadors'' from organizations
    interested in the health and well-being of older people to promote
    Go4Life, our new exercise and physical activity website
    (www.nia.nih.gov/Go4Life.)
                      technologies to accelerate discovery
        New GWAS (genome-wide association study) technologies are
    transforming our understanding of the origins of disease and disability
    by facilitating rapid comparisons of the full genomes of thousands of
    individuals. This research may lead to the identification of novel
    disease pathways that can be targeted to develop new treatments. In the
    largest GWAS ever conducted in AD research, scientists with the AD
    Genetics Consortium found that a previously unconfirmed gene variant,
    BIN 1, affects development of late-onset AD and identified four
    additional genetic variants significant for the disease. The genes
    identified by this study may implicate pathways involved in
    inflammation and the movement of proteins and lipids both within and
    between cells as being important in the disease process. In a another
    large GWAS, NIA intramural researchers joined an international research
    consortium to confirm six previously identified genes for Parkinson's
    disease and identify five new genes or loci (an area on the chromosome
    where a gene is thought to be located).
        A new NIA-supported initiative is underway to develop technologies
    to better understand the life span and fate of cells in various tissues
    of aged mammals. In these studies, cells are permanently marked at a
    specific point in the organism's life and those marked cells are
    followed to determine their fate and traits over time. These studies
    will provide important insights into aging at the cell and tissue
    levels.
                   using science to inform health care reform
        Research that will lead to the identification of more effective and
    less expensive clinical interventions is a high priority for NIA,
    particularly through a broad portfolio of comparative effectiveness
    research (CER). A major CER effort has been NIA's administration, on
    behalf of the Agency for Health Care Research and Quality and the
    Office of the DHHS Secretary, of an initiative identifying ways that
    principles of behavioral economics could be used to encourage
    healthcare providers to incorporate findings from CER studies into
    their practices. Other ongoing CER studies include a randomized trial
    of behavioral economic interventions to reduce risk of cardiovascular
    disease; a study comparing various motivators to increase HIV
    screening; and a study comparing the effects of an intensive exercise
    program vs. stretching and range of motion exercises on ambulation in
    hip fracture patients.
        Surprisingly little definitive evidence exists on the impact
    insuring the uninsured has on their health-related behaviors (including
    healthcare usage) and outcomes. However, NIA-supported investigators
    are currently taking advantage of a remarkable opportunity to develop
    such evidence. For a brief period in 2008, Oregon opened a waiting list
    for enrollment in its previously closed public health insurance program
    for certain low income adults, and then offered randomly selected
    people the opportunity to enroll. By comparing individuals who obtained
    health insurance through this program with otherwise eligible
    individuals who were not selected in the ``insurance lottery,'' the
    investigators are assessing the impact of insurance on healthcare usage
    and health outcomes, including the differing impacts on different
    groups. Understanding the consequences of health insurance coverage
    will be central to evaluating proposals to expand or modify health
    insurance coverage in the United States.
        Recently, NIA-supported investigators studying older populations in
    the United States, England, and 11 European countries found that
    retirement prior to age 65 was associated with a significant decline in
    cognitive performance. The investigators suggest that this may be in
    part because for many people retirement leads to a less stimulating
    daily environment, and the prospect of retirement reduces the incentive
    to engage in mentally stimulating activities on the job. It is possible
    (although not yet proven) that the recent trend of American workers
    delaying retirement may eventually lead to improved cognitive
    performance in this group.
                          new investigators, new ideas
        As the American population grows older, the need for healthcare
    professionals who specialize in the unique needs of older individuals
    is becoming ever more urgent. To address this increase in demand
    effectively, we must foster the development of physician-scientists
    whose research will lead to improved care and more effective treatment
    options for older patients with complex medical conditions. Recently,
    NIA established the Grants for Early Medical/Surgical Subspecialists'
    Transition to Aging Research (GEMSSTAR) program to support physicians
    who seek to become clinician-scientists in geriatric aspects of their
    subspecialty. We anticipate supporting 18 to 20 emerging physician-
    scientists in this program.
        Once again, thank you. I welcome your questions.
                                     ______

     Prepared Statement of Roger I. Glass, M.D., Ph.D., Director, Fogarty
                              International Center
        Mr. Chairman and Members of the Committee: I am pleased to present
    the fiscal year 2012 President's budget for the Fogarty International
    Center (FIC). The fiscal year 2012 budget of $71,211,000 reflects an
    increase of $1,835,000 over the comparable fiscal year 2011
    appropriation of $69,376,000.
        When it comes to global health, there is no ``them''--only ``us.''
    \1\ In an increasingly interdependent world, the United States and
    nations around the globe share diseases, as well as the burden that
    these diseases inflict on healthy people. In fact, the interests of the
    American people are well-served when the United States promotes global
    health, as healthy nations are more likely to succeed in economic
    development and enjoy political stability. In addition, Americans have
    a strong humanitarian tradition and have long supported efforts to
    improve the health of people around the world. The U.S. Government
    (USG) has recognized these realities, and has made global health a
    national priority. For these investments to yield the maximum benefit
    however, U.S. and foreign scientists must work together to generate the
    scientific evidence that will inform how best to allocate resources.
    These researchers will contribute the necessary local expertise and
    knowledge to thwart pandemics and fight diseases that prevent societies
    from achieving their full potential. They will also empower nations to
    more effectively improve the health of their own populations. The
    Fogarty International Center plays a unique role at the National
    Institutes of Health (NIH) and in the USG by supporting the development
    of global health research expertise in the United States and abroad.
    ---------------------------------------------------------------------------
        \1\ Global Health Council, Washington, DC.
    ---------------------------------------------------------------------------
                          new investigators, new ideas
        Research advances are more likely occur when investigators study
    diseases onsite to develop health interventions that are responsive to
    local and international priorities. Therefore, Fogarty supports long-
    term research and training partnerships between United States and low-
    and middle-income country (LMIC) research institutions, which has
    resulted in the training of more than 5,000 researchers--many of whom
    contribute to major scientific advances. For example, the first results
    from a large clinical trial testing candidate microbicides that use
    anti-retrovirals (ARVs) found that the incorporation of an ARV into a
    vaginal gel was more than 50 percent protective against HIV infection
    when used as directed. This advance is a key step toward empowering
    women with a safe and effective HIV prevention tool. Notably, six of
    the study's authors are current or former Fogarty-sponsored trainees.
        To increase the pool of physicians who have the necessary skills to
    conduct robust and critical health research, and to support country-
    driven efforts that enhance the sustainability of gains made under
    PEPFAR, Fogarty is also administering a major new program called the
    Medical Education Partnership Initiative (MEPI)--a joint effort of the
    Office of the Global AIDS Coordinator, HRSA, DOD, USAID, CDC, and NIH.
    MEPI supports institutions in Sub-Saharan African countries and their
    U.S. partners to develop new models of medical education, and to
    strengthen the ability of medical students and faculty to conduct
    research that responds to the health needs of their countries.
        Non-communicable diseases--such as heart disease, stroke, cancer,
    and diabetes--are in fact the leading causes of worldwide mortality,
    accounting for 60 percent of all deaths. According to the World Health
    Organization, 80 percent of this burden is in LMICs, where these
    diseases affect people disproportionately during their most
    economically productive years. Fogarty is addressing this challenge
    through its expanded program on Chronic, Non-Communicable Diseases and
    Disorders across the Lifespan, which will support training of in-
    country scientists to conduct research on these diseases. Given the
    high burden of non-communicable diseases in the United States,
    knowledge gained from these research activities can inform domestic
    efforts to prevent and treat these diseases--particularly in low-
    resource settings.
        Fogarty also supports the training of U.S. investigators to conduct
    global health research and actively engage in international scientific
    collaborations. These investments directly respond to the overwhelming
    demand for global health opportunities on university campuses across
    the United States, and are helping early career scientists to build
    long-term relationships and acquire skills that will help to ensure
    that the United States continues to be a global leader in health
    innovation.
             enhancement of evidence base for health care decisions
        There is a tremendous gap between scientific advances and health
    outcomes in the developing world. Therefore, there is an urgent need to
    bridge the gap between what we know and what we do. Fogarty has
    expanded support for research training in implementation science, which
    generates knowledge and methods to better integrate research findings
    and proven health interventions into health policy and practice.
        For example without a significant shift in global prevalence
    patterns, smoking is projected to cause roughly 8 million deaths
    annually by 2030; notably, more than 80 percent of these deaths will
    occur in LMICs. Fogarty's International Tobacco and Health Research and
    Capacity Building Program addresses the critical role of research and
    local research capacity in reducing the global burden of tobacco
    consumption and the need to generate a solid evidence base that can
    inform effective local tobacco control strategies and health policies.
    The program supports epidemiological and behavioral research, as well
    as prevention, treatment, communications, implementation, health
    services and policy research. In Delhi, India, researchers are testing
    the efficacy and cost-effectiveness of a community-based behavioral
    intervention for tobacco cessation among youth living in low-income
    communities. Such studies can inform efforts to curb adolescent smoking
    in the United States--particularly in resource-poor settings.
        Another example is Fogarty's International Implementation,
    Clinical, Operational, and Health Services Research Training Award for
    AIDS and Tuberculosis program, which supports training of scientists
    and health professionals in developing countries to conduct research-
    related to implementation of prevention, care and treatment
    interventions for HIV and/or TB. Researchers supported by this program
    recently made a significant discovery regarding the treatment of
    patients with both HIV/AIDS and TB. In these resource-limited settings,
    a high proportion of patients begin antiretroviral therapy (ART) while
    on TB treatment, and paradoxical tuberculosis-associated immune
    reconstitution inflammatory syndrome (TB-IRIS) is a frequent
    complication of the ART. To address this disease management challenge,
    investigators in South Africa found that a 4-week course of prednisone
    reduced the need for hospitalization and therapeutic procedures, and
    hastened improvements in symptoms, performance, and quality of life--
    all without excess adverse events.
        Fogarty has also partnered with the Bill and Melinda Gates
    Foundation and the Foundation for NIH on a study that examines the
    relationship between malnutrition and intestinal infections, and also
    the consequences of these conditions on various aspects of child health
    and development. Investigators across multiple international research
    sites seek to facilitate the design of more targeted, cost-effective
    interventions that will reduce the burden of child morbidity and
    mortality from diarrheal diseases. One area of focus is the impact of
    malnutrition, along with damage to the gut (from repeated and
    persistent episodes of diarrheal disease), on the effectiveness of
    childhood vaccines. In many low-resource settings, the immunity
    conferred by various vaccines is significantly lower than in high-
    income countries. A better understanding of the links between nutrients
    and the health and function of the intestinal immune system will likely
    lead to the development of targeted and modified vaccine formulations
    and delivery strategies (e.g., dosing, schedules) for improved control
    of intestinal infections.
                      technologies to accelerate discovery
        With increasing globalization, the need to monitor, diagnose and
    respond to epidemics has risen dramatically. Since 1998, Fogarty has
    supported partnerships between the United States and LMIC research
    institutions to increase the capacity of biomedical scientists to
    design, access and use modern information technology in support of
    health sciences research. These partnerships are training biomedical
    and behavioral scientists, engineers, clinicians, librarians, and other
    health professionals to access, manage, analyze, and share biomedical
    information electronically. They are also training individuals who will
    be capable of developing new informatics applications. This will
    increase the ability of local scientists and institutions to conduct
    multi-site clinical trials and perform international disease
    surveillance and prevention programs. Several Fogarty-supported
    informatics projects have now reached new levels of maturity, expanding
    to form regional networks and leveraging tools and lessons learned to
    benefit more researchers. For example, a program in Brazil is sharing
    its materials with Mozambique, where Portuguese is also the national
    language. Researchers in Peru are building a Latin American training
    network, and a university in South Africa is forming a consortium to
    strengthen biomedical informatics throughout Africa.
              translational sciences and therapeutics development
        Fogarty's International Cooperative Biodiversity Groups program
    supports natural products drug discovery and ethnomedical and
    botanicals research. Investigators supported by this program are
    generating new and exciting leads from natural products that may result
    in new therapeutics for a range of diseases. For example, a promising
    new weapon in the war against malaria may come from seaweed found in
    Fiji, as discovered by Fogarty grantee Dr. Julia Kubanek, a chemical
    ecologist at the Georgia Institute of Technology. She and her team
    discovered that a type of red algae in Fiji has strong anti-malarial
    properties. Animal studies have begun to further explore the compound's
    potential as a new therapeutic.
        In conclusion, to effectively confront complex health issues that
    transcend national boundaries, more scientific collaborations must be
    developed and strengthened. Deep regional expertise enables Fogarty to
    facilitate these scientific collaborations. In the context of advancing
    science and health, Fogarty seeks opportunities to bridge differences
    between countries that might otherwise not engage and to build trust by
    encouraging scientists from around the world to work together to
    address shared health challenges. These partnerships promote goodwill,
    stability and peace, and effectively harness science for diplomacy. As
    the world continues to become more interdependent, international
    scientific partnerships will play a critical role in building bridges
    and in improving health for people worldwide. Working in partnership
    with rest of the NIH, Fogarty's unique programs will continue to enable
    scientists in the United States and abroad to work together to tackle
    the most pressing and complex health challenges of our time.
                                     ______

      Prepared Statement of Dr. Kenneth Warren, Ph.D., Director, National
                   Institute on Alcohol Abuse and Alcoholism
        Mr. Chairman and Members of the Committee: I am pleased to present
    the President's fiscal year 2012 budget request for the National
    Institute on Alcohol Abuse and Alcoholism (NIAAA), of the National
    Institutes of Health (NIH). The fiscal year 2012 budget includes
    $469,197,000 for the NIAAA, which reflects an increase of $11,304,000
    over the fiscal year 2011 level of $457,893,000, comparable for
    transfers proposed in the President's request.
               alcohol and healthcare--transforming the landscape
        NIAAA-supported research is leading to dramatic changes in the
    understanding of alcohol-related problems and their prevention and
    treatment across the lifespan. By translating this research into new
    and better prevention and treatment approaches we have the ability to
    reduce the heathcare burden due to alcohol and enhance the well-being
    of individuals, their families, and society-at-large.
                              scope of the problem
        According to the World Health Organization, alcohol is among the
    ten leading causes of death and disability worldwide; and according to
    the Centers for Disease Control and Prevention (CDC), alcohol is also a
    major cause of preventable death and disability in the United States.
    As the United States. implements healthcare reform, it is important to
    recognize that alcohol misuse costs our Nation an estimated $235
    billion annually.\1\
    ---------------------------------------------------------------------------
        \1\ Rehm J, et al. The Lancet 373(9682): 2223-2233, June 27, 2009-
    July 3, 2009.
    ---------------------------------------------------------------------------
        The consequences of alcohol misuse can affect both drinkers and
    those around them at all stages of life. NIAAA's National Epidemiologic
    Survey on Alcohol and Related Conditions (NESARC) estimates that almost
    18 million people in the United States. ages 18 and older suffer from
    alcohol abuse or dependence (collectively known as alcohol use
    disorders, AUDs). The highest prevalence of alcohol dependence, which
    encompasses a broad spectrum of disease ranging from a single episode
    of a few years duration to a chronic relapsing disorder, occurs among
    18-24 year olds. Of note, more than 85 percent of individuals with an
    AUD do not have another drug use disorder. Returning war veterans
    represent a particularly vulnerable population for developing AUDs that
    co-occur with Post Traumatic Stress Disorder (PTSD) and other mental
    health problems. Chronic, heavy alcohol use can damage tissues and
    organs, most notably in the brain, liver, heart, pancreas, and
    esophagus. According to the CDC, in 2007, alcoholic liver disease
    accounted for over 14,000 deaths and in 2008 was responsible for nearly
    20 percent of U.S. liver transplants.
        Alcohol misuse can also have second hand effects, both direct
    effects of alcohol exposure such as damage to the developing embryo due
    to drinking by the pregnant mother, as well as indirect effects
    experienced by individuals other than the drinker such as car crashes,
    sexual assault, and violence. According to an analysis of NIAAA's
    NESARC, one in four children grow up in a household where alcohol is a
    problem, putting them at risk for short and long-term adverse physical
    and psychological health outcomes.
    Research to Practice
        NIAAA-supported research is increasing our understanding of how to
    identify and address alcohol-related problems across the lifespan.
    Research shows that early identification and intervention are key to
    reducing future health problems and can dramatically reduce healthcare
    and other costs for individuals who misuse alcohol and those around
    them.
    The Value of Screening and Brief Intervention
        The medical and economic value of screening and brief intervention
    (SBI) to identify and address high risk drinking behavior early has
    been well documented. In fact, according to an analysis in the American
    Journal of Preventive Medicine, SBI for alcohol misuse was ranked
    similarly in cost-effectiveness to screening for colorectal cancer and
    hypertension, and to influenza immunization. Using NIAAA's A
    Clinician's Guide: Helping Patients Who Drink Too Much, SBI can be
    performed efficiently and effectively by primary care clinicians. By
    intervening early, providers are able to offer their patients more
    appealing, accessible options to address their alcohol problems,
    options that are less resource intensive and less expensive than those
    needed to treat more severe forms of dependence. For individuals who
    want to assess and address their drinking behavior on their own, NIAAA
    has developed an interactive Web site and booklet, Rethinking Drinking,
    http://rethinkingdrinking.niaaa.nih.gov. These tools offer evidence-
    based information about risky drinking patterns, the alcohol content of
    drinks, and the signs of an alcohol problem, along with other resources
    to help people who choose to cut back or stop drinking. Tools such as
    Rethinking Drinking may benefit those who could ultimately recover from
    dependence without treatment by decreasing the severity and duration of
    dependence. For others it may provide the motivation to seek
    professional help.
    Underage and College Drinking
        According to the Substance Abuse and Mental Health Services
    Administration, more than one-fourth of 16-17 year olds drank in the
    past 30 days, and 17 percent engaged in binge drinking, i.e. drinking
    more than five drinks on an occasion. For 18-20 year olds, over one-
    third engaged in binge drinking in the past 30 days. According to The
    Surgeon General's Call to Action to Prevent and Reduce Underage
    Drinking, each year underage drinking results in the death of about
    5,000 people under the age of 21 from alcohol-related injuries. This
    number is equivalent to the incoming freshman class at Virginia Tech,
    and greater than the total student body at the United States Naval
    Academy. Given the widespread use of alcohol and high prevalence of
    binge drinking by children and adolescents, and the link between early
    alcohol use and later problems including alcohol dependence, it is
    important to identify children and adolescents who are at high risk for
    alcohol use and/or alcohol use disorders. NIAAA will soon release an
    easy to use two question screener and guide for pediatricians and other
    clinicians who provide medical care to children and adolescents. This
    empirically based screening instrument is devised to identify children
    at elevated risk for using alcohol as well as those who have already
    begun to experiment or are more heavily involved with alcohol. In
    addition to identifying individuals who need any level of intervention,
    health practitioners can also use the screening process to provide
    information to patients and their parents about alcohol's effects on
    the developing body and brain. In collaboration with other Federal and
    non-Federal partners NIAAA will implement and evaluate the new guide.
        Alcohol use is also a serious public health and safety problem
    among college students with adverse consequences that range from poor
    academic performance to alcohol poisoning. NIAAA has an ongoing
    research focus on reducing college drinking and its consequences.
    Research encompasses both individual approaches, such as screening and
    brief intervention in college health centers, and environmental
    approaches including studies on college and community policies. NIAAA
    has also established a College Presidents Working Group to advise the
    Institute.
    Exploiting Technology to Improve Treatment
        For those who need treatment, NIAAA seeks to provide more and
    improved options. Individuals experience alcohol differently, for some
    it provides almost immediate euphoria, others can drink much higher
    quantities yet feel relatively little effect. Both types may be at risk
    for developing alcohol dependence. Clinical trials with alcohol
    dependent patients testing a variety of medications suggest that, just
    as their physiological response to alcohol differs, so too does their
    response to a specific treatment; and genes appear to be responsible,
    at least in part, for these differences. Given that alcohol dependence
    is a complex disorder influenced by multiple genes, along with the
    evidence that specific treatments only work for subsets of individuals,
    NIAAA continues to seek additional medications that target different
    molecules and pathways in the brain. A number of medications currently
    prescribed for other indications are being evaluated as
    pharmacotherapies to reduce heavy drinking including: the mood
    stabilizing drug quetiapine, the antiepileptic drug levetiracetum, the
    smoking cessation drug varenicline and the anti-nausea drug
    ondansetron. Recently, clinical trials with ondansetron revealed that
    individuals with specific variations in a gene which encodes the
    serotonin transporter respond better to treatment than individuals
    without these variants. Similarly, individuals with a specific variant
    in the mu opioid gene respond better to the FDA-approved alcohol
    dependence treatment naltrexone than those lacking the variant. The
    identification of additional medications, along with the knowledge of
    what works for whom, will soon make personalized treatment for alcohol
    dependence a reality. NIAAA's efforts to make testing of compounds more
    efficient, its active role in engaging the pharmaceutical industry in
    concert with its willingness to test novel compounds, and its work with
    the FDA to improve guidelines and methodology for alcohol clinical
    trials have greatly accelerated the pace of medications development for
    alcohol dependence.
        In parallel, NIAAA is exploiting technological advances in genomics
    to determine the multiple underlying genetic signatures that contribute
    to the range and severity of alcohol use disorders. As part of the next
    NIAAA NESARC, DNA samples will be collected from an estimated 46,000
    people for use in genome-wide association analyses. The level and
    complexity of information derived from new, large-scale, comprehensive
    genomic studies will facilitate our ability to correlate genetic make-
    up with subtypes of alcohol dependence improving our ability to match
    patients with treatments.
        Treating the medical consequences of heavy chronic drinking is also
    a priority. For example, currently liver transplantation is often the
    only viable option for treating advanced liver disease but it is a
    prolonged, expensive and risky process only available to patients who
    maintain abstinence. To expand treatment options, NIAAA is supporting
    studies to test a number of compounds that target progressive stages of
    liver disease including fatty liver and liver fibrosis. In addition,
    seminal research is providing a better understanding of why some
    individuals develop liver cirrhosis whereas others who consume similar
    amounts of alcohol do not. Over-activation of the body's natural repair
    mechanisms may actually promote liver disease, suggesting new targets
    for prevention and treatment of alcoholic and non-alcoholic liver
    disease.
                                     ______

    Prepared Statement of Stephen I. Katz, M.D., Ph.D., Director, National
          Institute of Arthritis and Musculoskeletal and Skin Diseases
        Mr. Chairman and Members of the Committee: I am pleased to present
    the President's fiscal year 2012 budget for the National Institute of
    Arthritis and Musculoskeletal and Skin Diseases (NIAMS) of the National
    Institutes of Health (NIH). The fiscal year 2012 budget includes
    $547,891,000 which is $14,002,000 more than the comparable fiscal year
    2011 appropriation of $533,889,000.
                                  introduction
        NIAMS addresses diseases that affect individuals of all ages, of
    all racial and ethnic backgrounds, and across all economic strata; many
    disproportionately affect women and minorities. Some are rare
    disorders, but many are very common, and all have a major impact on the
    quality of people's lives. Twenty-five years of NIAMS-funded research
    has contributed greatly to a variety of new treatment and prevention
    strategies that are reducing the burden the diseases place on
    individuals, their families, and society.
                leveraging basic science to improve patient care
        NIAMS research has been the basis for the development and testing
    of many new medications, including biologic therapies for autoimmune
    diseases. The newly approved drug belimumab, the first lupus treatment
    to receive U.S. Food and Drug Administration approval in over 50 years,
    interferes with a molecule that NIAMS-funded researchers showed to be
    involved in the immune dysfunction that characterizes this disorder.
    Other, more recent basic research results suggest another existing
    drug, omalizumab, may prevent lupus-associated kidney damage. NIAMS
    investigators in Bethesda, Maryland, are planning to start testing the
    drug's safety for lupus patients soon.
        Basic research into disease mechanisms also is explaining why some
    therapies do not work as well as expected. In 2003, investigators were
    baffled when two NIAMS-funded clinical trials showed that combining two
    medications (a bisphosphonate and parathyroid hormone) that each
    improve bone mass and prevent fractures did not help people any more
    than either drug did individually. Eight years later, research into the
    mechanisms by which bisphosphonates preserve bone revealed that they
    interfere with parathyroid hormone's bone-forming activity. This
    discovery can help physicians choose drug regimens that are best for
    their patients.
                developing tools to diagnose and monitor disease
        Improvements in bone health have underscored the importance of
    identifying which of the 40 million Americans \1\ who have low bone
    mass are most likely to break a bone. Several large, NIAMS-funded
    studies have indicated that spine fractures predict both future spine
    fractures and debilitating hip fractures. Researchers recently
    published evidence that women who have mild spine defects may also be
    at risk of hip fractures and could benefit from lifestyle changes or
    drugs that prevent bone deterioration. However, the ability to
    distinguish between deformities related to fragile bones and those from
    other causes is critical. If imaging tools that are under development
    can make this distinction, clinicians will be better able to predict
    patients' risk and monitor responses to therapies. Also, the new tools
    potentially could reduce the cost of clinical trials by allowing
    investigators to assess a medication's effects relatively quickly.
    ---------------------------------------------------------------------------
        \1\ Looker AC, et al. J Bone Miner Res. 2010 Jan;25(1):64-71. PMID:
    19580459.
    ---------------------------------------------------------------------------
        Other researchers are testing whether a specific type of magnetic
    resonance imaging can predict worsening of knee arthritis. Preliminary
    work--using images that are available to the research community through
    a public-private partnership supported by the NIH and various
    companies--is promising. If confirmed, clinicians could use the
    technology to identify patients whose knee cartilage is likely to
    rapidly deteriorate due to osteoarthritis. Moreover, like the imaging
    tools mentioned above, the discovery and validation of structural
    changes that researchers can visualize could lead to shorter, more
    efficient trials of promising disease-modifying agents that may help
    the more than 27 million Americans \2\ who have osteoarthritis pain in
    their knees or other joints.
    ---------------------------------------------------------------------------
        \1\*Lawrence RC, et al. Arthritis Rheum. 2008 Jan;58(1):26-35.
    PMID: 18163497.
    ---------------------------------------------------------------------------
        Many diseases within the NIAMS mission involve pain, fatigue, and
    other difficult-to-measure symptoms. A test to quantify changes in
    these parameters could enhance clinical outcomes research and,
    ultimately, clinical practice. NIAMS is one of several NIH components
    engaged in the Patient-Reported Outcomes Measurement Information System
    (PROMIS) initiative to develop such a tool. In addition to managing
    PROMIS on behalf of the NIH, NIAMS encourages researchers to use the
    resource. For example, NIAMS is funding a study to test questions for
    fibromyalgia patients, along with information collected through PROMIS,
    for development of disease-specific measures that allow investigators
    and healthcare providers to monitor patients more effectively.
      applying genetics, genomics, and other cutting-edge research to new
                                   treatments
        Researchers have been trying to determine for decades if pain and
    itch send different signals to the brain. Difficulties distinguishing
    the two symptoms at molecular and cellular levels had hindered this
    effort, but a group of NIAMS investigators finally identified an itch-
    specific molecule. Their work also illuminated a previously elusive
    mechanism by which the itch message travels through the spinal cord to
    be perceived by the brain. Such a discovery should pave the way for
    studies into how chronic itch develops, and make it possible, for the
    first time, to design better treatments.
        Research is providing hope to patients with epidermolysis bullosa
    (EB), a group of rare, inherited blistering skin conditions. When
    investigators repaired the genetic defect in an EB patient, NIAMS-
    funded scientists wondered if gene therapy might also work for another
    form of the disease. The strategy seemed promising in a mouse model of
    recessive dystrophic EB (characterized by large, painful blisters, open
    wounds, and early death due to cancer). A first-in-human clinical trial
    will begin this year.
        NIAMS also is funding a Phase I clinical trial that suggests that a
    different gene transfer approach may correct the molecular defect
    underlying type-2 limb-girdle muscular dystrophy (LGMD-2D). The study,
    supported through one of the Senator Paul D. Wellstone Muscular
    Dystrophy Cooperative Research Centers, demonstrated that the procedure
    could safely produce the corrected protein for at least 6 months. The
    data provide a framework that investigators can use when designing
    subsequent LGMD-2D clinical trials. Furthermore, researchers can
    leverage the study's findings about immune responses as they develop
    gene-based therapies for other diseases.
        In the past 12 months, muscular dystrophy researchers also have
    made considerable progress toward understanding the genetic
    underpinnings of facioscapulohumeral muscular dystrophy (FSHD). Prior
    findings from an NIH-funded FSHD patient registry showed that the
    disease is associated with a shorter-than-normal series of repeated
    genetic sequences. Recent technologic advances enabled researchers to
    identify a genetic pattern within these sequences in FSHD patients.
    This discovery, combined with findings that the defects cause FSHD by
    activating a gene and allowing its product to accumulate in muscle, are
    enabling new directions that will accelerate progress. For example,
    researchers can now engineer animal models of the disease, something
    that they could not do without a basic understanding of the genes
    involved.
        Like FSHD, many health problems are influenced by complex genetic
    factors. Over the last few years, the ability of genome-wide
    association (GWAS) approaches to identify gene variants related to
    disease risk has matured from an intriguing concept to a widely used
    scientific tool. These analyses can require thousands of patients, and
    often entail data sharing among NIAMS-funded researchers and scientists
    around the globe.
        An international GWAS team including researchers at the NIH
    Clinical Center showed that a gene involved in the body's immune
    response underlies a person's susceptibility to a painful, inflammatory
    condition called Behcet's disease, which primarily affects people of
    Asian, Middle Eastern, Turkish, or European descent. The gene linked to
    Behcet's disease is associated with other conditions for which
    treatments exist or are being developed. Because of this connection,
    therapies might be available sooner than if the investigators had found
    a completely new disease mechanism.
        In the past year, other genetic studies uncovered additional,
    shared links among diseases. Investigators discovered that rare
    variants of a gene encoding the enzyme sialic acid acetylesterase are
    associated with rheumatoid arthritis and type 1 diabetes, and may play
    a role in other autoimmune diseases. Likewise, researchers leveraging
    the NIAMS-sponsored National Alopecia Areata Registry found that genes
    associated with rheumatoid arthritis and type 1 diabetes are linked to
    the development of alopecia areata, a disease in which the body's
    immune system attacks the hair follicles and causes hair loss. As with
    Behcet's disease, the possibility of a common mechanism is particularly
    exciting because drugs under development for other diseases might also
    be effective against alopecia areata.
        GWAS also holds promise for understanding the genetic differences
    that give rise to more common diseases, such as osteoporosis. The NIAMS
    dedicated funds from the American Recovery and Reinvestment Act of 2009
    toward developing a resource that investigators can use to identify
    molecular changes that influence bone health. The discovery of gene
    variants that protect against osteoporosis or increase a person's risk
    of having low bone mass is likely to suggest targets that researchers
    can pursue when exploring new ways to prevent fragility fractures.
    Moreover, investigators could use genetic markers to identify
    appropriate participants for clinical trials. Data from this effort is
    likely to be available to the wider research community at the end of
    this year.
                                   conclusion
        Twenty-five years ago, a few months after Congress passed the
    Health Research Extension Act of 1985 (Public Law 99-158), the NIH
    established the NIAMS. Over the past two and one-half decades, the
    increased emphasis on research on arthritis and musculoskeletal and
    skin disorders has benefited nearly every household in our Nation. We
    are proud of the scientific advances that our researchers have made
    toward helping people who have diseases of the bones, joints, muscles,
    and skin, and are excitedly looking forward to the discoveries they
    will make in the future.
                                     ______

      Prepared Statement of Roderic I. Pettigrew, Ph.D., M.D., Director,
          National Institute of Biomedical Imaging and Bioengineering
        Mr. Chairman and Members of the Committee: I am pleased to present
    the President's fiscal year 2012 budget request for the National
    Institute of Biomedical Imaging and Bioengineering (NIBIB) of the
    National Institutes of Health (NIH). The fiscal year 2012 budget is
    $322,106,000, which is $8,573,000 more than the fiscal year 2011
    appropriation of $313,533,000. This statement is submitted with the
    recognition of the Department's notification to the Congress of an NIH
    reorganization that would establish a new National Center for Advancing
    Translational Sciences and reallocate the remaining portions of the
    National Center for Research Resources to other parts of NIH, including
    NIBIB.
        The mission of NIBIB is to improve human health by leading the
    development and accelerating the application of biomedical
    technologies. NIBIB invests resources in scientific and technological
    research opportunities at the convergence of the quantitative and life
    sciences, and in training the next generation of researchers. The
    Institute is at the forefront of translating scientific advances into
    engineered medical solutions. Ultimately, NIBIB seeks to realize
    innovations that address healthcare challenges, reduce disease
    mortality and morbidity, and enhance quality of life. To accomplish
    this goal, NIBIB continues to fund bold and far-reaching projects that
    facilitate discovery and translate basic science into new and better
    healthcare.
               translational science and therapeutics development
        Biodegradable Home-Based Vaccination System.--Influenza is a major
    cause of morbidity and mortality worldwide. Despite vaccination
    campaigns, the CDC attributes 36,000 deaths and 226,000
    hospitalizations per year in the United States to influenza, with an
    associated cost of approximately $100 billion per year. The number of
    cases could be greatly reduced if more people were vaccinated and if
    the vaccine was more effective. Researchers at the Georgia Institute of
    Technology are addressing both issues by developing a bio-dissolvable
    micro-patch that will allow people to vaccinate themselves. The patch
    is painless, has an application time of just seconds, has no
    biohazardous waste, does not require refrigeration for storage, and
    develops an enhanced immune response to flu. The patch combines cutting
    edge technology and user-friendly simplicity to address this
    significant public health problem.
        Noninvasive Image-Guided Therapy: Focused Ultrasound.--NIBIB
    supports research to develop and promote innovative image-guided
    therapies. One of these technologies is High-Intensity Focused
    Ultrasound (HIFU). HIFU is a non-invasive, image-guided and controlled
    new therapy delivery system which consists of a highly focused beam of
    high-intensity ultrasound that is capable of ablating tissue in a
    targeted region of the body, without harming surrounding tissues.
    Researchers are combining magnetic resonance imaging and HIFU to form
    an image-guided therapy delivery system for non-invasive tumor
    ablation, which can either replace or complement surgery or radiation
    therapy. In addition, transcranial transmission of HIFU can also induce
    the opening of the blood-brain barrier, which allows delivery of drugs
    directly to specific locations in the brain. HIFU for treatment of
    uterine fibroids is now an FDA-approved clinical procedure. These
    developments could revolutionize surgery, cancer therapy and the
    delivery of therapeutic agents in new targeted approaches.
        Regenerative Medicine for Wounded Warriors.--The NIBIB is the lead
    NIH institute for participation in the U.S. Military's signature Armed
    Forces Institute for Regenerative Medicine (AFIRM), now in its third
    year. AFIRM is a multi-institutional, interdisciplinary network to
    develop advanced treatment options for our wounded servicemen and
    women. Researchers are addressing many severe medical conditions
    including burns, compartment syndrome, complex craniofacial injuries,
    limb/digit salvage, and wound healing.
                     technologies to accelerate discoveries
        Monitoring Tumor Cells and Cancer Biology.--NIBIB Quantum Grant
    investigators have successfully developed a test capable of detecting a
    single cancer cell among the billions of normal cells in a blood
    sample. The microchip device, known as the HB-Chip (after the micro
    herringbone pattern on the chip surface), enables the isolation of rare
    circulating tumor cells that may be the source of cancer metastasis.
    Subsequent molecular characterizations of these cells have led to the
    discovery of several subtypes of prostate, breast, and lung cancer.
    These subtypes serve as the basis for customized cancer treatments that
    are tailored to specific patients. The isolation and characterization
    of circulating tumor cells has the potential to revolutionize the
    management of care in cancer patients. Recently, Johnson & Johnson
    announced a partnership with the researchers at Massachusetts General
    Hospital to further develop and market this blood test. ``Stand Up to
    Cancer,'' an organization focused on translational cancer research, is
    supporting four leading cancer centers to launch clinical trials using
    the HB-Chip to determine the sensitivity and specificity of the device
    for various cancers.
        Global Technologies for Disease at the Point of Care.--NIBIB has
    partnered with the Department of Biotechnology and the Ministry of
    Science and Technology in India to support the development of low-cost
    diagnostic and therapeutic technologies that will be used in
    underserved communities worldwide. As the prevalence of chronic
    diseases in low-resource settings increases, PATH (Program for
    Appropriate Technology in Health, a nonprofit organization that
    improves the health of people around the world) is working on new
    initiatives to tackle diabetes. NIBIB-supported researchers are
    evaluating cost-effective technologies to monitor and screen for
    gestational and type 2 diabetes in India. These technologies are also
    applicable to rural and low resource settings in the United States and
    can lead to more effective interventions and therapies.
        In the United States, about 500 mothers die every year during
    childbirth, and in Africa, childbirth-related deaths are nearly 300,000
    annually. Many of these deaths could be prevented if these populations
    had ready access to ultrasound exams, which identify mothers at high
    risk for birth complications. In addition, cardiovascular disease and
    abdominal illnesses could be broadly monitored and managed with wide
    access to ultrasound exams. NIBIB has supported the successful
    development by GE of a hand-held battery powered portable ultrasound
    system (VSCANTM) that costs approximately $8,000 but has the
    features of a conventional hospital or office based system costing
    approximately $200,000. The broad goal is to make ultrasound imaging as
    available as stethoscopes, to facilitate earlier detection and
    monitoring response to therapies.
           technologies to improve evidence-based clinical decisions
        Patients routinely receive their healthcare at multiple locations
    ranging from physician's offices to major medical centers. For optimal
    care, medical records and medical imaging studies must be readily
    available at different sites. To address the need for sharing of images
    and to enhance the adoption of evidence and comparative effectiveness
    in clinical decisions, NIBIB has funded several coordinated projects.
        Patient Controlled Web-Based Access and Sharing of Medical
    Images.--A contract with the Radiological Society of North America
    (RSNA) includes five academic institutions: UCSF, University of
    Maryland, Mayo Clinic, University of Chicago, and Mount Sinai. Two
    additional grants provide support to Wake Forest University and the
    University of Alabama at Birmingham. Each of these projects is
    developing an approach to patient-controlled medical image sharing
    systems for secured image sharing among radiologists and clinicians
    across organizational boundaries. The project at Wake Forest University
    has a special focus on image sharing in rural and under-served areas.
    Validation testing of patient health records that can accept images
    with the appropriate controls and privacy safeguards has begun and will
    start enrolling patients in the near future.
        On Line Decision Support Systems.--NIBIB is providing resources to
    the Brigham and Women's Hospital and the Massachusetts General Hospital
    to implement information technology systems that include clinical
    decision support capability. These systems enable the care providers to
    make clinical decisions that are based on the best available evidence
    and the patient's comprehensive medical data set, including clinical
    images.
                          new investigators, new ideas
        Nanoparticles for Improved Drug Delivery: Overcoming the Mucus
    Barrier.--The delivery of bioactive molecules to target tissues can
    significantly improve drug effectiveness while reducing side effects by
    concentrating medicine at selected sites in the body. While the barrier
    properties of mucus provide protection against infection and other
    potentially toxic particles, they also have thwarted efforts to achieve
    uniform and sustained drug delivery to mucosal surfaces, and have
    likely prevented successful delivery of genes that could potentially
    treat fatal diseases, such as cystic fibrosis. The work of NIBIB
    grantee Dr. Justin Hanes at Johns Hopkins University seeks to
    understand the properties of mucosal barriers and use this knowledge to
    guide the development of polymeric nanoparticulate carriers capable of
    more efficient drug and gene delivery to the respiratory tract, female
    reproductive tract, gastrointestinal tract, surface of the eye, and
    other mucosal tissues for improved therapies. The delivery of bioactive
    molecules to target tissues can significantly improve drug
    effectiveness while reducing side effects by concentrating medicine at
    selected sites in the body.
        Robotic Prostheses for Amputees.--Despite significant technological
    advances over the past decade, state-of-the-art transfemoral prostheses
    are unable to provide power for joint motion. The absence of joint
    power significantly impairs the ability of these prostheses to restore
    many locomotive functions, including walking upstairs and up slopes,
    running, and jumping, all of which require significant net positive
    power at the knee joint, ankle joint, or both. Dr. Michael Goldfarb, an
    NIBIB Edward C. Nagy Young Investigator, recently reported the
    development of the first robotic transfemoral prosthesis with fully
    powered knee and ankle joints. The device allows above-the-knee
    amputees to walk 25 percent faster with less energy than is expended
    with conventional prosthetics and provides increased balance, agility,
    and recovery reflexes to prevent falls. In April, Freedom Innovations
    announced a worldwide licensing agreement for exclusive rights to
    commercialize this device.
        The Institute's emphasis on interdisciplinary approaches to
    biomedical research has provided unprecedented opportunities for
    collaborations among the life and physical scientists leading to
    advances in biology and medicine through the quantitative, physical
    sciences, and engineering perspective, as well as the development of
    technologies that reflect the translation of biological mechanisms.
    These advances will produce remarkable improvements in the health of
    individuals around the world.
                                     ______

       Prepared Statement of Alan E. Guttmacher, M.D., Director, Eunice
         Kennedy Shriver National Institute of Child Health and Human
                                  Development
        Mr. Chairman and Members of the Committee: I am pleased to present
    the fiscal year 2012 President's budget request for the Eunice Kennedy
    Shriver National Institute of Child Health and Human Development
    (NICHD) of $1,352,189,000. This reflects an increase of $35,466,000
    over the fiscal year 2011 level of $1,316,723,000.
        In my short time as NICHD Director, the breadth and importance of
    the Institute's mission have already impressed me. Our research changes
    clinical practice and improves health for many people, particularly
    those who may be under-represented in medical research--pregnant women
    and their offspring; adolescents; and people with intellectual,
    developmental, and physical disabilities. Our research shows that even
    simple approaches can have significant impact. For example, a recent
    study found that an inexpensive program teaching newborn care to
    Zambian midwives reduced deaths in the first week of life by 40
    percent. Today, I would like to highlight a few other examples of
    NICHD's recent progress toward improving health, and describe a new
    effort to position our research to continue to contribute to a
    healthier Nation and world.
                  improving healthcare for women and children
        Thanks partly to NICHD research, Centers for Disease Control and
    Prevention (CDC) data show that the preterm birth rate in the United
    States declined for the second year in a row in 2008. Still, 12 percent
    of all pregnancies end in preterm birth, a leading cause of infant
    death in our country. Preterm infants have greater risk for breathing
    problems, life-threatening infections, cerebral palsy, and
    developmental disabilities. In recent years, NICHD research showed that
    treating pregnant women with a prior history of preterm birth with a
    type of progesterone reduced their risk of another preterm delivery.
    Now, a new study shows that a vaginal gel containing another type of
    progesterone substantially reduces the risk of premature delivery in
    women with a short cervix. With adoption of such treatments, the
    preterm birth rate should drop further.
        Spina bifida, which occurs when the fetal spinal column does not
    close properly, affects nearly 1,500 U.S. infants a year, according to
    the CDC. The most common and severe form of spina bifida,
    myelomeningocele, can cause paralysis, problems with nerve function,
    and brain damage. Recently, the NICHD reported an important trial, the
    Management of Myelomeningocele Study (MOMS). MOMS researchers compared
    standard surgical repair of the spinal cord after birth to repair while
    the fetus is in utero. They found that repairing the spinal cord in the
    womb greatly reduced risk of death and the need to divert fluid from
    the brain. It also doubled the chance of walking and improved later
    motor and cognitive development. Infants undergoing prenatal surgery,
    however, were also more likely to be born preterm, and their mothers
    more likely to experience a uterine tear in childbirth. While
    researchers continue to study this specialized surgery, the initial
    findings promise to improve the quality of life for thousands of
    children.
        New findings also can improve healthcare for women: NICHD
    researchers recently showed that women's cholesterol levels correspond
    with monthly changes in estrogen levels. On average, the total
    cholesterol level of the women studied varied 19 percent over the
    course of the menstrual cycle. Although previous data showed that
    estrogen-containing oral contraceptives or menopausal hormone therapy
    could affect cholesterol levels, this was the first study to show
    conclusively that the cyclical levels of naturally occurring hormones
    have similar effects. This natural variation suggests that clinicians
    should consider the phases of a woman's monthly cycle when evaluating
    her cholesterol levels and before prescribing treatment to help protect
    women against heart disease.
            new technoliges advance hope for autism and parkinson's
        Autism spectrum disorder (ASD) encompasses a range of conditions
    involving impaired social interactions and communication, atypical
    behaviors, and health problems. While ASD is known to have genetic
    components, researchers have not identified a consistent pattern of
    variant genes. In fact, dozens of gene variants, along with other
    factors, are now linked with ASD, complicating, but also advancing, our
    understanding of the condition and ability to develop new treatments.
    Using advanced imaging technology, NICHD-supported researchers
    identified a gene that impairs communication between parts of the
    brain. Additional genetic studies may reveal ASD subtypes and how
    certain genes function and interact with each other. This research
    could help individualize treatments based on a child's genetic profile.
    New technologies also hold promise for other neurologic conditions,
    such as Parkinson's disease, which results from a loss of brain cells
    that help coordinate movement. NICHD-supported researchers injected
    stem cells from the endometrium (lining of the uterus) into the brains
    of mice with a laboratory-induced form of the disease. These new cells
    took over the function of the brain cells eradicated by Parkinson's.
    This is the first time that scientists showed endometrial stem cells
    could assume the properties of the tissue into which they were
    transplanted. Since endometrial stem cells are widely available, this
    suggests that women with Parkinson's disease might serve as their own
    stem cell donors, or healthy endometrial stem cells might be stored and
    later matched to individuals with the disease.
                  translating science to advance rehabilation
        Applying basic scientific findings to clinical problems can help
    scientists develop new diagnostics or therapeutics for many conditions.
    For instance, NICHD researchers seeking to understand how the vitamin
    folate is metabolized found that the vitamin appears to promote healing
    in rats with damaged spinal cord tissue. Up to 20,000 people yearly
    suffer a spinal cord injury, and about 200,000 people currently live
    with such injuries, according to the National Center for Injury
    Prevention and Control. Folate, a B vitamin that naturally occurs in
    leafy green vegetables and other foods, plays an important role in
    early embryonic brain and spinal cord development. Further
    translational studies on folate could lead to new techniques to help
    regenerate nerve fibers and heal damaged nervous system tissue.
                      the national children's study (ncs)
        The NCS is designed to examine the effects of genetic factors and a
    broad range of environmental factors such as physical environment and
    family, community, and cultural influences on the development and
    health of children in the United States over time. The NCS will yield a
    rich repository of environmental and genetic/genomic data and
    biospecimens that can be mined by scientists for years to come and help
    answer questions concerning the earliest origins of health and disease.
    Over the past year, the NCS has been in a pilot phase, known as the
    ``Vanguard Study,'' enrolling about 650 children in 37 sites as of
    February 2011. Three separate recruitment strategies are being tested
    to optimize participation and cost management. During the coming year,
    a range of experts will review ongoing findings, allowing staff to
    develop, by late summer 2011, evidence-based cost-estimates and
    recommendations for the initial phase of the Main Study.
                             vision for the future
        The NICHD has embarked on crafting a vision for the future that
    inspires the institute and its partners to achieve critical scientific
    goals and meet pressing public health needs. In early 2011, in a series
    of workshops, we asked leading scientific and health experts to
    identify what the scientific future should look like in 10 years and
    what knowledge must be obtained to reach these new frontiers. We
    focused on such areas as plasticity, development, cognition, behavior,
    reproduction, pregnancy and pregnancy outcomes, developmental origins
    of health and disease, environment, and diagnostics and therapeutics.
    Resultant white papers are posted on our website for additional public
    comment. In June, we will assemble another diverse group of experts to
    refine these concepts and identify those that are most promising. We
    will publish the final vision document by early 2012, helping to ensure
    that NICHD addresses the most important science for the Nation's women,
    children, families, and individuals with special needs.
        Mr. Chairman and members of the Committee, thank you for your
    continued support of NICHD's important work. I would be pleased to
    respond to any questions.
                                     ______

     Prepared Statement of Nora Volkow, M.D., Director, National Institute
                                 on Drug Abuse
        Mr. Chairman and Members of the Committee: I am pleased to present
    the President's fiscal year 2012 budget request for the National
    Institute on Drug Abuse (NIDA). The fiscal year 2012 budget of
    $1,080,018,000 includes an increase of $30,377,000 over the comparable
    fiscal year 2011 level. The following statement updates NIDA's
    scientific progress in addressing drug abuse and addiction. These
    public health problems cost our society more than $600 billion annually
    in health- and crime-related costs and losses in productivity, not to
    mention incalculable personal and social devastation (ONDCP 2004; Rehm
    et al. 2009; CDC 2007). NIDA has crossed a threshold into a new
    research era, unprecedented in its scope, and transformative in its
    prevention, treatment, and policy implications for substance use
    disorders (SUDs).
             return on investment: technologies to speed discovery
        New technologies and scientific breakthroughs continue to generate
    actionable information about the genetics, chemistry, and circuitry of
    the human brain. This knowledge has dramatically enhanced our
    understanding of the underlying vulnerabilities and the long-term
    effects of addiction on neurophysiology and behavior. Continuing
    advances in DNA sequencing and analytical tools have transformed the
    landscape of genomic exploration. For example, we can now engage in
    high resolution and accurate sequencing of vast genomic tracts, from
    many different individuals, to systematically search for and identify
    addiction risk variants, which may open up new targets for medications.
    Also, we are dissecting the epigenetic processes that can affect gene
    expression through persistent but reversible changes. Epigenetics
    research has started to help explain the deleterious impact of known
    environmental risk factors, like poverty or chronic stress, on
    vulnerability for SUDs. The burgeoning availability of genetic,
    epigenetic, and environmental data heralds new opportunities for
    translational applications. NIDA is committed to optimizing this
    potential through harmonization efforts that help ensure the
    comparability of pooled data.
        Harmonized databases are crucial for individualized medicine. This
    is clear in the genomics field, but also in the emerging field of
    globally connected biomarkers, or the ``human connectome,'' and for
    brain imaging. NIDA is supporting research to develop biomarkers to
    screen for drug exposure and addiction vulnerability that would be more
    accurate, reliable, and sensitive than current tests (i.e. bodily
    fluids, hair, questionnaires) and would help transform the way SUDs are
    identified and treated.
        Other innovations, such as wireless remote sensing and virtual
    technologies, offer opportunities for transforming how prevention
    messages, real-time monitoring, and even some treatment modalities are
    delivered to the public. Having real-time, objective measures of drug
    use could have a huge impact on SUD treatments. One example is remote
    physiological monitoring (RPM), a rapidly evolving form of telemedicine
    that can track patients' health status (e.g., heart rate, blood
    pressure, skin temperature, and glucose levels) remotely, using devices
    that can store and transmit the results in real-time. NIDA is
    supplementing studies on the use of RPM for monitoring drug use to
    evaluate the effects of treatment interventions and their relationship
    to clinical outcomes. Such data could support the establishment of non-
    abstinence endpoints, which in turn could inform the Food and Drug
    Administration (FDA) addiction medications approval process.
                 emerging psychoactive threats to public health
        The past few years have witnessed several alarming trends,
    particularly prescription drug abuse. Although opioid analgesics are
    among the most effective medications for pain management, they are also
    associated with serious and growing public health problems, including
    drug abuse, addiction, and overdose deaths. The Substance Abuse and
    Mental Health Services Administration reports a six-fold increase in
    treatment admissions for opioid analgesics, from nearly 20,000 in 1998
    to about 120,000 in 2008, while the Centers for Disease Control and
    Prevention acknowledge that unintentional poisonings involving opioid
    analgesics have more than tripled from 1999 through 2007, exceeding the
    total number of deaths involving heroin and cocaine. These trends
    illustrate the challenge of balancing access to critical medications
    for those who need them and preventing their abuse, particularly when
    the public does not perceive their dangers and has much greater access
    to them from a decade-long surge in availability. In 2009, 202 million
    opioid prescriptions were dispensed in the United States making opioids
    the most prescribed class of medications. NIDA is committed to helping
    reverse this trend by providing information on the patterns and
    motivations behind their abuse, sponsoring research on developing pain
    medications with less abuse potential, and creating curricula to
    minimize diversion through better prescribing practices.
        Lingering public misperceptions, particularly among youth, continue
    to hinder our marijuana prevention efforts. The latest Monitoring the
    Future survey of 8th, 10th, and 12th graders reveals that daily
    marijuana use is up for all grades. These teens are not only at higher
    risk of becoming addicted, but they are functioning below optimal level
    at a time when their future depends on peak cognitive performance. Why
    is this happening now? We do not know for sure, but it is reasonable to
    infer that the public debates surrounding medical marijuana have
    increased confusion and lowered the perception of risk, an important
    factor in curtailing use.
        Meanwhile, new drugs routinely emerge and gain rapid notoriety
    thanks to the Internet. Recent examples include ``bath salts'' and
    ``spice,'' which are synthetic stimulants and cannabinoids,
    respectively.
             improving public healthcare--delivery and performance
        NIDA will continue to leverage our knowledge base into better
    strategies for battling addiction. To further this goal, NIDA takes
    advantage of collaborative research infrastructures designed to deploy
    proven strategies rapidly and effectively. For example, NIDA's Drug
    Abuse Treatment Clinical Trials Network (CTN) tests evidence-based
    treatments in community settings with diverse patient populations,
    optimizing the utility and cost-effectiveness of treatments and
    fostering their adoption. Similarly, NIDA's Criminal Justice-Drug Abuse
    Treatment Studies (CJ-DATS) network promotes multilevel collaborations
    to bring proven treatment models into the criminal justice system,
    disproportionately affected by both drug abuse and HIV. These
    infrastructures allow for the broad testing of promising new
    strategies. One example, called ``Seek, Test, and Treat,'' has great
    potential to improve the public health by expanding access to HIV
    testing and treatment, and ultimately reducing HIV spread.
        Another cornerstone of our strategy is to engage physicians as
    ``frontline'' responders to patient substance abuse, providing the
    science-based tools they need to identify potential substance abuse in
    their patients and offering better options for treatment. Recent
    research shows, for example, that compared with methadone,
    buprenorphine results in fewer neonatal abstinence symptoms among
    babies born to opioid-addicted mothers, and is associated with
    decreased hospital stays and thus, costs. To bolster education in the
    treatment of pain, NIDA is leading a multi-Institute effort to create
    Centers of Excellence (CoEs) to develop curricula for medical students,
    nurses, resident physicians, and others. Part of our NIDAMED physician
    outreach initiative, CoEs have also developed and are helping to
    disseminate substance abuse training curricula, woefully neglected in
    most medical training. NIDA continues to encourage physician screening
    of drug abuse with the help of a Web-based interactive screening tool
    that generates clinical recommendations. The broad availability of
    these resources is an important step toward integrating substance abuse
    screening, brief intervention, and referral to treatment (SBIRT) into
    medical care, which will enable better healthcare decisions and
    outcomes.
                     translation--therapeutics development
        To help those affected by the disease of addiction, we need to
    expand the pharmacological and behavioral tools available to treat
    SUDs. Thus, medications development is one of the main areas that
    benefits from new discoveries. For example, the century-old practice of
    vaccination has recently been found to be a viable approach for
    treating addiction. In this case, the body itself is coaxed to produce
    antibodies that bind a drug while still in the bloodstream, blocking
    its psychoactive effects in the brain. Already, a nicotine vaccine that
    reduces craving and withdrawal symptoms is in advanced stages of
    development and will be market-ready following approval by the FDA.
    Another strategy has been the development of long-acting, or depot,
    formulations of medications that serve to overcome poor compliance. One
    example is Vivitrol, an extended-release opioid antagonist
    (naltrexone), recently FDA-approved for treating opioid addiction. NIDA
    is now testing the use of depot medications in high-risk groups, such
    as criminal justice offenders, and in regions of the world that have
    high rates of HIV infection and are resistant to treatment with opioid
    agonist medications.
        In parallel, NIDA is supporting research on drug combinations, an
    effective strategy for treating many diseases (e.g., HIV/AIDS, cancer)
    and one starting to show success with addiction. For example, the
    combination of lofexidine (a hypertension medication) and marinol (a
    synthetic form of marijuana's THC) shows promise in treating withdrawal
    symptoms among marijuana-addicted individuals. Early results also
    suggest that a buprenorphine-naltrexone combination could be effective
    in treating cocaine addiction.
                          new investigators, new ideas
        To help sustain our commitment to the next generation of biomedical
    research scientists, NIDA supports multiple training initiatives at
    various career levels and areas of need (e.g., physician scientists,
    computational neuroscience, and medicinal chemists). Examples include
    efforts aimed at mentoring minority investigators and international
    HIV/AIDS researchers, as well as multi-Institute training programs. To
    identify and encourage the next generation of addiction scientists,
    NIDA also awards special prizes at the annual Intel International
    Science and Engineering Fair to high school students whose projects
    exemplify excellent achievement in addiction science.
        In closing, NIDA pledges to continue to tackle the emerging and
    significant public health needs related to drug abuse and addiction,
    taking advantage of unprecedented scientific opportunities to close the
    gaps in our knowledge base and develop and disseminate more effective
    strategies to prevent and treat drug abuse and addiction.
                                     ______

      Prepared Statement of James F. Battey, Jr., M.D., Ph.D., Director,
        National Institute on Deafness and Other Communication Disorders
        Mr. Chairman and Members of the Subcommittee: I am pleased to
    present the President's budget request for the National Institute on
    Deafness and Other Communication Disorders (NIDCD) of the National
    Institutes of Health (NIH). The fiscal year 2012 NIDCD budget of
    $426,043,000 includes an increase of $11,244,000 over the comparable
    fiscal year 2011 appropriation of $414,799,000. This statement is
    submitted with the recognition of the Department's notification to the
    Congress of an NIH reorganization that would establish a new National
    Center for Advancing Translational Sciences (NCATS).
        The NIDCD conducts and supports research and research training in
    the normal and disordered processes of hearing, balance, smell, taste,
    voice, speech, and language. Our Institute focuses on disorders that
    affect the quality of life of millions of Americans in their homes,
    workplaces, and communities. The physical, emotional, and economic
    impact for individuals living with these disorders is tremendous. NIDCD
    continues to make investments to improve our understanding of the
    underlying causes of communication disorders, as well as their
    treatment and prevention. It is a time of extraordinary promise, and I
    am excited to be able to share with you some of NIDCD's ongoing
    research and planned activities on communication disorders.
                         affordable hearing healthcare
        Hearing loss is a serious public health issue and has significant
    social and economic impacts. Approximately 17 percent of American
    adults, or 36 million individuals, report a hearing loss, and only
    about one in five of those individuals who could benefit from a hearing
    aid wears one. Additionally, hearing healthcare and hearing aids are
    only rarely covered by health insurance, and are not covered by
    Medicare. A recent industry survey found that the average cost per
    hearing aid to an individual is $1,600, and for many, the cost is much
    higher. Hearing aids are also consumable devices, often requiring
    replacement every 4-6 years, and frequent battery replacement. This
    makes hearing aids potentially the third highest cost item for an
    individual, following just behind the purchase of a home and car. In
    2009, NIDCD sponsored a workshop, Accessible and Affordable Hearing
    Health Care for Adults with Mild to Moderate Hearing Loss, to examine
    the factors that contribute to hearing healthcare access,
    affordability, and usage; and to develop a set of research objectives
    which could be explored in the future. Based on the recommendations,
    NIDCD published several targeted research initiatives for hearing
    healthcare: to explore new approaches that could lead to improved
    access, assessment, and intervention; to develop methods to determine
    the success of new or improved approaches; and to create small business
    technologies to improve access for underserved patients. The research
    supported through these and other NIDCD-sponsored efforts will enhance
    the evidence-base for hearing healthcare decisions, and provide a
    strong research base for future policy decisions related to affordable
    hearing healthcare.
                                    tinnitus
        Tinnitus--a perceived ringing, buzzing or roaring in the ears--is a
    major public health concern, affecting more than 25 million American
    adults. It can range in severity from a mild condition, requiring no
    medical intervention, to a severe debilitating disease with significant
    physical, emotional, and economic impacts. The Department of Veterans
    Affairs reports tinnitus as the most prevalent service-connected
    disability for veterans receiving disability compensation. More than
    744,000 veterans received service-connected disability compensation for
    tinnitus in fiscal year 2010, presenting a significant cost burden for
    the Nation. Past research has shown that tinnitus is often associated
    with hearing loss; however, little is known about the specific neural
    dysfunctions that lead to the disorder. There are also limited
    treatment options available, and their effectiveness varies widely. In
    response to this need, NIDCD is supporting a strong research portfolio
    on tinnitus. In 2009, NIDCD sponsored a research symposium, Brain
    Stimulation for the Treatment of Tinnitus, to explore the potential
    translation of existing brain stimulation technologies for the
    treatment of tinnitus. Recently, NIDCD supported scientists have
    demonstrated that stimulation of the vagus nerve (a large nerve that
    runs from the head to the abdomen) with an implantable electrode, in
    combination with the playing of tones, is able to ``reset'' the brain,
    eliminating tinnitus in a rat model of the disease. (Vagus nerve
    stimulation is already in use for the treatment of epilepsy and
    depression in more than 50,000 individuals). By varying the tones
    played and the co-stimulation of the vagus nerve, scientists were able
    to abolish the tinnitus sensation and restore the normal function of
    the brain. These exciting findings are the first demonstration of a
    treatment that specifically erases the tinnitus, rather than simply
    masking the sound or providing coping mechanisms for the individual.
    Scientists are now working to translate these findings from the animal
    model into a novel therapeutic strategy for people with severe
    tinnitus.
                             vestibular prosthesis
        Based on the recent 2008 National Health Inventory Survey, Balance
    and Dizziness Supplement, about 15.5 percent of U.S. adults, or about
    33.6 million individuals, reported they had a problem with dizziness or
    balance in the past 12 months. Balance disorders are one of the reasons
    older people fall, and falls and fall-related injuries, such as hip
    fracture, can have a serious impact on an older person's life. One
    balance disorder which has been particularly difficult to treat is
    Meniere's disease. This disorder causes severe dizziness (vertigo),
    tinnitus, hearing loss, and a feeling of fullness or congestion in the
    ear. NIDCD estimates that approximately 615,000 individuals in the
    United States are currently diagnosed with Meniere's disease and that
    45,500 cases are newly diagnosed each year. While many individuals are
    able to manage the symptoms associated with Meniere's disease through
    diet, drugs, or surgery, up to 2 in 10 do not find adequate relief from
    their symptoms after exhausting all treatment options. NIDCD-supported
    scientists are working to adopt cochlear implant technologies to
    produce a vestibular implant that could counteract vertigo attacks that
    persist despite other treatments. Scientists have already demonstrated
    the ability of a vestibular implant to induce, and provide recovery
    from, vertigo attacks in animal models of Meniere's. Most recently,
    scientists have translated this technology to humans and performed
    their first implantation into an individual. While clinical trials are
    still several years away, this recent breakthrough provides hope to
    many for whom traditional treatments have failed.
                                   stuttering
        The popularity of the recent Academy Award winning movie, ``The
    King's Speech,'' has brought to light the communication challenges
    faced by approximately 3 million Americans each day. Stuttering can
    affect individuals of all ages, but occurs most frequently in young
    children between the ages of 2 and 6, with boys 3 times more likely
    than girls to stutter. Most children, however, outgrow their
    stuttering, and it is estimated that less than 1 percent of adults
    stutter. For those individuals who continue to stutter into adolescence
    and adulthood, there are limited treatment options. NIDCD supports a
    research portfolio on stuttering to understand the underlying genetic,
    neurologic, and physiologic causes of stuttering, to predict which
    children will continue to stutter, and to develop novel and effective
    therapies for treatment of stuttering. Recently, NIDCD intramural
    scientists pinpointed the first specific genes that underlie
    stuttering. Building on previous studies which identified a genetic
    region linked to stuttering, and harnessing new technologies in genetic
    sequencing, the researchers found mutations in three genes important in
    the recycling of cellular breakdown products inside cells. Different
    mutations in two of these genes are related to severe metabolic
    disorders, called mucolipidosis II and III, which cause joint,
    skeletal, heart, liver, and other health problems, including speech
    problems. The findings may result in the development of new drug
    therapies for individuals who stutter.
            olfactory deficits early warning of alzheimer's disease
        For several years, it has been know that individuals with
    Alzheimer's disease (AD) often exhibit an impaired sense of smell
    (olfaction), making a smell screening test an attractive opportunity
    for development as a biomarker of disease. However, it was not known
    why AD impacts olfaction. Recently, NIDCD-supported scientists used a
    mouse model of AD to identify pathological changes in the olfactory
    system very early in the animals' lives, indicating a sensitivity of
    the olfactory system to this type of damage. These changes manifested
    well in advance of the onset of changes in other areas of the brain
    involved in memory, and were predicted by the animals' performance on a
    smell discrimination task. In addition, NIDCD-supported scientists have
    used brain imaging of humans to examine changes in brain activity
    during smell discrimination tasks. These imaging studies have
    identified a significant blunting of response in individuals with AD.
    Both of these discoveries could lead to new, non-invasive tools to
    enhance the early diagnosis of AD, and better inform healthcare
    decisions for affected individuals.
                          new strategic plan for nidcd
        NIDCD has initiated the development process for a new Strategic
    Plan. In March 2011, NIDCD convened a series of working groups of
    scientific experts in the smell and taste; voice, speech, and language;
    and hearing and balance fields to advise us on emerging scientific
    opportunities in four priority areas: understanding normal function of
    communication systems; understanding diseases and disorders of
    communication systems; improving diagnosis, treatment, and prevention
    of communication disorders; and accelerating translation of research
    findings into practice. In addition, we remain committed to continuing
    our leadership in fostering the development of new investigators in the
    communication sciences. Our staff is currently working to compile these
    priority areas into a document that will guide our research investments
    from fiscal year 2012 through 2016. A draft will be made available for
    public comment later this year and we anticipate publication of our new
    Strategic Plan in January 2012.
        Mr. Chairman, I would like to thank you and Members of this
    Subcommittee for giving me the opportunity to present examples of
    recent research progress and to highlight some programs made possible
    through your support of the NIDCD.
                                     ______

     Prepared Statement of Dr. A. Isabel Garcia, D.D.S., M.P.H., Director,
             National Institute of Dental and Craniofacial Research
        Mr. Chairman and Members of the Committee: I am pleased to present
    the President's budget request for the National Institute of Dental and
    Craniofacial Research (NIDCR) of the National Institutes of Health
    (NIH). The fiscal year 2012 budget request for NIDCR is $420,369,000,
    which reflects an increase of $11,113,000 over the fiscal year 2011
    enacted level of $409,256,000 comparable for transfers proposed in the
    President's request.
        The NIDCR goal of improving the Nation's dental, oral, and
    craniofacial health is an ambitious one. It demands that we address the
    wide array of diseases and conditions that affect the oral cavity and
    craniofacial structures, including diseases such as dental caries
    (tooth decay) and periodontal diseases that are endemic in the United
    States, as well as birth defects such as cleft lip and palate, chronic
    oral-facial pain conditions, oral and pharyngeal cancers, and oral
    manifestations of systemic diseases, such as Sjogren's syndrome,
    diabetes, and HIV infection. NIDCR is committed to identifying
    effective preventive, diagnostic, and treatment approaches for these
    diseases and conditions. Today, I will describe how we are investing in
    basic discovery and preclinical studies across these myriad areas and
    applying new knowledge to the development of clinical trials and
    studies in humans.
                          accelerating basic discovery
        Joshua Lederberg, who shared the 1958 Nobel prize for discovering
    that bacteria can mate and exchange genes, once quipped about microbes
    that ``you know one when you see it.'' The problem, he explained, is
    that microbes were largely ``invisible'' and noticed only after their
    damage had been wrought. NIDCR-supported researchers and others
    recently identified--made ``visible''--more than 600 distinct microbial
    species as residents of the human mouth. NICDR scientists are also
    systematically exploring how the individual bacterial species assemble
    into biofilms. Biofilms are the living, mat-like microbial communities
    found on many parts of the human body, including our teeth and gums,
    and play a major role in the development of dental and oral disease.
        Microbial biofilms can form on any surface, including on medical
    devices, and are implicated in more than 80 percent of human
    infections. The oral cavity offers tremendous potential both as a
    diagnostic window and an easily accessible model for research aimed at
    understanding the host of bacteria associated with biofilm-mediated
    disease throughout the body. Researchers now possess the tools to
    extract a biofilm sample and determine the identities of most of its
    microbial inhabitants.
        Recently, NIDCR grantees devised a new fluorescent imaging system
    that successfully distinguished among 28 oral microbes within a single
    field of view and that soon will be able to distinguish among at least
    100, providing spatial analysis in three dimensions. Enhanced imaging
    of the oral biofilm will accelerate discovery in studies of biofilm
    formation, organization, and composition and thus the keys to their
    control. This structural understanding will form the basis for research
    aimed at development of tools to combat oral and other infectious
    diseases and improve health.
        An NIDCR grantee and colleagues recently performed a novel type of
    systematic genetic analysis to better elucidate microbial behavior. The
    researchers collected over 4,000 mutant bacterial strains and tested
    them in 324 different environmental conditions. Pulling all the data
    together, the scientists gained a fuller understanding of the
    functional molecular networks governing bacterial response. They also
    gleaned new information about a gene involved in antibiotic resistance
    and the synergy of three common antibiotic drugs.
        Both of the exciting advances described above were spearheaded by
    young investigators on NIDCR training grants, offering prime examples
    of the vital importance of continuing to support new investigators and
    new ideas. NIDCR is committed to developing and strengthening the
    workforce of researchers that can leverage the latest tools of
    discovery and are dedicated to solving urgent problems in oral, dental
    and craniofacial health. To enhance this critical pipeline further,
    NIDCR continues to create innovative new training and career programs,
    such as a new transition path for clinical researchers, as well as an
    initiative to catalyze the formation of multidisciplinary teams led by
    new investigators researching temporomandibular disorders and orofacial
    pain.
             translating basic science into improved public health
        Advances in studying oral microbial communities have the potential
    for rapid impact on research for new, more personally targeted,
    clinical treatment. A team of NIDCR-supported scientists recently
    reported that a microbe called Scardovia wiggsiae appears to be linked
    with severe forms of early childhood caries (ECC), the most prevalent
    chronic childhood disease in the United States. For decades, the oral
    bacterium Streptococcus mutans has been singled out as the primary
    pathogen involved in ECC. The scientists found that S. wiggsiae often
    was present in children with decayed teeth in the absence of S. mutans.
    The discovery of this bacterium's role in ECC offers a future target in
    efforts to identify children at risk and to prevent or stop progression
    of this disease before it leads to destruction of the teeth.
        The burden of craniofacial, oral, and dental disease, particularly
    untreated disease, falls heaviest on lower socioeconomic status (SES)
    groups, which include disproportionately large numbers of racial and
    ethnic minorities. Researchers, including those at the five NIDCR-
    supported Centers for Research to Reduce Disparities in Oral Health,
    continue working to identify creative, practical approaches to deal
    with pressing oral health issues, including ECC and oral and pharyngeal
    cancer. These approaches must be inexpensive, easily applied, and
    readily tailored to meet individual and community needs. Three of these
    Centers recently initiated clinical trials to test new interventions to
    prevent ECC among American Indian and Hispanic children and in
    residents of public housing. Children in low SES families are
    particularly vulnerable to ECC's painful and costly impact. Three
    additional trials will launch in fiscal year 2012.
                enhancing the evidence base for oral health care
        Tackling real-world clinical issues and generating evidence that
    will be of immediate value to practitioners and patients is the central
    goal of the NIDCR-supported dental Practice-based Research Networks
    (PBRNs). Conducting research in dental practices draws on the
    experience and insight of practicing clinicians to help identify and
    frame research questions. Because PBRN studies address practice-based
    problems, their results tend to be more quickly translated into daily
    clinical care.
        Leveraging the infrastructure of established dental practices for
    conducting PBRN studies also can be a powerful and cost-effective means
    to conduct clinical research. For example, the past decade brought
    reports that people who take bisphosphonates, a class of drug
    prescribed for osteoporosis or to treat the bone-wasting effects of
    cancer, can develop osteonecrosis (bone death) of the jaw, or ONJ. To
    address the problem, the three regional PBRNs, taking advantage of
    their presence in practices spanning multiple States, teamed up to
    carry out a collaborative study on ONJ. The study results, published in
    2010, confirmed that bisphosphonate use is a risk factor for ONJ, and
    provided additional important evidence to guide clinicians in their
    treatment of this challenging condition.
        In fiscal year 2012, NIDCR will launch a new National Dental PBRN.
    This single network, more national in scope and more representative of
    a greater variety of practice settings, will provide a framework to
    study and improve the delivery of oral care and will build upon the
    collaboration among the regional networks that was crucial to the
    successes to date. Critical to this effort is an improved capacity to
    collect data electronically. Using an adaptable electronic platform for
    enhanced connectivity, data sharing, and communication within and
    between networks will help providers conduct research effectively and
    efficiently and strengthen the PBRN enterprise.
                       developing new clinical treatments
        Each year, about 400,000 people worldwide are diagnosed with cancer
    in the head and neck region. In an effort to identify new treatments
    and improve the stagnant 5-year survival rate that hovers only slightly
    above 50 percent, NIDCR scientists focused their research on the
    immunosuppressive drug rapamycin. This research is now moving from the
    basic and preclinical phases, which included studies in an NIDCR-
    developed mouse model, to clinical studies. By fiscal year 2012,
    scientists will be recruiting subjects for a clinical trial to assess
    rapamycin's safety and efficacy in humans.
        Research is also needed to combat harmful treatment side effects
    for head and neck cancers. Many patients with head and neck cancers
    will receive radiation therapy, which has the significant long-term
    side effect of xerostomia (dry mouth). The salivary glands, damaged by
    the radiation used to kill nearby tumor cells, can become less
    permeable to the fluid that naturally flows through them and yield less
    saliva, or stop working altogether. Many functional and quality-of-life
    problems occur when oral tissues are deprived of saliva's protective
    properties, including difficulty chewing and swallowing, burning mouth,
    and greater risk of dental caries and oral fungal infections. Despite
    continuing efforts to eliminate this problem, many patients continue to
    suffer.
        Moving from bench to bedside, NIDCR scientists began the first
    gene-transfer study in people with radiation-induced xerostomia. The
    transferred gene, Aquaporin-1, encodes a protein that conveys fluid by
    forming pores, or water channels, in the cell membrane. The study
    assesses whether the transferred gene will open water channels in the
    duct cells, allowing the rapid movement of water through the duct. In
    fiscal year 2012, NIDCR will issue an initiative to stimulate
    additional research on restoring damaged salivary gland structure and
    function to complement this important clinical advance.
        As these highlights illustrate, NIDCR has made a strong commitment
    to advancing oral health science through efforts in the laboratory, in
    training sites, in dental practices, and in the community. This
    investment is providing new tools and scientific approaches that may
    greatly accelerate the next breakthroughs in oral health research.
    NIDCR will continue to support research that provides new and exciting
    leads that can translate into better ways to prevent, diagnose, and
    manage oral, dental, and craniofacial diseases and disorders. In so
    doing, NIDCR seeks to improve the oral health of the Nation.
                                     ______

       Prepared Statement of Linda S. Birnbaum Ph.D., D.A.B.T., A.T.S.,
       Director, National Institute of Environmental Health Sciences and
                                Health Services
        Mr. Chairman and Members of the Committee: I am pleased to present
    the President's fiscal year 2012 budget request for the National
    Institute of Environmental Health Sciences (NIEHS) of the National
    Institutes of Health (NIH). The fiscal year 2012 budget includes
    $700,537,000; an increase of $17,400,000 over the comparable fiscal
    year 2011 enacted level of $683,137,000, comparable for transfers
    proposed in the President's request.
                                  introduction
        Good health is vitally important for all Americans, and it depends
    on a clean and safe environment. Currently, our healthcare system
    expends huge resources controlling a variety of diseases and
    dysfunctions that are known to be at least partially connected with
    environmental exposures: asthma, cancer, developmental disabilities,
    neurological/cognitive deficits, heart attack, and many others.
    Preventing these diseases through prevention of adverse environmental
    exposures could make an enormous difference in reducing healthcare
    costs. At NIEHS, and through NIEHS-funded projects in research
    institutions across the United States, we are bringing all the tools of
    biomedical science to bear on the fundamental questions of the effects
    of environmental exposures to toxic substances on biological systems.
    Environmental health science is advancing at a tremendous rate and new
    tools--genetics, genomics, proteomics, metabolomics, informatics, and
    computational biology, just to name some of these new disciplines--give
    us new insights on how environmental effects happen in our bodies. They
    also point the way toward technologies and testing procedures to
    provide better and more timely information for the use of our agency
    partners who are responsible for policy decisions and regulations.
                 advances in toxicology and exposure assessment
        With our rapidly increasing understanding of the subtleties of
    biological effects of environmental exposures, we are moving toward a
    new kind of toxicological testing that is less expensive and time-
    consuming than our current methods, and also gives us an improved
    understanding of the actual effects on humans. Toxicology is becoming a
    more powerful predictive science focused on making target-specific,
    mechanism-based, biological observations. Alternative assays are
    targeting the key pathways, molecular events, and processes linked to
    disease or injury and incorporating them into a research and testing
    framework. Our National Toxicology Program (NTP) at NIEHS is laying the
    foundation for this new testing paradigm in partnership with the
    National Human Genome Research Institute, the Environmental Protection
    Agency, and the Food and Drug Administration. We are using quantitative
    high-throughput screening assays to test a large number of chemicals.
    The resulting data are being deposited into publicly accessible
    relational databases. Analyses of these results will set the stage for
    a new framework for toxicity testing.
        The NIEHS-led Exposure Biology Program (EBP), part of the NIH
    Genes, Environment and Health Initiative, has resulted in the
    development of dozens of new technological advances for personalized
    measurement of environmental exposures. At a recent workshop, EBP
    investigators presented their prototypes: miniaturized personal
    monitors for black carbon and other air pollutants; a wearable
    nanosensor array for real-time monitoring of exposure to diesel and
    gasoline exhaust; a personal aerosol sensor platform to link children's
    exposures to asthma severity; personal exposure assessment systems for
    chemical toxicants; gene expression biomarkers of airway response to
    tobacco exposure; and biomarkers of organophosphate-linked proteins.
    One prototype of a continuously operating wearable badge that provides
    real-time measurements of chemical toxicants has attracted subsequent
    R&D funding from the Department of Defense to develop this model for
    use by military personnel. Others are being moved into validation
    studies as a next step toward their deployment in environmental health
    research.
          epigenetics, endocrine disrupters, and environmental health
        Our understanding of chemical toxicity has been challenged by the
    new science of epigenetics, which is the study of changes to the
    packaging of the DNA molecules that influence the expression of genes,
    and hence the risks of diseases and altered development. Studies
    indicate that exposures that cause epigenetic changes can affect
    several generations.\1\ This new understanding heightens the need to
    protect people at critical times in their development when they are
    most vulnerable. NIEHS is making key investments in understanding basic
    epigenetic processes and how they are influenced by environmental
    factors. Recently, some of this work has provided a critical resource
    for understanding and characterizing properties of human induced
    pluripotent stem cells.\2\ The development of pluripotent stem cells
    shows promise for research and clinical applications in lieu of
    embryonic stem cells, but many questions remain to be answered about
    their structure, utility, and safety. NIEHS-funded investigators have
    established genome-wide reference maps of DNA methylation (an
    epigenetic marker) and gene expression in previously derived human
    embryonic cell lines and human iPS cell lines, to assess their
    epigenetic and transcriptional similarity and predict their
    differentiation efficiency. A separate report by another NIEHS-funded
    group reported ``hotspots'' of aberrant epigenomic reprogramming in
    human iPS cells.\3\ There are still many questions about the role of
    these important epigenetic processes which will need to be answered
    before iPS cells can be confidently used in research and therapy.
    ---------------------------------------------------------------------------
        \1\ Anway MD, Cupp AS, Uzumcu M, Skinner MK (2005) Epigenetic
    transgenerational actions of endocrine disruptors and male fertility.
    Science 308:1466-1469.
        \2\ Bock C, Kiskinis E, Verstappen G, et al. (2011) Reference maps
    of human ES and iPS cell variation enable high-throughpu
    characterization of pluripotent cell lines. Cell 144(3):439-52.
        \3\ Lister R, Pelizzola M, Kida YS, et al. (2011) Hotspots of
    aberrant epigenomic reprogramming in human induced pluripotent stem
    cells. Nature 471(7336):68-73.
    ---------------------------------------------------------------------------
        Related to the field of epigenetics is the key concept of ``windows
    of susceptibility.'' Research shows that the developmental processes
    that occur at fetal and early life stages are especially vulnerable to
    disruption from relatively low doses of certain chemicals.\4\ \5\ \6\
    We first saw this in the case of lead and other metals, such as mercury
    and arsenic, which we learned decades ago could harm neurological
    development as a result of fetal and childhood exposures. This concept
    also applies to hormonally active agents which disrupt the endocrine
    system. This is an active area of our research program. For example,
    NIEHS and NTP are funding important studies to fill the gaps in our
    knowledge about bisphenol A (BPA), a widely distributed compound used
    in plastics, can linings, thermal paper, and more. NTP's Center for
    Evaluation of Risks to Human Reproduction determined that there was
    ``some concern'' about effects to the brain, behavior, and prostate
    gland in fetuses, infants, and children exposed to BPA.\7\ NIEHS is now
    supporting an aggressive research effort to fill the research gaps in
    this area, especially concerning BPA effects on behavior, obesity,
    diabetes, reproductive disorders, development of prostate, breast and
    uterine cancer, asthma, cardiovascular diseases and transgenerational
    or epigenetic effects.
    ---------------------------------------------------------------------------
        \4\ Rogan WR, Ragan NB (2003) Evidence of effects of environmental
    chemicals on the endocrine system in children. Pediatrics 112:247-252.
        \5\ Dolinoy DC, Weidman JR, Jirtle RL (2007) Epigenetic gene
    regulation: Linking early developmental environment to adult disease.
    Reproductive Toxicology 23:297-307.
        \6\ Committee on Environmental Health, American Academy of
    Pediatrics (1999) Pediatric environmental health, 2nd edition, pp 9-23.
        \7\ http://www.niehs.nih.gov/news/media/questions/sya-bpa.cfm See
    ``What does some concern mean?''.
    ---------------------------------------------------------------------------
        Any consideration of important public health issues in the United
    States. has to include obesity. Environmental exposures are beginning
    to be implicated in the obesity epidemic.\8\ \9\ NIEHS is supporting
    research on the developmental origins of obesity and the theory that
    environmental exposures during development play an important role in
    the current epidemic of obesity, diabetes, and metabolic syndrome.
    There are data showing weight gain in adult rats and mice following
    developmental exposure to a number of different chemicals, such as
    tributyltin compounds,\10\ which have been termed ``obesogens'' by some
    researchers. A groundbreaking workshop on environmental factors in
    obesity and diabetes was sponsored by NIEHS in January 2011. Many
    research gaps still need to be filled, but if these early research
    results are confirmed, we may find it more useful to expand our
    approach to fighting obesity to include not just educating about diet
    and lifestyle but also reducing early life exposure to these
    ``obesogenic'' chemicals that might be setting the stage for us to gain
    weight later in life.
    ---------------------------------------------------------------------------
        \8\ Grun F, Blumberg B (2009) Endocrine disrupters as obesogens.
    Mol Cell Endocrinol 304:19-29.
        \9\ Verhulst SL, Nelen V, Hond ED, Koppen G, Beunckens C, Vael C,
    Schoeters G, Desager K (2009) Intrauterine exposure to environmental
    pollutants and body mass index during the first 3 years of life.
    Environ Health Perspect 117:122-126.
        \10\ Iguchi T, Watanabe H, Ohta Y, Blumberg B (2008) Developmental
    effects: oestrogen-induced vaginal changes and organotin-induced
    adipogenesis. Int J Androl 31:263-268.
    ---------------------------------------------------------------------------
                            planning for the future
        NIEHS recently began work on the development of a new Strategic
    Plan to set goals for guiding our research investments over the next 5
    years. Our process is designed to bring in information and perspectives
    from a wide variety of sources: community members, advocacy groups,
    agency partners, and scientists from all disciplines.
        In summary, understanding the connection between our health and our
    environment, with its mixture of chemicals, diet and lifestyle
    stressors, is a complex and intricate scientific endeavor. At NIEHS, we
    remain committed to leading the evolution of the field of environmental
    health sciences to meet emerging public health challenges.
                                     ______

        Prepared Statement of Thomas R. Insel, M.D., Director, National
                           Institute of Mental Health
        Mr. Chairman and Members of the Committee: I am pleased to present
    the President's budget request for the National Institute of Mental
    Health (NIMH) of the National Institutes of Health (NIH). The fiscal
    year 2012 NIMH request of $1,517,006,000 includes an increase of
    $40,981,000 over the fiscal year 2011 appropriated level of
    $1,476,025,000. In my statement, I will underscore the impact that
    mental disorders have on public health in the United States; outline
    examples of NIMH's strategies for reducing the burden associated with
    mental disorders; and, highlight examples of research activities that
    are advancing us toward this goal. I submit this statement with the
    recognition of the Department's notification to the Congress of an NIH
    reorganization that would establish a new National Center for Advancing
    Translational Sciences.
                     public health burden of mental illness
        NIMH's mission is to transform the understanding and treatment of
    mental illnesses through basic and clinical research, paving the way
    for prevention, recovery, and cure. The burden of mental illness is
    enormous. In 2009, an estimated 11 million American adults
    (approximately 1 in 20) suffer from serious mental illness.\1\
    According to the World Health Organization, mental disorders are the
    leading cause of medical disability in the United States and Canada.\2\
    In contrast to many other chronic medical conditions, mental disorders
    typically begin at an early age, usually before the age of 30. Mental
    disorders, such as schizophrenia, depression, and bipolar disorder, are
    increasingly recognized as the chronic medical illnesses of young
    people.
    ---------------------------------------------------------------------------
        \1\ SAMHSA. Results from the 2009 National Survey on Drug Use and
    Health: Mental Health Findings (Office of Applied Studies, NSDUH Series
    H-39, HHS Publication No. SMA 10-4609). Rockville, MD; 2010.
        \2\ The World Health Organization. The global burden of disease:
    2004 update, Table A2: Burden of disease in DALYs by cause, sex and
    income group in WHO regions, estimates for 2004. Geneva, Switzerland:
    WHO, 2008.
    ---------------------------------------------------------------------------
        The annual economic costs of mental illness in the United States
    are enormous. The direct costs of mental health treatment represent an
    estimated 6.2 percent of all healthcare spending,\3\ which, according
    to the Centers for Medicare and Medicaid Services, totals 15.8 percent
    of the gross domestic product. Indirect costs, which include all non-
    treatment-related costs such as Social Security disability payments,
    lost earnings, and incarceration, account for an even greater expense
    than the direct costs associated with mental healthcare. A conservative
    estimate places the total direct and indirect costs of mental illness
    at well over $300 billion annually.\4\
    ---------------------------------------------------------------------------
        \3\ Mark TL, et al. National Expenditures for Mental Health
    Services and Substance Abuse Treatment, 1993-2003. SAMHSA Publication
    No. SMA 07-4227. Rockville, MD: SAMHSA, 2007.
        \4\ Insel TR. Assessing the economic cost of serious mental
    illness. Am J Psychiatry. 2008 Jun;165(6):663-5.
    ---------------------------------------------------------------------------
        NIMH's mission is not merely to reduce the symptoms and disability
    associated with mental disorders, but to promote recovery, to extend
    healthy life, and ultimately, to discover preventive interventions. In
    the year ahead, NIMH will work toward this mission by fostering and
    facilitating a collaborative approach across the spectrum of mental
    health research approaches--from discovery to dissemination--to make a
    positive change in the lives of people with mental disorders and their
    families.
                      technologies to accelerate discovery
        Funding from the American Recovery and Reinvestment Act of 2009 has
    enabled NIMH to support infrastructure development that will provide a
    framework for future discoveries. One large, collaborative project that
    promises to provide researchers with an invaluable reference tool is
    the Transcriptional Atlas of Human Brain Development. This atlas is
    mapping when and where genes are switched on and off during normal
    brain development, because to understand disorders, scientists must
    first understand what the normal patterns of gene expression are during
    development. The atlas will contain data from 16 brain regions at 11
    developmental stages--ranging from embryonic development to mid-
    adulthood. These maps will highlight differences between prenatal and
    postnatal brains, changes across adolescence, and unique patterns of
    gene expression that only occur during development. The first maps from
    the atlas were released this year and will form the foundation for
    future maps and releases.
              translational sciences and therapeutics development
        NIMH-funded researchers are working to translate discoveries from
    basic science into targeted, rapidly acting therapeutics. Current
    antidepressant medications and cognitive behavioral therapies often
    require 6 to 8 weeks to have an effect. Previous NIMH research has
    shown that the drug ketamine can reduce depression, including thoughts
    of suicide, within 6 hours. However, long-term use is associated with
    side effects, and the mechanism by which ketamine works remained
    unclear, until NIMH-funded researchers made a significant discovery in
    2010. They identified how the brain responds to ketamine, as well as
    the molecular mechanism for this rapid response--the rapid activation
    of an enzyme, mTOR, which regulates cell growth, proliferation, and
    survival. The discovery of this cellular mechanism today helps point
    the way to developing practical, rapid-acting treatments for depression
    tomorrow.
        In tandem with this cutting-edge discovery-to-treatment research,
    NIMH is looking into ways to personalize and optimize current
    treatments for depression. While effective interventions do exist,
    there is considerable variation in individual treatment outcomes. The
    Establishing Moderators/Mediators for a Biosignature of Antidepressant
    Response in Clinical Care (EMBARC) study is working to develop a
    collaborative approach among researchers who are focusing on biological
    indicators (biomarkers) of depression. EMBARC researchers hope to
    identify a standard set of biomarkers and other measures that can be
    used to predict which interventions will produce the best treatment
    outcomes for an individual. Taken together with our advancing knowledge
    of ketamine, we can say with confidence that rapid, personalized, and
    effective treatments for depression are close at hand.
             enhancement of evidence-base for healthcare decisions
        NIMH's basic and translational research will improve U.S. public
    health only when they lead to improved mental healthcare. To improve
    the outcomes for people suffering from schizophrenia, NIMH is funding
    the Recovery After an Initial Schizophrenia Episode (RAISE) project--a
    large-scale clinical trial designed to alleviate the long-term
    disability associated with schizophrenia by intervening as early as
    possible after the first onset of symptoms, so that people with the
    disorder can lead more productive, independent lives. RAISE addresses
    the effectiveness of providing early, sustained, and integrated care to
    improve health and life functioning outcomes, and develops strategies
    to facilitate implementation of successful, cost-effective early
    interventions in the U.S. healthcare system. RAISE incorporates
    features necessary for rapid dissemination into community settings,
    thus accelerating the transition from research to practice.
        NIMH has also launched the Mental Health Research Network to
    encourage scientific collaboration among nine established research
    centers that are based in integrated, not-for-profit healthcare
    systems. These systems provide care coverage to a diverse population of
    10 million people in 11 States, and they share rich and compatible data
    resources to support a range of effectiveness research. Researchers
    have begun to use this network to address vital issues, including the
    development of a geographically and ethnically diverse autism research
    registry; a pilot study for a new type of therapy for postpartum
    depression; and, a longitudinal analysis of how suicide warning labels
    on antidepressants affect later suicidality among youth.
                          new investigators, new ideas
        The future of discovery and translational research lies in the next
    generation of mental health researchers. NIMH's Biobehavioral Research
    Awards for Innovative New Scientists (BRAINS) program provides support
    to early stage investigators to foster innovative research aimed at
    critical gaps identified by the NIMH Strategic Plan. NIMH also
    recognizes the importance of ensuring that our workforce reflects the
    diversity of backgrounds and perspectives that has made the United
    States a source of innovation. NIMH is leading an NIH Blueprint for
    Neuroscience initiative to enhance diversity in neuroscience through
    undergraduate research education experiences, and has established a
    supplemental funding program to provide underrepresented minority
    scholars with mentored research training in strong institutional
    training programs.
                   working collaboratively to combat suicide
        NIMH is committed to collaborating with other Federal agencies and
    private partners to hasten the development of interventions and to
    facilitate their widespread use by those most in need. As an example,
    NIMH has been concerned by the high rate of suicide among our Nation's
    military personnel, and has partnered with the Army to conduct the
    Study to Assess Risk and Resilience of Service Members (Army STARRS)--
    the largest mental health study of military personnel ever conducted.
    Early examination of Army STARRS data has begun to reveal potential
    predictors of risk for suicide among soldiers. Researchers plan to
    analyze additional historical data and new survey data collected by
    Army STARRS to confirm and expand upon these findings.
        Suicide among civilians is also of significant concern.
    Approximately 34,500 American lives are lost to suicide each year,
    nearly twice the number lost due to homicide, making it the 10th
    leading cause of death in the United States.\5\ \6\ To combat this
    issue, under the leadership of the Substance Abuse and Mental Health
    Services Administration, NIMH joined the Army, the Centers for Disease
    Control and Prevention, other NIH Institutes, and private partners to
    form the National Action Alliance for Suicide Prevention. NIMH is
    spearheading a Research Prioritization Taskforce on behalf of the
    Action Alliance to develop a strategic research agenda that could
    reduce suicide-related mortality by 20 percent in 5 years, or 50
    percent in 10 years, if fully implemented.
    ---------------------------------------------------------------------------
        \5\ CDC, National Center for Injury Prevention and Control. Web-
    based Injury Statistics Query and Reporting System.
        \6\ U.S. Department of Justice, Federal Bureau of Investigation.
    (September 2009). Crime in the United States, 2008.
    ---------------------------------------------------------------------------
        Successfully combating mental disorders requires collaboration
    across multiple levels of society; Federal agencies, the research
    community, private industry, and the individuals and families affected
    each day. Despite the tremendous burden of mental disorders, NIMH is up
    to the challenge of bringing all stakeholders to the table, harnessing
    scientific advances, and directing the next generation of research to
    improve the lives of people affected by mental disorders.
                                     ______

    Prepared Statement of John Ruffin, Ph.D., Director, National Institute
                   on Minority Health and Health Disparities
        Mr. Chairman and Members of the Committee: I am pleased to present
    the President's budget request for the National Institute on Minority
    Health and Health Disparities (NIMHD) of the National Institutes of
    Health (NIH). The fiscal year 2012 budget of $214,608,000 includes an
    increase of $5,073,000 over the fiscal year 2011 comparable
    appropriation level of $209,535,000.
        This statement is submitted with the recognition of the
    Department's notification to the Congress of an NIH reorganization that
    would establish a new National Center for Advancing Translational
    Sciences and reallocate the remaining portions of the National Center
    for Research Resources to other parts of NIH, including NIMHD.
                                  introduction
        Health disparity is an issue of immense proportions with health,
    economic, social and environmental impact for the Nation. Disparities
    in the burden of illness and premature death experienced by racial and
    ethnic minorities, low-income, and rural populations, apply to a broad
    spectrum of disease types. Evidence-based research reveals that health
    disparities are the result of interacting factors that may be genetic,
    biological, environmental, social, economic, or psychological in
    nature. The causes of and solutions to health disparities are
    multidimensional and require multidimensional approaches to improve
    health and eliminate the disparities.
        Health disparities have had a longstanding economic burden on the
    healthcare system. The Affordable Care Act (ACA) included several
    provisions aimed at mobilizing the Nation around actions to confront
    health disparities in order to overcome the multiple barriers faced by
    underserved communities in obtaining quality healthcare. One provision
    in the ACA re-designated the National Center on Minority Health and
    Health Disparities (NCMHD) at the NIH to an Institute--named the
    National Institute on Minority Health and Health Disparities. The NIMHD
    was created to strengthen the base for the acceleration of scientific
    discovery already initiated by the predecessor organization, the NCMHD,
    to understand health disparities and to identify and implement
    strategies to eradicate them across the Nation. In accordance with the
    Affordable Care Act, NIMHD is charged to plan, review, coordinate, and
    evaluate minority health and health disparities research activities
    conducted by the NIH Institutes and Centers (ICs). As health
    disparities transcend many diverse areas of biomedical science and
    public health, this work must involve all of the NIH ICs, and numerous
    Federal Government and non-Federal Government partners.
                        building on a decade of progress
        During the past decade, under the aegis of the NCMHD, the NIMHD
    launched its congressional mandates, and established new programmatic
    initiatives and partnerships, allowing it to create the infrastructure
    required to be at the cutting edge of scientific discovery through its
    independent programs and support for collaborative research, research
    infrastructure development, and outreach projects with partners within
    the NIH, HHS, and beyond.
        The foundation of the NIMHD's research portfolio is the NIMHD
    Exploratory and Comprehensive Centers of Excellence (COE) programs.
    Research in the COEs spans the wide array of diseases, health
    conditions, and complex non-biological factors contributing to health
    disparities. Translational research and the development of appropriate
    health interventions is a particular strength of the NIMHD COEs. The
    NIMHD University of Puerto Rico-Cambridge Health Alliance Research
    Center of Excellence has focused its research on Latino health and
    healthcare disparities, specifically mental disorders, substance abuse
    and asthma. This COE has generated and tested models aimed to improve
    health service delivery to eliminate these disparities. This includes
    multi-level interventions at the provider, individual/family and policy
    levels to reduce health services disparities and has provided
    invaluable data to understand the magnitude of substance abuse
    treatment disparities and the social and economic burden of these
    disparities.
        In addition, NIMHD COEs have assisted in emergency response to
    disasters with health disparities implications such as Hurricane
    Katrina in 2005, and the Haiti earthquake in 2010. NIMHD COEs responded
    to the Haitian earthquake crisis with assistance to Haitian communities
    in south Florida and beyond the borders of the country. These efforts
    have improved the understanding of the global nature of health
    disparities.
        To effectively conduct research, individuals, institutions and
    organizations must have the capacity and access to the resources that
    are necessary to conduct research. NIMHD is a leader in advancing the
    NIH efforts to increase the number of underserved populations
    represented in science and medicine. The NIMHD Health Disparities
    Research and the Clinical Research for Individuals from Disadvantaged
    Backgrounds Loan Repayment Programs (LRP) have supported more than
    2,300 individuals representing multiple disciplines through loan
    repayment of educational loans. More than 60 percent of the LRP
    scholars represent racial/ethnic minority populations. The program has
    incentivized the pursuit of a scientific or health disparities research
    career and many former LRP recipients have been successful in competing
    for other NIH grants. Also, NIMHD offers the opportunity for LRP
    recipients to transition into becoming independent investigators
    through its Disparities Research and Education Advancing our Mission
    (DREAM) program in its Intramural Research Program (IRP). During their
    2-year appointment at the NIH conducting research on health
    disparities, the DREAM fellows work with mentors within the NIH
    Intramural Research Program across different NIH Institutes and
    Centers. After the 2-year period, the DREAM fellows have the option of
    returning to their originating academic institution or to a health
    disparity community to further hone their research skills and complete
    the final 3 years of the program.
        In addition, programs such as the Research Centers in Minority
    Institutions and the new NIMHD Science Education Initiative which
    focuses on promoting science education and increasing the pool of
    individuals from health disparity populations in the science field
    starting from kindergarten through the post-doctoral level, will play a
    key role in advancing the NIMHD's activities in this area.
        There is growing interest in scientific research including health
    disparities research at academic institutions throughout the Nation.
    However, many institutions have limited or no current capacity to
    conduct scientific research. Recognizing the variance in capacity among
    institutions of higher education, the NIMHD has invested considerable
    resources in the enhancement of research infrastructure and capacity of
    less research-intensive institutions through programs such as the NIMHD
    Building Research Infrastructure and Capacity (BRIC) program. Over
    time, the BRIC awards have been instrumental in transforming the
    abilities of some institutions to conduct health disparity research.
    For example, San Francisco State University (SFSU) through the
    development of shared research facilities has resulted in the
    publication of approximately 70 research articles on a variety of
    scientific topics, 76 SFSU students have entered highly competitive
    Ph.D. programs, and BRIC-supported faculty have received more than $13
    million in support to conduct health disparity research. Importantly,
    BRIC support has provided a strong base for institutions to expand
    their graduate level educational programs to include new doctorate
    opportunities to advance health disparities research, as well as the
    development of NIMHD Centers of Excellence.
               a new era in the fight against health disparities
        The next decade will focus on bridging persistent gaps in health
    disparities, sustaining effective investments, and developing and
    adapting innovative approaches to health disparities. NIMHD will lead
    the development, implementation and evaluation of the agency's health
    disparities research agenda in collaboration with the other NIH
    Institutes and Centers. Research on minority health and health
    disparities, research capacity-building and outreach/information
    dissemination priorities across the NIH will emphasize areas such as:
    translational research, genetics and biological factors, global health,
    social determinants of health, behavioral and social sciences,
    innovative health technologies, developing a diverse scientific
    workforce, health informatics capacity, public-private partnerships,
    social networking, and diverse participation in clinical trials.
        NIMHD will advance this health disparities research agenda through
    translational research and dissemination of research findings for the
    benefit of clinical practice and health disparity communities.
    Community and population health intervention studies that map social,
    economic and environmental determinants will provide greater insight
    into the underlying causes of health disparities. In addition, primary
    care and prevention research to inform healthcare reform, improve
    healthcare quality, reduce costs and ultimately improve health outcomes
    for health disparity populations will be examined.
        In today's culturally diverse and technologically advanced society,
    the construction of health messages that do not consider culture,
    history, environments, or literacy levels of certain health disparity
    communities can result in the inability of those communities to receive
    health information. NIMHD is committed to supporting and developing
    vehicles to translate and deliver research findings and health
    information to health disparity communities in a culturally and
    linguistically appropriate manner.
                                   conclusion
        While many health disparities concerns of the past decade remain
    pervasive, the NIMHD sees opportunities to accelerate the pace of
    scientific discovery and translation. Within the context of the NIH and
    HHS priorities for eliminating health disparities, the NIMHD will
    intensify and diversify its research focus to elucidate the Nation's
    understanding of health disparities. Research strategies must continue
    to be innovative and the results of this research must reach the
    community at a faster pace. The NIMHD is committed to strengthening its
    research efforts to realize these goals.
                                     ______

       Prepared Statement of Story C. Landis, Ph.D., Director, National
                 Institute of Neurological Disorders and Stroke
        Mr. Chairman and Members of the Committee: I am pleased to present
    the fiscal year 2012 President's budget request for NINDS. The fiscal
    year 2012 budget is $1,664,253,000. Our mission is to reduce the burden
    of neurological disorders through research. NINDS research has improved
    diagnosis, prevention, and treatment, but the best of medical science
    is still far from optimal for most nervous system disorders.
    Fortunately, advances in understanding the brain and its disorders are
    providing extraordinary opportunities for progress.
               enhancing the evidence base for medical decisions
        U.S. Centers for Disease Control and Prevention statistics show
    that from 1997 to 2007 the stroke death rate in the United States
    decreased 34.3 percent, and the number of stroke deaths declined 18.8
    percent, which translates to thousands of lives saved and thousands
    with reduced disability every year. For decades, NINDS clinical trials
    have contributed to this trend by providing evidence that enables
    physicians to choose the best stroke prevention interventions according
    to each person's risk factors. In April, NINDS stopped a stroke
    prevention clinical trial early because the results were already clear
    \1\. The trial included patients at high risk because of a prior non-
    disabling stroke and severe narrowing of arteries to the brain.
    Angioplasty combined with stenting, which opens clogged arteries with a
    tiny balloon and inserts a device to prop them open, plus aggressive
    medical therapy led to a higher risk of stroke than the medical therapy
    alone. Another recent NINDS clinical trial showed that a procedure
    using stents is as safe and effective in preventing stroke as carotid
    endartarectomy, a more invasive surgical procedure to clear arteries,
    in people with certain risk factors.\2\ Follow up to monitor longer
    term results is continuing for both trials. NINDS clinical trials are
    similarly guiding treatment for other diseases. A recent clinical trial
    showed that an older drug, ethosuximide, may be the best first drug to
    test to prevent seizures with minimum side effects in children with
    absence epilepsy, providing much needed guidance for treating this
    common disorder \3\. An NINDS-Department of Veterans' Affairs trial
    showed that surgical implantation of deep brain stimulators (DBS) can
    yield better movement and quality of life than drug treatment for
    people with advanced Parkinson's disease, and more recent results of
    this trial provided information about choosing the best site in the
    brain to implant electrodes for each patient \4\. NINDS currently
    supports 32 multi-site clinical trials to test the safety and
    effectiveness of interventions in stroke, epilepsy, traumatic brain
    injury, multiple sclerosis, muscular dystrophy, and other diseases, and
    more than 120 earlier phase trials that are essential steps toward
    large efficacy trials.
    ---------------------------------------------------------------------------
        \1\ http://www.nlm.nih.gov/databases/alerts/
    intracranial_arterial_stenosis.html.
        \2\ Brott TG et al. Stenting Compared to Endarterectomy for
    Treatment of Carotid Artery Stenosis, New England Journal of Medicine
    363:11-23 2010.
        \3\ Glauser et al. Ethosuximide, Valproic Acid, and Lamotrigine in
    Childhood Absence Epilepsy. New England Journal of Medicine. 362:790-
    799 2010.
        \4\ Weaver F. et al. Best Medical Therapy versus Bilateral Deep
    Brain Stimulation for Patients with Advanced Parkinson's Disease: A
    Randomized Controlled Trial. JAMA 301:63-73 2009; Follett et al.
    Pallidal versus Subthalamic Deep Brain Stimulation for Parkinson's
    Disease. New England Journal of Medicine 362:2077-91 2010.
    ---------------------------------------------------------------------------
                        advancing translational science
        Since long before the term ``translational'' became common, NINDS
    has pushed development of basic science advances into drug, biologic,
    and device therapies. The first enzyme therapy for inherited metabolic
    diseases, several drugs for epilepsy, the first emergency treatment for
    stroke, and pioneering technology for devices that replace lost nervous
    system function are among advances that NINDS translational research
    made possible. Often, industry capitalizes on NIH basic science
    findings to develop a new therapy. However, rare diseases, bold new
    therapeutic strategies, and new uses for existing drugs are all
    challenges that NINDS is more likely than industry to take on. This is
    especially so now because drug companies, citing the extraordinary
    challenges of brain research, are reducing programs to develop nervous
    system drugs \5\.
    ---------------------------------------------------------------------------
        \5\ ``R&D Cuts Curb Brain-Drug Pipeline,'' The Wall Street Jounal,
    March 27, 2011.
    ---------------------------------------------------------------------------
        NINDS launched the Cooperative Program in Translational Research in
    2003 to exploit increasing opportunities from neuroscience research.
    This program supports teams of academic and small business
    investigators to carry out milestone-driven, preclinical therapy
    development for a broad range of neurological disorders. The first
    candidate therapies from this program have moved into clinical testing
    for disorders including stroke, Batten disease, and muscular dystrophy.
        Several NINDS programs meet special translational needs for
    particular diseases. Among these are the Anticonvulsant Screening
    Program, the Specialized Centers of Translational Research in Stroke
    (SPOTRIAS), the Udall Centers of Excellence in Parkinson's Disease, and
    the Wellstone Centers for Muscular Dystrophy Research. NINDS chose
    spinal muscular atrophy (SMA) as the disease to pilot another
    innovative approach to drug development. With experts from academia,
    industry, and FDA, the SMA Project designed a drug development plan and
    is implementing the plan through a ``virtual pharma'' organization that
    engages resources via contracts. Promising drug candidates are now in
    advanced pre-clinical testing, and the Project is working toward
    certification for a clinical trial in 2012. Building on the SMA Project
    strategy, NINDS is leading the NIH Blueprint for Neuroscience in a
    larger scale Grand Challenge on Neurotherapeutics. The challenge goal
    is to develop truly novel drugs that will transform the treatment of
    nervous system diseases. The NINDS Intramural Research Program, which
    has a long record of therapy development, is also accelerating
    translational research under a new Clinical Director. NINDS
    translational programs work closely with all of the NIH-wide programs
    and resources that will become part of the National Center for
    Advancing Translational Sciences (NCATS), and will certainly benefit
    from NCATS programs to catalyze translational research.
        Because novel therapies for several neurological diseases are
    moving toward readiness for clinical testing, NINDS is developing a
    multi-site clinical network to improve the speed and effectiveness of
    the early steps in clinical testing of novel therapies for neurological
    disorders. Better early phase testing will increase the likelihood of
    success in larger and more expensive phase III clinical trials of
    effectiveness. This network will test promising interventions, whether
    they arise from academia, foundations, or industry, and will engage
    expertise much greater than the Institute could dedicate to separate
    networks for each of the many neurological diseases. This is especially
    important for rare disorders, including pediatric diseases. A project
    to validate biomarkers for SMA will be among the network's first
    studies.
        Another major clinical initiative will develop and validate
    biomarkers for Parkinson's disease, that is, measurable indicators of
    the disease process. Biomarkers research, which NINDS supports for many
    disorders, exemplifies another way that NINDS programs can catalyze
    both NIH and industry therapy development efforts. With biomarkers for
    neurodegenerative disorders, clinical trials can determine in months,
    rather than years, whether drugs are slowing the progression of disease
    and understand why a new treatment worked or did not. Better biomarkers
    can reduce the cost of research and speed the development of better
    treatments in NIH and industry.
                    accelerating progress through technology
        An extraordinary array of technologies has accelerated progress in
    neuroscience. These range in scale from imaging activity of the
    thinking human brain as people carry out complex tasks, to
    understanding atom by atom how molecules control electrical activity in
    brain cells. This year research demonstrated the power of whole genome
    sequencing to understand Charcot-Marie-Tooth disorder, a peripheral
    nerve disease \6\. This is a harbinger of personalized genomics for
    many diseases. Next generation genomics research is underway for
    several neurological disorders. A ``Center without Walls'' will bring
    together the best possible team, regardless of geography, to apply
    advanced genomics to epilepsy. On another technological frontier, ARRA
    enabled NINDS to accelerate research on induced pluripotent stem cells
    (iPSC's) that can be derived from patients with Parkinson's,
    Huntington's, ALS, epilepsy, and other disorders. A spate of new
    technologies, from methods that label nerve cells with more than a
    hundred different colors, to computerized three-dimensional
    reconstruction of intricate nerve cell circuits, to techniques that
    control the activity of individual nerve cells with light, are arming
    neuroscientists to meet the longstanding challenge of understanding how
    circuits of nerve cells underlie memory, perception, complex movement,
    and other higher brain functions. This has implications for
    understanding autism, epilepsy, Parkinson's, Alzheimer's, and many
    other diseases.
    ---------------------------------------------------------------------------
        \6\ Lupski JR et al. Whole-genome sequencing in a patient with
    Charcot-Marie-Tooth neuropathy. New England Journal of Medicine
    362:1181-91 2010.
    ---------------------------------------------------------------------------
                  encouraging new investigators and new ideas
        When progress against disease is not forthcoming, a gap in basic
    understanding of the normal brain or the disease process is often the
    cause. Physicians and scientists across academia and industry agree
    that basic research propels long-term progress against disease. The
    insight and ingenuity of the research community is the key. Supporting
    a vigorous scientific community and investigator-initiated research are
    thus high priorities throughout NINDS programs and policies. To
    encourage innovative research, for example, the EUREKA (Exceptional
    Unconventional Research Enabling Knowledge Acceleration) program
    complements the NIH Pioneer Awards, New Innovator Awards, and
    Transformative R01's, all of which support neuroscientists. To prepare
    the next generation of neuroscientists, NINDS training and career
    development programs are tailored to the needs of basic and clinical
    researchers, and funding policies favor early stage investigators.
    NINDS encourages cooperative research and promotes sharing through
    several programs. Examples include the Common Data Elements program,
    Human Genetics Resource Center, consortia on induced pluripotent stem
    cells, disease centers programs, and other grants to multi-investigator
    teams. NINDS is improving programs on workforce diversity and health
    disparities based on guidance from an external review and planning
    process that was completed in 2011.
                               concluding remarks
        Neurological disorders present formidable challenges. Nonetheless,
    prospects for progress have never been more encouraging because of
    progress in understanding the nervous system and its diseases at every
    level from molecules through the working human brain. NINDS is
    aggressively pursuing better prevention and treatment with a balance of
    basic, translational, and clinical research, supported through
    investigator-initiated and priority-targeted programs.
                                     ______

      Prepared Statement of Patricia A. Grady, Ph.D., RN, FAAN, Director,
                     National Institute of Nursing Research
        Mr. Chairman and Members of the Committee: I am pleased to present
    the President's fiscal year 2012 budget request for the National
    Institute of Nursing Research (NINR) of the National Institutes of
    Health (NIH). The fiscal year 2012 budget includes $148,114,000 which
    is $3,857,000 more than the comparable fiscal year 2011 appropriation
    of $144,257,000.
                                  introduction
        I appreciate the opportunity to share with you some of the exciting
    areas of research that we support at the National Institute of Nursing
    Research (NINR). As you know, a unique combination of societal trends
    challenges our Nation's health, including an aging population,
    increased chronic illness and obesity rates, and shortages in the
    healthcare workforce. At NINR, we address these issues by supporting
    research across the life span that: builds the scientific foundation
    for clinical practice; improves quality of life through managing and
    easing symptoms of illness; promotes health and prevents disease
    through biological and behavioral interventions; and enhances end-of-
    life and palliative care. We also seek to ensure future discoveries by
    training the next generation of nurse scientists. NINR's emphasis on
    clinical research and training places NINR in a position to make major
    contributions to trans-NIH initiatives to enhance the evidence-base for
    healthcare decisions, promote translational research, and support new
    investigators and new ideas. NINR was established 25 years ago, in
    1986, as the National Center for Nursing Research. This year, we are
    commemorating our 25th anniversary through a series of scientific
    outreach events to celebrate our longstanding emphasis on translating
    science to improve health and clinical practice. In our first event, a
    scientific symposium entitled ``Bringing Science to Life,'' some of our
    distinguished scientists presented cutting edge research on topics as
    varied as: the role of sleep in health and safety; managing chronic
    illness in racially/ethnically diverse groups; testing interventions to
    educate and support parents with premature infants; and understanding
    the biological underpinnings of muscular dystrophy. This Anniversary is
    an opportunity to review what NINR science has accomplished, and more
    importantly, to envision and plan the next phase of evidence-based
    research to meet future health and healthcare needs, challenges, and
    priorities. As we look forward to the next 25 years, we are confident
    that NINR-supported science will play an ever-increasing role in
    addressing the most pressing issues facing our Nation's health. I
    would, next, like to share with you some examples of the research that
    we support and how it improves quality of life.
                 childhood and adolescence: risk and resilience
        From birth through young adulthood, children and adolescents face
    many health challenges and also demonstrate incredible resilience. NINR
    supports research to promote positive outcomes for children and
    families facing a myriad of challenges. For example, chronic health
    conditions in children, such as diabetes, arthritis, and obesity, pose
    challenges for the entire family and require sustained attention to
    treatment adherence and health assessment. NINR-funded scientists have
    made advances both in understanding the family's role in children's
    health and in improving assessment strategies. One study found that
    although parents detected significant pain in their child following the
    child's surgery, they tended to under-treat it, suggesting that
    educating parents about pain management may be beneficial. Another
    study found that screening children's waist circumference, which can be
    easily implemented in schools, identifies more cases of high blood
    pressure than the usual measure of body mass index alone. A current
    initiative led by NINR aims to improve self-management of chronic
    illness in children. An increasing challenge later in childhood comes
    from HIV, with adolescents and young adults comprising one-third to
    one-half of new infections in the United States,\1\ despite numerous
    prevention campaigns. Moreover, adolescents from racial/ethnic minority
    groups are disproportionately affected.\2\ A new NINR initiative
    supports projects to examine psychosocial, cognitive, and neurological
    predictors of HIV/AIDS risk decisionmaking in adolescents. This
    research will provide an evidence-base to guide future culturally and
    developmentally relevant interventions to prevent HIV/AIDS.
    ---------------------------------------------------------------------------
        \1\ National Institute for Child Health and Human Development.
    AIDS/HIV. 2008.
        \2\ Centers for Disease Control and Prevention. 2008. HIV/AIDS
    among youth.
    ---------------------------------------------------------------------------
                 challenges and changes in an aging population
        The population of our Nation is aging rapidly, due in large part to
    increased longevity and the aging of the baby boomers. These changes
    are giving rise to significant challenges, resulting in a need for:
    improved strategies to manage co-occurring chronic illnesses; better
    interventions to support family caregivers; and new ways to address
    health disparities and meet the needs of an elderly population that is
    more racially and ethnically diverse than ever before. One pressing
    challenge is the increase in the number of older adults with multiple
    chronic illnesses, such as heart disease, diabetes, and arthritis. Such
    older adults have complex care needs, face long-term self-management of
    illness, and may experience poor coordination of care in the community.
    In a recent NINR-supported Nurse Coordinated Care Intervention,
    advanced practice nurses developed individualized care plans for older
    adults, which included family members and ongoing follow-up care. The
    intervention improved health outcomes and reduced costs of care for
    Medicare patients. A new NINR initiative, that benefits not only older
    adults but individuals across the life span, supports research that
    translates basic genomic science to clinical practice with the goal of
    preventing and alleviating symptoms of chronic illness. Such efforts
    have the potential to improve quality of life for older adults and
    families. Another challenge is Alzheimer's disease (AD), which is
    incurable, affects up to 5.1 million Americans, and is expected to
    dramatically increase in incidence by the year 2030.\3\ NINR is
    addressing the quality of care for AD patients, and the quality of life
    of, and burden on, family caregivers. For example, researchers funded
    by NINR and the National Institute on Aging (NIA) developed an
    intervention to teach caregivers about AD, stress management, and
    maintaining their own health. The intervention showed promising
    improvements in emotional, mental, and physical health in racially
    diverse groups.
    ---------------------------------------------------------------------------
        \3\ National Institute on Aging. 2009 Progress report on
    Alzheimer's disease: Translating new knowledge.
    ---------------------------------------------------------------------------
                end of life: supporting individuals and families
        As a society we are living longer lives than ever before; however,
    we are also more likely to die from chronic and sometimes painful
    illnesses \4\ that require families to make complex decisions about
    life and death issues, often without adequate support and information.
    As the lead NIH Institute on issues related to end-of-life research,
    NINR supports research leading to evidence-based end-of-life and
    palliative care that ultimately assists individuals, families, and
    healthcare professionals in alleviating symptoms, planning for end-of-
    life decisions, and promoting psychological, social, spiritual, and
    physical well-being. NINR's Office of Research on End-of-Life Science
    and Palliative Care, Investigator Training, and Education coordinates
    research, training, and educational efforts in end-of-life and
    palliative care science. One NINR-supported study recently examined the
    effectiveness of a program to communicate patient preferences for end-
    of-life decisions to clinicians. Compared to traditional practices such
    as Do-Not-Resuscitate orders, the program led to fewer unwanted life-
    sustaining treatments without affecting quality of remaining life. In
    addition, a new NINR initiative begun in 2011 will support research to
    address issues related to end-of-life and palliative care for
    individuals with chronic illness who also experience life-threatening
    acute illness. Finally, on August 10-12, 2011, NINR, with support from
    partners across the NIH, will convene a forum entitled ``The Science of
    Compassion: Future Directions in End-of-Life and Palliative Care.''
    This forum is intended to energize and mobilize end-of-life and
    palliative care research and to draw attention to the end-of-life and
    palliative care processes, the care options available to patients and
    their families, and the obligations of health service communities to
    address these complex needs.
    ---------------------------------------------------------------------------
        \4\ Centers for Disease Control and Prevention and The Merck
    Company Foundation. The state of aging and health in America 2007.
    Whitehouse Station, NJ: The Merck Company Foundation; 2007.
    ---------------------------------------------------------------------------
                   training the next generation of scientists
        NINR places strong emphasis on equipping the next generation of
    scientists with the necessary skills to conduct research that improves
    the Nation's health. In light of the societal trends that will
    characterize the coming decades, NINR recognizes that tomorrow's nurse
    scientists need to be trained in rigorous, innovative, and
    interdisciplinary research that reaches diverse individuals, families,
    and communities. NINR supports young scientists and junior and senior
    scholars through grant funding, fellowships, and career development
    awards. NINR also offers an intensive summer training program, the
    Summer Genetics Institute, to improve research and clinical practice
    among graduate students and faculty by providing a foundation in
    molecular genetics. Additionally, our Pain Boot Camp, held for the
    first time in 2010, is a 1-week research intensive program where
    participants learn innovative pain research methodology from nationally
    and internationally known scientists. NINR's efforts to invest in new
    investigators and new ideas are critical investments in preparing a
    nursing workforce to address the healthcare challenges of the coming
    years.
                      future directions in nursing science
        Nursing science is at the forefront of efforts to improve health
    and healthcare practice. NINR is currently formulating its new
    strategic plan and will continue its focus on the unique social,
    cultural, societal, genetic, and biological factors that contribute to
    disease prevention, health promotion, and self-management of illness.
    We look forward to the next 25 years in which nursing science, focused
    on individuals, patients and families, will make critical contributions
    to improving healthcare practice and quality of life across the disease
    spectrum and across the lifespan. Thank you, Mr. Chairman. I will be
    happy to answer any questions that the Committee might have.
                                     ______

     Prepared Statement of Donald A.B. Lindberg, M.D., Director, National
                              Library of Medicine
        Mr. Chairman and Members of the Committee: I am pleased to present
    the President's fiscal year 2012 budget request for the National
    Library of Medicine (NLM) of the National Institutes of Health (NIH).
    The fiscal year 2012 NIH request includes $387,153,000 for NLM, which
    is $24,420,000 more than the comparable fiscal year 2011 NLM
    appropriation of $362,733,000.
        As the world's largest biomedical library and the producer of
    internationally trusted electronic information services, NLM delivers
    trillions of bytes of data to millions of users every day. Many who
    begin a search in Google, another search engine, or a mobile ``app''
    actually receive health information from an NLM website. Now in its
    175th year, NLM is a key link in the chain that makes the results of
    biomedical research--DNA sequences, clinical trials data, toxicology
    and environmental health data, published scientific articles, and
    consumer health information--readily available to scientists, health
    professionals, and the public worldwide. A leader in biomedical
    informatics and information technology, NLM also conducts and supports
    leading-edge informatics research and development in electronic health
    records, clinical decision support, information retrieval, advanced
    imaging, computational biology, telecommunications, and disaster
    response.
        NLM's programs and services directly support NIH's four key
    initiatives. The Library organizes and provides access to massive
    amounts of scientific data from high throughput sequencing; assembles
    data about small molecules to support research and therapeutic
    discovery; provides the world's largest clinical trials registry and
    results database; and is the definitive source of published evidence
    for healthcare decisions. Research supported or conducted by NLM
    underpins today's electronic health record systems. The Library has
    been the principal funder of university-based informatics research
    training for 40 years, supporting the development of today's leaders in
    informatics research and health information technology. NLM's databases
    and its partnership with the Nation's health sciences libraries deliver
    research results wherever they can fuel discovery and support health
    decisionmaking.
                         research information resources
        NLM's PubMed/MEDLINE database is the world's gateway to research
    results published in the biomedical literature, linking to full-text
    articles in PubMed Central, including those deposited under the NIH
    Public Access Policy, and on publishers' websites, as well as
    connecting to vast collections of scientific data. Through its National
    Center for Biotechnology Information (NCBI), NLM is a hub for the
    international exchange and use of molecular biology and genomic
    information, with databases accessed by more than 2 million users
    daily. NCBI meets the challenge of organizing, analyzing, and
    disseminating scientific research data with more than 40 integrated
    databases and analysis tools that enable genomic discoveries in the
    21st century. These databases are fundamental to the identification of
    important associations between genes and disease and to the translation
    of new knowledge into better diagnoses and treatments. Resources such
    as dbGAP and the upcoming Genetic Testing Registry (GTR) create a
    bridge between basic research and clinical applications. dbGaP links
    genotype and phenotype information from clinical studies to identify
    genetic factors that influence health and serves as the public
    repository for data from genome wide association studies (GWAS)
    supported by NIH and other research funders. The GTR will be a central
    source for healthcare providers and patients to find detailed
    information about genetic tests and the laboratories that offer them.
        NLM also stands at the center of international exchange of data
    about clinical research studies. NLM's Lister Hill National Center for
    Biomedical Communications builds ClinicalTrials.gov, the world's
    largest clinical trials database, including registration data for more
    than 106,000 clinical studies with sites in 174 countries.
    ClinicalTrials.gov has novel and flexible mechanisms that enable
    submission of summary results data for clinical trials subject to the
    Food and Drug Administration Amendments Act of 2007. To date, summary
    results are available for about 3,400 completed trials of FDA-approved
    drugs, biological products, and devices--providing a new and growing
    source of evidence on efficacy and comparative effectiveness.
              health data standards and electronic health records
        Electronic health records with advanced decision-support
    capabilities and connections to relevant health information will be
    essential to achieving personalized medicine and will help Americans to
    manage their own health. For 40 years, NLM has supported seminal
    research on electronic health records, clinical decision support, and
    health information exchange, including concepts and methods now used by
    MicroSoft Health Vault and Google Health. As the central coordinating
    body for clinical terminology standards within HHS, NLM works closely
    with the Office of the National Coordinator for Health Information
    Technology (ONC) to facilitate adoption and ``meaningful use'' of
    electronic health records (EHRs). NLM supports, develops, and
    disseminates key data standards for U.S. health information exchange in
    ONC's criteria for certification of electronic health records. NLM is
    actively engaged in research on Next Generation EHRs, while also
    developing tools and frequently used subsets of large terminologies to
    help EHR developers and users implement health data standards right
    now. Most recently, NLM released MedlinePlus Connect, which allows
    application developers to establish direct links from a patient's view
    of his or her EHR to high quality health information relevant to that
    person's specific health conditions, medications, and (coming soon)
    recent tests.
                      information services for the public
        This new EHR connection builds upon NLM's extensive information
    services for patients, families and the public. The Library's
    MedlinePlus website provides integrated access to high quality consumer
    health information produced by all NIH components and HHS agencies,
    other Federal departments, and authoritative private organizations and
    serves as a gateway to specialized NLM information sources for
    consumers, such as the Genetic Home Reference and the Household
    Products database. Available in English and Spanish, with selected
    information in 40 other languages, MedlinePlus averages well over
    600,000 visits per day. Covering nearly 900 health topics, MedlinePlus
    has interactive tutorials for persons with low literacy, an illustrated
    medical encyclopedia, surgical videos and links to the scientific
    literature in PubMed. Mobile MedlinePlus, also in both English and
    Spanish, reaches the large and rapidly growing mobile Internet
    audience.
        The NIH MedlinePlus quarterly magazine is an outreach effort made
    possible with support from many parts of NIH and the Friends of the
    NLM. Like MedlinePlus itself, the magazine is free and contains no
    advertising. It is distributed to the public via physician offices,
    community health centers, libraries and other locations and has a
    readership of up to 5 million nationwide. Each issue focuses on the
    latest research results, clinical trials and new or updated guidelines
    from the 27 NIH Institutes and Centers. A Spanish/English version, NIH
    MedlinePlus Salud, launched with support from the National Alliance for
    Hispanic Health and the National Hispanic Medical Association,
    addresses the specific health needs of the growing Hispanic population
    and showcases the many Hispanic outreach efforts and relevant research
    results funded by the NIH.
        To be of greatest use to the widest audience, NLM's information
    services must be known and readily accessible. The Library's outreach
    program, with a special emphasis on reaching underserved populations,
    relies heavily on the more than 6,300-member National Network of
    Libraries of Medicine (NN/LM). The NN/LM is a network of academic
    health sciences libraries, hospital libraries, public libraries and
    community-based organizations working to bring the message about NLM's
    free, high-quality health information resources to communities across
    the Nation.
                        disaster information management
        Events of the past year, such as the Deepwater Horizon oil spill
    and the earthquake, tsunami, and radiation event in Japan, demonstrated
    yet again the importance of rapid, organized response to natural
    disasters and other emergencies. NLM has a long history of providing
    health information to prepare for, respond to, and recover from
    disasters and has tools and advanced information services designed for
    use by emergency planners, responders and managers. Through its
    Disaster Information Management Resource Center, NLM builds on proven
    emergency backup and response mechanisms within the National Network of
    Libraries of Medicine to promote effective use of libraries and
    disaster information specialists in disaster preparedness and response.
    NLM also conducts research on new methods for sharing health
    information in emergencies as its contribution to the Bethesda Hospital
    Emergency Preparedness Partnership, a model of private-public hospital
    collaboration for coordinated disaster planning. NLM partners with the
    Pan American Health Organization (PAHO) and other bodies in the Latin
    American Network for Disaster and Health Information to promote
    capacity-building in the area of disaster information management.
        Within 2 days of the gulf oil spill, NLM launched a web page
    focused on the potential effects of oil on human health, which quickly
    became a highly regarded resource for evidence-based information by
    Federal, State, and local agencies and communities. NLM continued to
    support information needs in Haiti, including onsite assistance to PAHO
    in setting up a system for collecting information from cholera
    treatment centers. The Radiation Emergency Medical Management (REMM)
    tool, previously developed by NLM, the HHS Office of the Assistant
    Secretary for Preparedness and Response, CDC and NCI, was deployed in
    Japan, via the web and on mobile devices, to assist with assessing and
    managing the health effects of radiation. NLM also activated the
    Emergency Access Initiative, a partnership with publishers and medical
    libraries which provides free temporary access to key electronic
    medical journals and books when disasters interrupt regular health
    information services, and provided practical advice to Japanese
    libraries and archives on rescuing water-damaged books and documents.
        In summary, NLM's information services and research programs serve
    the Nation and the world by supporting scientific discovery, clinical
    research, education, healthcare delivery, public health response, and
    the empowerment of people to improve personal health. The Library is
    committed to the innovative use of computing and communications to
    enhance public access to the results of biomedical research.
                                     ______

      Prepared Statement of Jack Whitescarver, Ph.D., Director, Office of
                                 AIDS Research
        Mr. Chairman and Members of the Committee: I am pleased to present
    the fiscal year 2012 President's budget request for the trans-NIH AIDS
    research program, which is $3,159,531,000. This amount is an increase
    of $100,254,000 over the fiscal year 2011 enacted level. It includes
    the total NIH funding for research on HIV/AIDS and the wide spectrum of
    AIDS-associated malignancies, opportunistic infections, co-infections,
    and clinical complications; intramural and extramural research;
    research management support; research centers; and training. It also
    includes a transfer of approximately $27 million to the HHS Office of
    the Assistant Secretary of Health to foster collaborations across HHS
    agencies and finance high priority initiatives in support of the
    President's National HIV/AIDS Strategy.
                               the aids pandemic
        Nearly 30 years since the recognition of AIDS and the
    identification of HIV as its causative agent, the HIV/AIDS pandemic
    remains a global scourge. UNAIDS reports that in 2009, more than 33
    million people were estimated to be living with HIV/AIDS; 2.6 million
    were newly infected; and 1.8 million people died of AIDS-related
    illnesses. The majority of cases worldwide are the result of
    heterosexual transmission, and women represent more than 50 percent of
    HIV infections worldwide. More than 1,000 children become infected each
    day, most of them as newborns. More than 25 million men, women, and
    children worldwide have already died.
        In the United States, CDC reports that more than 1.1 million people
    are estimated to be HIV-infected; approximately 56,300 new infections
    occur each year; and someone is infected with HIV every 9\1/2\ minutes.
    HIV/AIDS continues to be an unrelenting public health crisis,
    disproportionately affecting racial and ethnic populations, women of
    color, young adults, and men who have sex with men. The number of
    individuals aged 50 years and older living with HIV/AIDS is increasing,
    due in part to antiretroviral therapy, which has made it possible for
    many HIV-infected persons to live longer, but also due to new
    infections in individuals over the age of 50.
                           nih aids research program
        To address this pandemic, NIH has established the most significant
    AIDS research program in the world, a comprehensive program of basic,
    clinical, translational, and behavioral research in domestic and
    international settings--a multi-disciplinary, global research program
    carried out by every NIH institute and center in accordance with their
    mission. This diverse research portfolio requires an unprecedented
    level of trans-NIH planning, scientific priority-setting, and resource
    management. The Office of AIDS Research (OAR) was authorized to plan,
    coordinate, evaluate, and budget all NIH AIDS research, functioning as
    an ``institute without walls,'' to identify the highest priority areas
    of scientific opportunity, enhance collaboration, minimize duplication,
    and ensure that precious research dollars are invested effectively and
    efficiently.
                   new scientific advances and opportunities
        The past year has been a significant one for AIDS research. The NIH
    investment in the priority areas of HIV prevention research and in
    basic science over the past several years has resulted in important
    progress in critical areas of the NIH AIDS research program. Recent
    research advances by NIH intramural and extramural investigators have
    opened doors for new and exciting research opportunities in the search
    for strategies to prevent, treat, and ultimately cure HIV infection.
    These advances include:
        Technologies to accelerate discovery--
      --Vaccines.--A team of scientists led by researchers at the NIAID
            Vaccine Research Center discovered two potent human antibodies
            that can stop more than 90 percent of known global HIV strains
            from infecting human cells in the laboratory and determined the
            structural analysis of how they work. The novel techniques used
            in this research may accelerate HIV vaccine research as well as
            the development of vaccines for other infectious diseases. An
            HIV vaccine clinical trial conducted in Thailand by NIH and the
            Department of Defense demonstrated the first indication of a
            modest but positive effect in preventing HIV infection. The
            trial marked the first step in proving the concept that a
            vaccine to prevent HIV infection is feasible.
      --Microbicides.--For the first time in nearly 15 years of research,
            scientists discovered a vaginal microbicide gel that gives
            women a level of protection against HIV infection. The study,
            sponsored by USAID and conducted by the Centre for the AIDS
            Programme of Research in South Africa (CAPRISA), found that the
            use of a microbicide gel containing the antiretroviral drug
            tenofovir resulted in 39 percent fewer HIV infections compared
            with a placebo gel. NIH provided substantial support and
            resources to establish the infrastructure and training for
            CAPRISA. Ongoing and future NIH clinical trials will build on
            these study results with the goal of bringing a safe and
            effective microbicide to licensure.
      --Basic Science.--This past year, using genome-wide association
            studies, NIH-sponsored researchers made an important discovery
            related to the genetics of an individual's immune system. These
            genes appear to be involved in the control of HIV disease
            progression among a group of individuals considered ``elite
            controllers,'' who have been exposed to HIV over an extended
            period, but whose immune systems have controlled the infection
            without therapy and without symptoms. These findings will
            contribute to the development of potential HIV prevention
            strategies.
        Translational sciences and therapeutic development.--New lymphoma
    regimens have been developed that can be tailored to specific tumor
    types. This development has markedly improved the therapeutic outcome
    and survival of patients with AIDS-related lymphoma. In addition,
    progress in both basic science and treatment research aimed at
    eliminating viral reservoirs has been significant enough that
    scientists are now, for the first time, planning to conduct research
    aimed at a cure. NIH has announced several initiatives to generate new
    ideas for curing HIV infection through domestic and international
    partnerships among government, industry, and academia.
        Enhancement of evidence-base for healthcare decisions.--In the
    critical area of treatment as prevention, two recent studies have
    demonstrated the effectiveness of new multi-drug antiretroviral
    regimens for the prevention of mother-to-child-transmission of HIV
    during pregnancy and breastfeeding. In addition, a large international
    NIH clinical trial provided strong evidence that the use of pre-
    exposure prophylaxis (PrEP), that is, the use of antiretroviral
    treatment before exposure to prevent infection, can reduce risk of HIV
    acquisition in men who have sex with men. Additional and continued
    research is needed to determine whether PrEP will be similarly
    effective at preventing HIV infection in other at-risk populations and
    assist healthcare workers in providing these potential options.
                           trans-nih plan and budget
        These advances, while preliminary and incremental, provide the
    groundwork for further scientific investigation and the building blocks
    for the development of the trans-NIH AIDS strategic Plan, developed by
    OAR in collaboration with both government and non-government experts.
    The priorities of the strategic Plan guide the development of the
    trans-NIH AIDS research budget. OAR develops each IC's AIDS research
    allocation based on the Plan, scientific opportunities, and the IC's
    capacity to absorb and expend resources for the most meritorious
    science--not on a formula. This process reduces redundancy, promotes
    harmonization, and assures cross-Institute collaboration. The
    priorities of the Plan will establish the biomedical and behavioral
    research foundation necessary to implement the major goals of the
    President's National HIV/AIDS Strategy and to implement the NIH
    Director's themes.
                     fiscal year 2012 scientific priorities
        A growing proportion of patients receiving long-term antiretroviral
    therapy (ART) are demonstrating treatment failure, experiencing serious
    drug toxicities and side effects, and developing drug resistance.
    Recent studies have shown an increased incidence of malignancies, as
    well as cardiovascular and metabolic complications, and premature aging
    associated with long-term HIV disease and ART. NIH research will
    address the need to develop better, less toxic treatments and to
    investigate how genetic determinants, sex, gender, race, age, pregnancy
    status, nutritional status, and other factors interact to affect
    treatment success or failure and/or disease progression.
        NIH-funded research is needed to address the causes of HIV-related
    health disparities, their role in disease transmission and acquisition,
    and their impact on treatment access and effectiveness. These include
    disparities among racial and ethnic populations in the United States;
    between developed and resource-constrained nations; between men and
    women; between youth and older individuals; and disparities based on
    sexual identity. In addition, specific fiscal year 2012 research
    priorities include: biomedical and behavioral research focused on the
    domestic AIDS epidemic, particularly in racial and ethnic populations
    of the United States; research to build on important research advances
    in prevention research in the past year in the areas of microbicides,
    vaccines, and treatment as prevention; research to prevent and treat
    HIV-associated co-morbidities, malignancies, and clinical
    complications; research to address the complex issues around AIDS and
    aging; research to better understand the issues of adolescents and
    AIDS; basic and therapeutic research focused on elimination of viral
    reservoirs leading toward a cure; genetic studies to delineate the
    genetic basis for immune responses to HIV and to sequence HIV-
    associated tumors; and research on feasibility, effectiveness, and
    sustainability required for the scale-up and implementation of
    interventions in communities at risk.
                                    summary
        The OAR has utilized its authorities to shift AIDS research program
    priorities and resources to meet the changing epidemic and scientific
    opportunities. This investment in AIDS research has produced
    groundbreaking scientific advances. AIDS research also is helping to
    unravel the mysteries surrounding many other cardiovascular, malignant,
    neurologic, autoimmune, metabolic, and infectious diseases as well as
    the complex issues of aging and dementia. Despite these advances,
    however, AIDS has not been conquered, and serious challenges lie ahead.
    The HIV/AIDS pandemic will remain the most serious public health crisis
    of our time until better, more effective, and affordable prevention and
    treatment regimens are developed and universally available. NIH will
    continue its efforts to prevent, treat, and eventually cure AIDS.
        Thank you for your continuing support for our efforts.
                                     ______

       Prepared Statement of Lawrence A. Tabak, D.D.S., Ph.D., Principal
                 Deputy Director, National Institutes of Health
        Mr. Chairman and Members of the Committee: I am pleased to present
    the fiscal year 2012 President's budget request for the Office of the
    Director (OD). The fiscal year 2012 budget includes $1,298,412,000; an
    increase of $132,451,000 over the comparable fiscal year 2011 enacted
    level of $1,165,961,000, comparable for transfers proposed in the
    President's request.
        The OD promotes and fosters NIH research and research training
    efforts in the prevention and treatment of disease through the
    oversight of the Intramural Research program and through coordination
    of program offices responsible for stimulating specific areas of
    research throughout NIH to complement the ongoing efforts of the
    Institutes and Centers. The OD also develops policies in response to
    emerging scientific opportunities employing ethical and legal
    considerations; maintains peer review policies; provides oversight of
    grant and contract award functions; coordinates information technology
    across the Agency; and coordinates the communication of health
    information to the public and scientific community. Moreover, the OD
    provides the core management and administrative services, such as
    budget and financial management, personnel, property, and procurement
    services, ethics oversight, and the administration of equal employment
    policies and practices.
        The principal OD offices providing these activities include the
    Offices of Extramural Research, Intramural Research, Science Policy,
    Communications and Public Liaison, Legislative Policy and Analysis,
    Equal Opportunity and Diversity Management, Financial Management,
    Budget, Management, Human Resources, Chief Information Office, and the
    Executive Office. This request contains funds to support the functions
    of these offices as will be outlined in the Program, Project and
    Activities Table which follows.
        The statement is submitted with the recognition of the Department's
    notification to the Congress of an NIH reorganization that would
    establish a new National Center for Advancing Translational Sciences
    and reallocate the remaining portions of the National Center for
    Research Resources to other parts of NIH, including the OD.
     division of program coordination, planning, and strategic initiatives
                                    (dpcpsi)
        The DPCPSI mission includes identifying the most compelling
    scientific opportunities, emerging public health challenges, and
    scientific knowledge gaps that merit further research or would
    otherwise benefit from strategic coordination and planning across the
    Agency. DPCPSI provides key support of research that is consistent with
    the NIH Director's Themes. The Division is comprised of the Office of
    AIDS Research, Office of Research on Women's Health, Office of
    Behavioral and Social Sciences Research, Office of Disease Prevention,
    Office of Medical Applications of Research, Office of Dietary
    Supplements, Office of Rare Diseases Research, and the Office of
    Strategic Coordination (OSC). The OSC is responsible for the oversight
    and management of the NIH Common Fund. The Division is responsible for
    agency-wide effort in portfolio analysis and also manages NIH-wide
    evaluation and performance activities, including the Evaluation Set-
    Aside program and the Government Performance and Results Act plans and
    reports. The fiscal year 2012 budget for DPCPSI/Office of the Director
    is $8,401,000. Descriptions of the eight programmatic offices within
    DPCPSI, and their separate budgets, follow.
                          the office of aids research
        The Office of AIDS Research (OAR) plays a unique role at NIH,
    establishing a plan for the AIDS research program. OAR coordinates the
    scientific, budgetary, legislative, and policy elements of the NIH AIDS
    research program. OAR's response to the AIDS epidemic requires a unique
    and complex multi-institute, multi-disciplinary, global research
    program. This diverse research portfolio demands an unprecedented level
    of scientific coordination and management of research funds to identify
    the highest priority areas of scientific opportunity, enhance
    collaboration, minimize duplication, and ensure that precious research
    dollars are invested effectively and efficiently, allowing NIH to
    pursue a united research front against the global AIDS epidemic. The
    fiscal year 2012 budget for OAR is $65,760,000.
                    the office of research on women's health
        The Office of Research on Women's Health (ORWH) mission is to
    enhance and expand research supported by the NIH to adequately address
    women's health. This is done by identifying gaps in knowledge, and
    collaborating with the ICs to stimulate and support innovative research
    including interdisciplinary scientific approaches to women's health and
    studies of sex and gender differences in health and diseases. ORWH
    continues to lead efforts to ensure adherence to policies for the
    inclusion of women and minorities in clinical research The fiscal year
    2012 budget for ORWH is $43,811,000.
             the office of behavioral and social sciences research
        The Office of Behavioral and Social Sciences Research (OBSSR) was
    established by Congress to stimulate behavioral and social science
    research at NIH and to integrate it more fully into the NIH research
    enterprise. The Office furthers the NIH mission by emphasizing the
    critical role that behavioral and social factors play in health,
    healthcare, and well-being. The Office supports the activities of the
    NIH Basic Behavioral and Social Science Opportunity Network, a trans-
    NIH initiative to expand the agency's funding of basic behavioral and
    social sciences research. The fiscal year 2012 budget for OBSSR is
    $27,949,000.
                        the office of disease prevention
        The primary mission of the Office of Disease Prevention (ODP) is to
    stimulate disease prevention research across the NIH and to coordinate
    and collaborate on related activities with other Federal agencies as
    well as the private sector. The fiscal year 2012 budget for ODP is
    $1,400,000. The Office of Medical Applications of Research (OMAR),
    Office of Dietary Supplements (ODS), and Office of Rare Diseases
    Research (ORDR) are within the ODP organizational structure.
        The Office of Medical Applications of Research (OMAR) mission is to
    work with NIH Institutes, Centers, and Offices to assess, translate and
    disseminate the results of biomedical research that can be used in the
    delivery of important health interventions to the public. The fiscal
    year 2012 budget for OMAR is $4,877,000.
        The Office of Dietary Supplements (ODS) promotes study of the use
    of dietary supplements by supporting investigator-initiated research,
    and through other major mechanisms. The fiscal year 2012 budget for ODS
    is $28,691,000.
        The Office of Rare Diseases Research (ORDR) supports activities
    that stimulate research on rare diseases by collaborating with the
    research institutes, research investigators, patient advocacy groups,
    the pharmaceutical industry, and Federal regulatory and research
    agencies. The fiscal year 2012 budget for ORDR is $18,423,000.
            the office of strategic coordination and the common fund
        The Office of Strategic Coordination (OSC) facilitates strategic
    planning and management of Common Fund-supported programs by working
    with groups of staff from across the NIH to develop and implement each
    individual program while providing central management for the Common
    Fund as a whole. The NIH Common Fund was enacted into law by Congress
    through the 2006 NIH Reform Act to support cross-cutting, trans-NIH
    programs that require participation by at least two NIH Institutes or
    Centers (ICs) or would otherwise benefit from strategic planning and
    coordination. The Common Fund provides limited-term funding for new
    programs that are intended to catalyze research in the ICs through the
    development of cross-cutting resources, technologies, and data sets.
    Common Fund programs do not address any particular disease or
    condition, but rather, are designed to be broadly relevant. The fiscal
    year 2012 budget for the Common Fund is $556,890,000.
                        the office of science education
        The Office of Science Education (OSE) develops science education
    programs, instructional materials, and career resources that serve our
    Nation's science teachers, their students (kindergarten through
    college), and the public. OSE's activities are an important component
    to the overall Agency effort to achieve the NIH Director's goal to
    reinvigorate and empower the biomedical research community and enhance
    America's competitiveness in the global economy. The OSE creates
    programs to improve science education in schools (the NIH Curriculum
    Supplement Series) that stimulate interest in health and medical
    science careers (LifeWorks Web site); and advance public understanding
    of medical science, research, and careers; and advises NIH leadership
    about science education issues. The OSE website is a central source of
    information about available education resources and programs. http://
    science.education.nih.gov. The fiscal year 2012 budget for OSE is
    $4,120,000.
                    loan repayment and scholarship programs
        The Office of Intramural Training and Education administers the NIH
    Intramural Loan Repayment and Undergraduate Scholarship Programs
    (UGSP). The Loan Repayment Programs (LRPs) seek to recruit and retain
    highly qualified physicians, dentists, and other health professionals
    with doctoral-level degrees. These programs offer financial incentives
    and other benefits to attract highly qualified physicians, nurses, and
    scientists into careers in biomedical, behavioral, and clinical
    research as employees of the NIH. The NIH UGSP offers competitive
    scholarships to exceptional college students from disadvantaged
    backgrounds that are committed to biomedical, behavioral, and social
    science health-related research careers at the NIH. The fiscal year
    2012 budget is $7,653,000 for the Intramural Loan Repayment and
    Undergraduate Scholarship Programs.
        I am happy to answer any questions you may have about the OD's
    programs and activities as well as our plans for the upcoming year.
                                     ______

        Prepared Statement of Jeremy M. Berg, Ph.D., Director, National
                     Institute of General Medical Sciences
        Mr. Chairman and Members of the Committee: I am pleased to present
    the fiscal year 2012 President's budget request for the National
    Institute of General Medical Sciences (NIGMS). The fiscal year 2012
    budget request includes $2,102,300,000, an increase of $70,263,000
    above the fiscal year 2011 appropriation of $2,032,037,000, which has
    been adjusted comparably to reflect NIH proposed transfers. This
    statement is submitted with the recognition of the Department's
    notification to the Congress of an NIH reorganization that would
    establish a new National Center for Advancing Translational Sciences
    and reallocate the remaining portions of the National Center for
    Research Resources to other parts of NIH.
        Since the mid-20th century, NIGMS has played a leading role as
    NIH's ``basic research institute.'' Spanning a broad spectrum, the
    Institute's mission supports discovery ranging from how cells work to
    how diseases affect communities across towns, nations, and countries.
    NIGMS-supported scientists probe the unknown to solve mysteries about
    fundamental life processes. This effort goes well beyond the need to
    satisfy innate curiosity; answering basic research questions such as
    how bacterial and human cells divide, move, and communicate has
    increased our knowledge about infections, cancer, birth defects, and
    heart disease in ways that would have been difficult to achieve with
    more directed studies. Other ongoing NIGMS research investments, such
    as in chemistry, continue to provide tangible benefits to society and
    our economy. This past year, an NIGMS-supported scientist shared a
    Nobel Prize for his discovery of a ground-breaking chemistry method
    that is used routinely in the pharmaceutical, electronic and
    agricultural industries.
        Continued investment in basic research is vital because many of
    today's therapies, although effective, nevertheless have significant
    limitations. Treatments that are applied after the onset of serious
    illness--kidney transplants and dialysis, bypass surgery for coronary
    artery disease, surgical removal of tumors--though often lifesaving,
    are still not optimal. Treating disease before such interventions are
    needed would likely improve both outcomes and quality of life. Basic
    biomedical and behavioral research has the power to move treatments in
    this direction, and in the coming years, emerging biotechnology and
    nanotechnology tools will give researchers unprecedented precision to
    detect and derail disease at its earliest stages.
                      technologies to accelerate discovery
        Basic research on stem cells remains one of the most rapidly
    advancing areas of biomedicine, in large part because of the knowledge
    base scientists already have about how cells behave and change. NIGMS-
    supported research on stem cells continues to provide hope that these
    multitalented cells will find use in customized therapies for a range
    of conditions. In the near term, stem cells are providing researchers
    powerful tools for understanding diseases and developing drugs to treat
    them. This past year, NIGMS-funded researchers made important progress
    on several fronts:
      --Stem cell research pioneer James Thomson, D.V.M., Ph.D., created a
            powerful tool to trace the individual steps in a deadly cancer
            by turning the clock back on blood cells from a person with
            leukemia.
      --Chemist Laura Kiessling, Ph.D., developed an inexpensive and simple
            synthetic culture system for growing embryonic stem cells in
            the laboratory.
      --NIH Director's New Innovator Awardee Alysson Muotri, Ph.D., used
            cells from a person with Rett syndrome to create a cellular
            model of autism.
        Another area showing great promise is molecular diagnosis. This
    past year, NIH Director's Pioneer Awardee Thomas Kodadek, Ph.D.,
    applied a unique and creative strategy that conducts an ``immune
    surveillance'' of human blood to look for early signs of disease before
    symptoms appear. To date, he has obtained exciting evidence that
    Alzheimer's disease may be detectable by this approach, and he has
    licensed the technology to further its development and application.
        The study of systems--of cells, organs, and diseases--is an
    important area of basic discovery within the NIGMS mission. In 2010,
    the Institute grew its support of systems biology by adding two new
    National Centers for Systems Biology. All 12 centers integrate
    approaches from engineering, genomics, and systems and synthetic
    biology to identify principles and architectural features involved in
    common cellular behaviors, including the response to disease-causing
    microorganisms, poisons, and metabolic imbalances.
        Computer modeling is a key element of all systems biology, and a
    central aspect of the NIGMS-led Models of Infectious Disease Agent
    Study (MIDAS). This international effort continues to add new research
    expertise to increase its capacity to simulate disease spread, evaluate
    different intervention strategies, and help inform public health
    officials and policymakers. This past year, two MIDAS findings are
    worth highlighting:
      --One MIDAS study used computer modeling to analyze the spread of
            H1N1 flu in a Pennsylvania elementary school. The researchers
            collected extensive data from seating charts, school
            timetables, bus schedules, nurse logs, attendance records and
            questionnaires. The findings indicated that transmission occurs
            mostly through girl-to-girl and boy-to-boy interactions and
            that sitting directly next to a child with the flu does not
            raise a child's risk of getting it.
      --In another MIDAS study, researchers learned that the Haiti cholera
            outbreak that followed that Nation's colossal earthquake in
            2010 could have been blunted with the use of a mobile stockpile
            of oral cholera vaccine.
              translational sciences and therapeutics development
        Since the landmark discovery of the structure of DNA in the 1950s,
    our increasing knowledge of how all living things share a basic set of
    working parts has catalyzed progress in biomedicine. Large-scale
    efforts to scan and compare genomes are teaching scientists about
    individual differences in DNA scripts that predispose us to disease.
    However, such sequence information is only useful if it can be properly
    interpreted. NIGMS has been at the forefront of supporting research
    that facilitates this interpretation, leading to numerous discoveries
    that have revealed new, unforeseen mechanisms by which DNA information
    is made operational.
        As one example, the NIGMS Protein Structure Initiative (PSI) has
    been creating knowledge and providing tools to researchers for more
    than 10 years. This past year, NIGMS enhanced this signature effort by
    launching PSI:Biology, a new program that supports research
    partnerships between groups of biologists and high-throughput structure
    determination centers to solve medically important problems. Already
    this investment is bearing fruit, yielding new structures that show how
    the largest class of drug receptors functions.
        Another example is a pilot study by an individual scientist that
    searched systematically for environmental factors--nutrients, chemicals
    and toxins--that may be linked to diabetes. Based conceptually on the
    Genome-Wide Association Studies approach, Atul Butte, M.D., Ph.D.,
    developed a new technique he calls Environment-Wide Association
    Studies. In this method, he considered many different factors at once,
    using health survey data from the U.S. Centers for Disease Control and
    Prevention, which led him to identify 266 environmental factors linked
    to type 2 diabetes. This example highlights the tremendous potential
    benefits of integrating existing data sources and asking the right
    questions.
             enhancement of evidence base for healthcare decisions
        Although medicines have been revolutionary in humankind's ability
    to stay healthy, we now know that people having widely varying
    responses to the drugs they take to heal their various ills. NIGMS has
    been a long-time supporter of pharmacogenomics, the study of how our
    DNA influences the way we respond to medications. This area of research
    is an especially important focus in our country today, as the baby-boom
    generation gets older and is more likely to take multiple medicines
    routinely. NIGMS leads the trans-NIH Pharmacogenomics Research Network
    (PGRN), a nationwide collaborative of scientists looking for clues to
    inherited variability in the response to medicines used to treat heart
    disease, asthma, cancer, depression and addiction.
        This past year, two new groups joined the network, adding
    rheumatoid arthritis and bipolar disorder as new focus areas. Over the
    next 5 years, the PGRN plans to expand to pursue cutting-edge DNA
    sequencing methods and statistical analysis, as well as to perform
    pilot studies to learn about medication response from de-identified
    medical records in healthcare systems. Furthermore, previous PGRN-based
    discoveries are now moving further into clinical application with
    evidence accumulating on improved outcomes and lower costs.
                          new investigators, new ideas
        Biomedical and behavioral research is a human endeavor, and NIGMS
    has a long-standing commitment to supporting and sustaining the people
    behind the research. Creativity comes from the sparks of individual
    minds, and thus the Institute has always adhered to the principle that
    a healthy workforce is an essential ingredient for good science that
    leads to better health for all.
        Science and the conduct of research continue to evolve, though, as
    do workforce needs. It is our responsibility to stay attuned to these
    new needs and opportunities. In 2010, NIGMS launched a process to
    examine its activities and general philosophy of research training--to
    assure that all of the Institute's activities related to the training
    of scientists are aligned with our commitment to build an excellent,
    diverse research workforce to help achieve the NIH mission, now and in
    the long term.
        NIGMS gathered data and input from the scientific community through
    a series of regional meetings across the country, as well as through
    other means of electronic communication including a webinar, online
    postings, and comment submissions via e-mail. The resulting plan,
    Investing in the Future, the NIGMS Strategic Plan for Biomedical and
    Behavioral Research Training, was released in early 2011.
        A key focus of this plan is the importance of putting the needs of
    trainees first--by focusing on mentoring, career guidance, and
    diversity. The plan also affirms the Institute's strong assertion that
    there are multiple avenues in which a well-trained scientist can make
    meaningful contributions to society. These include research careers in
    academia, Government, or the private sector, as well as careers
    centered on teaching, science policy, patent law, communicating science
    to the public, and other areas.
        In closing, and on the cusp of my departure from Federal service, I
    want to note how proud I have been to play a role in furthering the
    basic research that has had such a profound effect on the health and
    well-being of our Nation. I will treasure the time and effort spent
    leading the fine institution that is NIGMS.

                    AVERAGE COST OF RESEARCH PROJECT GRANTS

        Senator Harkin. Well, thank you, Dr. Collins. Very poignant
    ending for your testimony.
        We will now begin a round of 5-minute questions.
        Dr. Collins, in addition to drastically cutting NIH
    funding, the House Appropriations bill would have required NIH
    to fund a minimum number of new competing research grants and
    put a ceiling on the average cost to them.
        I have a letter here from a number of different entities--
    American Association for Cancer Research, American Medical
    Colleges, American University--a whole list of different people
    who've written us a letter saying that this would really hamper
    the ability of NIH to fund the best, the most innovative, the
    brightest by putting a cap on it. Now, you have to fund so many
    and you have to--I think it was 9,000--and then they put a cap
    on it of, I think, $400,000, if I'm not mistaken.
        Again, I'd like you to speak to that. We've been down this
    road before over the last 25 or 30 years that I've been on this
    subcommittee, in saying that NIH really ought to do this on a
    peer-reviewed basis. Some of the projects cost more, some cost
    less, but to limit it and then to say you have to do so many,
    takes away the ability to really do a good peer-reviewed
    systematic approach to this.
        I would like you to respond to that and what that would
    mean to NIH if, in fact, we were to set a limit on how much and
    to mandate that you have to fund at least so many grants.
        Dr. Collins. Senator, I appreciate the question. This is a
    very serious issue and you've set it up quite well in terms of
    what the risks might he here.
        Certainly, that feature of the language that was part of
    H.R. 1 was deeply troubling to those of us at NIH, because, as
    you have just said, the goal of all of us who tried to carry
    out our responsibilities to support the very best biomedical
    research is to utilize the tools of peer review, to seek advice
    from the scientific community and our advisory councils about
    how best to utilize the resources that the taxpayers, through
    this Congress gives to us.
        The idea that we would have to manage that enterprise in an
    arbitrary way to try to hit a certain number of grants, and
    particularly to try to hit some average cost of a new and
    competing grant could potentially seriously interfere with the
    flexibility that we believe is necessary for the best science
    to be supported.
        For instance, clinical trials tend to be more expensive.
    Would this kind of a limit on the average costs of a new and
    competing grant find its way into conversations about, well,
    maybe we should do fewer clinical trials and more grants that
    happen to be inexpensive, like conference grants? That would
    be, I think, a serious intrusion into the ways in which,
    really, scientific decisions should be made.
        So I agree with you that that particular kind of way of
    tying NIH's hands would be very unfortunate. Given all of the
    scientific opportunities that we have right now, we should be
    able to pursue them in a way that represents the best decisions
    and not managed in this sort of arbitrary way by trying to hit
    certain numerical grant limits.

                                    DIABETES

        Senator Harkin. I appreciate that.
        Dr. Rodgers, on diabetes, I think we saw that chart there
    about moderate changes in diet and exercise resulting in a huge
    decrease in the incidence of the disease. I had 71 percent and
    the chart said 58 percent, so I have to figure out why there's
    a difference here. When you testified a few years ago on this,
    you said you would be undertaking a follow-up study to see
    whether these could be sustained over time. What's happened?
        Dr. Rodgers. That's correct, Senator, and thanks for the
    question.
        First of all, the 71 percent, even though the average
    improvement in terms of a reduction with that intensive
    lifestyle modification was 58 percent for all comers, among the
    people over 60 years of age, it was 71 percent. So they really
    enjoyed the best benefit of all of the subsets of the patients
    studied.
        Now, the initial trial, the diabetes prevention trial, was
    published in 2002, and, at that point, the reduction was 58
    percent for intensive lifestyle, 31 percent for a drug,
    metformin.
        But, more recently, the 10-year follow-up, which is what I
    was referring to at that hearing, was just published in the
    Lancet in 2009, and that shows, as Dr. Collins mentioned, a
    durable effect out 10 years. These patients who engaged in the
    intensive lifestyle still showed a reduction of their going on
    to develop diabetes, and the patients, in fact, who were on the
    metformin also continued to show an improvement.
        Senator Harkin. Very good.
        Now, my 5 minutes is up, but I have other questions for
    other people here. I'll do that on my second round.
        Senator Shelby.

                             NCATS BUDGET AMENDMENT

        Senator Shelby. Thank you, Mr. Chairman.
        Dr. Collins, I'm going to get back into NCATS for a minute.
    I think it's very important, and I think it has great promise.
        I think that NCATS proposal requires thoughtful
    consideration to the effect that it will have on NIH, the
    extramural research community and the private pharmaceutical
    market. You've alluded to this a little.
        As I stated, I remain concerned that this announcement was
    made in December, yet we don't have some details before the
    subcommittee yet.
        The reorganization will impact all of NIH's 27 Institutes
    and Centers and will shift at least $1.3 billion. I believe the
    subcommittee needs to review such a proposal, especially one
    that has such a potential impact on the NIH community.
        My question is when will we receive some more details that
    we can renew--for the staff and the subcommittee--or do you
    have a timeline? I know it's a difficult transition.
        Dr. Collins. Senator, it's a very fair question, and I had
    certainly hoped that by the time of this hearing we would have
    been able to provide the full details about the budgetary
    consequences of standing up this new and exciting new center.
        It is a complicated process. The recommendation to do this
    came forward from my Scientific Management Review Board last
    December 7.
        Rather than putting this off until fiscal year 2013, which
    I thought would really have wasted an opportunity, we decided
    we would try to move as quickly as possible. Although some
    people said, ``Hey, this is the Government. You can't possibly
    do that by October'', well, they used to say that about the
    Genome Project. So I decided that we could, and we should,
    because this is the best way to move the science forward.
        But, of course, what this means is taking a number of
    components that already exist in various institutes and in the
    common funded NIH and moving them together into this new
    synergistic entity. That's important to point out.
        Actually, what we're talking about is not to create new
    budgetary implications, with the one exception of the Cures
    Acceleration Network, which is in the President's fiscal year
    2012 budget at $100 million, and which we hope this
    subcommittee and others will see fit to support, because it'll
    give us some flexibilities in terms of how we manage the budget
    that we would dearly love to have.
        But the other pieces of NCATS are basically derived from
    existing programs that are moved together in a way that are
    going to be highly complementary and synergistic.
        We needed, of course, to consult with our communities, with
    our constituencies, and, as we figured out how to do the
    shifting right down to every employee to make sure that the
    programs were encouraged and nurtured, we had to be sure we had
    that right.
        We are at the point now where we believe we have that
    together. It needs, of course, to be reviewed by the Department
    of Health and Human Services (HHS) and Office of Management and
    Budget (OMB) experts. We hope to get that to you, Senator, in
    the fairly near future, within, certainly, the next few weeks
    and, hopefully, a very few weeks.

                       COST OF DE-RISKING PHARMACEUTICALS

        Senator Shelby. Dr. Collins, you've also described the
    NCATS mission as one of what you call de-risk--that moves basic
    scientific discoveries beyond the lab to a point where the
    private pharmaceutical market feels confident enough to jump
    in.
        What is the policy or what would you think the policy would
    be if a selected project is successfully de-risked, but no
    companies produce the drug or medical product? I know you've
    thought about that.
        Dr. Collins. And, indeed, I should point out that this is
    an activity which NIH has been engaged in for some long periods
    of time, and my colleagues, particularly from the National
    Cancer Institute (NCI) and National Institute of Allergy and
    Infectious Diseases (NIAID), have been supporting this kind of
    translational effort in always looking for a commercial partner
    at the earliest moment in order to be able to carry a project
    through to completion and limit the amount of dollars that the
    taxpayers have to cover.
        I would say projects that get undertaken at this point need
    to think about that from the very beginning. There will be
    instances perhaps where no commercial partner can be found,
    even all the way through to the end of a phase III trial, but
    they will be rare indeed, because those are very expensive
    enterprises.
        But for very rare diseases, where the economic incentives
    are simply going to be very limited, and especially if one is
    in a circumstance where you could conduct such a clinical trial
    by repurposing a drug that's already been approved for
    something else, then NIH may very well find it worthwhile to
    undertake that effort.
        But you're quite right to point this out. We have to get
    the balance----

                        HEALTH PREPAREDNESS AND OBESITY

        Senator Shelby. Absolutely.
        Just want to touch on health disparities. You got into it a
    little. Health disparities most often associated with the ethic
    population persist in rural United States. Stroke, diabetes,
    kidney disease and cancer are all more prevalent in both the
    African-American community as well as the South.
        One of the root causes to health disparity is the obesity
    epidemic that is rampant in our Nation. You pointed it out in
    your slides. Southern States have the highest rates in the
    Nation.
        My question is should we be looking for a new paradigm that
    broadly addresses this critical national issue at multiple
    levels for molecules to behavior to policy? You touched on it
    with your slide. And how can NIH help the American people meet
    that challenge?
        Dr. Collins. So, Senator, I really appreciate the question
    because this is an enormous public-health challenge for all
    communities, but particularly so for certain underserved
    communities.
        I'm going to turn to my colleagues, Dr. Rodgers and Dr.
    Shurin, who lead the Obesity Task Force at NIH, who are just
    putting forward a new research plan that's quite exciting.
        Dr. Rodgers. Thank you, Senator.
        Because of the extreme importance of this project, and
    particularly the recognition that obesity is occurring much
    more frequently in children in this country, we've also asked
    Dr. Collins for his permission to have the Director of the
    Child Health Institute on board as a co-chair of this obesity
    research task force.
        As Dr. Collins indicated, we just put out this last month a
    strategic plan which highlights a blueprint for research in
    these critical areas related to prevention and potential
    treatment of obesity, particularly in health disparities or in
    certain ethnic and racial groups, in older adults, in young
    children.
        And it recognizes the fact that obesity is a multifaceted
    problem, and, therefore, you need multifaceted solutions,
    including behavioral, medical, surgical and others.
        Senator Shelby. How important is behavioral here----
        Dr. Rodgers. Behavioral research is extremely important.
    For example, we know that for childhood obesity just decreasing
    screen time, the amount of time kids are in front of the
    television, the computer, video games can greatly reduce the
    risk. Increasing physical activity is another important
    component to this.
        Let me turn to my colleague, Dr. Shurin, who actually has a
    very active program involving children.
        Dr. Shurin. Thank you, Senator. We share your very deep
    concerns about this.
        One of the things that Dr. Rodgers and I have done is to
    convene a group, a collaborative on obesity with the CDC and
    the Department of Agriculture with the support of the Robert
    Wood Johnson Foundation, which has a particular interest in
    childhood obesity.
        So we have a multifaceted research program. Much of it is
    community-based research, but it also ties in to many
    biologically and behaviorally oriented research programs really
    looking at the factors that impact obesity.
        As Dr. Rodgers has said, we've got several studies now
    which show a very profound influence of screen time. Physical
    activity is at least as important as diet, but dietary issues
    are obviously of major importance. And we have a very rich
    portfolio of research projects looking at what are the most
    effective interventional strategies.
        Many of these are site-based, worksite-based and school-
    based programs. I think one of the things that's particularly
    important is that many of the projects that we get into which
    look very promising don't actually pan out. It's very helpful
    for us to know what doesn't work, so we can really be fairly
    aggressive in pursuing the ones that do.
        The impact of policy changes, the engagement of the food
    industry and of preventive health services we think are
    particularly important. We initiated a program called We Can,
    which is ways of enhancing childhood activity and nutrition,
    which we have now several thousand community partners aimed
    very heavily at reducing screen time and increasing physical
    activity and focusing very heavily on dietary activities.
        We have several collaborations with the food industry, with
    several partners in the food industry which have become
    increasingly responsive, but we think that there are probably
    going to have to be some policy approaches that will have an
    impact on this, that simply relying on individual choices is
    not going to be sufficient.
        Senator Shelby. Thank you. Thank you, Mr. Chairman.
        Senator Harkin. Thank you. In keeping with the
    subcommittee's policy in order of appearance here at the
    subcommittee be Senator Reed, Senator Moran, Senator Mikulski,
    Senator Brown.
        Senator Reed.

                             GLOBAL COMPETITIVENESS

        Senator Reed. Thank you very much, Mr. Chairman, and thank
    you, doctors.
        Dr. Collins, just a quick point, that Chinese facility that
    you mentioned to is supported by the Chinese Government or do
    we know?
        Dr. Collins. Interesting. It is partly supported by the
    Government, but they actually have put this in place by taking
    out a bank-supported loan to allow them to purchase 128 of
    these----
        Senator Mikulski. They didn't get it here.
        Dr. Collins. Senator Mikulski is correct. It was not at an
    American bank. And they have purchased 128 of these sequencing
    machines, the largest collection in the world, and they are
    quite confident that the value economically will fully justify
    the cost of buying the machines.
        They've also hired about 4,000 of the smartest young
    scientists that I've ever seen in one place from all over China
    who are in their 20s and who are prepared to change the world
    and probably are going to.
        And we should celebrate that. I don't mean in any way to
    say I think this is a bad thing, but it worries me to see that
    China has taken that kind of initiative and we have not.
        Senator Reed. But the financing might be considered quasi
    private and public together, but this is clearly an initiative
    at the highest levels of the Chinese Government to get this
    done.
        Dr. Collins. Yes.
        Senator Reed. And we are at this debate here in the United
    States about what we will commit as a Government to not only
    the genome sequencing, but so many of the innovative proposals
    you've talked about.
        Dr. Collins. That's correct----

                          NIC VOLKER TREATMENT DETAILS

        Senator Reed. Just want to clarify that.
        I thought also, joining the chairman, that the poignant
    story of Nic--I wonder did he or his doctors avail themselves
    to the National Cord Blood Registry, CDC's the MATCH? Was that
    a----
        Dr. Collins. I don't know in terms of where his stem cell
    transplant came from. I can find that out for you, Senator.

                               PEDIATRIC RESEARCH

        Senator Reed. But that's an initiative that Senator Hatch
    and I worked on and I hope it contributed to that great story.
        [The information follows:]
                    Nic and the National Blood Cord Registry
        David A. Margolis, M.D., professor of pediatrics and director of
    the Bone Marrow Transplant Program at the Children's Hospital of
    Wisconsin, said, ``Our donor coordinator says `Yes. If it were not for
    the National Marrow Donor Program, and the single access that it
    provides, the search (for Nic's cord blood stem cell donor) would have
    been more difficult, time consuming, and may not have yielded the same
    results.' ''

        Senator Reed. But this raises a larger question, then, in
    terms--that I have with respect to the amount of resources
    going to pediatric research. You've cited several examples. Dr.
    Rodgers, Dr. Shurin have talked about, you know, the research
    you're doing in children's obesity, et cetera.
        For example, I'm told that only about 4 percent of the
    funds in the National Cancer Institute are for pediatric
    cancers. That might be good news, because it might represent
    that it's a relatively healthy population, but just generally a
    sense do you think we're making the right allocation of
    resources to pediatric research?
        If we're not, are there structural issues; that is, is the
    peer-based review tilted toward adult experts rather than
    pediatric experts? Any comments I'd appreciate.
        Dr. Collins. Well, quickly, and then I'll ask Dr. Varmus to
    address the pediatric oncology issue, but we have an entire
    Institute at NIH, the National Institute of Child Health and
    Human Development, which has as its major focus pediatric
    research and which certainly is a place of a great deal of
    interest and excitement right now because there are so many
    promising developments in childhood illness.
        We also are investing in a very large national project, an
    unprecedented one, the National Children's Study, which will
    enroll 100,000 kids beginning even before conception through
    pregnancy and up to age 21 in order to comprehensively collect
    the kind of information about environmental exposures and
    genetics that may shed light on diseases like autism and
    diabetes that have continued to vex us.
        I would say, yes, there's a lot of investment. Could there
    be more? You bet there could, but that would probably be true
    in virtually every area that we're looking at. With these 17 to
    18 percent success rates that were mentioned by the chairman,
    we are clearly not able to support a lot of great science that
    we'd like to support.
        Senator Reed. Before Dr. Varmus, I must say that Brown
    University Medical School is participating along with Women and
    Infants Hospital, and Dr. Rodgers is their commencement
    speaker, because he's one of the most illustrious Brown
    University medical graduates in the history of the program. I
    had to put that in the record. Forgive me, Dr. Collins.
        Dr. Varmus.
        Dr. Varmus. Senator Reed, thank you very much, and I
    appreciate your honoring my colleague, Dr. Rodgers.
        You're correct that the amount of money we specifically
    identify as being devoted to pediatric cancer research is about
    4 percent of our budget, which is about $200 million a year,
    but, of course, a great deal of other funding that we're
    involved in addresses cancer more generally and is applicable
    to pediatric problems.
        Let me say a few words more broadly about pediatric cancer.
    Chairman Harkin alluded to the fact that we do cure most
    patients with leukemia. Pediatric cancers, in general, are much
    more effectively treated, whether they're brain tumors or
    neuroblastomas or Wilms tumor or leukemias, but, nevertheless,
    there still is an increased incidence of childhood cancers over
    the last several years by about 30 percent, but a continuing
    decline in mortality.
        Nevertheless, mortality figures do not tell us the whole
    story. There are severe consequences of being treated for
    cancer at an early age--developmental defects, loss of mental
    capacity in some individuals, and, of course, a very high
    incidence of second tumors, particularly in survivors' 20s and
    30s.
        We're trying to address these problems in a variety of
    ways. We're trying to understand the cancers more profoundly
    with some of the genomic-sequencing techniques that Dr. Collins
    alluded to.
        We, in fact, have spent Recovery Act money on a new project
    to study pediatric cancers in great detail. And we have new
    therapeutic maneuvers that are based on more targeted, bullet-
    specific drugs and antibodies that have been very effective in
    reducing mortality rates in neuroblastoma and leukemias with
    therapies that are less toxic.
        We have paid a lot of attention to the survivors of
    pediatric cancer. We have a nationwide survivors study for
    pediatric cancer that has enrolled over 20,000 patients in
    roughly 37 different centers. So with these and other projects,
    we think we're making a pretty good effort to control the
    consequences of treatment of pediatric cancer and to do a
    better job in treating pediatric cancers in a less toxic
    manner.
        But you're correct, we could do more, but, as you know, we
    have budget constraints this year. It's unlikely that we'll see
    a very significant increase in that domain or any other in the
    coming year.

                  BIOMEDICAL RESEARCH RESOURCES AND WORKFORCE

        Senator Reed. Thank you very much. Thank you, gentlemen.
    Thank you, Dr. Shurin. Thank you, Mr. Chairman.
        Senator Moran. Chairman Harkin, thank you.
        Dr. Collins and your colleagues, fellow doctors, I
    appreciate the opportunity to have this conversation with you
    this morning.
        This is a beginning course for me. I have 4 months of being
    a United States Senator and being a member of this
    subcommittee, but I'm excited about joining Senator Harkin and
    Senator Shelby and my colleagues here.
        I think medical research is a huge component of the future
    of our country. I think it matters greatly, and I commend you
    for your efforts to date.
        In my healthcare reform bill, we would support medical
    research in a dramatic way. I think it's a cost-saving measure.
    It's about saving people's lives, improving the quality of
    their life. And so from an economic--as you point out--but also
    from a personal, humanitarian point of view, what we do here in
    this subcommittee and what you do at NIH matters greatly.
        And I would welcome the opportunity to become better
    acquainted with NIH, its personnel, its mission. Maybe the
    people in the rows behind you--I want my doctors out there
    doing the research, but I'm happy to have others at NIH devote
    some time to educating me so that I can better understand how
    we can advance the cause of medical research here in the United
    States.
        I would ask first if there is something missing. We're here
    in an appropriations subcommittee, but other than money, is
    there something missing at NIH or here in our country, in the
    United States, that makes it much more difficult or makes it
    difficult for you to reach the goals that you outlined for us
    today or is this just a financial issue, how many dollars do we
    devote? What are the other, if any, impediments toward success?
        Dr. Collins. Well, Senator, I appreciate the question and
    certainly appreciate your strong statement of support, and you
    are most welcome to come and visit us at NIH. We'd love to host
    you for a visit and show you some of the things that are going
    on in the laboratories and in the clinical center, the largest
    research hospital in the world, that's up there in Bethesda.
        Senator Moran. Thank you.
        Dr. Collins. But as you know, most of the money that NIH
    sends out in grants goes to the 50 States, including Kansas,
    and we're very proud of the research that's going on there in
    your State.
        Senator Moran. Thank you.
        Dr. Collins. In terms of other things that potentially are
    barriers, certainly we do not have what I would call a vigorous
    pipeline of young scientists coming into our field, and part of
    that is the sad state of K through 12 science education in this
    country, which has certainly, by any measure, slipped badly
    over where it used to be back in the--30 or 40 years ago in the
    sort of post-Sputnik arena where science education was really
    emphasized.
        Now, in many schools, it is unfortunately quite
    rudimentary, and I think we lose, therefore, the chance to
    capture young people's imagination that science would be a
    place they wanted to spend their own careers. And that means we
    have fewer American-born individuals who are clamoring to come
    in to our laboratories and make the next great discoveries.
        We have lots of interest from individuals born in other
    countries to do that, but that interest has actually declined a
    bit as more opportunities are present in their own countries.
        Some of them, certainly in large numbers, still come to
    train in our universities, but they often now go back to their
    original homes and carry out research instead of staying in the
    United States. And some of our visa practices have not helped
    in that regard in terms of making such talented scientists from
    other countries feel less welcome than we wish they were.
        It seems to me that would be a very important area for us
    to, again, try to get right, because it is to our advantage to
    recruit such individuals--and our universities are still seen
    as the very best in the world--to come and do their research,
    but then for us to also be able to capture their talents in an
    ongoing way I think would be a great advantage. That is just
    one of the areas.
        But, frankly, the major concern that I think we have is
    just the lack of sufficient resources to chase down all of the
    great ideas that are now potentially possible.

                           INTERDISCIPLINARY RESEARCH

        Senator Moran. I appreciate that answer and look forward to
    finding solutions in that regard and understand now the
    importance you place upon the resources.
        I did visit the University of Kansas last week and one of
    the research facilities there, the Molecular Libraries Program,
    and I'm very interested in what the ranking member pursued in
    regard to NCATS.
        And when I heard your testimony today, my assumption is
    that this will take a lot of different kinds of scientists
    engaged in this effort, and I guess an initial question would
    be what steps would you anticipate being taken to ensure that
    the best of American science in as many areas will have that
    opportunity to contribute to this new program?
        Dr. Collins. Well, a very appropriate point. It will take
    an interdisciplinary effort of a considerably revolutionary
    sort.
        It means bringing together biologists and chemists--as no
    doubt you saw at the Molecular Libraries Program in Kansas--
    along with computational experts, structural biologists who can
    actually figure out the shape of molecules and figure out which
    shapes fit together in a way that might make a particular drug
    work, immunologists who can help us with monoclonal antibody
    development, engineers who can work on devices that will be the
    next generation of what we need for all manner of medical
    applications, and those disciplines traditionally haven't had
    such an easy time talking to each other, and one of our goals
    through this program and many others is to do that.
        Maybe this is also partly in answer to your first question
    about what are some of the barriers. In some way our own
    traditional disciplines have presented some of that problem,
    although I think those barriers are coming down.
        Clearly, there's a lot of excitement--and I suspect you
    perceived that in your visit to the Kansas center--about the
    potential here of bringing those disciplines together with
    these new comprehensive sciences to enable academic
    investigators to play a larger role in reengineering this
    broken pipeline to try to make it possible to come up with
    therapeutics and devices and diagnostics in a shorter time
    period.
        This resonates with me for the same kind of feeling I had
    about the Genome Project 20 years ago. It was controversial
    then, too, of course. A lot of people wondered whether this was
    biting off more than the Government could chew, but it
    recruited into the effort some of the best and brightest minds
    of that generation because they could see the potential.
        I think that same atmosphere is beginning to appear in
    translational science, and I suspect once we have the programs
    in place it will not be hard to recruit some really brilliant
    minds to play a role in this.
        Harold, did you want to add to that?
        Dr. Varmus. I think it might be important to reassure you,
    Mr. Moran, about the effort that's being made in translational
    research across the institutes.
        As Francis alluded to in his testimony, a great deal of
    work--interdisciplinary work, indeed--has gone on in the
    Institutes and will continue to go on, while NCATS provides a
    catalytic advantage to the efforts that we're making by
    providing new methodologies, ways to analyze how translational
    research is done, some core facilities.
        But, as you probably know from going to your cancer center
    at the University of Kansas, that there is a lot of
    translational research going on there, and that's done by
    interdisciplinary teams.
        So all of us at the NIH are engaged in this process and
    we've had a lot of experience in gathering multidisciplinary
    teams over the last decade or so to do this kind of work.
        Senator Moran. So it's not new and we know it can be done.
    It's being done today.
        Dr. Varmus. But we're all engaged in the process, and it's
    not going to fall solely on the head of NCATS.
        Senator Moran. And, unfortunately, I'm on the social
    science in my education and I detect that the same thing may be
    there between chemistry and biology as there is between history
    and political science.
        Dr. Varmus. Well, there could well be. Yes----
        Senator Moran. But I appreciate that, and I did see the
    enthusiasm. That was perhaps the takeaway of my visit is the
    excitement that is there and the belief in the potential of
    what can be accomplished.
        Dr. Varmus. Yes.
        Senator Moran. It's very appealing to me.
        Dr. Collins. Dr. Fauci wants to add something.
        Dr. Fauci. There is one other thing that sometimes gets
    misunderstood. We mention--and Dr. Varmus mentioned also that
    there's a lot of translational research going on.
        What the center is going to be directing itself at is to
    really advance what we call the discipline of translational
    research, in other words, to help us to do more innovative ways
    of approaching translational research. So translational
    research goes on to the tune of many billions of dollars at the
    NIH, mostly in the big Institutes, but some of the smaller
    Institutes also.
        What we want to do is advance the discipline of how it's
    done, making it a 21st century approach toward translational
    research as opposed to relying on many of the methodologies
    that have been good, but that we think we can do better on.
    That's what it's really all about, putting forth the discipline
    and improving the discipline of translational research.
        Senator Harkin. Thank you. Thank you, Senator Moran.
        Senator Mikulski.

                                 SUPPORT OF NIH

        Senator Mikulski. Thank you very much, Mr. Chairman. I'm
    very proud of the fact that NIH is located in the State of
    Maryland. And for more than 25 years, I've visited NIH
    regularly, and every time I come, my eyes pop with wonder, my
    heart beats with excitement and I just--one of the reasons I
    wanted to be here today was to tell you and all of the people
    who work at NIH how proud I am of you, and how America ought to
    be proud of you.
        Dr. Collins, you did path-breaking pioneering work when
    mapping the genome. And we were in a race. You had another
    competitor down the street. You broke the code and we
    invented--not only mapped the code, but came up with new fields
    called computational biology, bioinformatics, new exciting
    careers that help both us in particularly the private sector be
    able to come up with new products.
        And, Dr. Fauci, you, what you've done. You were the guy who
    broke the AIDS code. You were the guy that came here when we
    were gripped in fear and near panic when we were shut down due
    to anthrax and we had no place to turn in our United States
    Government for information, but we turned to you and you kept
    us on the right path, so that we could keep the doors of the
    Capitol----
        Dr. Varmus, a former head of NIH. You know, NIH Directors
    don't leave. They leave legacies, and then they come back to
    create new ones, and we're so glad to see you. And we note that
    when you were at Sloan-Kettering you had a lot of other zeros
    behind your compensation package, which says something about
    why you came back.
        And to Dr. Rodgers and Dr. Shurin, who also was educated at
    Hopkins, we're just glad to see you.
        And, Mr. Chairman, and what they do is the work that helps
    us manage the biggest budget busters in our healthcare budget--
    diabetes, heart disease, the chronic conditions that lead to
    chronic problems in the way we live, in the way we have to fund
    healthcare.
        So I wanted to be here today to say for all the people work
    at the institutes, all the people work at the various offices,
    all the lab techs, the security guards, the fire department,
    we're really proud of you.
        So having said that, I want to make sure we help NIH be
    NIH. So I want to stick to the basic mission in addition to
    these exciting new ideas.
        Dr. Collins, how many research grants did NIH fund last
    year, and how many requests did you get for funding? In other
    words, what is the funding gap, and particularly not only with
    the tried and true research, but also with those promising
    young, maybe more upstart type thinking?
        Dr. Collins. So in fiscal year 2010, we funded
    approximately 9,300 research grants. The success rate in fiscal
    year 2010 came out at just about 20 percent; that is, one out
    of five that were able to be supported.
        With the fiscal year 2011 budget now in front of us, now
    that it's been decided, we won't do that well, because, of
    course, as you know, after the dust all settled, we ended up
    with a 1-percent cut of $320 million, although I really want to
    express my appreciation----
        Senator Mikulski. So that's what one percent means, $320
    million?
        Dr. Collins. That's correct. But I do want to express my
    appreciation to members of this subcommittee, because I know
    there was a great deal of debate about exactly where the dust
    would all settle out, and certainly many of the proposals were
    vastly worse than this, and I know many people really went to
    bat for NIH, and we appreciate that enormously.
        But we do believe that in fiscal year 2011--with some
    uncertainty in the number, because we don't actually know how
    many grants we will receive, and, of course, we're talking
    about a proportionality here--that the success rate will fall
    to approximately 17 to 18 percent, and that will be the lowest
    in history.
        We will do our best to try to manage the resources that
    we've got, and we've made a number of adjustments to try to
    keep that number----
        Senator Mikulski. But for every one grant that you can
    fund, let's even go to before fiscal 2011, how many are
    unfunded?
        Dr. Collins. So it would be five out of the six. If you
    have six grants in front of you, we're going to fund one of
    them and five of them are going to go begging.

                               WORKFORCE PIPELINE

        Senator Mikulski. All of which are quite promising.
        Now, let's go to much is made about recruiting young people
    into science, and we want a lot of initiatives in that, but
    young people follow opportunity. So when we look at your
    internship, your fellowship program, both for high school,
    undergraduates and so on, again, how many students can you have
    come in to NIH? And how many--In other words, how many can you
    take and how many apply? What's the enthusiasm gap here?
        Dr. Collins. Well, there is enormous enthusiasm. Certainly,
    we run a number of internship programs on the NIH campus. We
    have a program for high school students and college students
    who come and spend 10 weeks in the summer. That is always
    oversubscribed by at least a factor of five in terms of the
    number of slots that we have available and the space that's in
    the labs.
        We also have a program for individuals who are finishing
    college, who are really interested in science, but they're not
    sure whether they want to go to graduate school or medical
    school. They come and spend 1 year, sometimes 2 years doing
    full-time research in the lab.
        I have three of those students in my lab right now. They're
    enormously energized, excited about what they're doing, and
    they go on to do great things. This is a really important
    program.
        But there again, the number of applications we have for
    that so-called post bac program is at least four or five times
    greater than the number of slots that we have available to
    offer.
        Senator Mikulski. So while we're busy--You know, we like to
    pound our chest and come up with all kinds of things in
    education to encourage people for science, but our young people
    are going in it, but they need opportunity, both in the public
    as well as in the private sector.
        Dr. Collins. So, Senator, I've just set up, as part of my
    advisory committee to the Director, a working group to look at
    our workforce issues, and I've asked Dr. Shirley Tilghman, the
    president of Princeton, to co-chair that, because I think we
    need a better handle on what the supply-and-demand issues are
    in terms of the biomedical research workforce.
        We want to be sure that we're looking forward with a clear
    eye toward all of the different pathways that are going to need
    well-trained, doctoral-level biomedical researchers and that
    we, NIH, as a major source of training support are
    appropriately tuning our programs so that we have the numbers
    right in terms of how many people we are bringing in and what
    kinds of careers we're preparing them for.

                        EFFECTS OF A GOVERNMENT SHUTDOWN

        Senator Mikulski. Well, I think this would be enormously
    useful to this subcommittee, Mr. Chairman, because, as you
    know, this is a topic--a big public-policy topic they ponder
    all of the time.
        My last just comment or question is with all the talk of
    the shutdown and during H.R. 1, a cut to the National Cancer
    Institute, which was stunning to many people, including me,
    what is the morale at NIH now that they thought that they might
    be sent home and told that they were non-essential and the cuts
    might be coming?
        I mean, I must say both the chairman and the ranking member
    were enormously supported to minimize the disaster, but it was
    not a victory.
        Dr. Collins. So I would say this was a very difficult
    period to go through. We were required, of course, in
    preparation for what appeared to be a very high likelihood of a
    shutdown, to define how we would manage that, and that meant
    defining which particular employees were considered essential
    and which were excepted, was the term that was used, and which
    were non-excepted.
        And, of course, those who were involved in patient care or
    management of animals couldn't very well just not come to work,
    but others were told, ``I'm sorry. If there is a shutdown, you
    can't come to work.''
        Think about how that feels if you're a post-doctoral fellow
    who's in the middle of an experiment that you've been working
    on for 2 or 3 weeks and has another couple of weeks to go and
    you're being told, ``I'm sorry. You're not allowed to come to
    work tomorrow if the Government shuts down.'' It did have a
    very significant effect. People were quite shaken up by that.
        I think people are--in the aftermath of that--feeling a
    little uncertain about what it's like to work in this
    environment and hoping that we won't face that again. But,
    again, I think everybody understands these are terribly,
    terribly difficult times for our country.

                     INFLATION EFFECTS ON PURCHASING POWER

        I just want to show you one image because I think it might
    be actually useful.
        [The information follows:]

        Senator Mikulski. Okay. I'm going to just--chairman
    regulate the time, but I'm fine with it, but if that's okay
    with the chairman.
        Dr. Collins. It'll take 1 second. This is basically why we
    are in such a crunch.
        Senator Mikulski. Well this is a terrific slide.
        Dr. Collins. So this is--this shows----
        Senator Mikulski. It's more like the way my heart went up
    during the shutdown mode.
        Dr. Collins. So in blue, you see the appropriations for NIH
    going back to 1998. You see the doubling that happened between
    1998 and 2003, and then you see that since 2003 the NIH budget
    has been much more in a flat trajectory.
        But in yellow, you see the effects of inflation, the
    biomedical research and development index, which has been
    eating away at our buying power since 2003, placing us now,
    even with the President's budget, in the range of what we were
    at 2001. So we're sort of where we were 10 years ago.
        You see the Recovery Act dollars there in 2009 and 2010,
    which were a wonderful boost to the scientific community, but,
    of course, that was 2-year money.
        That is why the success rates are now dropping to where
    they are. It's all pretty much clear what the consequences
    would be once one considers what's happened to buying power for
    research.
        Senator Mikulski. Thank you. Mr. Chairman, thank you.
        Senator Harkin. Senator Mikulski.
        Senator Mikulski. You are the genius club. I mean, you
    really are. So thank you.
        Dr. Collins. Thanks.
        Senator Harkin. Senator Brown.

                               NEW INVESTIGATORS

        Senator Brown. Thank you, Mr. Chairman. And I've always so
    enjoyed having panels from NIH, some of the smartest people in
    the country, especially those who used to teach in Cleveland,
    Dr. Shurin.
        But thank you. I mean, it really is illuminating and we
    thank you so much for your service. This is such an example of
    public service and why government matters.
        And when I hear some of the know-nothings that hold jobs
    like we hold say that the Government is broke and that
    Government can't function and Government doesn't contribute
    anything and Government doesn't create jobs, you know, I think
    about the special forces. Those were Government employees that
    were in Abbottabad, but I think primarily of what NIH does and
    what you contribute to public health and to wealth of our
    country.
        I want to take up on what Senator Mikulski said, and Dr.
    Collins' response, on the one out of five grants. I was in the
    House, ranking Democrat on the subcommittee back when we
    actually wanted to fund public health bipartisanly in this
    country 15 years ago, doubled the budget at NIH.
        And I remember in those days those numbers that some of
    your predecessors--well, some of you and some of your
    predecessors--would cite, now that we fund one out of five
    grants or one out of six grants. It's gotten a bit worse than
    what Senator Mikulski said.
        The other part of that story that I remember is the young
    researchers that you are always looking to attract when you
    teach at med schools and you counsel people and you mentor
    people, those are the least likely to be the one out of five
    that gets the grants--or the one out of six--because my
    understanding is that people that have done these grants over
    time kind of know how to win the grants better than the young,
    bright researcher also applying for the grant. So the numbers,
    in some sense, among younger, hungry researchers are even
    worse, the ratios, and too many of these young people leave the
    field.
        And I think that's, to me, the most compelling reason that
    this fervor to cut budgets as--we need to address our budget
    deficit, but we're creating terrible deficits in young
    scientists and terrible deficits in the public body of
    knowledge, I just want to say.

                            COST OF PHARMACEUTICALS

        Let me go--two issues I want to talk briefly about. One is
    the issue of the Makena drug, the progesterone that was
    developed over time into a--produced by compounding pharmacies
    as you know, has made a huge difference, provable huge
    difference, clinically trialed--if that's a verb or adverb--
    huge difference in preventing early birth, pre-term births.
        We know what this KV Pharmaceuticals in St. Louis did. We
    also know that you at NIH have invested $21 million on now four
    clinical trials, in the midst of the fourth one and still
    investing in this and finding, I think, more indications,
    perhaps, to use this drug, this progesterone, this compounded
    pharmacy drug.
        Well, just give me your thoughts, briefly, if you would,
    how do we prevent this from happening? The Food and Drug
    Administration (FDA) has stepped in and done something pretty
    unusual and pretty gutsy by saying they're not going to enforce
    the cease-and-desist order on compounding pharmacies.
        So when I talk to obgyns and visit hospitals--I was at
    University Hospitals yesterday in Cleveland--2 days ago--
    talking about they're still compounding it, still producing
    this.
        When taxpayers invest in this and it's clearly a drug in
    the public interest and one company can get exclusivity for 7
    years, while you continue to do these clinical trials
    expanding--in a sense expanding their market on this fourth
    clinical trial you're doing--and I know this cuts across FDA,
    HHS as a whole and you and CDC and all, but what do we do about
    this?
        Dr. Collins. Well, Senator, I think you spoke out quite
    strongly about the Makena situation and I think brought a lot
    of attention to a circumstance that really was deeply
    troubling, that a drug--let's just call it 17P--that was
    previously available and compounded by pharmacists and then was
    put into a clinical trial, ultimately ended up, after FDA
    approval and orphan-drug status, going up in cost from
    something that cost $10 or $20 to something that costs $1,500.
        We were also deeply alarmed to see that and quite pleased
    to see FDA step in and say they were not going to go after
    pharmacists that continued to provide the compounded material.
        And that, by the way, also, and along with your strong
    statements and that from some of the professional groups, did
    cause KV Pharmaceuticals to drop their costs, but still at a
    much higher level than they were in the old days.
        NIH has its hands a bit tied in this situation. Back in the
    1990s, when Harold Varmus was NIH Director, we had a big
    discussion about whether drugs that NIH plays a role in
    developing should have some sort of reasonable pricing clause
    attached to any kind of licensing that we would do to a
    company.
        And while that might have seemed like a way to avoid
    another kind of Makena outcome, it was a poison pill for any
    serious relationship that NIH would have with a company. No
    company in this country or elsewhere would be interested in a
    partnership with NIH under those circumstances.
        What we can do is to make sure that if profits ensue and
    NIH has made a contribution to that, in terms of genuine
    intellectual property discoveries, that there should be royalty
    sharing on that basis.
        But when it comes to setting the price, as KV did, even
    though we supported the clinical research, we are probably not
    the agency in a position to be able to do something to step in
    and interfere with their pricing decision.
        It was the public outcry, your outcry, Representative
    DeLauro, the professional societies that I think actually
    turned the tide.
        Senator Brown. But that outcry only brought the price from
    $1,500 multiplied times 20, with 20 weeks of treatment, as you
    know----
        Dr. Collins. Yes.
        Senator Brown [continuing]. $1,500, $30,000, when it was 20
    times $10 or $20--depending on the compounded pharmacy's
    charge--down to $690. So the outcry worked with FDA. The outcry
    barely worked with KV.
        But is there a way to sort of cross the--I understand that
    you don't want to engage in partnering and price-setting and
    all that, but--or maybe you do--but when a company so
    overreaches like this, it was such an affront to the public
    interest, if there's a way, sort of across help agencies we
    could find some solutions or----
        I mean, Dr. Hamburg was in here and she said, well, you
    know, FDA didn't do this. She wasn't defensive at all, but then
    FDA did something. This was before they made that decision.
        But I just will follow up with you, but I'd like to see if
    there's a way to----

                                CANCER CLUSTERS

        My other question--I'm sorry to go over the 5 minutes, Mr.
    Chairman--Dr. Varmus, you had talked about pediatric cancers
    and Senator Reed had asked you about that.
        There's a cancer cluster in Clyde, Ohio, where many, many
    children, under 12 in most cases, have developed cancer, and I
    know you see these. There are four or five believed to be
    cancer clusters. I don't know if that's a particular medical
    term, but is certainly what we talk about.
        What is NIH's role in sort of examining these, exploring
    these, finding out the environmental cause, if it is that, as I
    presume--I guess I presume it is. What is your role in that?
        Dr. Varmus. Well, we do investigate that. We have a
    Division of Epidemiological Cancer Research that will look at
    these clusters to ascertain whether or not the cluster is real.
    Because, as you might expect, if cancers are distributed in
    their frequency across the country, there are going to be some
    places that just, by chance, have a particularly high or
    particularly low incidence, and there are several classical
    examples of clusters that turned out only to be arithmetic
    aberrations, but without any clear indication of causes.
        On the other hand, there have been clusters of cancers that
    are linked to certain practices or to exposure to industrial
    mutagens, and we would go in with collaboration with the
    National Institute of Environmental Health Sciences and try to
    ascertain what might be a precipitating cause.
        So we do have a role and we would--I don't know about the
    one you're citing, but we can certainly look into it and report
    back to you on what----
        Senator Brown. We have talked to NIH overall, but we will
    specifically talk to you.
        Thank you, Mr. Chairman.
        [The information follows:]
                           Clyde, Ohio Cancer Cluster
        State and Federal Responses to Cancer Cluster Reports.--State and
    local health departments respond to cancer cluster reports and provide
    the first level of response and review of the most current local data
    for the area. If needed, these local health departments can request
    assistance from Federal agencies, including the National Center for
    Chronic Disease Prevention and Health Promotion (NCCDPHP) of the
    Centers for Disease Control and Prevention (CDC), the Agency for Toxic
    Substances and Disease Registry (ATSDR), and the U.S. Environmental
    Protection Agency (EPA). CDC's role in investigating potential cancer
    clusters is to provide technical assistance to States at their request
    as they conduct their investigations. In State cancer registries,
    States have the data needed to determine whether a cluster exists.
        National Cancer Institute (NCI).--NCI does not investigate
    anecdotal clusters of individual cancer cases in neighborhoods, but
    rather clusters of counties with elevated rates as part of the
    geographic mapping strategy to identify and investigate high-risk
    populations for etiologic insights. However, upon occasion NCI's
    Division of Cancer Epidemiology and Genetics (DCEG) may be called upon
    to consult with local and State health officials and CDC experts as
    they investigate purported cancer clusters.
        DCEG's research portfolio includes analysis of cancer treands in
    human populations, and DCEG investigators conduct studies both within
    the U.S. and around the world where the incidence of certain cancers is
    significantly higher than might be expected. Examples of such
    investigations include lung cancer in coastal communities in the U.S.,
    which was linked to asbestos exposure in ship yards, and oral cancer in
    women in the rural south, which was linked to smokeless tobacco use.
    DCEG researchers are currently investigating the reasons for the very
    high rates of bladder cancer in northern New England; they will soon be
    reporting data from this effort. They are also conducting a study to
    explore the elevated rates of Burkitt's lymphoma in regions in Africa.
        Regarding the Clyde, Ohio Investigations.--It is our understanding
    that there was a multi-year analysis of a suspected cancer cluster in
    Clyde, Ohio by the Ohio Department of Health (ODH). Both CDC and ATSDR
    provided technical assistance to the State officials over the course of
    the multi-year assessment. While NCI has not received any reports or
    conclusions, it is our understanding that the assessment's final
    conclusion was that the data were inconclusive and there was no cancer
    cluster identified. These Federal public health agencies are continuing
    their collaboration with ODH and are available to provide support as
    needed.

                                  FLU VACCINE

        Senator Harkin. Thank you, Senator Brown.
        Dr. Fauci, for years, you've been here, year after year,
    and we've talked about flu vaccines, and, some time ago, I
    remember you talked about progress being made toward a--perhaps
    a universal type flu vaccine. You mentioned it in your written
    statement, which I read last night. Again, how close are we?
        Dr. Fauci. Well, I can't give you an exact time in years,
    because every time a vaccinologist does that, he or she gets
    burned. So I'll refrain from that, but I can tell you that we
    clearly are considerably closer than when I spoke to you last
    time at a hearing when we were talking about the possibility of
    getting away from that very frustrating situation where each
    year you have to hopefully guess right, and we do most of the
    time, but not all the time.
        But even more importantly, when we're faced with a pandemic
    flu like we were with the 2009 H1N1, when we made a vaccine
    after isolating the virus, but the production issues were such
    that by the time we got enough to distribute, unfortunately,
    the pandemic had already peaked. Fortunately for us, it was a
    relatively mild one, but that's not going to happen all the
    time.
        So what's happened in the last year since we spoke, Mr.
    Chairman, is that there have been a number of experiments that
    have been conducted both at the NIH and by our grantees and
    contractors, which have really identified components of the
    influenza virus that the body generally does not make a very
    good response to readily, and that part of the virus is the one
    that would give you protection against virtually all strains.
        And one of the reasons is is that it's sort of hidden from
    the view of the immune system. The thing that the immune system
    sees really clearly is the part of the virus that changes from
    season to season, and that really changes a lot when you get a
    pandemic. There's a part of the virus that the body can make an
    immune response to that it doesn't usually see very well.
        So what investigators have done, in a very simple way, is
    that to put that particular component of the virus in a form
    that the body would see it much more sharply and clearly. This
    has been done in animal models and proven to be inducing
    responses that are good against decades of changes of
    influenza.
        And, now, those studies are being done in what we call
    phase I trials in humans, and the early work indicates that,
    clearly, it looks quite safe, and, second, it is inducing
    responses that span multiple years.
        So I believe it's really just a matter of time. As you
    know, clinical trials, when you want to prove safety and
    efficacy over a period of time, naturally would take years, but
    it's on a track that I believe it's going to happen. I don't
    think it's going to be a question of if. It's going to be a
    question of when. So we're really quite excited about it.
        And that's a very good example of that transition from
    fundamental basic research observations on molecules and their
    confirmation and how that ultimately gets translated into
    something that, if successful, is going to have enormous public
    health benefit.
        Senator Harkin. Well it would. I mean, the amount of just
    savings alone on annual flu shots would be incredible, aside
    from the fact that you wouldn't--I would, from what I
    understand is if this was really developed, the threat of
    pandemics would not be as large as they are now either.
        Dr. Fauci. The ultimate goal is to have on the shelf, ready
    for utilization a vaccine that does have the universal
    characteristics to it, so that if you do get a change with a
    pandemic, that you can actually have that particular virus be
    covered by it.
        So we'd like to get it to the form--I don't think it's
    going to be perfectly this way, Mr. Chairman, but it's going to
    be close. I don't think it's going to be one flu vaccine and
    that's it for the rest of your life.
        It'll probably be having to be given every several years to
    continue to boost the immune system, but we would like to be
    the way we are, for example, with measles or hepatitis or
    polio, where you just make a lot of it, you have it available
    and when you need it, you deploy it, as opposed to having to
    play catch up every single time a new virus emerges.

                               MEDICAL MILESTONES

        Senator Harkin. Very good.
        Dr. Varmus, in 2001, Gleevec was on the cover of all our
    national news magazines, talked about it being the magic bullet
    that would herald in a new age in the war against cancer. For
    the first time, we had a drug that specifically targeted a
    known cancer gene. It took this deadly blood disease, turned it
    into a chronic, but survivable condition.
        We were told that Gleevec was the promise of the future. We
    talked about it in our subcommittee hearings at that time, but
    that was 10 years ago. We haven't had any other Gleevecs.
    What's happened? How come no more Gleevecs?
        Dr. Varmus. Well, I wouldn't characterize it quite that
    way, Senator. Gleevec remains the poster child for targeted
    therapy.
        Senator Harkin. Yes.
        Dr. Varmus. And just to give you a brief update, it's used
    not only for the treatment of chronic myeloid leukemia, the
    leukemia you heard about, it's used for the treatment of
    several other diseases in which potential targets for the drug
    are mutated, and that includes gastrointestinal stromal tumors,
    a number of other blood diseases, and, indeed, a few other
    diseases in a few cases in which certain genes are known to be
    mutated as a result of analysis of the genome of those cancers.
        Moreover, it's recently been shown that we can deal with
    drug resistance, a common problem in cancer therapy, by using
    drugs closely related to Gleevec but not identical to it and to
    treat patients who become resistant to Gleevec.
        Second, it's been shown recently that a person in their 40s
    or 50s who develop--leukemia now have a normal life expectancy,
    which was previously 5 years. That's a dramatic change and it
    shows that the efficacy of Gleevec has been sustained over the
    last 10 years, and, actually, the evidence that it's effective
    is only strengthened.
        There are a number of other targeted therapies. They tend
    to work quite well initially. Patients become--their tumors
    become resistant to therapy. Let me give you a couple of
    examples.
        One happens to involve my own work on lung cancer, which is
    a significant percentage, perhaps 10 percent, of cancers have
    mutations in some specific genes against which we have
    effective inhibitors, but, generally speaking, within 1 year or
    so, on average, patients become resistant to those drugs. We
    don't have good therapies to counter the tumors that are
    resistant.
        Recently, in the case of a disease called metastatic
    melanoma, a disease that is secondary to finding a skin tumor,
    but the tumor has spread to the liver, bones, and other sites,
    it's been found as recently as 7 or 8 years ago, that about 60
    percent of those cancers have a mutation in a specific gene
    against which an inhibitor has been developed.
        It's extremely effective, again, in inducing remissions in
    a fairly non-toxic way. This is, again, an orally available
    drug that promotes a dramatic regression in the size of tumors.
        There are two drugs that do this. They are very likely soon
    to be approved by the FDA. They don't cause persistent
    regressions, but there's every reason to hope that additional
    drugs will be on the way to help counter drug resistance.
        So I would say that we've had a number of other targeted
    therapies. They have not, in general, been quite as dramatic as
    Gleevec, but most of us who are working in this area are quite
    optimistic about a number of new drugs, some of which I haven't
    mentioned, that are in the pipeline.
        Senator Harkin. That drug you mentioned about metastatic
    melanoma, you mentioned it in your written testimony.
        Dr. Varmus. Correct.
        Senator Harkin. What's the name of the drug? I forget----
        Dr. Varmus. Well, there are two things that I mentioned in
    my testimony, Senator, first was these so-called inhibitors of
    BRAF. These drugs are not yet on the market. One comes from
    Flexicon, one from GlaxoSmithKline (GSK).
        Senator Harkin. Yes.
        Dr. Varmus. There's also a new immunotherapy called
    ipilimumab, which has been approved by the FDA. That's not the
    same kind of targeted therapy, but it's a dramatic development,
    because it's one of the first immunological approaches.
        There are others, but this is one of the first that
    actually displays how we can manipulate our understanding of
    the immune system to galvanize the response of the immune
    system against a variety of cancers, including melanoma.
        Senator Harkin. But I can't even pronounce that word,
    ipilimumab?
        Dr. Varmus. Ipilimumab.
        Senator Harkin. Thank you very much.
        Dr. Varmus. Yes, I'm not responsible for that, Senator. It
    would not have been my choice. Ipi for short.
        Senator Harkin. It seems to me this is about as important
    as Gleevec. I mean, this attacks metastatic melanoma in later
    stages.
        Dr. Varmus. Correct.
        Senator Harkin. And this has always been a death sentence
    before.
        Dr. Varmus. As does the drug that inhibits the BRAF
    mutation. But ipilimumab does not work in all cases, but does
    prolong life significantly in a very substantial 15 to 30
    percent of patients who have metastatic melanoma. It is a major
    development, no question about it.
        One of the open questions is why do a certain subset of
    patients with this disease respond and others not respond.
        There are other inhibitors of the so-called brakes on the
    immune system that are in development, and I think may be
    combined with ipilimumab or used as an alternative when
    ipilimumab doesn't work.
        So we're quite optimistic after many years of trying to
    manipulate the immune system that we have some very serious
    handles on how the immune system works that we can use in
    cancer therapies.
        Senator Harkin. Very good. Thanks, Dr. Varmus.
        Recognize Senator Shelby, then I see Senator Kirk has
    joined us. I'll go to Senator Kirk next.

           ACADEMIA-INDUSTRY COLLABORATION TO REPURPOSE DRUG COMPOUND

        Senator Shelby. Thank you.
        Dr. Collins, repurposing drugs, you alluded to that
    earlier. As we have searched for treatments, as you do, and
    others, investigators, to the healthcare challenges, one of the
    clear ways that some people believe we can continue drug
    development is by finding new uses for drugs that were
    discontinued or halted mid-development. By leveraging existing
    compounds, researchers in industry can develop and have new,
    novel treatments for patients.
        It's my understanding that the NIH recently held a
    roundtable discussion regarding rescuing and repurposing
    compounds. Seems like that's an ideal opportunity for academia
    to team with industry to bring treatments to patients faster.
    Could you expand on that? What are you doing here and how?
        Dr. Collins. I'd be happy to, Senator, because this is a
    really exciting potential area to speed up the process of
    developing new treatments for diseases that currently lack
    effective interventions, and it's another example of the kind
    of thing that NCATS will be able to catalyze just by its
    convening power.
        Yes, we did have this meeting just about 10 days ago. We
    invited major leaders from pharmaceutical and biotech
    industries to meet with NIH investigators, with academic
    experts and to ask the question: Are there in fact, already
    sitting in medicine bottles or in freezers of companies that
    have tried various compounds and abandoned them along the way
    opportunities to take molecules about which we already know a
    lot and find a new use for them?
        Senator Shelby. Do you have any examples or is it too
    early?
        Dr. Collins. We have some very striking examples. Maybe
    I'll even ask Dr. Shurin to tell the example of Marfan
    syndrome. So let me set this up.
        Marfan syndrome is a genetic condition caused by a single
    glitch in a gene called fibrillin and is characterized by very
    tall stature, and, unfortunately, by a high risk of an aortic
    dissection, which is often fatal. So Flo Hyman, the volleyball
    star, died suddenly because of that condition, and it's not
    that rare.
        And many of us thought, well, we'll never come up with a
    therapy for that in the next 50 years, because it's too rare
    for there to be much economic interest, but something pretty
    interesting happened. Do you want to tell that story?
        Dr. Shurin. One of our investigators at Johns Hopkins, Dr.
    Hal Dietz, discovered that a drug, losartan, which is used for
    blood pressure--it's an approved drug--actually cures Marfan
    syndrome, not only in the test tube, but also in mice.
        And so we were able, using our existing Pediatric Heart
    Network, to rapidly launch a clinical trial. We had the first
    patient enrolled about 5 months after we had opened the trial
    and, working very closely with the Marfan Foundation, have been
    able to complete enrollment.
        The results are not yet fully available. The trends are
    looking very good, and we've been very excited by this. But the
    ability to do this with the cooperation of the drug
    manufacturer and the patient advocacy groups has been really
    quite spectacular.
        Dr. Collins. So that's an example.
        My own lab works on a disease called Progeria, the most
    dramatic form of premature aging. These kids age about seven
    times the normal rate and usually die by age 12 or 13 of heart
    attack or stroke.
        By discovering the genetic cause of that disease,
    understanding the pathway that's involved, it became clear that
    a drug class developed for cancer might actually turn out to be
    beneficial in this premature-aging disease.
        They've just completed a 2-year clinical trial on kids with
    Progeria using this supposed cancer drug, and while the results
    are not yet published, I'm hearing very encouraging noises. So
    it's repurposing a very different idea of what that drug would
    be used for for a new application.
        I am sure that if we had a systematic way of trolling the
    landscape to identify other such opportunities there would be
    lots more.

                          INTER-AGENCY COLLABORATIONS

        Senator Shelby. Dr. Collins, dealing with NIH-FDA
    collaboration, which is, I think, is very important, what do
    you think would be the best results to come from increased NIH-
    FDA collaboration? Are there topics in particular that you're
    working on with the NIH and partnering there to move--I assume
    moving drugs to market and getting them approved safely is very
    important.
        Dr. Collins. Commissioner Margaret Hamburg and I have been
    meeting for now almost 2 years to talk about ways that our
    agencies could work more closely together. And she is a strong
    advocate, and I share that same view with her, that regulatory
    science--that is, applying science to how reviews are done of
    drugs and devices--is very much a possible solution to the
    current logjam of trying to get products through that pipeline.
        Senator Shelby. We would all benefit from that, wouldn't
    we?
        Dr. Collins. We would, indeed.
        And so she and I have together started a regulatory science
    research program. We formed a leadership council between the
    two of us which involves the senior leadership of both of our
    agencies. We've identified six areas that we think are
    particularly ripe for progress, such things as how do you do
    toxicology more efficiently? How do you deal with combination
    therapies like Dr. Varmus was mentioning may be necessary for
    cancer when, in fact, that's hard to review. You have to come
    up with new ways to look at that.
        And I think together, working as sister agencies, we can
    make progress that neither of us could have done alone, and
    we're totally committed to making that happen.
        Senator Shelby. How do you collaborate with CDC?
        Dr. Collins. Oh, quite intensively.
        Senator Shelby. I know you do.
        Dr. Collins. Tom Frieden, the head of CDC, and I were on
    the phone yesterday, and that happens regularly, about areas of
    shared interest, and that includes global health as well as
    domestic issues.
        He and I have exchanged people by going back and forth to
    look at shared projects. We obviously work very closely in the
    area of infectious disease.
        Maybe Dr. Fauci would want to make a comment about your
    relationship with CDC, because it's so important.
        Dr. Fauci. Yes. We have very strong and long-standing
    collaborations, particularly in the arena of global health with
    the emphasis on infectious diseases, even though global health
    certainly encompasses more than just infectious diseases.
        An example of that is we share some of our sites. The CDC
    has epidemiological sites and posts for surveillance of
    disease. We are now incorporating many of those sites in our
    clinical trials of drugs, so many of the trials that take place
    are really strong collaborations between the CDC and the NIH,
    and that's worked very well.

                                CYSTIC FIBROSIS

        Senator Shelby. Dr. Collins, I enjoyed seeing you last
    night, and you know better than anybody that they've come out
    with a new drug in the treatment of lupus for many things.
    That's a breakthrough of many, many years.
        What about cystic fibrosis? Where are you in this area? I
    know you've done a lot of research in that area, too.
        Dr. Collins. Senator, I appreciate the question. I enjoyed
    the experience of chatting with you last night at the Lupus
    Foundation of America event. And they are very excited, and
    justifiably so, at the approval of Benlysta, this first drug
    for lupus in a long time.
        Cystic fibrosis is an area of intense interest for me,
    because I was part of the team that found the cause of that in
    1989, and that has now, finally, after many years of struggle,
    led to a very exciting time therapeutically.
        So just in the last few months, a drug developed using this
    same approach to try to identify small molecules, the same kind
    of thing that Senator Moran was seeing in Kansas, this, in this
    case, done as a partnership with a company called Vertex, found
    a molecule which goes by a not terribly friendly name, VX-770,
    which, in fact, for that category of patients with cystic
    fibrosis who have a particular mutation in the gene, appears to
    be highly effective, and taken over the course of just a month
    improves lung function. It reduces the sweat chloride, which
    has been the diagnostic hallmark of cystic fibrosis----
        Senator Shelby. This has been out how long now?
        Dr. Collins. This is still in clinical trials. It hasn't
    yet been approved by the FDA, but the phase III trial results
    look extremely promising.
        Senator Shelby. That would herald, if it were approved by
    FDA--It's in clinical trials now.
        Dr. Collins. That would be an enormous step forward.
        Senator Shelby. A huge breakthrough, hopefully, for cystic
    fibrosis.
        Dr. Collins. Now, the down side is that this particular
    drug is only likely to be effective in that subset of patients
    with cystic fibrosis who have a particular mutation in the
    cystic fibrosis gene. The common mutation would not necessarily
    respond to this drug. You wouldn't expect it would.
        There is another drug in the pipeline a few steps behind,
    VX-809, which is targeted toward the common mutation. We all
    have high hopes that that will turn out to be just as
    effective, but we have to wait and see what the clinical trials
    show.
        Senator Shelby. But it holds promise for the people with
    cystic fibrosis and their families.
        Dr. Collins. I've been in this field for 25 years. I've not
    seen more excitement and hope about a therapeutic intervention
    in that whole time until now.
        Senator Shelby. Thank you.
        Senator Harkin. Thank you.
        Senator Kirk.

                       HEALTHCARE SPENDING POLICY OPTIONS

        Senator Kirk. Thank you, Mr. Chairman, and I'm sort of
    overawed to see this group here. I followed in the Congress
    Congressman John Porter, very much a supporter of NIH and
    Research!America.
        And, to me, it's interesting, in these times of deficits
    and debt in which the largest bond purchaser in America, Pimco,
    has now divested itself of all U.S. Treasury securities,
    because he's worried about the long-term future of us being
    able to borrow money.
        I just met with one of the Chinese top officials in meeting
    Secretary Clinton, and they also talked about how they were
    making moves to leave U.S. debt.
        And so it's--over the long term, I wonder how we might be
    able to borrow the kind of monies that are being thought of.
        With these kind of limitations, you wonder, then, what
    direction you take with regard to healthcare policy. And there
    are obviously two main directions, if the Government is to
    support it, and that is to subsidize care or to subsidize
    research.
        Now, in subsidizing care, I guess the rough numbers are
    Medicare is now $370 billion and Medicaid is $300 billion. So
    that's very, very expensive now and growing quite rapidly, but
    $670 billion in the subsidizing care path.
        In the subsidizing research, NIH comes in at $26 billion,
    and yet I think offers a much brighter future of a virtuous
    cycle of better and better patient outcomes, faster and faster
    innovation and dramatic reversals in disease outcomes, as we've
    seen in several cancers or, for example, in juvenile diabetes.
        And so in a resource-constrained area--and I think either
    the Congress is going to make budget cuts or the bond market is
    going to make budget cuts to the Federal budget--you then say
    do we double down on subsidizing care or do we continue on the
    funding research side, and because this also has a huge
    economic benefit to the United States, I very much favor NIH,
    where I worry about the long-term sustainability of other parts
    of the budget.
         So let me ask you somewhat of a theological question on
    how we move forward in this environment, which is the
    President's healthcare bill set up an independent payment
    advisory board to ration care and basically to deny care in
    several areas. Its goal, I think, over time will be to
    replicate the power and authority of the British NIH's NICE
    rationing board.
        Have we thought about NIH's relationship to IPAB and how we
    would advise the people who would be denying care under
    Medicare how they would keep up with medical research and
    technology?
        Dr. Collins. So these are difficult questions indeed,
    Senator. NIH's role as the prime supporter of biomedical
    research is to provide the evidence that is necessary for
    making wise healthcare decisions, but, obviously, those
    decisions depend on more than just the scientific evidence.
    They also depend on how society wants to expend its resources.
        But I think we can help in substantial ways with the very
    frightening cost curve that otherwise faces us. If you'll
    permit me, I'd just like to show you one example of the kind of
    looming problem that we have in front of us if nothing is done.

        This curve shows you for one disease, Alzheimer's disease,
    what we are currently spending, which in 2010 is about $180
    billion, and which by the projections that many people have
    made, if nothing is done, if research is unsuccessful or not
    supported, will rise to more than $1 trillion just for that one
    disease in 2050, and the number of effected individuals at that
    point will be in the neighborhood of 13 million. One disease.
        And, yet, at the present time, our investments in research
    on Alzheimer's disease fall somewhat less than $1 billion. So,
    clearly, we feel a great responsibility to move that curve in a
    different direction. If we could even come up with a
    therapeutic approach that would slow the onset of disease,
    delay it by 5 years, you could cut these costs almost in half,
    and, obviously, something more dramatic would have an even more
    beneficial effect. That's what we see as our mission----
        Senator Kirk. I'm just wondering--My time has run out, but
    if we--I think IPAB's future depends on the presidential
    election. Should the President prevail, then IPAB and the
    healthcare bill is with us. Should the President be defeated, I
    think that much of the healthcare bill will be wiped out and
    IPAB with it.
        But on the potential that the President is reelected, have
    you thought about--because what I'm worried about is IPAB will
    become an incredibly bureaucratic, stultified organization. It
    will review diseases and protocols, but the danger is that they
    will be working on heart disease and a breakthrough comes in
    cancer that revolutionizes research and they will not have the
    bureaucratic means to switch and then advise for a new payment.
    And we have such a pace of innovation that a huge state
    bureaucracy inevitably will slow down and be unable to keep
    pace with medical innovation.
        In fact, I would actually argue it probably will kill a lot
    of medical innovation as it locks in payment methodologies the
    way Medicare has.
        But have you begun to think about how you might relate to
    this new bureaucracy?
        Dr. Collins. Well, again, Senator, I think our best answer
    to that is to do the rigorous research that actually not only
    tries new therapeutic approaches, but also does comparisons,
    when there's more than one alternative, to see what works, and
    then to do what we do routinely, and which we believe is a
    strong part of our job, is to make that data immediately
    available, publish it, make sure it's propagated so that nobody
    is left in the dark about knowing what the results have been.
        And then I guess I'm just enough of an optimist to think if
    the data is there and if it's compelling, it'll be hard to
    ignore. But I hear your concern.
        Senator Kirk. I would just simply finish up by saying
    should IPAB not survive--I hope it doesn't, but should it
    survive I think we might want to think about a more formal data
    transmission between NIH and IPAB, because, otherwise, IPAB, I
    think, will rapidly cause Medicare to fall behind technology
    and innovation.
        Thank you, Mr. Chairman.
        Senator Harkin. Senator Moran.

                     EFFECTS OF RESEACH ON HEALTHCARE COSTS

        Senator Moran. Mr. Chairman, thank you again.
        Dr. Collins, perhaps my question is in ways related to the
    Alzheimer's chart you just showed, which was a request that do
    you have information to substantiate my suggestion or a belief
    that money spent on biomedical research results in cost savings
    in healthcare? Is there that kind of science-based fact that
    substantiates my feelings?
        Dr. Collins. So those are complex economic analyses, and
    even economists will tend to disagree with each other about the
    right way to do it. Let me just cite a couple of figures,
    though.
        If you look, for instance, at heart disease, what's
    happened in the last 40 years, Dr. Shurin will tell you we've
    seen a 60-percent drop in mortality from heart attack during
    those 40 years. The cost of that, if you average it out per
    American per year, in terms of the research that led to those
    advances, beginning with the Framingham Study, going through
    with the development of understanding about cholesterol and
    ultimately the development of statins, was about $3.70 per
    American per year, the cost of a latte, and not even a grande
    latte, that would be a tall, I think.
        So and if you add up the economic benefits that have
    resulted from the increase in longevity that have occurred
    between 1970 and 2000, I am told credible economists believe
    that adds up to $91 trillion. Michael Milken, in a recent
    editorial in The Wall Street Journal runs through a lot of
    those figures and they seem to be cited by reasonable experts.
        If we were to diminish the frequency of cancer by just one
    percent--and that's actually happening each year. Each time the
    frequency of cancer goes down by 1 percent, economists say
    that's saving our country $500 billion in terms of economy that
    is sustained as a result of having those people with us. So the
    return is enormous.
        I could cite you specific examples of new technologies, but
    the big picture is quite compelling.

                          RARE AND NEGLECTED DISEASES

        Senator Moran. Well, I'm not surprised by that. It would be
    very helpful to have that--I don't like the word sound byte,
    but that phrase that says for every dollar spent, here's what
    we're able to save in otherwise spending on healthcare.
        Let me go back to something more specific and just ask you
    to elaborate upon the value of academic and nonprofit research
    institutions' role in developing therapies and treatments for
    rare and neglected diseases through NCATS, as you propose, and
    through your therapeutic and rare neglected disease program
    that you already have.
        I mean, is this something that you envision as having a
    significant role in the future as you develop NCATS are these
    neglected diseases?
        Dr. Collins. Indeed. And, in fact, the 27 Institutes and
    Centers at NIH have been engaged in such efforts for rare and
    neglected diseases for some time.
        We expect that the advent of NCATS serving as a hub of this
    activity will further encourage that and hopefully contribute
    innovations that will result in more rapid progress and also a
    lower failure rate.
        The TRND Program, Therapeutics for Rare and Neglected
    Diseases, which the Congress authorized 2 years ago, is
    specifically devoted to identifying projects that might
    otherwise sit there untouched, where there's a real promise in
    taking a therapeutic and moving it into the preclinical space,
    which is often called the Valley of Death, because that's where
    often good projects go to die.
        Take example sickle-cell disease. There's a TRND Program
    right now pursuing an interesting therapeutic for sickle-cell
    disease originally identified at a university, Virginia
    Commonwealth University, then licensed out to a biotech
    company, AESRX.
        The biotech company carried it to a certain level and then
    ran out of money, and venture capital is hard to find these
    days unless you have something that's going to result in
    profits within a couple of years.
        So the company has now partnered with the NIH to move this
    forward. The preclinical studies look very good. This will, as
    I understand it, be submitted to the FDA for an IND application
    later this year, and clinical trials may well get under way
    within 1 year at our NIH Clinical Center.
        If this were successful, this would be a radical new
    approach to sickle-cell disease. The way this molecule works is
    unlike anything that's been tried for this disease before.
        And while this is certainly a neglected and relatively rare
    disease, it still affects tens of thousands, hundreds of
    thousands of individuals in this United States and many more
    across the world. So it's a good example of a way in which NIH
    may be able to assist in the current scientific environment to
    move projects forward that otherwise would have languished.
        Senator Moran. Thank you very much. Mr. Chairman, thank
    you. And let me express my gratitude to all of you for your
    public service.
        Senator Harkin. Well, I want to thank you all for being
    here, again, for another enlightening session.

                         ADDITIONAL COMMITTEE QUESTIONS

        I have some other questions I won't propound now, but I'll
    submit those in writing, and the record will remain open for a
    week for other Senators to submit further questions or
    statements.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                   Questions Submitted by Senator Tom Harkin
      national center for complementary and alternative medicine (nccam)
                                advisory council
        Question. The statute for the NCCAM stipulates that of the 18
    appointed members of the Center's Advisory Council, 9 must be
    practitioners licensed in one or more of the major systems with which
    the Center is concerned, and at least three shall represent the
    interests of individual consumers of complementary and alternative
    medicine. Is the NCCAM meeting this requirement? Of the four new
    members announced on June 6, 2011, how many meet one of the two
    categories described above?
        Answer. The composition of the National Advisory Council for
    Complementary and Alternative Medicine meets the statutory requirements
    concerning membership. Collectively, its membership includes the
    expertise required for it to carry out its requirements to provide
    second level peer review and other advice across the broad and varied
    spectrum of clinical practice and scientific disciplines which fall
    under the Center's mandate.
        On Friday, June 3, 2011, four new members joined the NCCAM Advisory
    Council. Brian M. Berman, MD, LAC, is a licensed physician and
    acupuncturist. James Lloyd Michener, MD, is professor and chairman of
    the Department of Community and Family Medicine and Director of the
    Duke Center for Community Research. Dr. Michener also represents the
    interests of individual consumers of complementary and alternative
    medicine (CAM). Daniel C. Cherkin, Ph.D., is an epidemiologist and
    highly experienced clinical researcher who has conducted a number of
    major studies that have provided evidence for benefit of CAM therapies
    (including chiropractic manipulation, acupuncture, and massage) for low
    back pain. David G.I. Kingston, Ph.D., is a widely respected natural
    products chemist whose research focuses on the chemistry of
    biologically active natural products and the discovery of new therapies
    for cancer and malaria from plants.
                          the nccam research successes
        Question. Under the statute that created the NCCAM, the general
    purposes of the Center include ``identifying, investigating, and
    validating complementary and alternative treatment, diagnostic and
    prevention modalities, disciplines and systems.'' Please identify all
    instances in the past 10 years in which the NCCAM-supported research
    has validated complementary and alternative treatment, diagnostic and
    prevention modalities, disciplines and systems.
        Answer. The NCCAM is strongly committed to the highest standards of
    evidence-based medicine. Validating health interventions is a process
    that begins with evidence developed in peer-reviewed basic and clinical
    research. Next, the evidence from multiple studies is collectively
    assessed through formal systematic review methods. Finally, if these
    earlier steps indicate sufficient usefulness and safety, professional
    organizations and health policy makers undertake the development of
    guidelines and recommendations regarding use and clinical practice.
    This process, collectively referred to as evidence-based medicine,
    entails assimilation of the body of scientific evidence; almost never
    does a single study result in consensus that an intervention is valid.
        Eleven years ago, when the NCCAM was created, there was no
    significant evidence-base on the biological properties, safety, and
    efficacy of the vast majority of CAM modalities. The Center's first
    decade was therefore focused on the conduct and support of basic and
    applied research that addressed this lack of scientific information.
    The results of that investment now include an emerging evidence base
    that is dramatically stronger in terms of both quality and quantity.
    Basic research and clinical trials, large and small, have yielded
    results--both ``positive'' and ``negative''--regarding the effects,
    efficacy, safety, and in some cases, promise regarding CAM
    interventions.
        Critically, sufficient evidence regarding some CAM interventions
    has now been developed to permit informative evidence-based analyses
    and systematic reviews by independent organizations (e.g., the Cochrane
    Collaboration) using the rigorous standards of evidence-based medicine.
    Indeed, such analyses now point increasingly toward clinically helpful
    conclusions regarding usefulness and safety--or lack thereof--of
    specific CAM interventions and practices.
        Notably, the expanding evidence base now includes a large body of
    science that points toward specific, very promising opportunities to
    improve healthcare and health promotion using CAM-inclusive strategies.
    These opportunities are reflected directly in the NCCAM's recently-
    released third strategic plan. Important examples include the
    following:
    Mind and Body Practices
      --Developing better, comprehensive strategies for management of
            chronic back pain and defining the roles of acupuncture, spinal
            manipulation, and massage in those strategies
      --Exploring the role of specific promising CAM practices or
            disciplines (e.g., meditation, yoga, or acupuncture) in
            developing better strategies for alleviating symptoms (e.g.,
            chronic pain, stress) or in promoting healthier lifestyles
      --Exploring the associations between well-characterized pathways of
            pain processing and acupuncture analgesia or the placebo
            response
      --Exploring the associations of major pathways of cognitive
            processing and emotion regulation by meditative practices
      --Studying the influence of the provider-patient/client interaction,
            context effects, and the placebo response on outcomes of CAM
            interventions
    Natural Products
      --Studying the molecular targets and biological effects of
            potentially beneficial small molecules that are constituents of
            natural products or diet (e.g., quercetin, curcumin, or other
            polyphenols and flavonoids)
      --Defining the anti-inflammatory actions of omega-3 fatty acids
      --Employing state-of-the-art tools and technologies to study the
            effects of probiotics on the human microbiome
      --Developing evidence regarding the safety profile of certain widely
            used natural products, including interactions with drugs and
            other herbals or dietary supplements
        The growing evidence base is clearly influencing professional
    practice guidelines of mainstream professional medical societies, and
    the practice of integrative medicine. Complementary and alternative
    therapies are increasingly being accepted and integrated into
    conventional healthcare systems. For example, recent data show that
    approximately half the hospices in the United States and 9 out of 10
    Department of Veterans Affairs facilities offer some complementary or
    alternative therapies. The Consortium of Academic Health Centers in
    Integrative Medicine, an organization of integrative medicine
    departments at academic medical centers, has grown from 11 members in
    2002 to 43 members in 2011. Medical societies such as the American
    College of Physicians, the American Academy of Pediatrics and the
    American Academy of Family Physicians have formulated policies
    regarding complementary therapies and offer educational material about
    these forms of treatment. The Departments of Defense and Veterans
    Affairs are also actively pursuing care and research initiatives that
    include various CAM interventions in treatment and prevention of
    problems such as chronic pain and post-traumatic stress disorder
    afflicting our wounded warriors.
        In the appendices, we have included a status report on the process
    of validation of selected interventions. In Appendix A, we present
    examples of specific complementary and alternative interventions for
    which a sufficient number of individual studies exist for systematic
    reviews to conclude the interventions appear to offer benefit. In
    Appendix B, we list numerous additional examples of individual NCCAM-
    supported studies that provide preliminary evidence of benefit in other
    indications. We feel it important to provide both types of information
    in addressing the subcommittee's specific questions because the
    processes of evidence-based validation of health practices and
    decisionmaking regarding their use are iterative, and draw on a variety
    of such sources rather than merely single studies.
     appendix a: the status of the evidence based reviews and professional
         guidelines for select complementary and alternative therapies
        The examples of systematic reviews and professional assessments
    cited here all include evidence derived from clinical and mechanistic
    research supported by the NCCAM. As is true with the evidence in most
    areas of healthcare, there continues to be controversy about some of
    these conclusions, and not all systematic reviews come to the same
    conclusions.
    Role of Complementary Therapies in the Management of Chronic Low Back
            Pain
        Management of chronic low back pain is a critical challenge for our
    healthcare system and a major driver of healthcare costs. Complementary
    interventions are increasingly being integrated into the care of
    chronic back pain patients, and there is substantial recognition,
    supported by findings from the NCCAM research, that complementary
    therapies, particularly chiropractic and osteopathic spinal
    manipulation, massage, acupuncture, and meditative exercise forms such
    as yoga, can make important contributions to improved outcomes for
    patients. Many systematic reviews have assessed these therapeutic
    approaches. The Joint Clinical Practice Guideline for low back pain,
    developed by the American College of Physicians and the American Pain
    Society, reflects the strength of this evidence base and the emerging
    professional consensus for the value of the incorporation of
    complementary approaches. To quote directly from the summary:

        ``For patients who do not improve with self-care options,
    clinicians should consider the addition of nonpharmacologic therapy
    with proven benefits-for acute low back pain, spinal manipulation; for
    chronic or sub-acute low back pain, intensive interdisciplinary
    rehabilitation, exercise therapy, acupuncture, massage therapy, spinal
    manipulation, yoga, cognitive-behavioral therapy, or progressive
    relaxation.''--Joint Clinical Practice Guideline, American College of
    Physicians and American Pain Society. Annals of Internal Medicine,
    2007: 147,478.

        Nevertheless, there is also a consensus among healthcare providers,
    both conventional and complementary, that, current approaches are not
    satisfactory for many patients suffering with back pain. Moving
    forward, a major area of emphasis for the NCCAM, as described in the
    NCCAM's 2011 Strategic Plan, will be improving management of chronic
    back pain. Research is needed to optimize complementary therapies, to
    understand better who benefits from them, and to develop better systems
    of integrated care that improve real world application of these helpful
    therapeutic techniques.
    Role of Natural Products in Promotion of Health and Wellness
        The NCCAM's natural product research portfolio, carefully assessed
    during our strategic planning process, has yielded many important
    lessons that will guide us moving forward. Fundamental scientific
    understanding of potential beneficial mechanisms of many dietary
    supplements and natural products has increased markedly, with some
    notable examples described below. New high-throughput technologies and
    modern genomic tools have created important new scientific
    opportunities. We have learned much about the challenges of translation
    of these findings to clinical efficacy research. The future emphasis,
    as described in our strategic plan and strongly supported by both
    academic investigators and leaders of the botanical and dietary
    supplement industry, is on the development of strong biological
    mechanistic hypotheses, sensitive biological signatures of effect, and
    carefully optimized trial designs.
        A few examples of the independent systematic reviews that have
    provided validation of the potential value of natural products or other
    dietary supplements are as follows:
      --Fish Oil for the Prevention of Cardiovascular Disease.--``Dietary
            supplementation with omega-3 fatty acids should be considered
            in the secondary prevention of cardiovascular events.''--
            Clinical Cardiol. 2009: 32, 365.
      --Melatonin for the Prevention and Treatment of Jet Lag.--``Melatonin
            is remarkably effective in preventing or reducing jet lag, and
            occasional short-term use appears to be safe.''--Cochrane
            Database Syst Rev 2002: 1520.
      --Probiotics for Prevention of Necrotizing Enterocolitis in Preterm
            Infants.--``Enteral supplementation of probiotics prevents
            severe necrotizing enterocolitis and all cause mortality in
            preterm infants.''--Cochrane Database Syst Rev 2008: 5496.
      --Prebiotics and Probiotics for Hepatic Encephalopathy.--``The use of
            prebiotics, probiotics and synbiotics was associated with
            significant improvement in minimal hepatic encephalopathy.''--
            Ailment Pharmacol Ther 2011: 33.
      --Probiotics for Acute Infectious Diarrhea.--``Used alongside
            rehydration therapy, probiotics appear to be safe and have
            clear beneficial effects in shortening the duration and
            reducing stool frequency in acute infectious diarrhea.''--
            Cochrane Database Syst Rev 2010: 3048.
      --Zinc for the Common Cold.--``Zinc administered within 24 hours of
            onset of symptoms reduces the duration and severity of the
            common cold in healthy people.''--Cochrane Database Syst Rev
            2006: 1364.
    Role of Complementary Therapies in the Management of Pain and Other
            Troublesome Symptoms
        Concern is often voiced that the processes of evidence-based
    medicine could not accommodate the evidence emerging from research on
    many complementary therapies. In fact, this is a challenge common to
    evaluation of the evidence of many nonpharmacological interventions,
    including psychotherapy and surgery. The NCCAM's strategic plan
    addresses this challenge by calling for increased use of outcomes and
    effectiveness research methodology, and collaboration with experts who
    work in other fields facing similar challenges. Nonetheless, several
    examples are provided below which illustrate that rigorous research on
    these complicated therapies is possible and can meet the exacting
    standards of evidence-based review.
      --The Cochrane Collaborative has reviewed the evidence that
            acupuncture may provide benefit for migraine prophylaxis and
            for treatment of tension-type headache, and concluded that it
            has value in both situations.--Cochrane Database Syst Rev 2009:
            1218, Cochrane Database Syst Rev 2009: 7587.
      --The Cochrane Collaborative has reviewed the evidence that
            acupuncture may be useful for postoperative nausea and
            vomiting, as well as for nausea and vomiting which has been
            induced by cancer chemotherapy. Systematic reviews conclude
            benefit in both cases.--Cochrane Database Syst Rev 2009, 3281,
            National Cancer Institute, PDQ summary.
      --A systematic review published in the British Journal of Anesthesia
            concluded that perioperative acupuncture is a useful adjunct
            for acute postoperative pain management.--Br. J Anaesth 2008:
            101, 151.
    appendix b: the nccam-supported studies that contain evidence of value
                                     of cam
        Listed below are the NCCAM-supported studies, which contain
    evidence of the value of CAM. Consistent with the priorities of the
    NCCAM's strategic plan, these findings are grouped into three major
    categories: Mind and Body Interventions; Natural Products
    Interventions; and Population-Based Research. Within each category, the
    findings are listed in reverse chronological order by the publication
    date.
    Mind and Body Interventions
                Chronic Pain
        Review of CAM Practices for Back and Neck Pain Shows Modest
    Benefit.--According to a recent review published by the Agency for
    Healthcare Research and Quality, the benefits of complementary and
    alternative therapies for back and neck pain--such as acupuncture,
    massage, and spinal manipulation--are modest in size but provide more
    benefit than usual medical care. While these effects are most evident
    following the end of treatment, the authors of the report noted that
    very few studies looked at long-term outcomes. Back and neck pain are
    important health problems that affect millions of Americans, and back
    pain is the most common medical condition for which people use
    complementary and alternative medicine (CAM). They noted that more
    well-designed studies are needed to draw more definitive conclusions
    regarding the benefits of CAM therapies for pain. http://nccam.nih.gov/
    research/results/spotlight/100110.htm.--AHRQ Publication No.
    10(11)E007. Rockville, MD: Agency for Healthcare Research and Quality.
    October 2010.
        Tai Chi May Benefit Patients With Fibromyalgia.--Fibromyalgia is a
    disorder characterized by muscle pain, fatigue, and other symptoms.
    Researchers, funded in part by the NCCAM, evaluated the physical and
    psychological benefits of tai chi (which combines meditation, slow
    movements, deep breathing, and relaxation) in 66 people with
    fibromyalgia. The participants were assigned to one of two groups: an
    attention control group that received wellness education and practiced
    stretching exercises, or a tai chi group that received instruction in
    tai chi principles and techniques and practiced 10 forms of Yang-style
    tai chi. Compared with the attention control group, the tai chi group
    had a significantly greater decrease in total score on the Fibromyalgia
    Impact Questionnaire at 12 weeks. In addition, the tai chi group
    demonstrated greater improvement in sleep quality, mood, and quality of
    life. Improvements were still present at 24 weeks. No adverse events
    were reported. The researchers concluded that these findings support
    previous research indicating benefits of tai chi for musculoskeletal
    pain, depression, and quality of life. The underlying mechanisms are
    unknown, and the researchers noted that larger, longer term studies are
    needed to evaluate the potential benefits of tai chi for patients with
    fibromyalgia. http://nccam.nih.gov/research/results/spotlight/
    081810.htm.--New England Journal of Medicine. 2010;363(8):743-754 and
    783-784.
        Analysis of National Survey Reveals Perceived Benefit of CAM for
    Back Pain.--According to an analysis of the 2002 National Health
    Interview Survey, approximately 6 percent of U.S. adults used
    complementary and alternative medicine (CAM) to treat their back pain
    during the previous year. The data from this analysis also revealed
    that a majority (60 percent) of survey respondents who used the most
    common CAM therapies for back pain perceived ``a great deal'' of
    benefit. The most common CAM therapies used for back pain--in
    descending order of perceived benefit--were chiropractic (66 percent),
    massage (56 percent), yoga/tai chi/qi gong (56 percent), acupuncture
    (42 percent), herbal therapies (32 percent), and relaxation techniques
    (28 percent). The specific factors associated with a greater perception
    of benefit from CAM use were having an improved self-reported health
    status, and using CAM because ``conventional medical treatment would
    not help.'' Back pain is the most common medical condition for which
    people use CAM, and these data give more insight into the use and
    perceived benefit of CAM therapies for this condition. The researchers
    suggested that this analysis demonstrates the need for future studies
    that include both self-reported outcomes and observer-based performance
    measures of patients using CAM therapies for back pain. http://
    nccam.nih.gov/research/results/spotlight/060110.htm.--Journal of the
    American Board of Family Medicine. 2010;23(3):354-362.
        Study of Spinal Manipulative Therapy for Neck-related Headaches
    Reports Findings on Dose and Efficacy.--Previous research suggests that
    spinal manipulative therapy (SMT) may be helpful for various types of
    chronic headaches, including cervicogenic headache (CGH), which is
    associated with neck pain and dysfunction. This randomized controlled
    trial evaluated the dose (number of treatments) and relative efficacy
    of SMT in a group of 80 patients with chronic CGH. Compared with
    massage, participants receiving SMT had greater improvements in CGH-
    related pain and disability, lasting to 24 weeks. These differences
    were clinically important and statistically significant. The dose
    effects of SMT treatments (i.e., differences between 8 and 16
    treatments) were small but significant. The mean number of headaches
    reported by SMT subjects decreased by more than half during the study.
    The researchers concluded that their findings support SMT as a viable
    option for treating CGH, but also point out that these findings should
    be considered preliminary. They suggest additional research to
    determine whether SMT results for patients with CGH are affected by
    treatment intensity and duration, use of other therapies, lifestyle
    changes, and an integrative care approach. http://nccam.nih.gov/
    research/results/spotlight/041310.htm.--Spine Journal. 2010;10(2):117-
    128.
        Preliminary Trial Finds Possible Benefits of Osteopathic Treatment
    for Back Pain During the Third Trimester of Pregnancy.--Most pregnant
    women experience low-back pain, which often is associated with sleep
    disturbance and can affect daily activities. Researchers investigated
    the effects of osteopathic manipulative treatment on back pain during
    the third trimester of pregnancy. They found that back-specific
    functioning deteriorated significantly less in the osteopathic
    manipulative treatment group than in the usual care or usual care with
    sham treatment groups. Although the results of this preliminary study
    suggest that osteopathic manipulation may have benefits for back-
    specific functioning, but not pain, in the third trimester of
    pregnancy, larger trials are needed before definitive conclusions can
    be drawn about its efficacy or effectiveness for this purpose. http://
    nccam.nih.gov/research/results/spotlight/032210.htm.--American Journal
    of Obstetrics and Gynecology. 2010;202(1):43.e1-43.e8.
        Tai Chi May Benefit Older Adults With Knee Osteoarthritis.--Knee
    osteoarthritis (OA) is an increasing problem among older adults,
    causing pain, functional limitations, and reduced quality of life.
    Researchers conducted a long-term, randomized, controlled trial
    comparing tai chi and conventional exercise in a group of 40 adults
    (mean age 65) with symptomatic knee OA. The tai chi group learned and
    practiced Yang-style tai chi, modified slightly to eliminate excess
    stress on the knees. The control group received wellness education and
    did stretching exercises. Compared with the control group, tai chi
    patients had greater improvement in measures of pain, physical
    function, self-efficacy (belief in one's own abilities), depression,
    and health-related quality of life. Although most differences between
    the two groups were statistically significant only at 12 weeks, the
    differences for self-efficacy and depression remained statistically
    significant at 24 and 48 weeks. No serious adverse events were
    reported. The researchers recommend additional studies of biologic
    mechanisms and approaches of tai chi, so its benefits can be extended
    to a broader population. http://nccam.nih.gov/research/results/
    spotlight/011510.htm.--Arthritis & Rheumatism. 2009;61(11):1545-1553.
        Iyengar Yoga for Chronic Low-back Pain Shows Promising Results.--
    Researchers conducted a clinical trial to evaluate the effects of
    Iyengar yoga (a popular style of yoga that uses props to help support
    the body during postures) on chronic low-back pain. They found that
    compared with the control group, the yoga group had significantly
    greater reductions in functional disability, pain, and depression, at
    weeks 12 and 24 and at the 6-month followup. There were no significant
    differences in pain medication usage between the groups; however, there
    appeared to be a trend toward decreased usage in the yoga group. The
    researchers concluded from their results that yoga decreases functional
    disability, pain, and depression in people with chronic low-back pain.
    However, they noted potential limitations of their study (e.g., heavy
    reliance on self-report instruments, and differential demands on yoga
    vs. control groups in terms of attention and group support) and suggest
    design considerations for future research. http://nccam.nih.gov/
    research/results/spotlight/112409.htm.--Spine. 2009;34(19):2066-2076.
        Managing Low-Back Pain: an Evidence-Based Approach for Primary Care
    Physicians.--A physician's response to a patient with low-back pain
    (LBP) should take into account psychological and social factors as well
    as physical symptoms, according to an article that looked at two case
    studies in light of evidence-based clinical guidelines developed by
    Roger Chou et al. for the American Pain Society and the American
    College of Physicians. The article's authors, recommend a measured
    approach to the use of imaging (x-rays and MRI/CT scans) and
    medication. The authors outline considerations in evaluating each
    patient and choosing action steps. The authors also noted that most
    people with chronic LBP will not become pain free. Physicians can help
    patients have a realistic outlook that focuses on improving functioning
    in addition to reducing pain. http://nccam.nih.gov/research/results/
    spotlight/040209.htm.--Journal of Family Practice. 2009;58(4):180-186.
        Study Finds Benefits of Therapeutic Massage for Chronic Neck
    Pain.--In a research study, 64 adults with neck pain persisting for at
    least 12 weeks were randomly assigned to receive either massage or a
    self-care book. The massage group had up to 10 treatments over a 10-
    week period, provided by licensed practitioners who used a variety of
    common Swedish and clinical massage techniques and also made typical
    self-care suggestions. After 10 weeks, the massage group was more
    likely than the self-care-book group to have clinically significant
    improvement in function and symptoms. At 26 weeks, the massage group
    tended to be more likely to report improvement in function but not in
    specific symptoms. For both function and symptoms, mean differences
    between the two groups were strongest at 4 weeks and not evident by 26
    weeks. At all followup points, the massage group was more likely than
    the self-care-book group to report global improvement ratings of
    ``better'' or ``much better.'' At 26 weeks, medication use had
    increased 14 percent for the self-care-book group but had not changed
    for the massage group. The researchers concluded that therapeutic
    massage is safe and may have benefits for treating chronic neck pain,
    at least in the short term. They recommended studies to determine
    optimal massage treatment, as well as larger, more comprehensive
    studies to follow patients for at least 1 year. http://nccam.nih.gov/
    research/results/spotlight/051809.htm.--Clinical Journal of Pain.
    2009;25(3):233-238.
        Massage Therapy May Ease Pain and Improve Mood in Advanced Cancer
    Patients.--Researchers investigated the benefits of massage versus
    simple touch therapy (placing both hands on specific body sites) in
    patients with advanced cancer. This multisite study--conducted at 15
    U.S. hospices in the Population-based Palliative Care Research
    Network--included 380 participants with advanced cancer who were
    experiencing moderate-to-severe pain. Results of the study showed that
    both the massage and simple touch therapy groups experienced
    statistically significant improvements in pain relief, physical and
    emotional distress, and quality of life. Immediate improvement in pain
    and mood was greater with massage than with simple touch; however,
    sustained effects of these therapies were not observed. The researchers
    concluded that massage therapy may provide some immediate relief for
    patients with advanced cancer. They also suggest that simple touch,
    which can be provided by family members and volunteers, may benefit
    these patients. http://nccam.nih.gov/research/results/spotlight/
    110608.htm.--Annals of Internal Medicine. 2008;149(6):369-379.
        Study Points to Cost-effectiveness of Naturopathic Care for Low-
    Back Pain.--Researchers who studied treatment alternatives for low-back
    pain in a group of 70 warehouse workers found that a naturopathic
    approach (incorporating a range of treatment options--acupuncture,
    exercise and dietary advice, relaxation training, and a back-care
    booklet) was more cost-effective than the employer's usual patient
    education program. Both the workers and the employer benefited from the
    naturopathic approach, which was associated with better health-related
    quality of life, less absenteeism, and lower costs for other treatments
    and pain medication. The study consisted of workers ages 18 to 65 who
    had experienced low-back pain for at least 6 weeks. The workers were
    randomly assigned to receive naturopathic care or patient education
    visits over a 3-month period. The 30-minute, onsite visits were
    conducted semiweekly (naturopathic) or biweekly (patient education).
    The researchers conclude that naturopathic care is more cost-effective
    than a patient education program in treating low-back pain. They also
    recommend further studies of the economic impact of naturopathic
    medicine, particularly to address the limitations of their evaluation.
    http://nccam.nih.gov/research/results/spotlight/070708.htm.--
    Alternative Therapies in Health and Medicine. 2008;14(2):32-39.
        Acupuncture Relieves Pain and Improves Function in Knee
    Osteoarthritis.--Acupuncture provides pain relief and improves function
    for people with osteoarthritis of the knee and serves as an effective
    addition to standard care, according to a landmark study. The
    researchers enrolled 570 patients with osteoarthritis of the knee, aged
    50 and older, to receive one of three treatments: acupuncture,
    simulated acupuncture (procedures that mimic acupuncture, sometimes
    also referred to as ``placebo'' or ``sham''), or participation in a
    control group. The control group followed the Arthritis Foundation's
    self-help course for managing their condition over 12 weeks.
    Participants in the actual and simulated acupuncture groups received 23
    treatment sessions over 26 weeks. All study participants continued to
    receive standard medical care from their primary physicians, including
    anti-inflammatory medications and opioid pain relievers. At the start
    of the study, participants' pain and knee function were assessed using
    standard arthritis research survey instruments and measurement tools.
    After 26 weeks participants in the acupuncture group had a 40 percent
    decrease in pain and a nearly 40 percent improvement in function
    compared to their assessments at the start of the study. Findings from
    this study begin to shed more light on acupuncture's possible
    mechanisms and potential benefits, especially in treating painful
    conditions such as arthritis. http://nccam.nih.gov/research/results/
    spotlight/052504.htm.--Annals of Internal Medicine. 2004;141(12):901-
    910.
    Stress/Anxiety
        Long-term Yoga Practice May Decrease Women's Stress.--Research has
    shown that women who practice hatha yoga (a common type of yoga
    involving body postures, breath control, and meditation) regularly
    recover from stress faster than women who are considered yoga
    ``novices.'' The research also showed that yoga may boost the mood of
    both yoga experts and novices. The researchers found that the novices'
    blood had 41 percent higher levels of the cytokine interleukin-6 (IL-6)
    than those of the experts. IL-6 is a stress-related compound that is
    thought to play a role in certain conditions such as cardiovascular
    disease and type 2 diabetes. In addition, the novices' levels of C-
    reactive protein, which serves as a general marker for inflammation,
    were nearly five times that of the yoga experts. Experts had lower
    heart rates in response to stress events than novices. The researchers
    suggested that this study offers insight into how yoga and its related
    practices may affect health. Regularly performing yoga could have
    health benefits, which may only become evident after years of practice.
    http://nccam.nih.gov/research/results/spotlight/051510.htm.--
    Psychosomatic Medicine. Feb 2010;72(2):113-121.
        A Form of Acupuncture May Help in Opioid Addiction.--Transcutaneous
    electric acupoint stimulation (TEAS), a form of acupuncture that uses
    skin electrodes to apply electrical stimulation at different points on
    the body, may help people addicted to opioid drugs. This study,
    supported in part by the NCCAM, also suggests that combining this
    technique with prescribed drugs that ease withdrawal symptoms may
    improve other outcomes for people addicted to opioids. Further,
    participants who received active TEAS were more than two times less
    likely to have used any drugs than those who received simulated TEAS.
    In addition, patients in the active TEAS group reported they were less
    bothered by pain and that they experienced greater improvements in
    overall health. However, the researchers noted that drug abstinence may
    have contributed to these improvements. The researchers noted several
    limitations of this study, including a small number of participants and
    brief duration of treatment. Despite these limitations, they suggested
    that additional studies with larger, more diverse populations and
    longer treatment durations are needed. http://nccam.nih.gov/research/
    results/spotlight/010410.htm.--Journal of Substance Abuse Treatment.
    2010;38(1):12-21.
        Transcendental Meditation Helps Young Adults Cope With Stress.--A
    study found that Transcendental Meditation (TM) helped college students
    decrease psychological distress and increase coping ability. For a
    group of students at high risk for developing hypertension, these
    changes also were associated with decreases in blood pressure. Compared
    with controls, the TM group had significant improvement in total
    psychological distress, anxiety, depression, anger/hostility, and
    coping ability. Changes in psychological distress and coping paralleled
    changes in blood pressure. According to the researchers, these findings
    suggest that young adults at risk of developing hypertension may be
    able to reduce that risk by practicing TM. The researchers recommend
    that future studies of TM in college students evaluate long-term
    effects on blood pressure and psychological distress. http://
    nccam.nih.gov/research/results/spotlight/051410.htm.--American Journal
    of Hypertension. Dec 2009;22(12):1326-1331.
        Mantram Instruction May Help HIV-positive Individuals Handle
    Stress.--Repeating a mantram (also known as a mantra--the practice of
    silently focusing on a spiritual word or phrase frequently throughout
    the day)--may help HIV-positive individuals develop coping skills and
    reduce anger. Researchers analyzed the effects of a group-based mantram
    training program, based on data from a study involving 93 HIV-positive
    individuals. After the 5-week intervention, the mantram group reported
    a significant increase (25 percent on average) in use of positive
    reappraisal coping (handling stressful situations by focusing on
    positive aspects), while the control group reported a significant
    decrease. At a 22-week followup, anger levels had decreased in the
    mantram group (13 percent on average) but not in the control group.
    According to the researchers, these findings suggest that repeating a
    mantram may help HIV-positive individuals examine stressful situations
    in a more nonjudgmental and accepting way, reducing the likelihood of
    an angry response. This is significant because reducing reactive anger
    may help individuals preserve supportive social relationships as well
    as maintain adherence to antiretroviral treatments. The researchers
    suggested additional studies to explore the effects of mantram on
    attention, cognitive processing, and acceptance-based responding.
    http://nccam.nih.gov/research/results/spotlight/010609.htm.--
    International Journal of Behavioral Medicine. 2009;16(1):74-80.
        Stress Management Interventions May Enhance Immune Function in
    People With HIV.--Stress management interventions may help to improve
    immune function and coping skills in HIV-positive individuals.
    Researchers assessed three interventions: cognitive-behavioral
    relaxation training (physical and mental relaxation techniques and
    active coping skills); focused tai chi training (exercises for balance,
    breathing, posturing and movement, and relaxation); and spiritual
    growth (discussions and personal journals to enhance spiritual
    awareness). None of the intervention groups differed from controls on
    measures of HIV-related psychological distress, quality of life, and
    health status, or on physiological stress response (cortisol levels).
    However, compared with controls, all three treatment groups had
    significant increases in lymphocyte proliferation (production of white
    blood cells), indicating enhanced immune function. The researchers
    noted the potentially important clinical implications of this finding.
    They recommend additional research to examine specific effects of
    stress management interventions in people with HIV. http://
    nccam.nih.gov/research/results/spotlight/060208.htm.--Journal of
    Consulting and Clinical Psychology. 2008;76(3):431-441.
        Acupuncture May Help Symptoms of Post-traumatic Stress Disorder.--A
    pilot study shows that acupuncture may help people with post-traumatic
    stress disorder. Post-traumatic stress disorder (PTSD) is an anxiety
    disorder that can develop after exposure to a terrifying event or
    ordeal in which grave physical harm occurred or was threatened.
    Traumatic events that may trigger PTSD include violent personal
    assaults, natural or human-caused disasters, accidents, or military
    combat. Researchers conducted a clinical trial examining the effect of
    acupuncture on the symptoms of PTSD. The researchers analyzed
    depression, anxiety, and impairment in 73 people with a diagnosis of
    PTSD. The participants were assigned to receive either acupuncture,
    group cognitive-behavioral therapy, or were put on the wait list as a
    control group. The people in the control group were offered treatment
    or referral for treatment at the end of their participation. The
    researchers found that acupuncture provided treatment effects similar
    to group cognitive-behavioral therapy; both interventions were superior
    to the control group. Additionally, treatment effects of both the
    acupuncture and the group therapy were maintained for 3 months after
    the end of treatment. The limitations are that the study consisted of a
    small group of participants that lacked diversity and that the results
    do not account for outside factors that may have affected the
    treatments' results. http://nccam.nih.gov/research/results/spotlight/
    092107.htm.--The Journal of Nervous and Mental Disease, June 2007.
        Self-hypnosis Beneficial for Women Undergoing Breast Biopsy.--
    Researchers have found that women who used self-hypnosis during a type
    of core needle breast biopsy experienced anxiety relief and reduced
    pain when compared with standard care. A large core needle breast
    biopsy is usually an outpatient procedure that limits the use of
    anesthetic. Women having this procedure often experience anxiety
    because of the possibility of a cancer diagnosis in addition to the
    anxiety that patients typically experience during a medical procedure.
    In this randomized, controlled trial researchers recruited 236 women
    who were randomly assigned to receive standard care, structured
    empathic attention from a research assistant, or guided self-hypnotic
    relaxation during the biopsy. The study found that both self-hypnosis
    and empathic attention reduced pain and anxiety during the procedure.
    Self-hypnosis provided greater anxiety relief than empathic attention.
    Neither intervention increased procedure time or significantly
    increased cost. As a result, the researchers suggest that self-hypnosis
    appears attractive for outpatient pain management. http://
    nccam.nih.gov/research/results/spotlight/122606.htm.--Pain, December
    2006.
                Basic and Translational Research
        Basic and translational research provides important insights into
    how CAM interventions can benefit human health. For example, animal
    studies help to identify biomarkers or signatures of biological effects
    that can be applied to future studies in humans.
        Mindfulness Meditation is Associated With Structural Changes in the
    Brain.--Practicing mindfulness meditation appears to be associated with
    measurable changes in the brain regions involved in memory, learning,
    and emotion, according to a research study that compared brain images
    of participants who participated in a mindfulness-based stress
    reduction program with those who did not. Specifically brain images in
    the meditation group revealed increases in gray matter concentration in
    the left hippocampus, which is an area of the brain involved in
    learning, memory, and emotional control, and is suspected of playing a
    role in producing some of the positive effects of meditation. The
    researchers concluded that these findings may represent an underlying
    brain mechanism associated with mindfulness-based improvements in
    mental health. Additional studies are needed to determine the
    associations between specific types of brain change and behavioral
    mechanisms thought to improve a variety of disorders. http://
    nccam.nih.gov/research/results/spotlight/012311.htm.--Psychiatry
    Research: Neuroimaging. 2011;191(1):36-43.
        Study Examines the Effects of Swedish Massage Therapy on Hormones,
    Immune Function.--Massage is used for many health purposes, but little
    is known about how it works on a biological level. This study examined
    the effects of one session of Swedish massage therapy--a form of
    massage using long strokes, kneading, deep circular movements,
    vibration, and tapping--on the body's hormonal response and immune
    function. Researchers randomly assigned 53 healthy adults to receive
    one session of either Swedish massage or light touch (in which the
    therapist used only a light touch with the back of the hand). The
    researchers found that participants who received Swedish massage had a
    significant decrease in the hormone arginine-vasopressin (which plays a
    role in regulating blood pressure and water retention) compared with
    those who were treated with light touch. Study data, although
    preliminary data, led the researchers to conclude that a single session
    of Swedish massage produces measurable biological effects and may have
    an effect on the immune system. However, more research is needed to
    determine the specific mechanisms and pathways behind these changes.
    http://nccam.nih.gov/research/results/spotlight/090110.htm.--The
    Journal of Alternative and Complementary Medicine. 2010;16(10):1-10.
        Electroacupuncture Relieves Cancer Pain in Laboratory Rats.--
    Electroacupuncture (acupuncture combined with electrical stimulation)
    has been used to treat cancer pain; however, the existing data on its
    efficacy and how it works are unclear. Researchers investigated the
    effects of electroacupuncture on cancer pain in rats and also looked at
    the underlying biomechanisms. The results showed that compared with the
    sham control, electroacupuncture significantly reduced cancer-induced
    bone pain. The researchers also examined the rats spinal cords to see
    whether electroacupuncture affected chemical processes thought to play
    a role in pain. They found that compared with the sham control,
    electroacupuncture inhibited up-regulation of two substances involved
    in these processes: spinal cord preprodynorphin mRNA and dynorphin. In
    a separate experiment, they found that injection of an antiserum
    against dynorphin also inhibited cancer-induced pain in the rats. The
    researchers concluded that electroacupuncture eases cancer pain in
    rats, at least in part by inhibiting spinal dynorphin. They note that
    their findings support the clinical use of electroacupuncture in the
    treatment of cancer pain. http://nccam.nih.gov/research/results/
    spotlight/040109.htm.--European Journal of Pain. 2008;12(7):870-878.
        Brain-Imaging Study Explores Analgesic Effect of Acupuncture.--
    Researchers used two imaging technologies--functional magnetic
    resonance imaging (fMRI) and positron emission tomography (PET)--to
    investigate how specific areas of the brain might be involved in
    acupuncture analgesia. The imaging results showed acupuncture-related
    changes in both of the brain's pain networks: the lateral network,
    which is associated with sensory aspects of pain perception, and the
    medial network, which is associated with affective aspects. However,
    the fMRI and PET results pointed to different areas in these networks,
    with one exception: both imaging technologies showed changes in the
    right medial orbitofrontal cortex--an indication that this area of the
    brain may be important in acupuncture analgesia. The researchers note
    that their preliminary findings demonstrate that imaging studies using
    more than one imaging technique have potential for clarifying the
    neural mechanisms of acupuncture. They point out that similar studies
    with much larger samples might reveal other areas of the brain where
    fMRI and PET results converge. http://nccam.nih.gov/research/results/
    spotlight/121208.htm.--Behavioural Brain Research. 2008;193(1):63-68.
        Green Tea May Help Protect Against Rheumatoid Arthritis.--
    Investigators examined the effects of green tea polyphenols on
    rheumatoid arthritis (RA) by using an animal (rat) model. The animals
    consumed green tea in their drinking water (controls drank water only)
    for 1 to 3 weeks before being injected with heat-killed Mycobacterium
    tuberculosis H37Ra to induce arthritis. The researchers found that
    green tea significantly reduced the severity of arthritis. They suggest
    that green tea affects arthritis by causing changes in various
    arthritis-related immune responses--it suppresses both cytokine IL-17
    (an inflammatory substance) and antibodies to Bhsp65 (a disease-related
    antigen), and increases cytokine IL-10 (an anti-inflammatory
    substance). Therefore, they recommend that green tea be further
    explored as a dietary therapy for use together with conventional
    treatment for managing RA. http://nccam.nih.gov/research/results/
    spotlight/120808.htm.--The Journal of Nutrition. 2008:138(11):2111-
    2116.
        Electroacupuncture May Help Alcohol Addiction.--Researchers
    examined the effects of electroacupuncture on alcohol intake by
    alcohol-preferring rats. After being trained to drink alcohol
    voluntarily and then subjected to alcohol deprivation, the rats
    received either electroacupuncture or sham electroacupuncture, and
    their alcohol intake was monitored after the intervention. Some rats
    were also pretreated with naltrexone (a drug that blocks the effects of
    opiates), so researchers could look for evidence that opiate mechanisms
    are involved in electroacupuncture's effects. The results showed that
    electroacupuncture reduced the rats' alcohol intake. The researchers
    also found that injecting the rats with naltrexone blocked the effect
    of electroacupuncture on alcohol intake-an indication that this effect
    may be through the brain's opiate system. On the basis of their
    findings, the researchers recommend rigorous clinical trials to study
    the effects of electroacupuncture in alcohol-addicted people. They also
    recommend further investigation of how electroacupuncture affects the
    brain. http://nccam.nih.gov/research/results/spotlight/022609.htm.--
    Neurochemical Research. 2008;33(10):2166-2170.
        Lifestyle Changes May Affect Cell-level Processes Related to
    Disease.--Disease risk, progression, and premature mortality--in many
    types of cancer and in cardiovascular and infectious diseases--have
    been linked to telomeres, which are protective DNA-protein complexes
    that keep cells genetically stable. The cellular enzyme telomerase is
    an important part of the body's maintenance system for these essential
    complexes. In a pilot study researchers investigated the effects of
    lifestyle changes on telomerase levels in 24 men with low-risk prostate
    cancer. The participants underwent a comprehensive lifestyle
    modification that included: improved nutrition, moderate aerobic
    exercise, stress management, and increased social support. After 3
    months, the study participants' telomerase activity had increased 29.8
    percent. Decreases in psychological distress and low-density
    lipoprotein (LDL) cholesterol were associated with the increase in
    telomerase activity. This is the first longitudinal study to suggest
    that lifestyle modifications (or any intervention) might significantly
    increase telomerase activity. The researchers emphasize that additional
    research is needed and recommend larger randomized controlled trials to
    confirm the findings. http://nccam.nih.gov/research/results/spotlight/
    100908.htm. The Lancet Oncology. Published online September 16, 2008.--
    Journal of Immunology. 2007;179(6):4249-4254.
        New Research Gives Insight Into How Acupuncture May Relieve Pain.--
    In the first study of its kind, researchers evaluated the effects of
    acupuncture on brain activity following active stimulation. The
    researchers used functional magnetic resonance imagery (fMRI) to
    monitor brain activity in 15 healthy adults before and after true
    acupuncture and sham acupuncture. The procedure lasted 150 seconds, and
    the rest period was 5.5 minutes. Analysis of the fMRI images showed
    that following true acupuncture--but not sham--there were increased
    connections among the parts of the brain involved in the perception and
    memory of pain. The subjects also reported stronger sensations with
    true acupuncture than with sham. The researchers concluded that
    acupuncture changes resting-state brain activity in ways that may
    account for its analgesic and other therapeutic effects. http://
    nccam.nih.gov/research/results/spotlight/111408.htm.--Pain.
    2008;136(3):407-418.
        Prostate Genes Altered by Intensive Diet and Lifestyle Changes.--A
    pilot study suggests that intensive lifestyle and diet changes may
    alter gene expression (the way a gene acts) in the prostate--possibly
    affecting the progression of prostate cancer. This pilot study included
    a group of 31 men with low-risk prostate cancer. These men declined
    immediate surgery, hormonal therapy, or radiation, and participated in
    an intensive 3-month nutritional and lifestyle intervention while
    researchers monitored their tumor progression. The men stuck to a low-
    fat, plant-based diet and took dietary supplements including fish oil,
    selenium, and vitamins C and E. They also participated in stress
    management activities, did moderate aerobic exercise, and attended
    group support sessions. The researchers found that there were changes
    in the men's RNA following the lifestyle and diet modifications.
    Certain RNA transcripts that play a critical role in tumor formation
    had ``up-regulated'' (increased) and others ``down-regulated''
    (decreased). The researchers concluded that intensive nutrition and
    lifestyle changes may alter gene expression in the prostate. They
    believe that understanding how these changes affect the prostate may
    lead to more effective prevention and treatment for prostate cancer,
    and recommend larger, randomized controlled trials to confirm the
    results of this pilot study. http://nccam.nih.gov/research/results/
    spotlight/100808.htm.--Proceedings of the National Academy of Sciences
    of the United States of America. 2008;105(24):8369-8374.
        Meditation May Increase Empathy.--Previous brain studies have shown
    that when a person witnesses someone else in an emotional state--such
    as disgust or pain--similar activity is seen in both people's brains.
    This shows a physiological base for empathy, defined as the ability to
    understand and share another person's experience. Now, research using
    advanced brain images (functional magnetic resonance imaging) have
    shown that compassion meditation--a specific form of Buddhist
    meditation--may increase the human capacity for empathy. In the study,
    researchers compared brain activity in meditation experts with that of
    subjects just learning the technique (16 in each group). They measured
    brain activity during meditation and at rest, in response to sounds
    designed to evoke a negative, positive, or neutral emotional response.
    The researchers found that both the novice and the expert meditators
    showed an increased empathy reaction when in a meditative state.
    However, the expert meditators showed a much greater reaction,
    especially to the negative sound, which may indicate a greater capacity
    for empathy as a result of their extensive meditation training. An
    increased capacity for empathy, the authors say, may have clinical and
    social importance. The next step, they add, is to investigate whether
    compassion meditation results in more altruistic behavior or other
    changes in social interaction. http://nccam.nih.gov/research/results/
    spotlight/060608.htm.--PLoS ONE [online journal], 2008.
        Meditation May Make Information Processing in the Brain More
    Efficient.--``Attentional-blink'' occurs when two pieces of information
    are presented to a person in very close succession, and the brain
    doesn't perceive the second piece of information because it is still
    processing the first. Researchers attempted to determine if intensive
    mental training through meditation could extend the brain's limits on
    information processing, reducing ``attentional-blink.'' Two groups of
    people--17 expert meditators and 23 novices--were compared to see if
    either was better at recognizing two pieces of information shown in
    quick succession. The participants were tested at the beginning and end
    of a 3-month period. For the intervening 3 months, the meditation
    practitioners participated in a retreat, during which they meditated
    for 10-12 hours a day. The novices participated in a 1-hour meditation
    class, and were asked to meditate for 20 minutes a day for the week
    before each test. The researchers found that intensive training did
    reduce ``attentional-blink.'' The participants who had gone through the
    mental training were more likely to perceive both pieces of information
    instead of just the first because the brain used fewer resources to
    detect the first piece of information--leaving more resources available
    to detect the second. The researchers also note that this study
    supports the idea that brain plasticity, or the ability of the brain to
    adapt, exists throughout life. http://nccam.nih.gov/research/results/
    spotlight/082307.htm.--PLOS Biology, June 2007.
                Quality of Life and Other Factors
        Quality of Life and Safety of Tai Chi and Green Tea Extracts in
    Postmenopausal Women.--For postmenopausal women with osteopenia (low
    bone mineral density), practicing tai chi and/or taking green tea
    polyphenols appears to be safe. Further, practicing tai chi by itself
    or in combination with green tea polyphenol supplements may improve
    quality of life; however, taking green tea supplements by themselves
    has no significant improvement in quality of life. The researchers
    noted that this is the first placebo-controlled, randomized study to
    evaluate the safety of long-term use of green tea supplements in
    postmenopausal women. Based on these findings, the researchers
    concluded that green tea polyphenols at a dose of 500 mg daily for 24
    weeks, alone or in combination with tai chi, appears to be safe in
    postmenopausal women with low bone mineral density. http://
    nccam.nih.gov/research/results/spotlight/121410.htm.--BMC Complementary
    and Alternative Medicine. 2010;10(1):76. [Epub ahead of print]
        Tai Chi and Qi Gong Show Some Beneficial Health Effects.--A review
    of scientific literature suggests that there is strong evidence of
    beneficial health effects of tai chi and qi gong, including for bone
    health, cardiopulmonary fitness, balance, and quality of life. Both tai
    chi and qi gong (also known as qigong) have origins in China and
    involve physical movement, mental focus, and deep breathing.
    Researchers analyzed 77 articles reporting the results of 66 randomized
    controlled trials of tai chi and qi gong. The studies involved a total
    of 6,410 participants. Of the many outcomes identified by the
    reviewers, current research suggests that the strongest and most
    consistent evidence of health benefits for tai chi or qi gong is for
    bone health, cardiopulmonary fitness, balance and factors associated
    with preventing falls, quality of life, and self-efficacy (the
    confidence in and perceived ability to perform a behavior). The
    reviewers concluded that the evidence is sufficient to suggest that tai
    chi and qi gong are a viable alternative to conventional forms of
    exercise. http://nccam.nih.gov/research/results/spotlight/071910.htm.--
    American Journal of Health Promotion. 2010;24(6):e1-e25.
        Hypnosis May Reduce Hot Flashes in Breast Cancer Survivors.--
    Researchers investigated the effects of hypnosis on hot flashes among
    women with a history of primary breast cancer, no current evidence of
    detectable disease, and at least 14 hot flashes per week over a 1-month
    period. Sixty women were assigned to receive either hypnosis (weekly
    50-minute sessions, plus instructions for at-home self-hypnosis) or no
    treatment. The women who received hypnosis had a 68-percent reduction
    in self-reported hot flash frequency/severity and experienced an
    average of 4.39 fewer hot flashes per day. Compared with controls, they
    also had significant improvements in self-reported anxiety, depression,
    interference with daily activities, and sleep. The researchers
    concluded that hypnosis appears to reduce perceived hot flashes in
    breast cancer survivors and may have additional benefits such as
    improved mood and sleep. They recommend long-term, randomized, placebo-
    controlled studies to further explore the benefits of hypnosis for
    breast cancer survivors. The researchers are currently conducting a
    randomized clinical trial with 200 participants. http://nccam.nih.gov/
    research/results/spotlight/102308.htm.--Journal of Clinical Oncology.
    Published online September 22, 2008.
        Tai Chi May Help Heart Failure Patients Sleep Better.--People with
    heart failure may benefit from practicing tai chi, according to
    researchers who analyzed sleep in 18 patients with chronic heart
    failure. All patients were on maximal medical therapy. The patients
    were assigned into one of two groups: a usual care group (the control)
    that received medication and diet/exercise counseling, or a tai chi
    group that received usual care plus 12 weeks of tai chi training.
    Compared with the usual care group, the tai chi group had significant
    improvements in sleep stability. The tai chi group also demonstrated
    significant quality-of-life improvements over the usual care group. The
    researchers concluded that a 12-week tai chi exercise program may help
    heart failure patients sleep better. They noted that it remains to be
    determined if any single component of tai chi--meditation, relaxation,
    or physical activity--may be responsible for the observed benefit. They
    suggested further research to better understand the mechanisms of tai
    chi's effects on sleep should include more conventional sleep testing
    to document sleep stages and patterns of sleep disruption. http://
    nccam.nih.gov/research/results/spotlight/072508.htm.--Sleep Medicine.
    2008;9(5):527-536.
        Tai Chi Chih Improves Sleep Quality in Older Adults.--Researchers
    conducted a randomized controlled trial to determine whether tai chi
    chih could improve sleep quality in healthy, older adults with moderate
    sleep complaints. In the study, 112 individuals aged 59 to 86
    participated in either tai chi chih training or health education
    classes for 25 weeks. Participants rated their sleep quality based on
    the Pittsburgh Sleep Quality Index, a self-rate questionnaire that
    assesses sleep quality, duration, and disturbances. The results of the
    study showed that the people who participated in tai chi chih sessions
    experienced slightly greater improvements in self-reported sleep
    quality. The researchers concluded that tai chi chih can be a useful
    nonpharmacologic approach to improving sleep quality in older adults
    with moderate sleep complaints, and may help to prevent the onset of
    insomnia. http://nccam.nih.gov/research/results/spotlight/031109.htm.--
    Sleep. 2008;31(7):1001-1008.
        Acupuncture Shows Promise in Improving Rates of Pregnancy Following
    IVF.--A review of seven clinical trials of acupuncture given with
    embryo transfer in women undergoing in vitro fertilization (IVF)
    suggests that acupuncture may improve rates of pregnancy. An estimated
    10 to 15 percent of couples experience reproductive difficulty and seek
    specialist fertility treatments, such as IVF. According to researchers
    who conducted the systematic review, acupuncture has been used in China
    for centuries to regulate the female reproductive system. With this in
    mind, the reviewers analyzed results from seven clinical trials of
    acupuncture in women who underwent IVF to see if rates of pregnancy
    were improved with acupuncture. The studies encompassed data on over
    1,366 women and compared acupuncture, given within 1 day of embryo
    transfer, with sham acupuncture, or no additional treatment. The
    reviewers found that acupuncture given as a complement to IVF increased
    the odds of achieving pregnancy. According to the researchers, the
    results indicate that 10 women undergoing IVF would need to be treated
    with acupuncture to bring about one additional pregnancy. The results,
    considered preliminary, point to a potential complementary treatment
    that may improve the success of IVF and the need to conduct additional
    clinical trials to confirm these findings. http://nccam.nih.gov/
    research/results/spotlight/020808.htm.--British Medical Journal.
    Published online February 2008.
        Tai Chi May Help Maintain Bone Mineral Density in Postmenopausal
    Women.--Tai chi may be a safe alternative to conventional exercise for
    maintaining bone mineral density (BMD) in postmenopausal women. Bone
    mineral density is one of the key indicators of bone strength and low
    BMD is associated with osteoporosis. Exercise is an important component
    of osteoporosis prevention and treatment. Researchers conducted a
    systematic review of research looking at the effect of tai chi, a mind-
    body practice that originated in China, on BMD. They found that tai chi
    may be an effective, safe, and practical intervention for maintaining
    BMD in postmenopausal women. The authors further note that the benefits
    of tai chi appeared similar to those of conventional exercise. However,
    tai chi may also improve balance, reduce fall frequency, and increase
    musculoskeletal strength. They note that the evidence is preliminary
    because the research they reviewed was of limited scope and quality,
    but enough evidence of effectiveness exists to warrant further
    research. http://nccam.nih.gov/research/results/spotlight/081407.htm.
    Archives of Physical Medicine and Rehabilitation, May 2007.
        Tai Chi Boosts Immunity to Shingles Virus in Older Adults.--Tai
    chi, a traditional Chinese form of exercise, may help older adults
    avoid getting shingles by increasing immunity to varicella-zoster virus
    and boosting the immune response to varicella vaccine. The study is the
    first rigorous clinical trial to suggest that a behavioral
    intervention, alone or together with a vaccine, can help protect older
    adults from the varicella virus, which causes both chickenpox and
    shingles. The randomized, controlled trial included 112 healthy adults
    ages 59 to 86. Each person took part in a 16-week program of either tai
    chi or health education with 120 minutes of instruction weekly. After
    the tai chi and health education programs, with periodic blood tests to
    determine levels of varicella virus immunity, people in both groups
    received a single injection of the chickenpox vaccine, VARIVAX. Nine
    weeks later, the investigators assessed each participant's level of
    varicella immunity and compared it to immunity at the start of the
    study. Tai chi alone was found to increase participants' immunity to
    varicella, and tai chi combined with the vaccine produced a
    significantly higher level of immunity, about a 40 percent increase,
    over the vaccine alone. The study also showed that the tai chi group's
    rate of increase in immunity over the course of the study was double
    that of the health education group. Finally, the tai chi group reported
    significant improvements in physical functioning, bodily pain, vitality
    and mental health. http://nccam.nih.gov/research/results/spotlight/
    040607.htm.--Journal of the American Geriatrics Society, April 2007.
        Study Compares Year-long Effectiveness of Four Weight-loss Plans.--
    The very low carbohydrate diet known as the Atkins diet may contribute
    to greater weight loss than higher carbohydrate plans without negative
    effects such as increased cholesterol. The study consisted of 311
    premenopausal women, all of whom were overweight or obese who were
    randomly assigned to 1 of 4 diets. Each of the diets used were selected
    for their different levels of carbohydrate consumption: the Atkins
    diet, the Zone diet, the LEARN diet and the Ornish diet. Participants
    in each group received books that accompanied their assigned diet plan,
    and attended hour-long classes with a registered dietitian once a week
    for the first 8 weeks. The researchers recorded body mass index (BMI);
    percent body fat; waist-hip ratio; as well as metabolic measures such
    as, insulin, cholesterol, glucose, triglyceride, and blood pressure
    levels. The Atkins diet group reported the most weight loss at 12
    months with an average loss of just over 10 pounds. They also had more
    favorable overall metabolic effects. Average weight loss across all
    four groups ranged from 3.5 to 10.4 pounds. The authors note that
    ``even modest reductions in excess weight have clinically significant
    effects on risk factors such as triglycerides and blood pressure.''
    http://nccam.nih.gov/research/results/spotlight/030607.htm.--Journal of
    the American Medical Association. March 2007.
    Natural Products Interventions
                Treatment or Enhancement of Treatment
        New Approach for Peanut Allergy in Children Holds Promise.--
    Currently, there are no treatments available for people with peanut
    allergy. A new treatment may be a safe and effective form of
    immunotherapy for those children. The double-blind, placebo-controlled
    study investigated the safety, clinical effectiveness, and immunologic
    changes with sublingual immunotherapy--a treatment that involves
    administering very small amounts of the allergen extract under a
    person's tongue. Though these findings are promising, more study is
    needed to determine whether sublingual immunotherapy can increase long-
    term tolerance to peanuts in children with peanut allergy. http://
    nccam.nih.gov/research/results/spotlight/022011.htm.--The Journal of
    Allergy and Clinical Immunology. 2011.
        Magnesium Supplements May Benefit People With Asthma.--Some
    previous studies have reported associations between low magnesium
    consumption and the development of asthma. This study provides
    additional evidence that adults with mild-to-moderate asthma may
    benefit from taking magnesium supplements. Researchers found that
    participants who took magnesium experienced significant improvement in
    lung activity and the ability to move air in and out of their lungs.
    Those taking magnesium also reported other improvements in asthma
    control and quality of life compared with people who received placebo.
    The researchers noted that this study adds to the body of research that
    shows subjective and objective benefits of magnesium supplements in
    people with mild-to-moderate asthma. http://nccam.nih.gov/research/
    results/spotlight/021110.htm.--Journal of Asthma. 2010;47(1):83-92.
        Study Shows Chamomile Capsules Ease Anxiety Symptoms.--Researchers
    conducted a randomized, double-blind, placebo-controlled trial to test
    the effects of chamomile extract in patients diagnosed with mild to
    moderate generalized anxiety disorder (GAD). Researchers used the
    Hamilton Anxiety Rating (HAM-A) and other tests to measure changes in
    anxiety symptoms over the course of the study; dosage adjustments were
    based on HAM-A scores. Compared with placebo, chamomile was associated
    with a greater reduction in mean HAM-A scores--the study's primary
    outcome measure. The difference was clinically meaningful and
    statistically significant. Chamomile also compared favorably with
    placebo on other outcome measures (although the differences were not
    statistically significant), and was well tolerated by participants.
    These results suggest that chamomile may have modest benefits for some
    people with mild to moderate GAD. As this was the first controlled
    trial of chamomile extract for anxiety, the researchers note that
    additional studies using larger samples and studying effects for longer
    periods of time would be helpful. They also point out that other
    chamomile species, preparations (e.g., extracts standardized to
    constituents other than apigenin), and formulations (e.g., oil or tea)
    might produce different results. http://nccam.nih.gov/research/results/
    spotlight/040310.htm.--Journal of Clinical Psychopharmacology. 2009
    Aug;29(4):378-382.
        Study Indicates Cranberry Juice Does Not Interfere With Two
    Antibiotics Women Take for Recurrent Urinary Tract Infections.--
    Cranberry juice, a popular home remedy for urinary tract infections
    (UT), is often taken along with low-dose antibiotics as a preventive
    measure. Because little is known about the potential of cranberry juice
    to interact with drugs, researchers studied cranberry's effects on two
    antibiotics frequently prescribed for UTI: amoxicillin and cefaclor.
    The data showed that cranberry juice did not significantly affect
    either antibiotic's oral absorption or renal clearance (i.e., how
    completely the body processed the drugs in the intestine and kidneys).
    Absorption took somewhat longer with cranberry juice, but the delay was
    small, and the total amount of antibiotic absorbed was not affected.
    Based on these results, the researchers concluded that cranberry juice
    cocktail, consumed in usual quantities, is unlikely to change the
    effects of these two antibiotics on UTIs. They noted that the same may
    or may not be true of other antibiotics, or when people who take
    antibiotics also drink a large quantity of concentrated cranberry
    juice. http://nccam.nih.gov/research/results/spotlight/081009.htm.--
    Antimicrobial Agents and Chemotherapy. 2009 Jul;53(7):2725-32.
        Traditional Chinese Herbs May Benefit People With Asthma.--
    Scientists reviewed research evidence on traditional Chinese medicine
    (TCM) herbs for asthma, focusing on studies reported since 2005. They
    determined that preliminary clinical trials of formulas containing
    Radix glycyrrhizae in combination with various other TCM herbs have had
    positive results. Laboratory findings on TCM herbal remedies suggest
    several possible mechanisms of action against asthma, including an
    anti-inflammatory effect, inhibition of smooth-muscle contraction in
    the airway, and modulation of immune system responses. http://
    nccam.nih.gov/research/results/spotlight/061609.htm.--Journal of
    Allergy and Clinical Immunology. 2009;123(2):297-306.
        A Review of St. John's Wort Extracts for Major Depression.--
    Researchers reviewed the scientific literature on St. John's wort for
    major depression and analyzed findings from randomized, double-blind
    studies comparing St. John's wort extracts with placebo and standard
    antidepressants. The researchers reviewed a total of 29 studies in
    5,489 people. The studies came from a variety of countries, tested
    several different St. John's wort extracts, and mainly included people
    with minor to moderately severe symptoms of depression. According to
    this literature review, St. John's wort extracts appeared to be
    superior to placebo, were as effective as standard antidepressants, and
    had fewer side effects than antidepressants. However, the findings from
    studies in German-speaking countries were disproportionately favorable,
    possibly because some subjects had slightly different types of
    depression, or because some of the small studies were flawed and overly
    optimistic in reporting their results. The authors noted the need to
    investigate the reasons for the differences between study findings from
    German-speaking countries and those from other countries. http://
    nccam.nih.gov/research/results/spotlight/120908.htm.--Cochrane Database
    of Systematic Reviews. 2008 8;(4):CD000448.
        Study Suggests Vitamin E May Help People With Asthma.--A form of
    vitamin E (gamma-tocopherol) commonly found in foods may be a useful
    additional treatment for asthma, according to preliminary research.
    Researchers investigated the biological activity of a gamma-tocopherol
    supplement in asthma patients. The researchers gave a daily dose of a
    vitamin E preparation rich in gamma-tocopherol to 16 volunteers. Eight
    healthy volunteers and eight volunteers with allergic asthma received
    one supplement daily during the first week, followed by a week with no
    treatment, and then two supplements daily for another week. They found
    similar results for both doses--the vitamin E supplements prevented
    inflammation and decreased oxidative stress without any adverse health
    effects. This research was an initial step in extending previous
    findings of gamma-tocopherol's anti-inflammatory effects in animals.
    Further research on vitamin E in patients with asthma is under way.
    http://nccam.nih.gov/research/results/spotlight/070208.htm.--Free
    Radical Biology & Medicine. 2008;45(1):40-49.
        Omega-3 Fatty Acids May Be Helpful in Psychiatric Care.--Omega-3
    fatty acids may hold promise for use in psychiatry, particularly for
    depression and bipolar disorder. Researchers conducted a meta-analysis
    of research looking at omega-3 fatty acid supplements as treatments for
    psychiatric conditions, such as depression, bipolar disorder,
    schizophrenia, dementia, and attention-deficit hyperactivity disorder.
    Omega-3 fatty acids are essential nutrients that the body cannot make
    on its own, so they must come from food sources. The richest source of
    these fatty acids is fish and seafood, but they can also be found in
    flaxseeds and some eggs. The authors suggest that omega-3 supplements
    may be helpful for people with depression or bipolar disorder as a
    complement to standard care. However, they were unable to determine
    benefits for other conditions such as schizophrenia and dementia. They
    also ``strongly recommend that patients with psychiatric disorders
    should not elect supplementation with omega-3 fatty acids in lieu of
    established psychiatric treatment options.'' They further recommend
    studies to look at how the nutrient may work, and large trials to
    conclusively determine the utility of omega-3 fatty acids in
    psychiatric care. http://nccam.nih.gov/research/results/spotlight/
    121506.htm.--Journal of Clinical Psychiatry, December 2006.
        Polyunsaturated Fatty Acids for Depression.--Omega-6 and omega-3
    fatty acids (also called PUFAs, short for polyunsaturated fatty acids)
    are among the CAM therapies used with the intent to help symptoms of
    depression. A team reviewing the evidence found five randomized
    controlled trials to be of sufficient quality for review, although all
    were small and of short duration. All but one of these trials found
    some improvement from using PUFAs for symptoms of depression,
    particularly from omega-3 fatty acids. The authors concluded that while
    the evidence to support using PUFA supplements as a treatment for
    depression is not strong, enough potential exists to merit further
    research. http://nccam.nih.gov/research/results/spotlight/050106.htm.--
    Journal of Affective Disorders, May 2006.
                Disease Prevention
        Ginkgo Does Not Shield Seniors' Hearts, But It May Protect Their
    Leg Arteries.--While findings from the Ginkgo Evaluation of Memory
    (GEM) study show that the herbal supplement Ginkgo biloba did not
    prevent heart attack, stroke, or death in a group of older adults, the
    herb may reduce the risk of developing peripheral arterial disease
    (also known as peripheral vascular disease), a painful and potentially
    life-threatening condition affecting blood circulation in the legs,
    arms, stomach, and kidneys. Of the 35 cases of peripheral arterial
    disease observed in the study, 23 patients received placebo and 12
    patients received ginkgo, a difference that was statistically
    significant. The researchers reported that this finding was consistent
    with European studies that reported improvements in patients with
    peripheral arterial disease who received ginkgo versus placebo. But,
    due to the small number of patients in whom this was seen, the
    researchers suggest larger trials to evaluate the herb before they
    would recommend it as a treatment for peripheral arterial disease. This
    study was a planned secondary outcome of the GEM study. http://
    nccam.nih.gov/research/results/spotlight/052110.htm.--Circulation:
    Cardiovascular Quality and Outcomes. 2010;3(1):41-47.
        Chinese Herbal Medicine May Benefit People With Pre-Diabetes.--In
    China and other Asian countries, Chinese herbal medicines have long
    been used to prevent or delay the onset of diabetes, and there is
    anecdotal evidence regarding efficacy for this purpose. A recent
    review, funded in part by the NCCAM, examined related clinical trials
    to see whether scientific evidence supports recommending Chinese herbal
    medicine as a treatment option for people with pre-diabetes. The review
    looked at 16 clinical trials involving 1,391 participants with pre-
    diabetes, 15 different herbal formulations, and various comparisons
    (i.e., lifestyle modification, drug interventions, placebo). Analysis
    of data from eight trials that included lifestyle modification as a
    comparison found that lifestyle modification combined with Chinese
    herbs was twice as effective as lifestyle modification alone in
    normalizing blood sugar levels. Participants who received herbal
    formulations were also less likely to develop full-blown diabetes
    during the study period. Due to limitations among the studies reviewed,
    the reviewers concluded that while their findings are promising,
    further, well-designed trials are needed to clarify the potential role
    of Chinese herbal medicines in glucose control and diabetes prevention.
    http://nccam.nih.gov/research/results/spotlight/110309.htm.--Cochrane
    Database of Systematic Reviews. 2009(4):CD00066690.
        Red Yeast Rice May Help Patients With High Cholesterol Who Cannot
    Take Statin Drugs.--In light of previous findings that red yeast rice
    can reduce levels of low-density lipoprotein (LDL, or ``bad''
    cholesterol), researchers investigated the effects of this supplement
    in patients with high cholesterol and a history of statin-associated
    myalgia (SAM). Compared with placebo, red yeast rice significantly
    decreased blood levels of LDL and total cholesterol over a 24-week
    period, without increasing the incidence of myalgia. Red yeast rice did
    not significantly affect levels of high-density lipoprotein (HDL, or
    ``good'' cholesterol), triglycerides, weight loss, or pain severity.
    This was the first randomized, double-blind, placebo-controlled trial
    to evaluate red yeast rice in patients who cannot take statin drugs
    because of muscle pain. The results suggest that red yeast rice may be
    a cholesterol-lowering alternative for these patients, but additional,
    larger studies are needed to establish long-term safety and efficacy.
    The researchers also suggest studies to compare red yeast rice directly
    with statins and to explore the role of lifestyle change therapy.
    http://nccam.nih.gov/research/results/spotlight/071709.htm.--Annals of
    Internal Medicine. 2009;150(12):830-839.
        Flaxseed Reduces Some Risk Factors of Cardiovascular Disease.--
    Flaxseed is rich in alpha linolenic acid (ALA), a plant-based omega-3
    fatty acid, as well as fiber and lignans (phytoestrogens), making it a
    possible functional food for reducing cardiovascular risk factors. A
    double blind, randomized, controlled clinical trial by researchers
    explored the effects of flaxseed on various cardiovascular risk factors
    in adults. Researchers found that flaxseed positively affected
    lipoprotein A and insulin sensitivity. They also found a modest but
    short-lived lowering effect in participants' LDL (``bad'') cholesterol
    levels. However, the researchers also noted that flaxseed significantly
    lowers HDL (``good'') cholesterol levels in men, although not in women.
    There were no changes noted in markers of inflammation or oxidative
    stress. The authors suggest that additional investigation of the HDL
    lowering effect among men may be warranted. http://nccam.nih.gov/
    research/results/spotlight/062308.htm.--Nutrition, 2008.
                Basic and Translational Research
        Basic and translational research provides important insights into
    how CAM interventions can benefit human health. For example, animal
    studies help to identify biomarkers or signatures of biological effects
    that can be applied to future studies in humans.
        Laboratory Study Suggests Potential Anti-cancer Benefit of White
    Tea Extract.--White tea extract increased a specific type of cell death
    in laboratory cultures of two different types of nonsmall cell lung
    cancer cells, indicating that the tea may have an anti-cancer effect.
    Although white tea comes from the same plant as green and black teas
    (Camellia sinensis), white tea goes through much less processing,
    resulting in a higher concentration of polyphenols. This study, for the
    first time, showed the roles of the PPAR-gamma and 15-LOX signaling
    pathways in white tea-induced apoptosis. (A reduction in PPAR-gamma in
    a tumor is linked to poor prognosis in patients with lung cancer.) The
    researchers also compared green tea extract with white tea extract and
    found that white tea extract was significantly more effective in
    increasing certain RNA transcripts (e.g., PPAR-gamma) that play a
    critical role in cell death. They noted, however, that the components
    in white tea extract that may be responsible for this outcome are not
    yet known. They noted that the findings from this preliminary study
    provide an important basis for more investigation of the anti-cancer
    properties of white tea extract and whether it may help prevent the
    development of lung cancer. http://nccam.nih.gov/research/results/
    spotlight/092110.htm.--Cancer Prevention Research. 2010;3(9):1132-1140.
        Laboratory Study Shows Turmeric May Have Bone-Protective Effects.--
    Turmeric--an herb commonly used in curry powders, mustards, and
    cheeses--may protect bones against osteoporosis. This study, which used
    an animal (rat) model of postmenopausal osteoporosis, builds on
    previous laboratory research examining turmeric's anti-arthritic
    properties. Funded in part by the NCCAM, the study tested two turmeric
    extracts containing different amounts of curcuminoids--(components of
    the herb) in female rats whose ovaries had been surgically removed
    (ovariectomy--a procedure that causes changes associated with
    menopause, including bone loss). Tests showed that while nonenriched
    turmeric extract did not have bone-protective effects, curcuminoid-
    enriched turmeric extract prevented up to 50 percent of bone loss, and
    also preserved bone structure and connectivity. Other physiological
    changes associated with ovariectomy (weight gain and shrinking of the
    uterus) were unaffected--an indication that the bone-protective effects
    did not involve an estrogen-based chemical pathway. The researchers
    concluded that turmeric may protect bones, but that the effect depends
    on the amount of curcuminoids present. However, they emphasized that
    clinical research is needed to evaluate the use of turmeric-derived
    curcuminoid products to guard against osteoporosis in humans. http://
    nccam.nih.gov/research/results/spotlight/093010.htm.--Journal of
    Agricultural and Food Chemistry. 2010;58(17):9498-9504.
        Effects of Milk Thistle Extract on the Hepatitis C Virus
    Lifecycle.--A laboratory study suggests that silymarin--an extract from
    the milk thistle plant--has multiple effects against the lifecycle of
    the hepatitis C virus. Hepatitis C is a chronic (long lasting) disease
    that primarily affects the liver and is often difficult to cure. This
    study examined the antiviral properties and mechanisms of silymarin on
    cultured (grown in a lab) human liver cells infected with the virus. By
    analyzing the interactions between silymarin and the virus, the
    researchers observed that silymarin prevented the entry and fusion of
    the hepatitis C virus into the target liver cells. They also found that
    silymarin inhibited the ability of the virus to produce RNA (a chemical
    that plays an important role in protein synthesis and other chemical
    activities of the cell), interfering with a portion of the virus's
    lifecycle. These findings build on previous research of silymarin's
    antiviral and anti-inflammatory properties and provide more information
    about the potential mechanisms involved in silymarin's antiviral
    actions. Further research, particularly in clinical trials, is needed
    to determine if silymarin could be a safe and effective supplement for
    treating hepatitis C in humans. http://nccam.nih.gov/research/results/
    spotlight/061610.htm.--Hepatology. 2010;51(6):1912-1921.
        Fish Oil Enhances Effects of Green Tea on Alzheimer's Disease in
    Mice.--Fish oil, when combined with epigallocatechin-3-gallate (EGCG--a
    polyphenol and antioxidant found in green tea), may affect chemical
    processes in the brain associated with Alzheimer's disease. This study,
    which used an animal (mouse) model of Alzheimer's disease, builds on
    previous research linking the disease to peptides (amino acid chains)
    called beta-amyloids and laboratory studies suggesting that EGCG
    decreases memory problems and beta-amyloid deposits in mice.
    Researchers found that the mice fed the combination of fish oil and
    EGCG had a significant reduction in amyloid deposits that have been
    linked with Alzheimer's disease. Upon examination of blood and brain
    tissues of the mice, the researchers found high levels of EGCG in the
    mice that were fed the combination of fish oil and low-dose EGCG
    compared with those fed low-dose EGCG alone. A possible explanation,
    according to the researchers, is that fish oil enhances the
    bioavailability of EGCG--that is, the degree to which EGCG was absorbed
    into the body and made available to the brain. This effect, in turn,
    may contribute to the increased effectiveness of this combination.
    Further research is necessary, however, to determine if the combination
    of fish oil and EGCG affects memory or cognition, and whether it might
    have potential as an option for people at risk of developing
    Alzheimer's disease. http://nccam.nih.gov/research/results/spotlight/
    031610.htm.--Neuroscience Letters. 2010;471(3):134-138.
        Laboratory Study Suggests Potential Anti-Cancer Benefit of
    Ginseng.--American ginseng (Panax quinquefolius) extract caused
    laboratory cultures of colorectal cancer cells to die, indicating that
    the herb may have an anti-cancer effect. Although results from the
    study suggest that combining ginseng with antioxidants such as vitamin
    C may potentially enhance this effect, there is no evidence yet that
    this laboratory research can be extended to treatments in people.
    Researchers treated two types of colorectal cancer cells with steamed
    American ginseng root extract. This caused damage to the cells'
    mitochondria, the internal structures that are involved with energy
    production, and led to apoptosis (cell death). It also increased levels
    of reactive oxygen species (ROS)--a byproduct of the processes in which
    cells use and break down oxygen (increased levels of ROS can either
    bring on cell death or activate the survival pathways that protect
    against it). Whether ROS acts to induce cell death or survival in
    response to ginseng depends on the specific biochemical pathways that
    are activated, and how this happens remains unknown. Further studies
    are needed. The researchers also noted the need for additional
    investigations to test whether combining ginseng and antioxidants might
    help prevent the development of colorectal cancers. http://
    nccam.nih.gov/research/results/spotlight/032510.htm.--Cancer Letters.
    2010;289(1):62-70.
        Mouse Study Shows Green Tea Polyphenols May Repair DNA Damage
    Caused by Ultraviolet (UV) Radiation.--Antioxidants found in green tea
    may help repair DNA damage caused by sun exposure, according to a
    recent study in mice. Exposure to UV radiation can damage DNA and, in
    turn, trigger suppression of the immune system--a risk factor for
    developing skin cancer. The study, funded in part by the NCCAM,
    examined the effects of polyphenols from the leaves of the green tea
    plant, which are thought to fight free radicals (highly unstable
    molecules that can damage cells) and have anticarcinogenic activity.
    Compared with the control group, the mice treated with green tea
    polyphenols had reduced immunosuppression from the UV radiation. This
    same group of mice also showed more rapid repair of DNA damaged by UV
    radiation. Further, the study showed that green tea polyphenols
    increased the levels of some nucleotide excision repair genes, which
    allow for DNA repair. The researchers noted that this study is the
    first to show that preventing skin cancer with green tea polyphenols in
    water may be due to the blocking of UV-induced immunosuppression in
    mice. More studies are needed to determine if green tea has any
    potential chemopreventive effect on skin cancer in people. http://
    nccam.nih.gov/research/results/spotlight/022110.htm.--Cancer Prevention
    Research. 2010;3(2):179-189.
        Cinnamon Bark and Ginseng in Herbal Formulas Increase Life Span of
    Roundworms.--Researchers used a roundworm that has some genetic and
    biochemical similarities to humans to examine complex herbal
    preparations thought to combat adverse effects of aging. The worms,
    called Caenorhabditis elegans, or C. elegans, have a brief life span
    (about 20 days). The researchers assessed two traditional Chinese
    multiherbal formulas--Huo Luo Xiao Ling Dan (HLXL), taken for chronic
    inflammatory pain (e.g., joint pain from arthritis); and Shi Quan Da Bu
    Tang (SQDB), taken to reduce fatigue and improve general wellness. They
    found that cinnamon bark, a component of both formulas, increased the
    worms' life span. Of all the individual components tested, two
    significantly prolonged life span: Cinnamomum cassia bark (present in
    both formulas) and Panax ginseng root (present in SQDB only). In light
    of these findings, the researchers concluded that C. elegans is a valid
    model for evaluating complex herbal preparations and may provide
    insight for future studies on longevity-promoting herbs. http://
    nccam.nih.gov/research/results/spotlight/052510.htm.--PLoS ONE [online
    journal]. 2010;5(2):9339.
        Laboratory Study Explores Anti-HIV Potential of Palmitic Acid.--In
    a laboratory study, a fatty acid from seaweed reduced the ability of
    HIV-1 viruses to enter immune system cells. Researchers evaluated
    palmitic acid (from Sargassum fusiforme, a type of seaweed that grows
    off the coasts of Japan and China) to see if palmitic acid reduced the
    ability of HIV-1 viruses to enter CD4+ T-cells (white blood cells that
    are HIV-1's main target). Palmitic acid blocked both X4-tropic and R5-
    tropic viruses, the HIV viruses that use a particular receptor (X4 or
    R5) to enter a cell. In addition, the study's findings showed that
    palmitic acid protected other cells against HIV-1, reducing X4
    infection in primary peripheral blood lymphocytes and R5 infection in
    primary macrophages (white blood cells). In all cases, the extent of
    the blocking effect depended on the concentration of palmitic acid, and
    most cells remained viable (alive) after treatment. The researchers
    noted that understanding the relationship between palmitic acid and CD4
    may lead to development of an effective microbicide product for
    preventing sexual transmission of HIV. http://nccam.nih.gov/research/
    results/spotlight/121409.htm.--AIDS Research and Human Retroviruses.
    2009;25(12):1231-1241.
        Study Uses Rat Liver Cells To Explore Cholesterol-Lowering
    Mechanisms of Tea.--There is evidence that tea consumption can reduce
    the risk of cardiovascular disease, apparently by lowering cholesterol
    levels in the blood. Researchers examined extracts from both green tea
    and black tea, as well as some components of green tea, for their
    effects on the synthesis of cholesterol in liver cells from rats. The
    study's finding that black tea was more effective than green tea in
    decreasing cholesterol synthesis in rat liver cells was unexpected, as
    was the finding that EGCG alone was less effective than whole green
    tea. Additional research may reveal more about the cholesterol-lowering
    mechanisms of both kinds of tea. http://nccam.nih.gov/research/results/
    spotlight/040510.htm.--Journal of Nutritional Biochemistry. 2009
    Oct;20(10):816-822.
        Evidence in Mice May Spur More Research on Fish Oil and Curcumin
    for Alzheimer's Disease.--A popular dietary supplement and a curry
    spice may affect Alzheimer's disease--related chemical processes in the
    brain, according to research findings. This study, which used an animal
    (mouse) model of Alzheimer's disease, builds on previous research
    linking the disease to peptides (amino acid chains) called b-amyloids
    and to defective insulin-processing by the brain. A particular b-
    amyloid, Ab-42, is associated with Alzheimer's disease. Funded in part
    by the NCCAM, the study looked at two dietary supplements: fish oil
    rich in the omega-3 fatty acid docosahexaenoic acid (DHA); and
    curcumin, a component of turmeric. Researchers fed the Alzheimer's
    disease--model mice a regular or fatty diet; some of the mice also
    received fish oil and/or curcumin. They found that the high-fat diet
    increased Alzheimer's disease--related chemical processes in the brain,
    and that fish oil and curcumin, alone or in combination, counteracted
    this effect. DHA and curcumin also protected cognitive performance for
    mice on the high-fat diet--i.e., how well the mice remembered a maze.
    http://nccam.nih.gov/research/results/spotlight/070109.htm.--Journal of
    Neuroscience. 2009;29(28):9078-9089.
        Animal Study Shows Connection Between Vitamin E, Lung Inflammation,
    and Asthma.--Citing study results in mice, researchers reported for the
    first time that the form of vitamin E found primarily in food (gamma-
    tocopherol) increased lung inflammation in induced asthma, while the
    form of vitamin E found primarily in dietary supplements (alpha-
    tocopherol) reduced inflammation. The researchers found that compared
    with placebo, alpha-tocopherol significantly reduced inflammation while
    gamma-tocopherol significantly increased inflammation. The researchers
    also found that the mechanism by which both forms of vitamin E work
    involves the regulation of endothelial cell signals during leukocyte
    (white blood cell) recruitment--a process that occurs during
    inflammation. Endothelial cells line the inner walls of blood vessels.
    The researchers concluded that the opposing activities of the two
    common forms of vitamin E on inflammation found in this study are
    consistent with the contradictory outcomes of vitamin E on asthma in
    previous clinical trials. They also noted that the information gained
    from this study could have a significant impact on designing and
    interpreting future clinical studies on vitamin E. http://
    nccam.nih.gov/research/results/spotlight/041109.htm.--The Journal of
    Immunology. 2009;182(7):4395-4405.
        Researchers Investigate Anti-inflammatory Effects of Pineapple
    Extract.--Previous research indicates that bromelain--an enzyme
    extracted from pineapple stems--may help inflammatory conditions such
    as allergic airway disease. Bromelain's anti-inflammatory effects have
    been attributed to its ability to alter the activation and expansion of
    the immune system's CD4+ T cells (a type of lymphocyte). To better
    understand the processes involved, the NCCAM-funded researchers
    conducted in vitro experiments with mouse cells, using bromelain
    derived from a commercially available, quality-tested product. The
    results show that bromelain reduces CD25 (a protein involved in
    inflammation) expression via proteolytic (enzymatic) action, in a dose-
    and time-dependent manner. The researchers' analysis of the mechanism
    involved found that bromelain apparently splits CD25 from the CD4+ T
    cells, and that the T cells remain functional--i.e., they can still
    divide--after bromelain treatment. The researchers concluded that the
    novel mechanism of action demonstrated in their experiment explains how
    bromelain may exert its therapeutic benefits in inflammatory
    conditions. http://nccam.nih.gov/research/results/spotlight/
    080309.htm.--International Immunopharmacology. 2009;9(3):340-346.
        Grape Seed Extract May Help Neurodegenerative Diseases.--In light
    of previous studies indicating that grape-derived polyphenols may
    inhibit protein misfolding, researchers examined the potential role of
    a particular grape seed polyphenol extract (GSPE) in preventing and
    treating tau-associated neurodegenerative disorders. The results of
    their in vitro study showed that GSPE is capable of interfering with
    the generation of tau protein aggregates and also disassociating
    preformed aggregates, suggesting that GSPE may affect processes
    critical to the onset and progression of neurodegeneration and
    cognitive dysfunctions in tauopathies. The researchers concluded that
    their laboratory findings, together with indications that this GSPE is
    likely to be safe and well-tolerated in people, support its development
    and testing as a therapy for Alzheimer's disease. http://nccam.nih.gov/
    research/results/spotlight/031209.htm.--Journal of Alzheimer's Disease.
    2009;16(2):433-439.
        Chinese Herbal Formula Shows Anti-Arthritis Effects in Animal
    Study.--Researchers analyzed the effects of a modified version of the
    classic Chinese formula Huo Luo Xiao Ling Dan (HLXL) in an animal (rat)
    model of adjuvant arthritis, which shares some features with human
    rheumatoid arthritis. The researchers induced adjuvant arthritis in
    male rats by injecting them with a complete Freund's adjuvant solution
    containing heat-killed Mycobacterium tuberculosis. On days 16 to 25,
    the rats were given a daily oral dose of either a quality controlled,
    11-herb HLXL preparation or liquid only. Compared with controls, the
    HLXL-treated rats had significantly decreased arthritis symptom scores;
    reduced paw edema; and lower TNF-a and IL-1b levels. No adverse effects
    were observed. Based on their results, the researchers concluded that
    this HLXL formula may have benefits for treating arthritis and related
    inflammatory disorders. http://nccam.nih.gov/research/results/
    spotlight/071609.htm.--Journal of Ethnopharmacology. 2009;121(3):366-
    371.
        Echium Oil Reduces Triglyceride Levels in Mice.--In light of
    previous research indicating that oil from the seeds of the Echium
    plantagineum plant can lower triglycerides in people, researchers used
    an animal model--mice with mildly elevated triglyceride levels--to
    investigate how echium oil achieves this effect. The researchers fed
    the mice diets supplemented with either echium oil, fish oil, or (as a
    control) palm oil. They found that both echium and fish oils had the
    following effects: reduced triglycerides in blood plasma and the liver;
    enriched EPA in plasma and the liver--echium less so than fish oil; and
    ``down-regulated'' (decreased the expression of) several genes involved
    in synthesis of triglycerides in the liver. The researchers concluded
    that echium oil may provide a botanical alternative to fish oil for
    reducing triglycerides. http://nccam.nih.gov/research/results/
    spotlight/022509.htm.--Journal of Nutritional Biochemistry.
    2008;19(10):655-663.
        Laboratory Study Shows Black Cohosh Promotes Bone Formation in
    Mouse Cells.--Results of laboratory research are the first to indicate
    that extracts of the herb black cohosh (Actaea racemosa) may stimulate
    bone formation. Researchers added an extract of black cohosh to a
    culture of bone-forming mouse cells. The researchers observed that a
    high dose (1,000 ng/mL) of the extract suppressed the production of
    these bone-forming cells, yet a lower dose (500 ng/mL) significantly
    increased the formation of bone nodules. When the cells were treated
    with a protein whose molecules attach to estrogen receptors in place of
    estrogen, this effect on bone nodule formation disappeared. Thus, the
    researchers suggest that ingredients within black cohosh contain a
    component that acts through estrogen receptors. The researchers
    concluded that their results provide a scientific explanation at the
    molecular level for claims that black cohosh may protect against
    postmenopausal osteoporosis. They also noted that studying extraction
    methods and identifying black cohosh's active components may make it
    possible to develop new ways to prevent and treat this condition.
    Although results from the study suggest that black cohosh may have
    potential implications for the prevention or treatment of
    postmenopausal bone loss, there is no evidence yet that this laboratory
    research can be extended to treatments in people. http://nccam.nih.gov/
    research/results/spotlight/090408.htm.--Bone. 2008;43(3):567-573.
        Pomegranate Extract May Be Helpful for Rheumatoid Arthritis (RA).--
    RA is an autoimmune disease characterized by joint pain, stiffness,
    inflammation, swelling, and sometimes joint destruction. The
    pomegranate has been used for centuries to treat inflammatory diseases,
    and people with RA sometimes take dietary supplements containing a
    pomegranate extract called POMx. However, little is known about the
    efficacy of POMx in suppressing joint problems associated with RA.
    Researchers used an animal model of RA--collagen-induced arthritis
    (CIA) in mice--to evaluate the effects of POMx. They found that POMx
    significantly reduced the incidence and severity of CIA in the mice.
    The arthritic joints of the POMx-fed mice had less inflammation, and
    destruction of bone and cartilage were alleviated. Consumption of POMx,
    the researchers also concluded, selectively inhibited signal
    transduction pathways and cytokines critical to development and
    maintenance of inflammation in RA. Although previous studies of POMx
    found cartilage-protective effects in human cell cultures, this is the
    first study to observe positive effects in a live model. The
    researchers note that the data from this study suggest the potential
    efficacy of POMx for arthritis prevention, but not for treatment in the
    presence of active inflammation; future studies will address disease-
    modifying effects of POMx. They also note that clinical trials are
    needed before POMx can be recommended as safe and effective for RA-
    related use in people. http://nccam.nih.gov/research/results/spotlight/
    120508.htm.--Nutrition. 2008;24(7--8):733-743.
        Two Studies Explore the Potential Health Benefits of Probiotics.--
    In two studies, researchers investigated how probiotics may have a role
    in treating gastrointestinal illnesses, boosting immunity, and
    preventing or slowing the development of certain types of cancer. In
    one study, researchers investigated how Lactobacillus reuteri ATCC PTA
    6475 might work to slow the growth of certain cancerous tumors. Their
    study documented the molecular mechanisms of the probiotic's effects in
    human myeloid leukemia-derived cells--i.e., how it regulates the
    proliferation of cancer cells and promotes cancer cell death. The
    researchers noted that a better understanding of these effects may lead
    to development of probiotic-based regimens for preventing colorectal
    cancer and inflammatory bowel disease. In another study, researchers
    looked at whether Lactobacillus acidophilus might enhance the immune-
    potentiating effects of an attenuated vaccine (a vaccine prepared from
    a weakened live virus) against human rotavirus infection--the most
    common cause of severe dehydrating diarrhea in infants and children
    worldwide. The investigators' tests on newborn pigs found that animals
    given both a vaccine and the probiotic had a better immune response
    than the animals given the vaccine alone. The researchers concluded
    that probiotics may offer a safe way to increase the effectiveness of
    rotavirus vaccine in humans. In both studies, the investigators called
    for additional research into the mechanisms behind the health-related
    effects of probiotics. http://nccam.nih.gov/research/results/spotlight/
    110508.htm.--Cellular Microbiology. 2008;10(7):1442-1452.--Vaccine.
    2008;26(29--30):3655-3661.
        Research Shows Promise of Pineapple Extract for Inflammatory Bowel
    Disease (IBD).--IBD, including Crohn's Disease (CD) and ulcerative
    colitis (UC), are characterized by inflammation of the gastrointestinal
    tract. Researchers have found that bromelain--an enzyme derived from
    pineapple stems--might be able to reduce inflammation in IBD.
    Researchers recruited patients with a confirmed diagnosis of CD or UC
    as well as a normal, non-IBD control group. In total, this pilot study
    recruited 51 participants: 8 controls, 20 with UC, and 23 with CD. To
    assess the effect of a bromelain preparation on the production of
    cytokines, colon biopsies obtained from patients with UC, CD, and
    normal controls were treated in the lab (in vitro) with bromelain. The
    researchers report that bromelain reduced production of several pro-
    inflammatory cytokines and chemokines that are elevated in IBD and play
    a role in the progression of IBD. The authors conclude that bromelain
    treatment could potentially benefit IBD patients if similar changes
    also occur when colon tissues are exposed to bromelain inside the body.
    The researchers also suggest that additional research is needed to
    understand how bromelain influences chemokine and cytokine production.
    http://nccam.nih.gov/research/results/spotlight/070108.htm.--Clinical
    Immunology (2008) 126, 345-352.
        Grape Seed Extract May Help Prevent and Treat Alzheimer's.--
    Emerging research shows a correlation between red wine consumption and
    reduced risk of Alzheimer's disease-type cognitive decline. Researchers
    found that grape seed-derived polyphenolics--similar to that in red
    wine--significantly reduced Alzheimer's disease-type cognitive
    deterioration in mice. Researchers conducted experiments in mice with
    Alzheimer's disease to see if a highly purified polyphenolic extract
    from Vitis vinifera (cabernet sauvignon) grape seeds, could affect
    Alzheimer's disease-type cognitive deterioration. The mice received 5
    months of either water containing grape seed extract or water alone as
    a placebo treatment. The mice were then given behavioral maze tests to
    determine cognitive function and brain tissue samples were tested to
    determine evidence of disease. The researchers found that mice treated
    with grape seed extract had significantly reduced Alzheimer's disease-
    type cognitive deterioration compared to the control mice. This is due
    to the prevention of a molecule called amyloid forming in the brain
    that has been shown to cause Alzheimer's disease-type cognitive
    impairment. http://nccam.nih.gov/research/results/spotlight/
    062408.htm.--The Journal of Neuroscience. 2008. 28(25);6388-6392.
        Chinese Herbal Formula May Be Helpful for Peanut Allergies.--A
    study in mice shows that a Chinese herbal formula may help prevent
    dangerous reactions to peanuts. Peanut allergies affect as many as 6
    percent of young children and are a major cause of anaphylaxis--a
    severe allergic reaction with respiratory symptoms that can be fatal.
    Researchers conducted experiments in mice with established peanut
    allergies to see if a formula of nine Chinese herbs, called FAHF-2,
    could reduce sensitivity to peanuts. The peanut-sensitive mice received
    7 weeks of oral treatment with FAHF-2 or water as a placebo treatment.
    The mice were then exposed to peanuts at 2 different times to see if
    they would have anaphylactic reactions. The researchers found that
    FAHF-2 completely protected the mice from a dangerous reaction on both
    occasions--showing that protection lasted at least 4 weeks after the
    treatment finished. The mice treated with the placebo (water) had
    anaphylactic reactions. The researchers note that the protection of
    FAHF-2 may result from a shift in the immune balance away from the
    allergic response. http://nccam.nih.gov/research/results/spotlight/
    012908.htm.--Clinical and Experimental Allergy, June 2007.
        Turmeric and Rheumatoid Arthritis Symptoms.--More than 2 million
    Americans suffer from rheumatoid arthritis (RA), a condition in which
    the body's immune system attacks the joints, causing pain, swelling,
    stiffness, and loss of function. The herb turmeric has been used for
    centuries in Ayurvedic medicine (a whole medical system that originated
    in India) as a treatment for inflammatory disorders, including RA. To
    study the effects of turmeric, researchers created symptoms in rats
    that mimic those of RA in humans. In a series of experiments, they
    treated the rats with different preparations and dosages of turmeric
    extracts. The results, measured in terms of joint swelling, suggested
    that an extract containing only curcuminoids (a family of chemicals
    that is the major component of turmeric) may be more effective for
    preventing RA symptoms than a more complex extract containing
    curcuminoids plus other turmeric compounds. They also noted that the
    curcuminoids-only formulas appeared safer and more effective at lower
    doses. Also, the researchers found that the compounds had greater
    effectiveness when the rats were treated before instead of after the
    onset of inflammation. The authors identified a need for well-designed
    preclinical and clinical studies to look further into turmeric for
    anti-inflammatory use. http://nccam.nih.gov/research/results/spotlight/
    030106.htm.--Journal of Natural Products, March 2006.
                Other Research
        Botanicals May Help Conditions Associated With Aging.--To evaluate
    the effectiveness of botanicals in relation to conditions such as high
    blood pressure, cardiovascular disease, cognitive decline, insulin
    resistance, and excess fats in the blood, researchers conducted a
    literature review and examined studies from their own laboratory. The
    researchers looked at effects of dietary soy; soy isoflavones (daidzein
    and genistein); grape seed extract, which has a high concentration of
    polyphenols; and puerarin, an isoflavone found in kudzu. The literature
    review found that soy seemed to lower blood pressure in men and
    postmenopausal women, help protect against cardiovascular diseases
    (including heart disease and atherosclerosis), and benefit people with
    diabetes. The researchers' own animal studies found that soy
    isoflavones protected against salt-sensitive hypertension in male rats
    and in female rats whose ovaries had been removed (OVX); grape seed
    extract reduced blood pressure and improved cognitive functioning in
    OVX female rats; and puerarin improved glucose control in male mice.
    The researchers concluded that the botanical compounds reviewed appear
    to have beneficial effects in animal models of disease (soy also has
    shown benefits in humans), and that the compounds may be more effective
    in relation to cardiovascular, metabolic, and cognitive function than
    for menopausal symptoms. They recommended that the compounds' safety
    and mechanisms of action should be carefully tested in the context of
    the disease status of potential users. http://nccam.nih.gov/research/
    results/spotlight/121008.htm.--Gender Medicine. 2008;
    5(suppl A):76S-90S.
        Botanical Research Centers Featured in American Journal of Clinical
    Nutrition.--The February 2008 issue of the American Journal of Clinical
    Nutrition features eight articles from the NIH Botanical Research
    Centers Program, which is co-funded by the NIH Office of Dietary
    Supplements and the NCCAM. The articles highlight different areas
    related to the Centers' research into botanical use, safety, and
    efficacy. They include evaluation of botanicals for improving health;
    technologies and experimental approaches to evaluating botanicals;
    botanicals and metabolic syndrome; echinacea in infection; botanicals
    for age-related diseases; ways in which botanical lipids affect
    inflammatory disorders; botanicals to improve women's health; and
    ensuring botanical dietary supplement safety. The Botanical Centers are
    intended to advance research activities in plant identification, as
    well as preclinical research and early phase clinical studies. Each
    Center has a broad interdisciplinary research program that focuses on
    collaborative activities. Each of the Centers was created with a high
    potential for translating findings into public health benefits. http://
    nccam.nih.gov/research/results/spotlight/042308.htm.--American Journal
    of Clinical Nutrition, 2008. Volume 87, Number 2, 463.
    Population-based Research
                Cancer Survivors Are More Likely Than General Population To
                        Use CAM, According to National Survey Analysis
        A recent analysis of the 2007 National Health Interview Survey
    revealed that cancer survivors are more likely to use complementary and
    alternative medicine (CAM) compared with the general population. Cancer
    survivors are also more likely to use CAM based on a recommendation by
    their healthcare providers and to talk to their healthcare providers
    about their CAM use. Although cancer survivors communicated more about
    their CAM use than the general population, the study authors emphasized
    the overall need for improving communication between patients and
    providers about CAM use to help ensure coordinated care. http://
    nccam.nih.gov/research/results/spotlight/032011.htm.--Journal of Cancer
    Survivorship: Research and Practice. 2011;5(1):8-17.
                Analysis of National Survey Shows CAM Use in People With
                        Pain or Neurological Conditions
        According to an analysis of the 2007 National Health Interview
    Survey, approximately 44 percent of American adults with pain or
    neurological conditions, compared to about 33 percent of people without
    those conditions, used complementary and alternative medicine (CAM)
    during the previous year. The most common CAM therapies used by people
    with these conditions were mind-body therapies (25 percent), such as
    deep breathing exercises, meditation, and yoga; biologically based
    therapies (21 percent), such as herbal therapies; manipulative and
    body-based therapies (19 percent), such as massage and chiropractic
    care; and alternative medical systems (4 percent). In addition,
    respondents with pain or neurological conditions indicated that they
    used CAM because conventional treatment did not work (20 percent vs. 10
    percent) and was too expensive (9 percent vs. 4 percent). The
    researchers noted that this analysis demonstrates the need for more
    robust studies on the efficacy of CAM therapies for people with these
    conditions. http://nccam.nih.gov/research/results/spotlight/
    111010.htm.--Journal of Neurology. 2010;257:1822-1831.
                Study Asks Adolescents With Inflammatory Bowel Disease
                        About Use of Complementary and Alternative Medicine
                        (CAM) Mind-body Therapies
        This study found that many adolescents with inflammatory bowel
    disease are currently using or would consider using CAM--specifically
    mind-body therapies such as relaxation and guided imagery--to help
    manage their symptoms. This disease is actually a group of disorders
    (including Crohn's disease and ulcerative colitis) that cause
    inflammation of the intestines. The physical and emotional problems
    associated with irritable bowel disease in adolescents often affect
    quality of life. The researchers noted that their findings provide
    groundwork for future studies to determine the effect of CAM therapies
    on health outcomes in adolescents with inflammatory bowel disease.
    http://nccam.nih.gov/research/results/spotlight/031110.htm.--
    Inflammatory Bowel Disease. 2010;16(3):501-506.
                Certain Categories of Complementary Therapies Appear To
                        Benefit Older Adults
        According to a recent analysis of data from the 2002 National
    Health Interview Survey and the 2003 Medical Expenditure Panel Survey,
    use of biologically based therapies (e.g., herbs or megavitamins) and
    manipulative/body-based therapies (e.g., chiropractic or massage) may
    be associated with better health outcomes among individuals age 55
    years and older. The analysis showed a statistical association between
    ability to function and use of biologically based therapies and
    manipulative/body-based therapies. The researchers concluded that some
    categories of complementary therapies may be more beneficial than
    others for older adults. They cautioned that these findings should not
    be interpreted as evidence for the efficacy of specific therapies.
    Although the findings indicate that the use of certain kinds of CAM
    therapies is associated with better health outcomes for older adults,
    only clinical trials can determine the efficacy of specific therapies.
    The researchers also noted that this is the first longitudinal
    assessment (analysis of data collected from the same people at
    different points in time) of possible connections between complementary
    therapy use and health outcomes in a national sample of older adults.
    They recommended additional population-based research in this area.
    http://nccam.nih.gov/research/results/spotlight/070810.htm.--Journal of
    Alternative and Complementary Medicine. 2010;16(7):701-706.
                Many Older People Use Both Prescription Drugs and Dietary
                        Supplements
        Researchers analyzed the use of prescription drugs and dietary
    supplements in a sample of 3,070 people aged 75 and older. The data had
    been gathered during the Gingko for the Evaluation of Memory (GEM)
    study, a clinical trial that examined the effects of Gingko biloba on
    the development of dementia. Nearly 75 percent of the GEM study
    participants took at least one prescription drug and one dietary
    supplement. Approximately 33 percent used three or more prescription
    drugs and three or more supplements. Furthermore, 10 percent of the
    participants combined five or more prescription drugs with five or more
    dietary supplements. Although supplements were taken along with all
    types of prescription drugs, individuals using prescribed nonsteroidal
    anti-inflammatory drugs (NSAIDs), thyroid drugs, and estrogens were
    more likely to use dietary supplements. Individuals who used
    prescription drugs for high blood pressure and diabetes were less
    likely to use dietary supplements. Based on these data, they recommend
    that patients discuss dietary supplement use with their healthcare
    providers. In addition, the researchers emphasized the need for further
    investigations to better define the clinical importance of interactions
    between drugs and supplements. http://nccam.nih.gov/research/results/
    spotlight/071509.htm.--Journal of the American Geriatric Society.
    2009;57(7):1197-1205.
                Translating CAM Research Results Into Clinical Practice:
                        Results From a National Survey of Physicians and
                        CAM Providers
        In an initial investigation of the potential for information from
    CAM research to influence clinical practice, a 2007 national survey
    asked acupuncturists, naturopaths, internists, and rheumatologists
    about their awareness of CAM clinical trials, their ability to
    interpret research results, and their use of research evidence in
    decisionmaking. The survey focused on awareness of two major NCCAM-
    funded clinical trials that studied acupuncture or glucosamine/
    chondroitin for osteoarthritis of the knee. Fifty-nine percent of the
    1,561 respondents were aware of at least one of the two clinical trials
    but only 23 percent were aware of both trials. The acupuncture trial
    was most familiar to acupuncturists and rheumatologists, the
    glucosamine/chondroitin trial to internists and rheumatologists.
    Overall, awareness was greatest among rheumatologists and those
    practicing in institutional or academic settings. All groups regarded
    clinical experience as ``very important'' in their decisionmaking,
    although CAM providers were more likely to rate it ``most important.''
    Physicians were much more likely than CAM providers to consider
    research results very important or ``very useful'' in their clinical
    decisionmaking. The survey team concluded that CAM research has the
    potential to make a difference in both conventional and alternative
    medicine clinical practice. They recommend concerted efforts to better
    train all clinicians in interpretation and use of evidence from
    research studies, and to improve the dissemination of research results.
    http://nccam.nih.gov/research/results/spotlight/041309.htm.--Archives
    of Internal Medicine. 2009;169(7): 670-677.
                National Survey Reports on CAM Use by Adults and Children
        The 2007 The National Health Interview Survey (NHIS) found that
    approximately 38 percent of adults and 12 percent of children use some
    form of CAM. Among both adults and children, the most commonly used CAM
    therapy is nonvitamin/nonmineral natural products; fish oil/omega-3 is
    the most popular natural product for adults, while echinacea is the
    most popular for children. Back pain is by far the most common
    condition prompting adults to use CAM. Among children, back or neck
    pain is the most common reason for using CAM, followed closely by head/
    chest colds. The 2002 NHIS also included a supplement on CAM use by
    adults. Overall usage among adults in 2002 (36 percent) was about the
    same as in 2007. Since 2002, usage has increased for some therapies,
    including deep breathing, meditation, massage, and yoga. Adult use of
    CAM for head/chest colds showed a marked decrease between 2002 and
    2007. The 2007 survey was the first to ask about CAM use by children.
    http://nccam.nih.gov/research/results/spotlight/123108.htm.--CDC
    National Health Statistics Report #12. 2008.
                New Findings on Sleep Disorders and CAM
        Based on a national survey, the NCCAM scientists found that over
    1.6 million American adults use some form of CAM to treat insomnia or
    trouble sleeping. The authors key findings are:
      --More than 17 percent of adults reported insomnia or trouble
            sleeping in the past 12 months. In this group, 4.5 percent used
            some form of CAM to treat these problems.
      --The CAM users were most likely to use biologically based therapies
            (nearly 65 percent), such as herbal therapies, or mind-body
            therapies (more than 39 percent), such as relaxation
            techniques. Most who used these two types of therapies said
            they were at least somewhat helpful for insomnia or trouble
            sleeping.
    http://nccam.nih.gov/research/results/spotlight/090106.htm.--Archives
    of Internal Medicine, September 2006.
                CAM Use High Among Adolescents
        Researchers conducting the first national survey of CAM use among
    adolescents in the United States analyzed responses from 1,280
    adolescents aged 14 to 19. They found that 79 percent had used at least
    one form of CAM during their lifetime and that females used CAM more
    than males. Among all participants, almost 30 percent had used one or
    more dietary supplements, and almost 10 percent had used supplements
    along with prescription medications in the preceding month. Many of the
    supplements the teens reported using were related to attempts to change
    body shape (e.g., creatine and weight-loss products). The authors urged
    that healthcare providers be aware of CAM and dietary supplement use by
    their adolescent patients, because of the lack of standardization in
    supplements, as well as their potential for safety risks and
    interactions with prescription medications.http://nccam.nih.gov/
    research/results/spotlight/040106.htm.--Journal of Adolescent Health
    April 2006.
                More Than One-third of U.S. Adults Use Complementary and
                        Alternative Medicine, According to a 2002
                        Government Survey
        According to the 2002 National Health Interview Survey (NHIS), 36
    percent of U.S. adults use some form of CAM. The most commonly used
    form of CAM was natural products (such as herbs and other botanicals).
    Other popular CAM therapies included deep breathing, meditation,
    chiropractic care, yoga, massage, and special diets. Echinacea was the
    most commonly used natural product. CAM was most often used to treat
    back pain, colds, neck pain, joint pain, and anxiety or depression. The
    survey also revealed variations in CAM use by population subgroups. For
    example, CAM use overall was more common among women, people with
    higher education, people who had been hospitalized in the past year,
    and former smokers (compared to current smokers or those who had never
    smoked). The authors noted that the information from this survey is a
    foundation for future studies of CAM as it relates to health and
    disease among population subgroups. http://nccam.nih.gov/research/
    results/spotlight/050810.htm.--CDC Advance Data Report #343. 2004.
                         the nccam research approaches
        Question. Individualized therapies that involve multiple approaches
    often do not lend themselves to traditional double-blind studies but
    are frequently used in integrative medicine. Please describe work that
    the NCCAM is doing to support research on these kinds of treatments.
        Answer. The NCCAM recognizes that assessing some of the
    individualized therapies used in integrative medicine in double-blind
    studies is challenging. Similar challenges confront other disciplines
    of healthcare research that employ individualized or multifaceted
    interventions, complex procedures, or system approaches (e.g.
    cognitive-behavioral therapy, surgery, or behavior change strategies).
    There is broad interest within the biomedical and behavioral research
    communities in applying effectiveness and outcomes approaches and
    pragmatic trial designs to such questions.
        Addressing this challenge is a high priority for the NCCAM as
    evidenced by its inclusion as one of our strategic plan objectives: to
    ``develop research examining the contributions of specific promising
    CAM approaches to better treatment and health promotion using the real-
    world methods and tools of the disciplines of observational, outcomes,
    health services, and effectiveness research.'' These methods and
    approaches also offer potential to address the challenges of conducting
    CAM research that reflects practice in the real world.
        Health provider networks, practice-based clinical research
    networks, and integrative medicine practices provide important venues
    in which to develop real-world evidence across a broad array of outcome
    measures regarding the effects and effectiveness of CAM approaches and
    their integration into strategies for treatment and health promotion.
    Practice-based research provides an important setting in which to study
    the complex interplay of intervention, the patient-provider
    relationship, and other important contextual and environmental factors
    involved in healthcare and health promotion. Indeed, many CAM and
    integrative care practices actively seek to employ these factors.
    Population-based and practice-based research strategies also offer
    great potential for developing evidence regarding the effectiveness of
    CAM-related interventions in engaging individuals in health-promoting
    behaviors and practices.
        The NCCAM is pursuing these approaches in the context of CAM and
    integrative medicine practice through collaboration with experts who
    confront similar challenges and opportunities. For example, the NCCAM
    is working with our colleagues at the Departments of Defense and
    Veterans Affairs to explore ways that CAM mind and body approaches can
    be used in integrative approaches to treat pain, stress disorders, and
    other symptoms. Further, the NCCAM has released a funding opportunity
    announcement to foster development of CAM research methodology titled,
    ``Translational Tools for Clinical Studies of Mind/Body and Manual
    Therapy CAM Interventions.'' It will ``encourage the development of
    improved research methodology to study safety, efficacy, and clinical
    effectiveness of mind-body interventions.''
        Additionally, the NCCAM has substantially increased its investment
    in research which advances our understanding of the usefulness of CAM
    interventions in real world settings. For example, in one promising
    study being funded by the NCCAM at the Mount Sinai School of Medicine,
    researchers are studying methods to utilize all available information
    regarding CAM treatments in patients with HIV. By utilizing randomized
    controlled trials along with observational studies, expert judgment and
    other types of data, they seek to develop a clinical prediction model
    to determine which CAM interventions are beneficial. Another study,
    this one at Brigham and Women's Hospital, is looking at the
    effectiveness of an integrative healthcare team at improving outcomes
    for chronic low back pain by focusing on observational data. These are
    just two examples of studies funded by the NCCAM that go beyond
    traditional double-blind studies by using real world data to support
    CAM research.
       national center for advancing translational sciences (ncats) and
                             preventative medicine
        Question. One goal of the NCATS is to accelerate the process by
    which scientific discoveries are turned into treatments and cures--
    moving discoveries more quickly through the ``valley of death'' or the
    time between discovery and available cures. In particular, the NIH has
    indicated that the NCATS would focus on the drug development pipeline
    with a hope of understanding and addressing the reasons that so many
    drugs fail in development. Meanwhile, research has increasingly shown
    how a healthy lifestyle, exercise or better nutrition can help prevent
    the onset of disease or the use of expensive medicines or treatments.
    Will translational research that focuses on prevention or disease
    control through lifestyle changes be incorporated into the new vision
    for the NCATS? If so, how? Or will the NCATS focus exclusively on drug
    development?
        Answer. As you point out, the prevention of diseases as well as
    their successful treatment may often require behavioral and lifestyle
    interventions or strategies. As such, a clear understanding of, and
    further research into, the role of behavioral and lifestyle factors in
    human health will be critical to the NCATS' success in catalyzing the
    development of new strategies to address human health and disease. The
    NCATS will support research to generate new methods and approaches
    aimed at accelerating the development, testing, and implementation of
    diagnostics, therapeutics, and prevention strategies. The NCATS
    prevention and behavioral research will be coordinated with the related
    work of the other NIH Institutes and Centers as well as with the Office
    of Disease Prevention and the Office of Behavioral and Social Sciences
    Research and carried out in part through the 60 institutions with
    Clinical and Translational Science Awards.
                 budgetary constraints on universal flu vaccine
        Question. The NIH-supported scientists are making significant
    progress toward developing a universal flu vaccine that would confer
    longer term protection against multiple influenza virus strains and
    make yearly flu shots a thing of the past. What would be the impact on
    public health if research on the universal flu vaccine were delayed or
    scaled back due to budget constraints at the NIH?
        Answer. The costly and time-consuming annual process of
    manufacturing, distributing, and administering millions of doses of
    seasonal influenza vaccine would become obsolete if researchers could
    design a vaccine that provides protection against a broad range of
    influenza strains over multiple influenza seasons. One strategy to
    overcome the need for a yearly influenza vaccine is to develop a
    vaccine against the common components of the influenza virus that do
    not change from year to year or from strain to strain. Recently,
    researchers supported by the National Institute of Allergy and
    Infectious Diseases (NIAID) have made significant breakthroughs in
    identifying the specific parts of influenza viral proteins that are
    unchanged among both seasonal and pandemic strains. So-called
    ``universal'' influenza vaccines that capitalize on these findings
    might one day provide protection against the broad range of viruses
    arising from seasonal antigenic drift (minor changes) and pandemic
    antigenic shift (major changes) that are the hallmark of influenza
    viruses.
        The NIAID is supporting a number of research projects to develop a
    vaccine that induces a potent immune response to the common elements of
    the influenza A virus that undergo very few changes from season to
    season and from strain to strain. Conserved internal proteins of the
    virus such as the M2 protein and conserved regions of the influenza
    envelope protein hemagglutinin (HA) have been identified as promising
    vaccine targets. For example, the NIAID-supported researchers found
    that a vaccine based on the M2 protein of H5N1 avian influenza virus
    elicited strong immune responses in mice. The HA protein of influenza
    virus, which is the protective antigen of the virus, has both a
    ``head'' region and a ``stem'' region. The NIAID-funded researchers
    recently generated a novel form of HA that elicited broadly cross-
    reactive antibodies against the stem region of a number of divergent
    seasonal and pandemic influenza subtypes and provided protection
    against disease in mouse challenge studies. In addition, the NIAID
    intramural researchers in the Vaccine Research Center demonstrated that
    a ``prime-boost'' vaccine strategy based on conserved regions of the HA
    protein could protect animals from infection with multiple strains of
    influenza that had been prevalent over many years. This ``prime-boost''
    vaccine strategy involves first priming the immune system with a
    vaccine containing the DNA of an influenza surface protein (HA) and
    then administering a second vaccine made from a seasonal influenza
    virus or from a weakened cold virus, to amplify the immune response
    generated by the first vaccine.
        Budget reductions could adversely affect the NIAID's ability to
    continue support of these activities in a robust and timely manner.
    Funding cuts could delay the development of new candidate vaccines for
    universal influenza and improved vaccines for seasonal influenza, as
    well as delay initiation of clinical trials necessary to test these
    vaccines. However, if budget reductions do materialize, the NIH would
    have to reevaluate its research priorities, and thus, the specific
    research areas to be impacted by such reductions would be determined at
    that time.
                   budgetary constraints on vaccine research
        Question. What other types of vaccine research underway at the NIH
    might also have to be delayed or scaled back due to budget constraints?
        Answer. Vaccines provide a safe, cost-effective, and efficient
    means of preventing illness, disability, and death from infectious
    diseases. The NIH is recognized as a worldwide leader in basic
    immunology research that underpins all vaccine development, and
    conducts or supports preclinical and clinical research on a broad
    spectrum of new and improved vaccine candidates. Recent progress in
    global vaccine research--from the RV 144 trial in Thailand that
    demonstrated that an HIV vaccine regimen provided a modest preventive
    effect, to the NIH-sponsored research advances that may unlock
    neutralizing antibody targets for a range of infectious diseases--
    highlights the need for a robust vaccine research portfolio at the NIH
    to pursue these and other advances in the field. A reduction in vaccine
    research funding at the NIH could slow the pace of ongoing efforts to
    develop new tools to prevent infectious diseases and could erode our
    ability to capitalize on scientific progress toward the development of
    vaccines.
        HIV vaccine research activities that could be slowed by reduced
    funding levels include the conduct of additional and important Phase
    IIb trials that are planned to further assess and improve upon the
    results of the RV144 HIV vaccine trial, especially in other risk groups
    and in countries other than Thailand. Reduced funding could also
    undermine other important HIV vaccine trials. For example,
    investigators conducting the HIV Vaccine Trials Network (HVTN) 505
    trial would likely be unable to expand the study to include 2,200
    participants at 21 sites in 18 U.S. cities in order to assess whether
    the candidate vaccine regimen can prevent HIV infection and/or reduce
    viral load. Decreased funding could also limit the NIH's ability to
    support efforts to identify other promising HIV vaccine candidates, and
    curtail our ability to test those candidates that hold the most promise
    and advance them into clinical trials. Again, however, specific
    research areas that may be impacted by budget reductions are subject to
    priority assessments and cannot be precisely predetermined.
        In addition to research to develop an HIV vaccine, the NIH is also
    supporting vaccine research across a range of other globally important
    diseases, including dengue, pandemic influenza, malaria, and
    tuberculosis, as well as diseases that might occur as a result of acts
    of bioterrorism. A reduction in funding could force the NIH to scale
    back efforts across many of its infectious disease research programs.
    Potential adverse effects include a reduced ability to support
    preclinical product development, which is intended to assist companies
    and academic investigators in developing essential products to prevent
    and treat infectious diseases. Reduced funding levels could limit the
    development of new and improved preclinical products required to
    confront and keep pace with emerging and re-emerging infectious
    diseases, including a planned array of vaccine-related product
    development services. Funding constraints could also adversely affect
    clinical research efforts at the NIH, limiting our ability to support
    clinical trials designed to assess influenza and malaria vaccines, and
    slowing the progress of trials. Finally, budget constraints could
    result in significant delays in advancing research projects focused on
    the development of next-generation vaccines for biodefense purposes.
                        guidance for use of class b cats
        Question. On March 18, the NIH released guidance on its plan to
    transition from the use of USDA Class B dogs to other legal sources
    (Notice NOT-OD-11-055). Why is there no mention of cats? The transition
    plan, as the NIH notes, is in accordance with the National Academy of
    Sciences report, Scientific and Humane Issues in the Use of Random
    Source Dogs and Cats in Research. The NIH notice also quotes from
    Senate report language regarding research on both dogs and cats, but
    the mention of cats was excised from the quotation. Does the NIH plan
    to issue a separate guidance dealing with cats?
        Answer. The NIH believes that sufficient numbers of cats currently
    are available through Class A vendors to support the needs of the NIH-
    supported research. Therefore, no plan for phase out is needed nor a
    plan for developing sufficient animals from Class A vendors. At
    present, the NIH has no plans to issue separate guidance dealing with
    cats.
                                 lupus research
        Question. How are the different NIH Institutes NIAID, National
    Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS),
    National Heart, Lung, and Blood Institute (NHLBI), National Institute
    of Diabetes and Digestive and Kidney Diseases (NIDDK), General
    Medicine, among others) working together to increase support for
    research on lupus? How will the new Translational Center work to
    address diseases like Lupus that cross multiple Institutes?
        Answer. Lupus is an autoimmune disease that affects the lives of
    many Americans. Ninety percent of Americans with lupus are women. Lupus
    can affect many parts of the body, including the joints, skin, kidneys,
    heart, lungs, blood vessels, and brain. Although people with the
    disease may have different symptoms, some of the most common ones
    include extreme fatigue, painful or swollen joints (arthritis),
    unexplained fever, skin rashes, and kidney problems.
        A wide range of basic, translational, and clinical research on
    lupus is being supported by many of the Institutes, Centers, and
    Offices at the NIH. Highlights of collaborative efforts include:
      --The Lupus Federal Working Group, established on behalf of the
            Department of Health and Human Services (HHS) Secretary by the
            NIH, facilitates collaboration among the NIH components, other
            Federal agencies, voluntary and professional organizations, and
            industry groups with an interest in lupus. The group is
            coordinated by the NIAMS and includes participation from nine
            other NIH Institutes and Centers.
      --The NIAID chairs the NIH Autoimmune Diseases Coordinating
            Committee, established by the Congress in fiscal year 1998 to
            increase collaboration and facilitate coordination of
            autoimmune diseases research among 21 NIH Institutes and
            Centers (ICs), other Federal agencies, and private health and
            patient advocacy groups.
      --In September 2010, the NIAMS, the National Cancer Institute (NCI),
            the NIAID, and the NIH Office of Research on Women's Health
            (ORWH) hosted a 2-day scientific meeting in Bethesda, Maryland,
            ``Systemic Lupus Erythematosus: From Mouse Models to Human
            Disease and Treatment.'' Clinicians and basic scientists from a
            variety of disciplines came together to discuss the clinical
            and molecular similarities and differences seen in human
            disease and animal models. Participants also discussed advances
            in lupus genetics, challenges and advances in the treatment of
            lupus, and emerging areas warranting further study.
      --The Autoimmunity Centers of Excellence (ACEs), sponsored by the
            NIAID, the NIDDK, the NIAMS, the National Institute of
            Neurological Disorders and Stroke (NINDS), and the ORWH,
            conduct collaborative research on autoimmune diseases,
            including lupus. This research includes clinical trials of
            immunomodulatory therapies and associated studies to understand
            the mechanism of disease and therapeutic effects.
      --The Human Leukocyte Antigen (HLA) Region Genomics in Immune-
            Mediated Diseases Consortium, a cooperative research group
            sponsored by the NIAID and the NINDS, focuses on defining the
            association between variations in the HLA genetic region and
            immune-mediated diseases, including lupus.
      --The Cooperative Study Group for Autoimmune Disease Prevention,
            sponsored by the NIAID, the NIDDK, and the Juvenile Diabetes
            Research Foundation International, focuses on research for the
            prevention of human autoimmune diseases, including lupus.
            Projects include the creation of improved models of disease
            pathogenesis and therapy to better understand immune mechanisms
            that will provide opportunities for prevention strategies.
      --The NIDDK and the NIAMS organized an April 2010 meeting, ``Novel
            Therapies to Enhance ESRD (End Stage Renal Disease) Patient
            Survival,'' which included a session on ``Lessons for
            Nephrologists from Lupus.'' The NIDDK is planning a meeting in
            mid-2012 that will focus on glomerular disease, including that
            arising from lupus.
      --The NIDDK-supported Chronic Kidney Disease Biomarkers Consortium--
            which seeks to discover and validate biomarkers for chronic
            kidney disease--is assessing inflammatory mediators as
            biomarkers for progression of kidney disease in patients with
            lupus who have had kidney biopsies. The Consortium will cross-
            validate its findings using a variety of patient cohorts,
            including those funded by the NIDDK (such as the Chronic Renal
            Insufficiency Cohort) and other ICs (such as the
            Atherosclerosis Risk in Communities Study, funded by the
            NHLBI).
        The proposed NIH NCATS has been designed to catalyze the
    development of innovative methods and technologies that will enhance
    the development, testing, and implementation of diagnostics and
    therapeutics across a wide range of conditions, including diseases such
    as lupus. The NCATS will encourage collaborations across all sectors,
    provide resources to enable therapeutics development, and support and
    enhance training in the relevant translational science disciplines.
             chronic obstructive pulmonary disease (copd) research
        Question. COPD is the third leading cause of death in the United
    States, killing approximately 141,075 Americans annually. Despite the
    growing burden of COPD, the United States does not currently have a
    comprehensive public health action plan on the disease. What activities
    are the NIH currently conducting on COPD and what is missing from the
    Federal response? Would a Federal action plan on COPD provide insights
    on how we could better address this leading killer?
        Answer. The NHLBI--the NIH component with primary responsibility
    for lung diseases--supports a wide range of research and education
    activities on COPD. Its programs include basic science and animal
    studies of underlying disease mechanisms; clinical studies of COPD risk
    factors, genetics, molecular and cellular defects, disease progression,
    and co-morbidities; translational studies of pathways and drugs that
    may lead to better treatments; clinical trials; comparative
    effectiveness research; and public and professional educational
    programs to increase awareness of COPD and knowledge about its
    symptoms, diagnosis, and treatment. Several other NIH components,
    including the NCI, the National Institute on Aging (NIA), the National
    Institute on Drug Abuse (NIDA), the National Institute of Environmental
    Health Sciences (NIEHS), the National Institute of General Medical
    Sciences (NIGMS), and the National Institute of Nursing Research
    (NINR), also support research relevant to COPD. For example, the NCI
    and the NHLBI are collaborating on an investigation of lung cancer and
    COPD. The NHLBI also cooperates with a number of other Federal agencies
    on this disease. The NHLBI Long Term Oxygen Treatment Trial is carried
    out in collaboration with CMS. The FDA collaborates with the NHLBI in a
    program called SPIROMICS, which is performing extensive molecular and
    clinical phenotyping of subjects with COPD to indentify biomarkers and
    characterize the heterogeneity in the patient population. VA Medical
    Centers participate in a number of the NHLBI clinical trials in COPD.
    The CDC is a partner in the NHLBI's COPD Learn More Breathe Better
    national public health education campaign. The NHLBI--CDC collaboration
    has led to the introduction of a module on COPD in the Behavioral Risk
    Factor Surveillance System Survey and to a recently released public
    health strategic framework for COPD prevention. Investigators supported
    jointly by the NHLBI and the AHRQ are setting up a large registry for
    comparative effectiveness research. Finally, the reports of the Surgeon
    General on the health effects of smoking are a constant guide for the
    NHLBI programmatic directions for COPD.
        These examples illustrate the extent and diversity of existing
    Government programs related to COPD, the cooperative and complementary
    interactions among Federal agencies in this area, and the central role
    that the NHLBI plays in the Government's efforts to control this
    disease. The NHLBI will continue to provide strong leadership for
    research and education activities to address this growing public health
    epidemic in collaboration with other components of the Federal
    Government. In particular, the NHLBI plans to host a forum of
    representatives from Federal Government agencies in fiscal year 2012 to
    share information regarding current activities related to COPD and to
    discuss opportunities for increasing cooperation among stakeholders and
    enhancing effectiveness of the Federal response to this debilitating
    and deadly disease. Whether a Federal action plan should be developed
    will almost certainly be a topic of discussion at the forum.
    clinical trials cooperative group program reorganization impact on the
                        gynecological cooperative group
        Question. The Institute of Medicine (IOM) of the National Academies
    was asked by the National Cancer Institute (NCI) to review the
    Institute's Clinical Trials Cooperative Group Program. One of the
    recommendations from that report is a reorganization of the Cooperative
    Group Structure that would entail restructuring and consolidating some
    of the cooperative groups. We understand that the reorganization may
    merge the Gynecological Cooperative Group (GOG) with the NSABP
    (National Surgical Adjuvant Breast and Bowel Project) and the RTOG
    (Radiation Therapy Oncology Group). Gynecological cancers are generally
    diagnosed by gynecologists and the GOG is the only cooperative group
    that studies gynecological cancers. Is our understanding of the
    reorganization plan for the GOG correct and, if so, what is the
    rationale for the planned merger of the GOG with these other groups?
    What is the scientific basis for it? If not, what is the current plan
    for the GOG? In general, what has been the process for making these
    reorganization decisions, what are the primary considerations and what
    is the timeframe and next steps for finalizing the reorganization
    decisions?
        Answer. For more than 50 years, the NCI has supported a standing
    infrastructure--the NCI Cooperative Group Program--to conduct large
    scale cancer clinical trials across the Nation, with successful
    completion of many important trials that have led to new treatments for
    cancer patients. Over time, however, oncology has evolved into a more
    molecularly based discipline including genetic sub-classification of
    tumors and individualized treatments. Accordingly, the NCI must ensure
    that the Cooperative Groups are optimally situated and well-prepared to
    continue to design, enroll and complete state-of-the-art trials for
    cancer patients.
        In 2009, the NCI commissioned the Institute of Medicine to review
    the Cooperative Group Program in order to gather independent and expert
    perspectives on the state of cancer clinical trials and to obtain
    advice about improvements in the NCI Cooperative Group Program. The IOM
    report ``A National Cancer Trials System for the 21st Century:
    Reinvigorating the NCI Cooperative Group Program'' was issued in April
    2010. The report called for a series of changes to the clinical trials
    program, including restructuring and consolidation of the adult
    Cooperative Groups.
        Transforming the NCI's Cooperative Group System into a highly
    integrated National Clinical Trials Network is one of the Institute's
    major initiatives. Enhancing the scientific basis for the clinical
    trials that the NCI supports is essential if marked improvements in
    cancer diagnosis, prevention, and therapy are to continue unabated. The
    increasing need for molecular screening of large patient populations to
    define categories appropriate for intervention provides an important
    rationale for consolidating the NCI-supported clinical research groups
    into a coordinated network. Furthermore, the NCI's commitment to
    strategic consolidation includes the requirement for a shared, and
    standardized, clinical trials data management IT infrastructure, for a
    facile process by which the phase III clinical trials portfolio is
    prioritized, and for the conduct of clinical investigations that are
    multimodal in nature, and involve understudied and underserved patient
    populations. The NCI's restructured clinical trials network, as
    envisioned, will be organized to move such studies forward both
    efficiently and with the necessary resources to conduct correlative
    scientific investigations capable of increasing the potential of these
    trials to change current medical practice.
        In addition to the ability to screen large patient populations, a
    coordinated network of a smaller number of consolidated Cooperative
    Groups will be better able to prioritize specific trials across all
    disease areas and to efficiently develop and complete multicenter
    trials. Consolidation will also enable optimal use of crucial
    biospecimens from the NCI-supported clinical trials. Finally,
    consolidation will address current disincentives to study less common
    diseases or to enroll patients to another Cooperative Group's trials.
        The NCI began a discussion with the Cooperative Group Chairs in
    November 2010 about changes to the Group structure and has participated
    in multiple discussions with the public. Throughout the process, the
    NCI has been--and remains--committed to having an open dialogue about
    changes to the Cooperative Group Program. The NCI has not dictated
    mergers among groups and instead has encouraged groups to voluntarily
    consolidate on their own. The Gynecological Oncology Group (GOG), the
    National Surgical Adjuvant Breast and Bowel Project (NSABP), and the
    Radiation Therapy Oncology Group (RTOG) have entered negotiations about
    consolidation, and as background for those discussions, the NCI program
    leadership met with the GOG Chair in May 2011 to discuss GOG concerns
    and to provide assurances that funding for gynecological cancers will
    be protected. The NCI expects that consolidation will greatly
    strengthen the overall program and will provide each of the
    consolidated Cooperative Groups with unique capabilities and a greatly
    expanded network of clinical sites to recruit patients for trials
    across the entire program.
        Since December 2010, the NCI has been gathering input from
    stakeholders and the cancer community about the plans to restructure
    the program. The comment period will close in July 2011, at which point
    the NCI will develop a concept proposal about the new structure and
    proceed with the NCI leadership review and presentation to the Board of
    Scientific Advisors in November 2011. The Funding Opportunity
    Announcement for the new Clinical Trials Program will be developed over
    the next several months, and released in July 2012. Applications will
    be accepted in November 2012 and reviewed over the next few months,
    with the consolidated Cooperative Groups being funded in fiscal year
    2014.
                                creation of suaa
        Question. Based on recommendations from the Scientific Management
    Review Board, the NIH has been considering the formation of a single
    institute that would be devoted to research related to substance use,
    abuse and addiction. The focus at the NIH seems to have turned away
    from this reorganization as attention has shifted to the creation of
    the NCATS. Is the NIH still considering the formation of this institute
    and, if so, what is the latest thinking on the creation of such an
    institute? What is the process and timeframe for making a decision and
    developing a plan?
        Answer. The NIH is actively considering the formation of a single
    Institute that will focus on substance use, abuse, and addiction-
    related research. After receiving the SMRB recommendations, Dr. Collins
    formed a Task Force of scientific experts to begin a comprehensive
    review of the NIH substance use, abuse, and addiction research
    portfolio. The Task Force has met with subject matter experts from
    across the NIH to gain a better understanding of the breadth and
    diversity of NIH's substance use, abuse, and addiction portfolio. This
    review has made it clear that this portfolio is very complex and taken
    together with the administrative steps that would be required to
    implement a reorganization of this magnitude, we determined that
    additional time would be advantageous. Additionally, during the last
    few months, many stakeholders have requested additional input into the
    development of the scientific plan for the new Institute.
        The NIH will continue to analyze our substance use, abuse, and
    addiction portfolio to provide a framework for a new proposed
    Institute. We will also develop a new scientific strategic plan to
    provide a framework for substance, use, abuse, and addiction-related
    research at NIH. This scientific strategic plan will be directed by the
    relevant Institute or Center Directors and will include extensive
    consultation with stakeholders, including scientists, patients, and the
    community, in addition to soliciting information from the Advisory
    Councils of the potentially affected Institutes and Centers. It is our
    intent to release the portfolio integration plan and the scientific
    strategic plan in the fall of 2012 for public comment, obtaining the
    Secretary's formal approval in December 2012 with the ultimate goal of
    notifying Congress through inclusion in the proposed reorganization in
    the fiscal year 2014 President's budget and standing up the new
    Institute at the beginning of fiscal year 2014 (October 1, 2013).
                   use of chimpanzees in biomedical research
        Question. In response to a request from the NIH, the Institute of
    Medicine (IOM) is conducting a study on the use of chimpanzees in
    biomedical and behavioral research. The study will assess the current
    and anticipated uses of chimpanzees in the NIH research and determine
    whether chimpanzees are and will be necessary for research needed to
    advance public health. The IOM is expected to release the report by the
    end of this year, in December 2011. Some interest groups have suggested
    that a moratorium be put in place on new funding for invasive research
    using chimpanzees pending the release of the IOM report. What would be
    the impacts of this type of temporary moratorium on the NIH research?
        Answer. NIH appreciates the Senator's continued interest in the use
    of chimpanzees in research. As you know, chimpanzees have been used in
    important research such as key studies on hepatitis, malaria, and
    vaccine research. The Senator wisely requested that NIH initiate an in-
    depth analysis to be performed by the Institute of Medicine (IOM) to
    assess the scientific need for the continued use of chimpanzees in
    biomedical research. The NIH has followed this advice and anticipates a
    thoughtful analysis and rigorous review that will be a valuable input
    as NIH charts the future course for the use of chimpanzees in research.
        In the interim, while the IOM study is ongoing, we believe it would
    be unwise to make any abrupt changes in our primate research programs.
    Therefore, we think it best to await the IOM report before making
    decisions that could have potentially far reaching implications.
                                     ______

                Questions Submitted by Senator Daniel K. Inouye
      the national institutes of health (nih) research support to hawaii
                             academic institutions
        Question. Over the years the subcommittee has urged the NIH to pay
    particular attention to developing a cadre of scientific investigators
    from rural America and in the case of Hawaii, from the neighbor
    islands. This month the College of Pharmacy at the University of Hawaii
    at Hilo will graduate its first class and I appreciate the ongoing
    efforts by the leadership of several of your Institutes to ensure that
    basic research infrastructure will be made available for their faculty
    and students. In order to attract the next generation of scientists, it
    is absolutely necessary that they be exposed to caring mentors and the
    joy of scientific inquiry in their early academic years. Those of us
    who represent rural America appreciate how difficult it can be to
    provide this critical nurturing experience, especially when bright high
    school students and undergraduate students have to face significant
    transportation barriers, such as exist in an island State. At this
    time, I would appreciate receiving a report detailing the extent to
    which your Institutes have been able to provide scientific resources to
    Hawaii, and particularly to the educational campuses on the various
    islands.
        Answer. The NIH has provided considerable support to Hawaii in an
    effort to ensure that Native Hawaiian and other Pacific Islanders have
    access to the clinical benefits of the NIH research. While research and
    training investments represent the majority of the NIH support to
    institutions in Hawaii, technical assistance to Hawaiian institutions
    has also been important. Periodically over the past decade, the NIH
    through the Office of Policy for Extramural Research Administration
    (OPERA) has provided workshops in Hawaii on the topics of the NIH
    policies, grant writing skills, and human subjects research issues
    including adverse event reporting, vulnerabilities of pediatric
    populations, and cultural issues involving Native Hawaiians
    participating in research studies. Also, the Office of Laboratory
    Animal Welfare (OLAW) presented several comprehensive overviews of the
    laws, regulations, and policies that govern the humane care and use of
    laboratory animals.
        The breadth of the research enterprise in Hawaii is quite
    impressive. In fiscal year 2010, more than 17 of the 27 NIH Institutes
    and Centers have provided support for academic institutions to conduct
    research activities ranging from basic biomedical science to behavioral
    interventions. For example, Chaminade University has a National
    Institute on Minority Health and Health Disparities (NIMHD) Building
    Research Infrastructure and Capacity grant which supports renovations,
    research training, student academic enrichment programs, and junior
    faculty career development activities. The University of Hawaii Hilo
    has received funding from the National Institute on Drug Abuse (NIDA)
    for the mentoring of clinical investigators and to conduct patient-
    oriented mental health services research, including post-traumatic
    stress disorder. The National Institute on Alcohol Abuse and Alcoholism
    (NIAAA) is supporting a project to develop research capabilities in the
    area of substance use and indigenous youth populations (e.g., Native
    Hawaiian) at Hawaii Pacific University.
        The University of Hawaii Manoa plays a pivotal role since it has
    the most robust research enterprise of all the Hawaiian institutions of
    higher education. They have received over 70 NIH awards over the past
    year. The NIMHD Center of Excellence, Partnerships for Cardiometabolic
    Disparities in Native and Pacific Peoples, has a focus on
    cardiometabolic health and eliminating health disparities among Native
    Hawaiians and other Pacific Islanders including Filipinos, Samoans, and
    Tongans. The Cancer Research Center of Hawaii is an NCI-designated
    Clinical Cancer Center and is the only such institution in the State of
    Hawaii. Moreover, the University of Hawaii Manoa Research Centers in
    Minority Institutions (RCMI) Multidisciplinary and Translational
    Research Infrastructure Expansion in Hawaii serves as the integrated
    ``home'' for clinical and translational science in the State of Hawaii.
    In addition, Hawaiian small business concerns have received NIH support
    for innovative ideas to improve health through the NIH Small Business
    Innovative Research and Small Business Technology Transfer programs.
    For example, Hawaii Biotech is taking the knowledge gained through its
    dengue fever and West Nile virus vaccine programs and applying it to
    tick-borne encephalitis. This project, Recombinant Subunit Vaccine for
    Tick-Borne Encephalitis, addresses an important unmet biodefense need
    within the United States since there is no registered tick-borne
    encephalitis vaccine.
        The NIH is pleased to be able to support biomedical research and
    student training programs to help further the health of Native
    Hawaiians and other Pacific Islanders. Recent discussions between the
    NIH Deputy Director and several faculity at the University of Hawaii
    Hilo may help identify additional gaps that could be filled through the
    NIH-University partnerships.
        Below is a list of all the NIH awards to Hawaiian institutions in
    fiscal year 2010.

                                           FISCAL YEAR 2010 HAWAII NIH AWARDS
    ----------------------------------------------------------------------------------------------------------------
            Organization name              Grant number        Institute/center              Project title
    ----------------------------------------------------------------------------------------------------------------
    CARDAX PHARMACEUTICALS, INC......  4R44AA018922-02.....  NIAAA..............  Heptax for Alcoholic Liver Disease
    CHAMINADE UNIVERSITY OF HONOLULU.  1P20MD006084-01.....  NIMHD..............  Chaminade University BRIC Project
    EAST-WEST CENTER.................  5R01HD042474-06.....  NICHD..............  Innovations in Early Life Course
                                                                                   Transitions
    HAWAII BIOTECH, INC..............  5R44AI055225-04.....  NIAID..............  Recombinant Subunit Vaccine For
                                                                                   Tick-Borne Encephalitis
    HAWAII PACIFIC UNIVERSITY........  3K01DA019884-04S1...  NIDA...............  Ecological Factors and Drug Use of
                                                                                   Native Hawaiian Youth
    HAWAII PACIFIC UNIVERSITY........  5K01DA019884-05.....  NIDA...............  Ecological Factors and Drug Use of
                                                                                   Native Hawaiian Youth
    KUAKINI MEDICAL CENTER...........  5U01AG017155-10.....  NIA................  Epidemiology of Aging and
                                                                                   Dementia--Autopsy Research
    KUAKINI MEDICAL CENTER...........  5U01AG019349-09.....  NIA................  Epidemiology of Brain Aging in the
                                                                                   Very Old
    KUAKINI MEDICAL CENTER...........  3R01AG027060-04S1...  NIA................  Defining the Healthy Aging
                                                                                   Phenotype
    NEUROBEHAVIORAL RESEARCH, INC....  5R01AA013659-08.....  NIAAA..............  Brain Morbidity in Treatment--
                                                                                   Naive Alcoholics
    NEUROBEHAVIORAL RESEARCH, INC....  5R01AA016944-03.....  NIAAA..............  Long-Term Abstinence Clinical
                                                                                   Issues and CNS Disinhibition
    NEUROBEHAVIORAL RESEARCH, INC....  5R01AA016303-04.....  NIAAA..............  Effects of heavy alcohol abuse on
                                                                                   adolescent brain structure and
                                                                                   function
    PACIFIC HEALTH RESEARCH INSTITUTE  5U10NS044448-08.....  NINDS..............  Parkinson's Disease
                                                                                   Neuroprotection Trial: Hawaii
                                                                                   Center
    PACIFIC HEALTH RESEARCH/EDUCATION  3U10NS044448-09S1...  NINDS..............  Parkinson's Disease
     INST.                                                                         Neuroprotection Trial: Hawaii
                                                                                   Center
    PACIFIC HEALTH RESEARCH/EDUCATION  3R01NS041265-10S1...  NINDS..............  Risk Factors for Pathologic
     INST.                                                                         Markers of Parkinson Disease
    PACIFIC HEALTH RESEARCH/EDUCATION  6U10NS044448-09.....  NINDS..............  Parkinson's Disease
     INST.                                                                         Neuroprotection Trial: Hawaii
                                                                                   Center
    PACIFIC HEALTH RESEARCH/EDUCATION  1R01DK089347-01.....  NIDDK..............  Reducing Cost-Related Medication
     INST.                                                                         Nonadherence in Persons with
                                                                                   Diabetes
    PANTHERA BIOPHARMA, LLC..........  5U01AI078067-03.....  NIAID..............  Antidotes to Anthrax Lethal Factor
                                                                                   Intoxication
    PAPA OLA LOKAHI..................  3U01CA114630-05S3...  NCI................  IMI HALE NATIVE HAWAIIAN CANCER
                                                                                   NETWORK
    PAPA OLA LOKAHI..................  1U54CA153459-01.....  NCI................  IMI HALE NATIVE HAWAIIAN CANCER
                                                                                   NETWORK
    PAPA OLA LOKAHI..................  3U01CA114630-05S4...  NCI................  IMI HALE NATIVE HAWAIIAN CANCER
                                                                                   NETWORK
    QUEEN'S MEDICAL CENTER...........  5R01GM063954-08.....  NIGMS..............  Molecular and functional
                                                                                   properties of the TRPM2 catioin
                                                                                   channel
    QUEEN'S MEDICAL CENTER...........  5R21CA139687-02.....  NCI................  Treatment Effects on Tumor 18F-
                                                                                   Choline Metabolism in Advanced
                                                                                   Prostate Cancer
    QUEEN'S MEDICAL CENTER...........  5R01GM080555-03.....  NIGMS..............  Molecular components of the store-
                                                                                   operated CRAC channel
    UNIVERSITY OF HAWAII AT HILO.....  5K24MH074468-05.....  NIMHD..............  Mentoring/Career Development in
                                                                                   PTSD Services Research
    UNIVERSITY OF HAWAII AT MANOA....  2P20RR016467-09A1...  NCRR...............  INBRE II: Hawaii Statewide
                                                                                   Research & Education Partnership
                                                                                   (HSREP)
    UNIVERSITY OF HAWAII AT MANOA....  3R01NS063932-03S1...  NINDS..............  HIV and Global Drug Therapies:
                                                                                   Peripheral Neuropathy
                                                                                   Complications and Mechanisms
    UNIVERSITY OF HAWAII AT MANOA....  5R01NS053345-05.....  NINDS..............  HIV-1 Proviral DNA and Monocyte
                                                                                   Phenotype in Relation to
                                                                                   Neurocognitive Function
    UNIVERSITY OF HAWAII AT MANOA....  5U54NS056883-04.....  NINDS..............  Imaging Studies in Neurotoxicity
                                                                                   and Neurodevelopment
    UNIVERSITY OF HAWAII AT MANOA....  5R01NS063932-03.....  NINDS..............  HIV and Global Drug Therapies:
                                                                                   Peripheral Neuropathy
                                                                                   Complications and Mechanisms
    UNIVERSITY OF HAWAII AT MANOA....  5R01NS053359-04.....  NINDS..............  HIV-1 Specific Immune Responses in
                                                                                   Thai Individuals with HIV
                                                                                   Dementia
    UNIVERSITY OF HAWAII AT MANOA....  5P20NR010671-04.....  NINR...............  Center for 'Ohana Self-Management
                                                                                   of Chronic Illnesses Hawaii
                                                                                   (COSMCI0): Building
    UNIVERSITY OF HAWAII AT MANOA....  5R01MH081845-02.....  NIMH...............  The Genetic Control of Social
                                                                                   Behavior in the Mouse
    UNIVERSITY OF HAWAII AT MANOA....  5R01MH079717-02.....  NIMH...............  Modeling monocyte and macrophage
                                                                                   based gene therapy for neuroAIDS
    UNIVERSITY OF HAWAII AT MANOA....  1R01EB011517-01.....  NIBIB..............  Spectral Spatial RF Pulses for
                                                                                   Gradient Echo fMRI
    UNIVERSITY OF HAWAII AT MANOA....  5R24MD001660-06.....  NIMHD..............  PILI 'Ohana Project: Partnerships
                                                                                   to Overcome Obesity Disparities
                                                                                   in Hawai'i
    UNIVERSITY OF HAWAII AT MANOA....  5R01CA115614-04.....  NCI................  Physical Activity in Women with
                                                                                   Infants
    UNIVERSITY OF HAWAII AT MANOA....  1U13HD063139-01.....  NICHD..............  Community-Based Capacity Building:
                                                                                   Academic-Community Partnerships
                                                                                   Using Partici
    UNIVERSITY OF HAWAII AT MANOA....  5G11HD054969-04.....  NICHD..............  Office of Research Development
                                                                                   (EARDA)
    UNIVERSITY OF HAWAII AT MANOA....  5F32HD055000-03.....  NICHD..............  Origins of neuronal patterning in
                                                                                   animal development
    UNIVERSITY OF HAWAII AT MANOA....  2T34GM007684-29A1...  NIGMS..............  Minority Access to Research
                                                                                   Careers
    UNIVERSITY OF HAWAII AT MANOA....  1R01GM093116-01.....  NIGMS..............  Gene regulatory network evolution
                                                                                   and the origin of biological
                                                                                   novelties
    UNIVERSITY OF HAWAII AT MANOA....  1P41GM094091-01.....  NIGMS..............  Accessing Cyanobacterial Chemical
                                                                                   Diversity: A Unique Natural
                                                                                   Product Library
    UNIVERSITY OF HAWAII AT MANOA....  5R01GM083158-03.....  NIGMS..............  Transposon Based Mammalian
                                                                                   Transgenesis and Transfection
    UNIVERSITY OF HAWAII AT MANOA....  1R01GM088266-01A1...  NIGMS..............  RSK-2 regulates integrin-mediated
                                                                                   adhesion and migration
    UNIVERSITY OF HAWAII AT MANOA....  1K01DK090091-01.....  NIDDK..............  Neighborhood Characteristics and
                                                                                   Diabetes Incidence in the
                                                                                   Multiethnic Cohort Stu
    UNIVERSITY OF HAWAII AT MANOA....  5R25DK078386-04.....  NIDDK..............  High School Students STEP-UP To
                                                                                   Biomedical Research
    UNIVERSITY OF HAWAII AT MANOA....  5R01DK079684-04.....  NIDDK..............  Multimedia intervention to
                                                                                   motivate ethnic teens to be
                                                                                   designated donors
    UNIVERSITY OF HAWAII AT MANOA....  3U10CA063844-17S1...  NCI................  Hawaii Minority-Based Clinical
                                                                                   Community Oncology Program
    UNIVERSITY OF HAWAII AT MANOA....  5P01CA114047-05.....  NCI................  Pathogenesis of mesothelioma
    UNIVERSITY OF HAWAII AT MANOA....  5R01CA058598-12.....  NCI................  Collaborative Genetic Study of
                                                                                   Ovarian Cancer Risk
    UNIVERSITY OF HAWAII AT MANOA....  5R01CA120799-04.....  NCI................  Testing Alternative Stage Models
                                                                                   of Smoking Cessation: An
                                                                                   Intervention Study
    UNIVERSITY OF HAWAII AT MANOA....  5R37CA054281-18.....  NCI................  Multiethnic Cohort Study of Diet
                                                                                   and Cancer
    UNIVERSITY OF HAWAII AT MANOA....  1R03CA150041-01.....  NCI................  Urinary Estrogen Metabolites in a
                                                                                   2-year Soy Trial Among
                                                                                   Premenopausal Women
    UNIVERSITY OF HAWAII AT MANOA....  3U54CA143727-02S1...  NCI................  University of Guam/Cancer Research
                                                                                   Center of Hawaii Partnership (1
                                                                                   of 2)
    UNIVERSITY OF HAWAII AT MANOA....  3P30CA071789-12S9...  NCI................  Cancer Research Center of Hawaii
    UNIVERSITY OF HAWAII AT MANOA....  3P30CA071789-12S8...  NCI................  Cancer Research Center of Hawaii
    UNIVERSITY OF HAWAII AT MANOA....  5U24CA074806-12.....  NCI................  The Colon Cancer Family Registry:
                                                                                   Hawaii
    UNIVERSITY OF HAWAII AT MANOA....  1R01CA153154-01.....  NCI................  Self-Control as a Moderator for
                                                                                   Effects of Mass Media on
                                                                                   Adolescent Substance Use
    UNIVERSITY OF HAWAII AT MANOA....  3U24CA074806-11S1...  NCI................  The Colon Cancer Family Registry:
                                                                                   Hawaii
    UNIVERSITY OF HAWAII AT MANOA....  7R01CA124687-03.....  NCI................  The Sphingolipid Pathway in Colon
                                                                                   Cancer Chemoprevention
    UNIVERSITY OF HAWAII AT MANOA....  2U10CA063844-17.....  NCI................  Hawaii Minority-Based Clinical
                                                                                   Community Oncology Program
    UNIVERSITY OF HAWAII AT MANOA....  5R21AT004844-02.....  NCCAM..............  Mechanisms by which selenium
                                                                                   influences T helper cells during
                                                                                   immune responses
    UNIVERSITY OF HAWAII AT MANOA....  5R21AT005139-02.....  NCCAM..............  Exploratory Studies on the Anti-
                                                                                   Breast Cancer Function of Bamboo
                                                                                   Extract
    UNIVERSITY OF HAWAII AT MANOA....  7R01AI054128-06.....  NIAID..............  Mechansim of activation of innate
                                                                                   immunity by ISS-DNA
    UNIVERSITY OF HAWAII AT MANOA....  5R01AI075057-03.....  NIAID..............  Intraspecies Transmission and
                                                                                   Infectivity of Insectivore-Borne
                                                                                   Hantaviruses
    UNIVERSITY OF HAWAII AT MANOA....  5R01AI071160-04.....  NIAID..............  Malarial Immunity in Pregnant
                                                                                   Cameroonian Women
    UNIVERSITY OF HAWAII AT MANOA....  1R01AI089999-01.....  NIAID..............  Selenoprotein K modulates calcium-
                                                                                   dependent signaling in immune
                                                                                   cells
    UNIVERSITY OF HAWAII AT MANOA....  5R01AI074554-03.....  NIAID..............  Global HIV Drug Therapies and
                                                                                   Mitochondrial Complications and
                                                                                   Mechanisms
    UNIVERSITY OF HAWAII AT MANOA....  5U01HG004802-03.....  NHGRI..............  Epidemiology of Putative Causal
                                                                                   Variants in the Multiethnic
                                                                                   Cohort
    UNIVERSITY OF HAWAII AT MANOA....  5R01DA021146-04.....  NIDA...............  RGR-based motion tracking for real-
                                                                                   time adaptive MR imaging and
                                                                                   spectroscopy
    UNIVERSITY OF HAWAII AT MANOA....  5R01DA021856-04.....  NIDA...............  The Project Success Model:
                                                                                   Evaluation of a Tiered
                                                                                   Intervention
    UNIVERSITY OF HAWAII AT MANOA....  5K02DA020569-05.....  NIDA...............  Parallel MRI for Substance Abuse
                                                                                   Research
    UNIVERSITY OF HAWAII AT MANOA....  5K23DA020801-05.....  NIDA...............  Neurodevelopment of
                                                                                   Methamphetamine Exposed Children
    UNIVERSITY OF HAWAII AT MANOA....  5R01DA019912-04.....  NIDA...............  Parallel MRI for High Field
                                                                                   Neuroimaging
    UNIVERSITY OF HAWAII AT MANOA....  5K24DA016170-07.....  NIDA...............  Neuroimaging and Mentoring in Drug
                                                                                   Abuse Research
    UNIVERSITY OF HAWAII AT MANOA....  1R24DA027318-01.....  NIDA...............  Factors for enhanced neurotoxicity
                                                                                   in methamphetamine abuse in HIV
                                                                                   infection
    UNIVERSITY OF HAWAII AT MANOA....  5K01DA021203-04.....  NIDA...............  Impact of Marijuana Exposure on
                                                                                   Brain Maturation
    UNIVERSITY OF HAWAII AT MANOA....  3R25RR024281-03S1...  NCRR...............  Pacific Education and Research for
                                                                                   Leadership in Science (PEARLS)
    UNIVERSITY OF HAWAII AT MANOA....  5P20RR024206-03.....  NCRR...............  Institute for Biogenesis Research:
                                                                                   COBRE
    UNIVERSITY OF HAWAII AT MANOA....  5P20RR016453-09.....  NCRR...............  COBRE: Center for Cardiovascular
                                                                                   Research
    UNIVERSITY OF HAWAII AT MANOA....  5R25CA090956-08.....  NCI................  Nutritional & Behavioral Cancer
                                                                                   Prevention in a Multiethnic
                                                                                   Population
    UNIVERSITY OF HAWAII AT MANOA....  5R01CA126895-03.....  NCI................  Whole Genome Scan for Modifier
                                                                                   Genes in Colorectal Cancer
    UNIVERSITY OF HAWAII AT MANOA....  5R01CA129063-03.....  NCI................  Inflammation and Innate Immunity
                                                                                   Genes and Colorectal Cancer Risk
    UNIVERSITY OF HAWAII AT MANOA....  5R03CA135699-02.....  NCI................  A pooled analysis of mammographic
                                                                                   density and breast cancer risk
    UNIVERSITY OF HAWAII AT MANOA....  5R01CA140636-02.....  NCI................  Characterizing Mitochondrial DNA
                                                                                   Susceptibility to Breast,
                                                                                   Colorectal, and Prosta
    UNIVERSITY OF HAWAII AT MANOA....  5R01CA080843-09.....  NCI................  Effects of Soy on Estrogens in
                                                                                   Breast Fluid and Urine
    UNIVERSITY OF HAWAII AT MANOA....  5U54CA143727-02.....  NCI................  University of Guam/Cancer Research
                                                                                   Center of Hawaii Partnership (1
                                                                                   of 2)
    UNIVERSITY OF HAWAII AT MANOA....  5K23HL088981-03.....  NHLBI..............  Cardiovascular autonomic function
                                                                                   in HIV virologic failure
    UNIVERSITY OF HAWAII AT MANOA....  5R01HL095135-03.....  NHLBI..............  Role of Oxidative Stress and
                                                                                   Inflammation in HIV
                                                                                   Cardiovascular Risk
    UNIVERSITY OF HAWAII AT MANOA....  1R01HL098423-01A1...  NHLBI..............  Role of mTOR in the diabetic heart
    UNIVERSITY OF HAWAII AT MANOA....  5UH1HL073449-07.....  NHLBI..............  University of Hawaii Research
                                                                                   Scientist Award in Molecular
                                                                                   Cardiology
    UNIVERSITY OF HAWAII AT MANOA....  5R21HL087289-02.....  NHLBI..............  Pseudoxanthoma elasticum: Elastic
                                                                                   fibers alterations and
                                                                                   characterization of seru
    UNIVERSITY OF HAWAII AT MANOA....  5R01HL081863-05.....  NHLBI..............  Rho kinase in immune-mediated
                                                                                   atherosclerosis
    UNIVERSITY OF HAWAII AT MANOA....  5R01AI068525-05.....  NIAID..............  Role of macrophages in HIV
                                                                                   Lipoatrophy
    UNIVERSITY OF HAWAII AT MANOA....  5G12RR003061-25.....  NCRR...............  Research Outcomes Accelerating
                                                                                   Discoveries for Medical
                                                                                   Applications and Practice
    UNIVERSITY OF HAWAII AT MANOA....  1R01HD060722-01A1...  NICHD..............  Contribution of Sperm Nucleus to
                                                                                   Paternal DNA Replication
    UNIVERSITY OF HAWAII AT MANOA....  5R21AG032405-02.....  NIA................  A Needle in a Haystack: New
                                                                                   approaches to Alzheimer's Drug
                                                                                   Discovery from Natural
    UNIVERSITY OF HAWAII AT MANOA....  2P20RR018727-06A1...  NCRR...............  Pacific Center for Emerging
                                                                                   Infectious Diseases Research
    UNIVERSITY OF HAWAII AT MANOA....  5P20MD000173-09.....  NIMHD..............  Partnerships for Cardiometabolic
                                                                                   Disparities in Native and Pacific
                                                                                   Peoples
    UNIVERSITY OF HAWAII AT MANOA....  5R01GM057873-11.....  NIGMS..............  Cyclopentannelation in Total
                                                                                   Synthesis
    UNIVERSITY OF HAWAII AT MANOA....  1U54RR026136-01A1...  NCRR...............  RCMI Multidisciplinary And
                                                                                   Translational Research
                                                                                   Infrastructure EXpansion Hawaii
    UNIVERSITY OF HAWAII AT MANOA....  5R25RR024281-03.....  NCRR...............  Pacific Education and Research for
                                                                                   Leadership in Science (PEARLS)
    ----------------------------------------------------------------------------------------------------------------

     the national institute of nursing research (ninr) support for end-of-
                   life care and health disparities research
        Question. The NINR will soon be celebrating its 25th anniversary.
    The late Senator Quentin Burdick and I were active in establishing the
    original Center and I am confident he would share my enthusiasm for how
    nicely it has matured over the years. At this time I would appreciate
    an update on the extent to which the NINR has been able to co-fund
    various initiatives with other NIH Institutes, particularly in the
    areas of end-of-life issues and racial and geographical disparities.
        Answer. Improving palliative and end-of-life care and eliminating
    health disparities are critical components of the NINR's research
    mission. Consistent with this mission, as well as the Institute's
    longstanding practice of extensive collaboration with other NIH ICs,
    the NINR co-funds numerous scientific efforts with other ICs focused on
    these two important topics.
        As the lead NIH Institute on issues related to end-of-life care
    research, the NINR, with support from partners across the NIH, will
    convene a forum on August 10-12, 2011, entitled ``The Science of
    Compassion: Future Directions in End-of-Life and Palliative Care.'' A
    part of the NINR's 25th Anniversary commemoration, this forum is
    intended to energize and mobilize palliative and end-of-life care
    research and to draw attention to palliative and end-of-life care
    processes, options available to patients and their families, and the
    healthcare community's obligation to address these complex needs. This
    event is co-sponsored by the following NIH partners: National Institute
    on Aging (NIA), Office of Rare Diseases Research, Office of Research on
    Women's Health, National Center for Complementary and Alternative
    Medicine, and the NIH Clinical Center Department of Bioethics.
        In addition, the NINR and the NIH Common Fund recently awarded $7.1
    million in funding provided by the American Recovery and Reinvestment
    Act to support a Palliative Care Research Cooperative (PCRC), a multi-
    institution effort to conduct collaborative research on palliative and
    end-of-life care. The PCRC will bring together experienced,
    multidisciplinary investigators to facilitate innovative, high-impact,
    clinically useful palliative care research to inform practice and
    health policy. The PCRC will address challenges associated with
    conducting research with individuals with life-limiting conditions, and
    could lead to significant improvements in the evidence base for
    palliative and end-of-life care.
        NINR also collaborates with other ICs to support basic, clinical,
    and translational research to address health disparities across the
    life span. The NINR currently co-funds an initiative focused on
    reducing health disparities in minority and underserved children,
    including children from: racial/ethnic minority groups; rural and low-
    income populations; and geographically isolated locations. The NINR,
    and other Institutes, have supported various important projects under
    this initiative. For example, the NINR-supported investigators are
    testing interventions to improve the well-being of African American,
    Hispanic, and White families where grandmothers are raising
    grandchildren. These custodial grand-families are at high risk for
    psychological difficulties and limited access to needed services. This
    initiative is co-funded with the following NIH Institutes: National
    Institute of Child Health and Human Development; National Heart, Lung,
    and Blood Institute; National Institute on Alcohol Abuse and
    Alcoholism; and the National Institute on Deafness and Other
    Communication Disorders.
        Additionally, researchers funded by the NINR and the NIA developed
    the Resources for Enhancing Alzheimer's Caregivers Health (REACH) II
    program which teaches caregivers about Alzheimer's disease, managing
    stress, and maintaining their own health. In a large sample of African
    American and White caregivers for Alzheimer's patients, those in the
    REACH II intervention reported better physical, emotional, and overall
    health and had lower scores for depression which contributed to
    reducing caregiving burden. To address the need for support of
    caregivers, particularly in racially/ethnically diverse families,
    multiple efforts across the Federal Government are currently underway
    to implement REACH in the community.
               health messages for the native hawaiian population
        Question. According to the fiscal year 2012 NIH CJ, the National
    Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
    ``supports a robust information dissemination and outreach program to
    distribute research-based information to the public, patients, and
    their healthcare providers.'' The NIAMS supported National
    Multicultural Outreach Initiative ``is creating a sustainable network
    of partners to assist in the development and dissemination of health
    messages and materials for racial and ethnic minority populations.''
    The Initiative will focus its efforts on reaching many different
    minority/ethnic populations including Native Hawaiians. ``Working with
    existing NIAMS partners, the Institute will develop research-based
    self-care messages and products, and ensure their distribution through
    trusted health and multicultural community channels. The NIAMS
    implemented critical phases of the Initiative in fiscal year 2011,
    namely, the development and pretesting of culturally and linguistically
    appropriate health messages and materials through audience research.''
        The NIAMS and its National Multicultural Outreach Initiative are
    supporting the development of health messages for racial and ethnic
    minority populations. What types of health messages are being developed
    and tested for the Native Hawaiian population?
        Answer. In fiscal year 2011, the NIAMS completed qualitative
    research with members of multicultural communities, including Native
    Hawaiians, to help inform the development of culturally appropriate and
    useful health education products for adults with medical conditions
    affecting the bones, joints, muscles, and skin. The NIAMS conducted a
    total of 18 focus groups (2 with Native Hawaiians), and 20 in-depth
    interviews (2 with Native Hawaiians) to gather feedback from
    individuals on preferences for different message concepts and formats
    for communicating health messages. The information gleaned from this
    audience research will enable the development of tailored products that
    raise awareness about the availability of reliable, research-based
    health information and resources from the NIAMS and partner
    organizations to help patients and their families manage their
    conditions.
        The NIAMS National Multicultural Outreach Initiative relies on the
    guidance and input from its working groups for the development and
    dissemination of health messages and products. These groups are
    comprised of national experts from multicultural communities, and
    include representation from the Native Hawaiian community.
       the national institute on minority health and health disparities
                 (nimhd) centers of excellence (coe) in hawaii
        Question. The fiscal year 2012 congressional justification states
    that the NIMHD has supported 91 COE sites in 35 States, the District of
    Columbia, Puerto Rico, and the U.S. Virgin Islands. According to the
    CJ, the ``types of institutions are diverse and include Historically
    Black Colleges and Universities, Hispanic-Serving Institutions, Tribal
    Colleges and Universities, Alaskan Native, and Native Hawaiian Serving
    Institutions.'' In fiscal year 2010, the 51 active COEs conducted
    transdisciplinary research on high priority diseases/conditions
    including ``cardiovascular disease, stroke, cancer, diabetes, HIV/AIDS,
    infant mortality, mental health, and obesity that disproportionately
    affect racial/ethnic minority and other health disparity populations.''
        Is the NIMHD currently supporting a COE at a Native Hawaiian
    Serving Institution? What high priority diseases or conditions are the
    focus of research at a COE in a Native Hawaiian Serving Institution?
        Answer. The NIMHD COE represent a scientific platform for
    innovative research projects, research training, and effective
    community engagement to address the health status of health disparity
    populations. The NIMHD has provided funding for a COE at the University
    of Hawaii Manoa since September 2002. This COE, Partnerships for
    Cardiometabolic Disparities in Native and Pacific Peoples, is a
    regional focal point for improving cardiometabolic health and
    eliminating health disparities among Native Hawaiians and other Pacific
    Islanders, including Filipinos, Samoans, and Tongans.
        The primary focus of the COE is obesity and diabetes which are
    known risk factors for cardiovascular disease. Eighty-two percent of
    Native Hawaiians are overweight or obese, which is considerably higher
    than the national average of 53 percent. Pacific Islander women with
    diabetes have a higher risk of myocardial infarction. Through dedicated
    efforts over the years, Partnerships for Cardiometabolic Disparities in
    Native and Pacific Peoples has made significant contributions to the
    improvements in the health of Native Hawaiians and other Pacific
    Islanders.
        In addition, supplemental funding was provided in July 2010 to
    support the establishment of the Comparative Effectiveness Research
    Approaches to Eliminate Cardiometabolic Disparities initiative as part
    of the COE. The intent of the project is to train researchers in
    comparative effectiveness research, to conduct innovative research, to
    establish diabetes and cardiometabolic disease registries, and to
    disseminate research results to communities with health disparities in
    Hawaii.
                     hereditary angiodema research support
        Question. Dr. Collins, I would like to thank you for your
    leadership of the National Institutes of Health, including its
    continuing emphasis on rare diseases. As you are aware, the NIH
    provides critical opportunities for research surrounding orphan
    conditions which otherwise may not have an opportunity for significant
    research. Recently, constituents and members of the U.S. Hereditary
    Angioedema Association (USHAEA), based in Honolulu, brought to my
    attention the absence of Federal support since 2009 for hereditary
    angioedema (HAE) research. I would appreciate receiving a report on why
    funding for this disease was eliminated and what your efforts are
    toward reinvigorating hereditary angioedema research support.
        Answer. HAE is a rare genetic disorder. HAE patients suffer from
    swelling of the hands, feet, abdomen, face and/or throat. Especially
    the latter is a major medical emergency that may be fatal. Estimates
    for the prevalence of HAE range from 1 in 10,000 to 1 in 50,000 people
    in the United States.
        In 2009, a number of research projects focusing on hereditary
    angioedema came to a natural end. For example, the most extensive
    project, sponsored by the Eunice Kennedy Shriver National Institute of
    Child Health and Human Development, C1 Inhibitor Gene and Hereditary
    Angioneurotic Edema, was last funded in 2008 after 23 years of research
    and concluded in 2010. The Principal Investigator did not apply for
    renewed funding for this project.
        The National Center of Research Resources (NCRR) funded Mount Sinai
    General Clinical Research Center project: CHANGE Trial (C1-Inhibitor in
    Hereditary Angioedema Nanofiltration Generation Evaluating Efficacy):
    Open-Label Safety/Efficacy Repeat Exposure Study of C1 Esterase
    Inhibitor (Human) in the Treatment of Acute Hereditary Angioedema (HAE)
    Attacks participant visits ended in March 2009 and closed in September
    2009. The results were published in the NEJM in August 2010 (PMID
    20818886). Currently, the NCRR-funded Mount Sinai Clinical and
    Translational Science Award supports the Phase III Randomized Double
    Blind, Placebo controlled Multicenter Study of Icatibant for
    Subcutaneous Injection in Patients with Acute Attacks of Hereditary
    Angioedema.
        The NCRR General Clinical Research Center at the University of
    Texas Medical Branch at Galveston (UTMB) conducted the Randomized,
    Placebo-Controlled, Double-blind Phase II Study of the Safety and
    Efficacy of Recombinant Human C1 Inhibitor for the Treatments of Acute
    Attacks in Patients with Hereditary Angioedema. The study ended in May
    2009.
        The NCRR-funded University of Texas Medical Branch at Galveston
    (UTMB) Clinical and Translational Science Award represents an
    additional site which conducted the Phase III Randomized Double-Blind,
    Placebo-Controlled Multicenter Study of Icatibant for Subcutaneous
    Injection in Patients with Acute Attacks of Hereditary Angioedema
    (HAE). This study was completed in May 2011.
        Currently, we also are supporting three training grants with
    projects investigating HAE, two from National Institute of Allergies
    and Infectious Diseases and one from the National Heart, Lung, and
    Blood Institute. These training grants are critical since they train
    the next generation of investigators. The trainees are expected to
    continue their careers with a research emphasis on HAE. The NIH would
    welcome the opportunity to support meritorious research studies
    focusing on hereditary angioedema (HAE).
        To stimulate future research activities and applications we would
    encourage investigators and advocates of HAE research to submit an
    application for a scientific conference grant. In addition to helping
    to identify research opportunities and needs and develop a research
    agenda and research priorities for HAE, such a conference could create
    significant research interest in this particular rare disease. The
    Office of Rare Diseases Research (ORDR), collaborating with other NIH
    research institutes, would be pleased to confer with the U.S.
    Hereditary Angioedema Association (U.S. HAEA) and interested research
    investigators about your concerns.
                    cancer prevelance and research in hawaii
        Question. Over the years the NCI has systematically invested in
    research activities targeting the unfortunately high incidence of
    cancer among my State's Native Hawaiian population. At one point the
    NCI researchers reported that Native Hawaiian women had the highest
    incidence of breast cancer in the world. I am confident that progress
    has been made and would appreciate a report describing the NCI's future
    plans for targeting the special needs of these indigenous people.
        Answer. The NCI funds research that focuses on Native Hawaiian,
    other Pacific Islander, and Asian American populations. These studies
    are supported to illuminate the causes of cancer in these populations;
    to improve screening rates so that when cancer appears, it can be
    treated at an early stage; to increase knowledge about treatment
    options so that patients and their physicians can make more informed
    choices about their care; to fund registries, surveys, and reports that
    generate the latest statistics and inform researchers, policy makers,
    and the public; to support cohorts that provide a population base from
    which to conduct important future research, and ultimately to prevent
    cancers in these populations.
    Current Efforts
        The NCI's Prostate, Lung, Colorectal, and Ovarian Cancer Screening
    Trial (PLCO) and National Lung Screening Trial (NLST) studies, with
    more than 200,000 participants, include programs in Hawaii and from
    diverse ethnic populations. At the Pacific Health Research and
    Education Institute in Honolulu, of the 13,200 study participants in
    Hawaii, approximately half were Asians (5,553) and Native Hawaiians and
    other Pacific Islanders (1,053).
        In the area of clinical trial recruitment of minorities, the
    University of Hawaii Minority-Based Community Clinical Oncology Program
    (MB-CCOP), funded since 1994, provides access to the NCI clinical
    trials in cancer prevention, treatment, and control to both children
    and adults.
        The NCI Community Network Program (CNP) Centers address disparities
    at the community level with outreach, research, and training. Two CNPs
    are oriented to Pacific Islanders (Imi Hale and Weaving an Islander
    Network for Cancer Awareness, Research and Training, or WINCART) and
    two other CNPs are focused on underserved Asians (Asian American
    Network for Cancer Awareness, Research, and Training, or AANCART, and
    the Asian Community Cancer Health Disparities Center, or ACCHD).
        National Outreach Program (NOP) supported by the Imi Hale Native
    Hawaiian Cancer Network is designed to reduce cancer incidence and
    mortality among Native Hawaiians by maintaining and expanding an
    infrastructure that:
      --Promotes cancer awareness within Native Hawaiian communities;
      --Provides education and training to develop Native Hawaiian
            researchers; and
      --Facilitates research that aims to reduce cancer health disparities
            experienced by Native Hawaiians.
        The Imi Hale Native Hawaiian Cancer Network made progress toward
    reducing cancer incidence and mortality among Native Hawaiians through
    a project, ``Woman to Woman-Micronesians United Lay Educator Program''
    for Native Hawaiians focused on increasing breast and cervical cancer
    screening. Six months of outreach activities resulted in screening of
    150 women. CNP-Southern California developed culturally tailored
    educational resources specifically for Native Hawaiians and the
    Marshallese, in colorectal cancer screening, which resulted in a
    library of culturally relevant resources. In addition to these primary
    efforts, the CNP Native Hawaiian trainees have submitted 40 grant
    applications and a total of 12 were ranked high enough for funding.
        Imi Hale has a dedicated Community Health Educator, who seeks to
    bridge the gap between the community and the research community by
    developing culturally tailored cancer information. For instance, to
    help women learn to do self-breast exams to detect lumps early, Imi
    published Breast Health Shower Cards in nine languages. In terms of
    breast cancer education, Imi Hale has produced a DVD entitled ``A
    Journey of Hope: When a Young Woman Gets Cancer.'' Seeking creative
    ways to educate women about breast cancer, Imi Hale created a breast
    cancer computer game (http://imihale.org/game/click_to_start.html). In
    addition, a series of brochures for Native Hawaiian breast cancer
    survivors called ``Talking Story Booklets'' has been developed. The
    outreach component works closely with such partners as the five Native
    Hawaiian healthcare Systems positioned on five islands.
      --Imi Hale Clinical partners include: Community Health Centers
            serving Native Hawaiian clients, the Queen`s Cancer Center and
            other hospitals, and the State-contracted Breast and Cervical
            Cancer Control Programs; and
      --Imi Hale Community partners include: Association of Hawaiian Civic
            Clubs, Hawaii State Tobacco Coalition, Office of Hawaiian
            Affairs, and other community agencies.
        A Comprehensive Partnership to Reduce Cancer Health Disparities
    Program between the University of Hawaii Cancer Center (UHCC) and the
    University of Guam (UOG) have an NCI-funded partnership with the aim of
    enhancing the awareness of cancer and cancer prevention and ultimately
    reducing the impact of cancer on the population in Hawaii, the
    Territory of Guam and the other U.S.-associated Pacific Island
    territories. The partnership supports projects designed to develop
    culturally appropriate guidelines for tobacco use prevention and
    cessation in youth with the underlying hypothesis that interventions to
    prevent tobacco use are more likely to succeed if they conform to
    culturally relevant guidelines developed with the active participation
    of the target youth themselves. The long-term goal of the community-
    based participatory outreach program is to engage the community as
    equal partners in tobacco control and cancer prevention research. The
    partnership also supports investigator-initiated cancer research
    projects that address different aspects of cancers in Hawaii and Guam
    including the development of protocols for studying oral precancerous
    lesions and other health risks among betel nut users in Hawaii, the
    Territory of Guam and the other U.S.-associated Pacific Island
    territories.
        The NCI Community Cancer Centers Program (NCCCP) is designed to
    create a community-based cancer center network to support basic,
    clinical and population-based research initiatives, addressing the full
    cancer care continuum--from prevention, screening, diagnosis,
    treatment, and survivorship through end-of-life care. The NCCCP pilot
    has added the Queen's Medical Center, Honolulu, Hawaii (The Queen's
    Cancer Center) to its 30 hospital network.
    Future Research
        The NCI will be launching a program to foster evidence-based
    research, data collection, and analysis within Asian American and
    Pacific Islander (AAPI) populations and subpopulations through a unique
    collaboration with the University of Guam, the University of Hawaii,
    the Pacific Regional Central Cancer Registry, and the Pacific Island
    Cancer Council. The NCI developed the Health Information National
    Trends Survey (HINTS) to monitor changes in the rapidly evolving field
    of health communication by collecting data across the Nation. The
    HINTS-Guam program will pilot test a localized survey instrument geared
    specifically to AAPI populations and subpopulations, including
    Chamorros and other Pacific Islanders living on Guam. Data collected
    from this survey will increase understanding of cancer information
    seeking, experiences, and behaviors (prevention, screening, treatment,
    etc.) among AAPI populations. Discussions have also begun on a HINTS
    pilot project to be conducted in Hawaii.
                 kidney disease and diabetes research in hawaii
        Question. It has recently come to my attention that my State's
    Filipino population has an extraordinarily high incidence of kidney
    disease. Similarly, several ethnic groups in Hawaii (including Native
    Hawaiians) have been found to have high incidences of diabetes.
    Accordingly, I would appreciate receiving a report on your efforts to
    develop initiatives targeting these populations, and particularly those
    which would stress prevention and perhaps diet.
        Answer. Data show that Filipinos in Hawaii seem to have a
    disproportionate burden of kidney disease. The NIDDK is naturally very
    concerned about kidney disease in Hawaiians, including the health
    disparity in the Filipino population, and has several initiatives in
    place to address the problem. First, our National Kidney Disease
    Education Program (NKDEP) provides materials that can be used in
    Hawaii's high risk populations. The NKDEP's materials aim to raise
    awareness of the seriousness of kidney disease, the importance of
    testing those at high risk (those with diabetes, high blood pressure,
    or a family history of kidney failure), and the availability of
    treatment to prevent or slow kidney failure. NKDEP's extensive new
    offerings on dietary intervention in chronic kidney disease for
    providers and patients would be particularly useful.
        The National Diabetes Education Program (NDEP) is sponsored by the
    NIDDK and Centers for Disease Control and Prevention (CDC) and includes
    more than 200 partners working together to improve the treatment and
    outcomes for people with diabetes, promote early diagnosis, and prevent
    or delay the onset of type 2 diabetes, a leading cause of kidney
    disease. The NDEP has a major focus on Asian Pacific Islanders; it has
    translated educational materials into Tagalog, one of the languages
    spoken in the Fillipino population. These materials address both
    prevention of diabetes and prevention of complications such as kidney
    disease. The University of Hawaii is a site for the Diabetes Prevention
    Program Outcomes Study, which recently reported data showing durability
    of effect of lifestyle intervention and the drug metformin at
    preventing or delaying onset of type 2 diabetes at 10 years follow-up.
        People whose disease progresses to kidney failure can be treated
    with a kidney transplant, though limitations on available donor organs
    is a chronic problem. The NIDDK's ``Minority Organ Donation Program''
    initiative supports an investigator at the University of Hawaii, Dr.
    Cheryl Albright, whose research focuses on educating Filipino high
    school students about signing up (on drivers' licenses) to donate
    organs. Students from Honolulu and other smaller Islands (including
    rural areas) are participants. The grant is in the fourth year and
    results are quite encouraging. The Filipino community is very
    interested in kidney transplants, and participated in the original
    National Minority Organ and Tissue Transplant Education Program (http:/
    /mottep.org/) to rally the community around kidney donation from
    relatives and friends.
        In another initiative, the NIDDK, in collaboration with the CDC and
    the Indian Health Service, has funded eight Tribal Colleges and
    Universities in the initiative ``Diabetes Education in Tribal
    Schools.'' This effort developed supplemental curricula, to be used in
    K-12 schools in American Indian and Alaska Native communities, about
    prevention and better management of diabetes, the most common cause of
    kidney failure. Although the cultural content is directed primarily
    toward American Indians, some Hawaiian schools participated in piloting
    the curricula. The project is completed and the curricula are being
    fielded in tribal schools. Also, the curricula were distributed to and
    currently are being used in Hawaiian schools, primarily on the Big
    Island of Hawaii.
                    stroke disparities in the united states
        Question. I am concerned that stroke apparently remains the number
    two killer in the United States and a major cause of disability. In
    addition, stroke affects some segments and regions of our population
    more than others. I understand that the State of Hawaii ranks 20 out of
    52 highest in our Nation for age-adjusted stroke deaths. Death rates
    from a certain type of stroke (intracerebral hemorrhage) are higher
    among Asians/Pacific Islanders than among Whites. More than 20 percent
    of Native Hawaiians or other Pacific Islanders have high blood
    pressure, a leading risk factor for stroke. Yet, the NIH invests only 1
    percent of its budget on stroke research. What is your Institute doing
    to address the disparities that exist in stroke burden among different
    cultural and racial populations in the United States?
        Answer. Stroke research at the NIH is comprehensive and includes
    research on basic disease mechanisms; epidemiology studies to assess
    stroke risk, occurrence and outcomes in the population; clinical
    research to develop effective prevention and acute treatment
    approaches; and development of strategies for improving recovery and
    rehabilitation in stroke patients. Clinical research in stroke is
    particularly a high priority at the National Institute of Neurological
    Disorders and Stroke (NINDS)--approximately 50 percent of its large
    Phase III trials are on stroke.
        The NINDS also supports major research initiatives aimed at better
    defining stroke risk, incidence and outcomes in the United States and
    among different subpopulations. Collections of population-based data
    help identify and explain health disparities in stroke, and inform the
    development of preventive interventions that target high risk
    populations.
      --In the Reasons for Geographic and Racial Differences in Stroke
            (REGARDS) study, investigators are exploring the geographical
            and racial influences on stroke risk in a cohort of about
            30,000 individuals, about half of whom live in the ``stroke
            belt'' region of the Southeastern United States. This large
            study has produced over 70 publications that have led to a
            better understanding of disparities in stroke in the United
            States. Data generated from this study continue to help
            researchers pinpoint why the stroke rate is higher in this
            region, and among African Americans, and to develop targeted
            strategies for intervention. Recent data from REGARDS indicated
            that overall time spent in the stroke belt is more predictive
            of hypertension--a powerful risk factor for stroke--than is
            current residence in the stroke belt. Data from the REGARDS
            study have also revealed that stroke survivors were more likely
            to have unrecognized hypertension and diabetes.
      --The Stroke Disparities Program is a multi-component program to
            address major stroke challenges in the African American
            community. The three projects in this program include:
        --an intervention strategy to increase stroke knowledge and reduce
                the time from symptom onset to hospital arrival (ASPIRE);
        --an intervention utilizing navigators for secondary stroke
                prevention that targets adherence to poststroke care
                (PROTECT DC); and
        --an observational imaging study to better understand racial and
                ethnic differences in risk, occurrence and outcomes of
                small brain hemorrhages (DECIPHER).
      --The NOrthern MAnhattan Study (NOMAS) investigators have been
            following a cohort of stroke-free adults, including whites,
            African Americans and Caribbean Hispanics in a Northern
            Manhattan community. Researchers are collecting imaging,
            biological and neuropsychological data to evaluate the
            relationship between biological and imaging predictors for
            stroke, heart attack and death, as well as cognitive decline.
            Using these markers in combination with other factors such as
            diet, alcohol use, smoking, and history of peripheral vessel
            disease, investigators are developing risk factor and cognitive
            ability assessment tools. Genetic studies involving this and
            other cohorts, have suggested that there may be genetic
            susceptibilities underlying left atrium size and
            atherosclerosis of the carotid arteries that contribute to
            stroke.
      --BASIC (Brain Attack Surveillance in Corpus Christi) investigators
            are comparing trends in recurrent stroke, as well as functional
            and cognitive outcomes following stroke, in 5,000 non-Hispanic
            whites and Mexican Americans in Corpus Christi, Texas. Data
            from this study have shown that Mexican Americans with atrial
            fibrillation are more likely to have recurrent strokes than
            whites, and the strokes are more likely to be severe. The
            investigators are also exploring associations between
            biological and social stroke risk factors, and recently found,
            for example, that the density of fast food restaurants was
            associated with neighborhood stroke risk.
      --Ethnic and Racial variation in Intracerebral Hemorrhage (ERICH), a
            study that was initiated in 2010, will identify differences in
            intracerebral hemorrhage (ICH) risk factor distribution and
            outcomes by race and ethnicity. This project will compare 3,000
            cases of ICH, among African Americans, Hispanics and non-
            Hispanic whites, to 3,000 demographically matched controls in
            order to identify differences in risk factor distribution and
            ICH outcome by race, ethnicity and location of ICH and to
            determine differences in imaging characteristics among African
            Americans and Hispanics compared to whites. The investigators
            will also collect DNA in order to combine with other cohorts to
            perform a genome-wide association study (GWAS) to identify
            genes that affect risk of ICH in whites, African Americans and
            Hispanics.
      --The Alaska Native Stroke Registry (ANSR) is a population-based
            surveillance study on the epidemiology of stroke in Alaska
            Natives. Comprehensive assessment of the stroke epidemiology,
            vascular risk factors, cultural understandings of vascular
            health and lifestyle, and structural barriers to risk reduction
            strategies has informed the development of a community level
            prevention intervention pilot program that aims to reduce the
            burden of stroke in the Alaska Native population.
                                     ______

                    Questions Submitted by Senator Herb Kohl
        comparison of age-related macular degeneration treatments trials
        Question. The National Institutes of Health (NIH) recently released
    results of the Comparison of Age-Related Macular Degeneration
    Treatments Trials (CATT), which found that Lucentis and off-label
    Avastin are similarly efficacious at treating neovascular age-related
    macular degeneration (wet AMD). Now that the CATT study is released,
    what is the NIH going to do with the results? The taxpayers spent
    millions of dollars on the CATT study to determine the comparative
    effectiveness of the drugs. I believe the trial results ought to be
    actionable.
        Answer. The National Eye Institute (NEI) recognizes its
    responsibility to fund and conduct scientifically valid clinical
    research and to disseminate the study results to the professional
    clinical community and the public.
        We collaborate extensively with ophthalmic organizations to apprise
    their members of CATT results. In particular, outreach to professional
    groups was the most effective and efficient means of reaching the
    clinical ophthalmic community regarding CATT findings. For example, the
    American Academy of Ophthalmology (AAO) has 30,000 member
    ophthalmologists who are the primary eye care professionals that treat
    wet AMD. The NEI worked with AAO to disseminate CATT results through
    the AAO's Website, newsletters, press releases, and its upcoming annual
    meeting. Additionally, the AAO Executive Director has written
    extensively to the membership in support of CATT. We will continue to
    work with AAO as they develop ``preferred practice plans'' for the
    treatment of wet AMD. The Association for Research in Vision and
    Ophthalmology (ARVO) is a 12,500 member eye research organization
    comprised of clinicians and investigators. CATT investigators presented
    their results at ARVO's annual meeting in May 2011. These two
    organizations will continue to provide information and guidance to
    their members about CATT so that the results can inform clinical care
    decisions.
        The NEI is also working to inform the public about the CATT
    findings. The release of the study was accompanied by an extensive
    media outreach campaign. For example, the NEI hosted a news briefing
    for journalists where the NEI Director and CATT investigators presented
    study findings and fielded questions from more than 60 media outlets.
    Supplemental background video footage was made available to broadcast
    outlets. A press release was also distributed widely to media outlets.
    The NEI generated robust media coverage for CATT, coverage that has
    been intense and more widespread than for other recent studies (see
    accompanying table), despite media competition from the royal wedding
    and the death of Osama Bin Laden. As follow-up to the initial media
    coverage, the NEI distributed CATT results to members of the National
    Eye Health Education Program (NEHEP), a partnership of 60 public and
    private organizations dedicated to eye health education. This program
    provides the NEI with direct access to community-based public health
    education efforts, and we are preparing an NEI webpage devoted to CATT
    along with a brochure including public health information about CATT.
        Of note, the May publication of CATT reported on first year
    results. The second year results will be published in the spring of
    2012. At that time, the NEI will repeat its efforts with professional
    organizations and the media to disseminate CATT results.

                                            NEI CLINICAL TRIAL MEDIA COVERAGE
    ----------------------------------------------------------------------------------------------------------------
                                                                                         Number of      Pick-up of
                               Study name                               Impressions    original news   original news
                                                                      (millions) \1\      stories       stories \2\
    ----------------------------------------------------------------------------------------------------------------
    CATT.--Comparison of AMD Treatment Trials (2011)................             296             157             234
    ETROP.--Early Treatment for Retinopathy of Prematurity Study                 257              20             138
     (2010).........................................................
    DRCR-DME.--Ranibizumab plus laser therapy for diabetic macular               232              42              29
     edema (2010)...................................................
    ACCORD.--Action to Control Cardiovascular Risk in Diabetes Eye                 8               9         ( \3\ )
     Study (2010)...................................................
    GWAS-AMD.--Genome-wide association study genes associated with                16              13               6
     AMD (2010).....................................................
    LALES.--Los Angeles Latino Eye Study (2010).....................               3               7         ( \3\ )
    Myopia.--Increased pevalence of myopia in United States (2009)..             158              76         ( \3\ )
    SCORE.--Standard Care vs. Corticosteroid for Retinal Vein                    150              27              79
     Occlusion (2009)...............................................
    LCA.--Leber Congenital Amaurosis (2009).........................             155              32              37
    CITT.--Convergence Insufficiency Treatment Trial (2008).........              44             117             183
    CDS.--Cornea Donor Study (2008).................................              63             118              74
    AREDS2.--Age Related Eye Disease Study 2 (2006).................              17              92         ( \3\ )
    ----------------------------------------------------------------------------------------------------------------
    \1\ Impressions.--Number of people exposed to the news story in print, online, or on television based on
      expected readership or viewers.
    \2\ Pick-up.--When an original story is reprinted in another outlet (i.e., an Associated Press article is
      printed in The Washington Post), it is counted as a pick-up.
    \3\ Not applicable.

        Question. How does the NIH share this information with other
    agencies within the Federal Government?
        Answer. In the preparation for the release of CATT, the NEI held a
    teleconference with relevant Department of Health and Human Services
    (HHS) agencies (FDA, CMS, CDC, and AHRQ) to inform them of CATT results
    and to coordinate the HHS response to media. In accordance with
    standard HHS and NIH operating procedures, the NEI distributed a draft
    press release for clearance within DHHS and responded to various issues
    prior to approval for release. This effort helped ensure a coordinated
    HHS response to CATT. Since this initial interaction, both the NEI
    staff and CATT leadership have been contacted by CMS staff to discuss
    the implications of the CATT study results.
        Question. Has the NIH's National Eye Institute considered what
    effect, if any, the CATT study might have on future physician
    prescribing behavior regarding Lucentis vs. off-label Avastin to treat
    wet AMD?
        Answer. Avastin, which inhibits the formation of new blood vessels,
    was approved by the FDA in 2004 for the treatment of colon cancer.
    Avastin is effective as an anti-cancer agent because inhibiting the
    blood supply to tumors inhibits their growth. Since wet AMD is due to
    leakage from new, abnormal blood vessels, ophthalmologists began trying
    Avastin off-label to treat this form of AMD in 2006 on the basis of
    both the cancer data and clinical trial results for Lucentis during the
    FDA approval process. At that time, Avastin off-label was the only
    available treatment for wet AMD that led to improvement in vision.
        The vast majority of patients treated for wet AMD participate in
    Medicare. After Lucentis was FDA-approved in 2007, most
    ophthalmologists continued to use Avastin because the cost was
    significantly lower than for Lucentis and because a number of reported
    cases demonstrated Avastin efficacy that appeared similar to that
    reported in the Lucentis clinical trials. Last May, Dr. Ross Brechner
    and colleagues (Centers for Medicare and Medicaid Services) and Dr.
    Phillip Rosenfeld (Bascom Palmer Eye Institute, University of Miami)
    published an analysis of Medicare claims for wet AMD during 2008.\1\
    They found that 64.4 percent of patients received Avastin and 35.6
    percent received Lucentis and concluded that despite its off-label
    designation, intravitreal Avastin is currently standard-of-care
    treatment for wet AMD. Medicare payments totaled $536.6 million for
    Lucentis and $20.3 million for Avastin.
    ---------------------------------------------------------------------------
        \1\ Brechner, R. J, P. J. Rosenfeld, J. D. Babish, and S. Caplan.
    Pharmacotherapy for Neovascular Age-Related Macular Degeneration: An
    Analysis of the 100 percent Medicare Fee-For-Service Part B Claims
    File. American Journal Ophthalmology 151:887-895, 2011.
    ---------------------------------------------------------------------------
        CATT was a very tightly controlled, well-designed study, which
    compared the two drugs in more than 1,100 patients. The exceptionally
    wide dissemination of CATT results means that the retinal specialists
    who treat AMD and the patients they care for are undoubtedly well aware
    of the equivalence. As such, an increase in the number of patients
    receiving Avastin as first line therapy is to be expected. Careful
    monitoring of use of the drugs by CMS is expected.
        Importantly, some patients with wet AMD respond better to Avastin,
    while others to Lucentis. In practice, if one is ineffective, the other
    may be tried. The fact that more than one drug is available is
    beneficial and allows ophthalmologists and patients treatment choices.
                                     ______

                Questions Submitted by Senator Mary L. Landrieu
                         interim status of idea program
        Question. Scientists have expressed their concern about programs
    that have been placed before under ``interim'' status and tend to lose
    direction and in some cases have disappeared. I am particularly
    concerned about the Institutional Development Award (IDeA) Program,
    which is so important to Louisiana. What is the reason for placing a
    program that serves 23 States and Puerto Rico on an interim status?
        Answer. The IDeA Program has not been placed in an interim status.
    Under the proposed creation of the National Center for Advancing
    Translational Sciences (NCATS), we considered moving the program to a
    new unit called the Office of Research Infrastructure Programs within
    the Office of the Director, Division of Program Coordination, Planning,
    and Strategic Initiatives. However, following extensive consultation
    and feedback from multiple stakeholders, including grantees,
    professional organizations, and the public, we concluded that the IDeA
    program is most closely aligned scientifically and programmatically
    with the mission and goals of the National Institute of General Medical
    Sciences (NIGMS). Therefore, the National Institutes of Health (NIH)
    intends on moving the IDeA program and the IDeA program staff to the
    NIGMS. We are confident the program will flourish as a vital component
    of the NIGMS.
      placement of national center for research resources (ncrr) programs
        Question. For many years the programs housed at the NCRR have
    worked synergistically to serve the IDeA community. Can this synergy
    continue by placing these programs under a single NIH institute?
        Answer. There is no reason why synergies established between IDeA
    and other NCRR programs will not continue to flourish at both the
    national level through programmatic communication and collaboration
    across institutes and centers and at the local level through
    institutional collaborations and interactions. Fostering collaborative
    research networks is an inherent part of the IDeA mission, and it
    excels at establishing connections and linkages. IDeA institutions
    currently collaborate with grantees of the Research Centers in Minority
    Institutions (RCMI) program as well as the Science Education
    Partnership Award Program (SEPA). The NIH encourages such
    collaborations, and they will continue.
      placement of idea within the national institute of minority health
                              disparities (nimhd)
        Question. It has been made public that some institute directors who
    have been approached to house IDeA programs have voiced reservations
    about housing these programs in their institutes based on their
    programmatic mission and staffing needs. We also know that the Advisory
    Council for the NIMHD has enthusiastically endorsed the idea of placing
    these programs in the NIMHD. Have you considered the possibility of
    placing these programs under the management of the NIMHD?
        Answer. An NIH National Center for Research Resources (NCRR) Task
    Force, charged with identifying the optimal new home for the IDeA
    program, considered a range of options, including its placement within
    the NIMHD. After careful analysis, fact-finding, and consultation, the
    Task Force recommended that this program be transferred to the National
    Institute of General Medical Sciences (NIGMS). The IDeA program fosters
    health-related research and enhances competitiveness of investigators
    at institutions located in States in which the aggregate success rate
    for applications to the NIH has been historically low. By its nature,
    the program extends beyond traditional capacity building in supporting
    research projects that are designed to strengthen future investigator-
    initiated research applications, most of which are focused on
    addressing basic science questions. The NIGMS has a basic science focus
    as well as a longstanding focus on institutional capacity building and
    career development. Given these synergies, the Task Force determined
    that the mission of the IDeA program is most closely aligned with the
    mission of the NIGMS and that the NIGMS would be the optimal new home
    for the IDeA Program.
    the clinical and translational science awards (ctsas) and the national
              center for advancing translational sciences (ncats)
        Question. With the final five CTSAs expected to be announced in the
    near future, I have a couple of questions for Dr. Collins on this
    program's future direction now that it is being moved to the new NCATS.
        Because the NCATS is primarily focused on drug development, what
    will become of the community research and integration aspect of the
    CTSAs' mission? Will community involvement continue to be a central
    focus of this program?
        The CTSAs represent translational research across the country, but
    there are no centers in the gulf south--an area with significant health
    needs that would benefit greatly from a CTSA and could contribute much
    to the network of centers. Is geographic distribution considered as
    CTSA sites are being selected?
        Answer. The mission of the NCATS will be to catalyze the
    development of innovative methods and technologies that will enhance
    the development, testing, and implementation of diagnostics and
    therapeutics across a wide range of human diseases and conditions. In
    addition to strengthening and streamlining the therapeutics development
    process, the NCATS will support research aimed at accelerating the
    development, testing, and implementation of products and techniques,
    including diagnostics, drugs, biologics, medical devices, and
    behavioral interventions, for the diagnosis, treatment, and prevention
    of disease. The CTSAs possess the requisite expertise across the full
    spectrum of translational research, and they will be integral to the
    success of the NCATS. The involvement of research sites across the
    Nation and the study of the integration of research findings at the
    community level will continue to be an important focus of the CTSA
    program.
        Institutions with CTSAs that are either close to or interact with
    communities and populations along the Gulf include the University of
    Texas Medical Branch in Galveston and the University of Alabama in
    Birmingham. The CTSA at the University of Texas Health Sciences Center
    at Houston serves gulf communities through its strong connections to
    UT's Brownsville campus.
        With regard to the selection of the CTSA sites, NCRR has used the
    peer review process to establish priority scores to guide funding
    decisions. All applications, together with their priority scores, were
    then reviewed by the National Advisory Research Resources Council,
    which is able to make recommendations, where needed, concerning
    geographic distribution. Going forward, scientific merit will continue
    to be the principal selection criterion, and considerations of program
    relevance and public health need will be factored in at subsequent
    levels of review.
     geographic distribution of small business innovative research (sbir)
                                     grants
        Question. As one of the largest funders of SBIR grants, can you
    tell me what the NIH is doing to ensure that there is a more balanced
    portfolio and increased participation from States that have
    traditionally received a small number of SBIR grants?
        Answer. The NIH prioritizes SBIR and Small Business Technology
    Transfer (STTR) outreach to States that historically have submitted a
    small number of SBIR applications and/or have lower success rates than
    the overall SBIR/STTR success rates. Each year, we hold an annual SBIR/
    STTR conference, this year on the NIH's campus in Maryland, but in past
    years in Ohio, Nebraska, Nevada, Georgia, and North Carolina. We also
    participate in direct one-on-one contact with current and potential
    applicants/grantees in several national, State, and regional SBIR
    events per year. Currently in fiscal year 2011, the NIH staff have
    already attended, presented, or participated on the SBIR program in
    Arizona, California, Florida, Kansas (via webinar), Kentucky, Maine,
    Maryland, Michigan, Missouri, Nebraska, New York, Virginia, Washington,
    DC, and Wisconsin. On the horizon is an event in Louisiana. These
    conferences attract attendees from across the country, and offers
    attendees an opportunity for one-on-one consultations with the NIH
    SBIR/STTR program, review and grants management staff. In addition,
    there are a number of other conferences/meetings in which the NIH
    offers consultation to SBIR/STTR applicants and similar outreach is
    conducted by the individual NIH Institutes and Centers. In all venues,
    the NIH educates as many current and potential applicants/grantees as
    possible about the SBIR program.
        In addition to these in-person opportunities, the NIH staff are
    available to provide assistance to all applicants from concept
    development through grant life-cycle by phone, email, webinars, and our
    Web sites. SBIR funding decisions ultimately are made at the NIH
    Institute level and are based on scientific merit (as determined by our
    two level peer-review system), available funding, and programmatic
    priority. Information about all NIH grant awards, including State
    location, can be accessed through our RePORTER Web site at http://
    projectreporter.nih.gov/reporter.cfm.
                         antiviral development for flu
        Question. Discussions regarding the prevention of a flu pandemic
    frequently focus on vaccine development, but it is my understanding
    that effective management of influenza will require the continued
    development of new antiviral drugs. I was pleased to learn that the
    National Institute of Allergy and Infectious Diseases (NIAID) recently
    held a workshop on the influenza antiviral research pipeline. Are we
    making progress in the development of antiviral drugs for influenza and
    does the NIAID have plans for any new initiatives in this area?
        Answer. In March 2011, the NIAID held the Influenza Antiviral
    Research Pipeline Workshop, which brought together stakeholders from a
    variety of sectors including academia, business, and government.
    Discussions focused on the state of influenza antiviral research and
    spanned all aspects from discovery to advanced clinical development.
    Workshop proceedings will be posted on the NIAID Web site in the near
    future.
        Currently, there are four drugs licensed to treat influenza:
    oseltamivir (Tamiflu), zanamivir (Relenza), rimantadine (Flumadine),
    and amantadine (Symmetrel). Ongoing NIAID efforts in influenza drug
    development include combination studies with licensed and experimental
    drugs, studies of the safety of antiviral drugs in infants and
    children, studies of broad-spectrum antivirals, studies of antibody
    therapeutics, and evaluation of novel drug targets. For example, the
    NIAID also supports in vitro and in vivo antiviral screening and other
    preclinical services to identify new antiviral candidates. In fiscal
    year 2010, more than 100,000 compounds were evaluated by high-
    throughput screening assays against multiple influenza A strains, and
    several hundred compounds were tested for their efficacy against
    influenza in animal models. Also, the NIAID is supporting the
    preclinical and clinical development of a novel antiviral drug
    candidate; a safety study has been completed and a Phase II clinical
    trial is ongoing.
        To meet the need for effective influenza management strategies, the
    NIAID will continue to support a robust influenza antiviral research
    portfolio, including discovery of drug targets, identification of
    compounds with novel mechanisms of action, and clinical studies to
    evaluate promising drug candidates.
                                stroke in women
        Question. My State of Louisiana lays in the Stroke Belt, a group of
    Southeastern States where stroke death rates are the highest in our
    Nation. I am concerned about the seriousness of stroke, particularly
    among women who account for 61 percent of stroke fatalities. Please
    tell this subcommittee what studies the NIH is conducting to combat
    stroke in women, including prevention and rehabilitation efforts. In
    addition, please highlight planned activities in these areas.
        Answer. The National Institute of Neurological Disorders and Stroke
    (NINDS) supports a large and broad portfolio of stroke research that
    includes numerous efforts to better understand and address the
    substantial burden that stroke places on women.
        The NINDS supports multiple research studies on the physiological
    basis for gender-related differences in stroke risk and outcomes. One
    study funded by the NINDS and the National Heart, Lung, and Blood
    Institute (NHLBI) will follow a cohort of women to identify biological
    and physiological markers associated with ischemic stroke, and to
    establish which of those are influenced by sex hormones or menopausal
    status. This study will inform future development of gender-specific
    predictors for stroke risk. In another study, investigators will
    explore how biological functions programmed by sex-specific chromosomes
    are related to gender differences observed in cell death pathways
    activated by a stroke. The NINDS also funds a study to investigate the
    role of estrogen receptors in gender-related differences in incidence
    of stroke associated with cardiovascular surgical procedures.
        The NINDS supports a number of surveillance studies that aim to
    illuminate differences in stroke knowledge, risk and outcomes among
    different sub-populations, including women, in order to inform
    development of tailored prevention intervention strategies. For
    example, the Reasons for Geographical and Racial Differences in Stroke
    Study (REGARDS) is a large cohort of more than 30,000 participants,
    more than half of whom are women. This comprehensive assessment of
    disparities in stroke risk and incidence is one of the largest
    longitudinal cohort studies of African Americans and the only national
    study of the epidemiology of cognitive change. The large representation
    of women in this important population-based study is significant as it
    allows for data analyses of gender-specific differences, as well as
    among different racial populations. For example, a recent publication
    from this study revealed that markers for inflammation led to more
    accurate vascular disease risk stratification, particularly in blacks
    and women, since they are at higher risk for increased levels of this
    marker. Studies from REGARDS will continue to improve our understanding
    of differences in stroke risk among a diverse U.S. population.
        The NINDS supports a large number of clinical studies to improve
    acute management and long-term outcomes in stroke. All of the NIH-
    funded clinical trials are required to set and justify target
    enrollment by race, ethnicity, and gender and to report on enrollment
    progress. Approximately half of the participants in all of the NINDS-
    supported stroke clinical trials are women so that data can be analyzed
    for gender-specific differences. These trials are investigating new
    approaches to treat acute stroke and brain hemorrhage, to reduce brain
    damage due to stroke and to improve rehabilitation strategies, which
    will provide all patients, including women, and their physicians with
    more therapy options and a better chance of survival and recovery after
    a stroke.
        The NINDS is embarking on a new stroke planning effort in 2011 to
    update research progress and activities in response to prior research
    recommendations, and to identify a specific set of high priority areas
    for advancing stroke research over the next 5-10 years. The planning
    effort will specifically address stroke prevention, treatment, and
    recovery in subpopulations, with a special emphasis on women and gender
    differences. Recommendations from this planning effort will inform
    future NINDS research investment and activities related to stroke in
    women.
                                 nci priorities
        Question. Dr. Varmus, you have stated a desire for the NCI to
    continue to fund as many grants as in previous years, even if this
    means cuts in other areas, such as the Cancer Center program. Could you
    tell us a bit more about your plans and priorities for the institute
    and possible changes on the horizon?
        Answer. Cancer is a complex disease requiring many approaches to
    make progress. It is important to fund as many meritorious grants as we
    possibly can within the resources we are given, because individual
    grants allow us to pursue new ideas effectively. We will be finding
    savings across the Institute by taking money away from routine
    administrative expenses, making cuts to the intramural and Cancer
    Centers programs, and by conducting reviews of large programs and
    cutting where possible. This will allow us to achieve acceptable grant
    levels and to protect certain imperatives.
        In addition, realignment of the clinical trial cooperative groups,
    as recommended by the Institute of Medicine report in 2010, will
    improve the efficiency of the overall system and enable the cooperative
    groups to conduct state of the art oncology research more consistently.
    Funding for this effort is a priority for the NCI. A second imperative
    is maintaining the pace of work on cancer genomics. The Cancer Genome
    Atlas (TCGA), a project undertaken by the National Cancer Institute and
    the National Human Genome Research Institute to gain an understanding
    of the molecular basis of cancer, has already produced results in brain
    cancer and ovarian cancer. The rate of discovery is dependent on the
    level of funding. Therefore, we place a high priority on protecting
    funding for this project and other meritorious efforts in cancer
    genomics. As TCGA is expanded to include many cancer types, the
    ultimate goal is to ensure that genetic information is applied to
    prevention, diagnosis, and treatment of cancer in clinical practice.
                                     ______

                Questions Submitted by Senator Richard J. Durbin
                    economic benefits of biomedical research
        Question. According to a recent Families USA report, every $1
    investment in medical research stimulates $2.43 in business activity--
    such as support staff, supplies, food services, and building
    development. Are you aware of other studies that attempt to quantify
    the local impact of the Federal investment in medical research? Are
    there any efforts underway at the NIH to capture the return-on-
    investment that taxpayers receive as a result of the Federal commitment
    to research?
        Answer. To the best of our knowledge, there are two comprehensive
    published studies that attempt a quantification of the economic effects
    of the NIH spending at the State level, both supported by research
    advocacy groups. Both studies rely on the Regional Input-Output
    Modeling System (RIMS II), developed by the Bureau of Economic Analysis
    at the Department of Commerce. RIMS II measures, at a State level, the
    economic multiplier effect generated by local demand. National
    aggregate averages are extrapolated from State data.
        The first report was released in June 2008 by Families USA and was
    titled ``In your own backyard.'' \1\ The report found, among other
    things, that in fiscal year 2007, the NIH funding supported more than
    350,000 jobs that generated wages in excess of $18 billion in the 50
    States. The average wage for these jobs was $52,000. It also found that
    $1 spent by the NIH funding generates $2.21 of business activity at the
    State level. This $2.21 figure is an average; individual States may
    vary (e.g., in Illinois, the figure is $2.43.)
    ---------------------------------------------------------------------------
        \1\ FamiliesUSA. (2008). In Your Own Backyard: How NIH Funding
    Helps Your State's Economy. Washington, DC. Retrieved December, 2008
    from http://www.familiesusa.org/issues/global-health/publications/in-
    your-own-backyard.html.
    ---------------------------------------------------------------------------
        More recently, in May 2011, the organization ``United for Medical
    Research'' released a report, titled: ``An Economic Engine. NIH
    Research, Employment and the Future of the Medical Innovation Sector.''
    \2\ The report draws three conclusions: the NIH extramural research is
    an important source of income and employment around the country; the
    complementary relationship between public NIH investment and private
    industry development is critical to the health and well-being of our
    Nation; and the U.S. medical innovation sector is facing increasing
    challenges in maintaining America's competitiveness and position as the
    world leader in medical research. The report found that in fiscal year
    2010, the NIH directly and indirectly supported nearly 488,000 jobs and
    produced $68 billion in new economic activity and that $1 of the NIH
    investments generated, on average, $2.60 of business activity, at the
    national level.
    ---------------------------------------------------------------------------
        \2\ Ehrlich, E. (2011). United for Medical Research from http://
    www.unitedformedicalresearch.com/wp-content/uploads/2011/05/
    UMR_Economic-Engine.pdf.
    ---------------------------------------------------------------------------
        The NIH has worked closely with experts in the field of labor and
    health economics and R&D evaluation on several projects. One of the
    studies found that a one dollar increase in the NIH funding leverages
    an additional 35 cents in funding from non-Federal sources.\3\
    ---------------------------------------------------------------------------
        \3\ Blume-Kohut, M., Kumar, K. B., & Sood, N. (2008). The Impact of
    Federal Funding on University R&D. Retrieved November 7, 2009 from
    http://www.rand.org/labor/seminars/brown_bag/pdfs/2008_sood.pdf
    ---------------------------------------------------------------------------
        Another study determined that 33 percent of all drugs approved by
    FDA and 58 percent of approved priority review new molecular entities
    (which tend to be the most innovative drugs) cite an NIH-funded
    publication or an NIH patent.\4\
    ---------------------------------------------------------------------------
        \4\ Lichtenberg, F. R., & Sampat, B. (2011). What are the
    respective roles of the public and private sectors in pharmaceutical
    innovation? Health Affairs, 30(2), 332-338.
    ---------------------------------------------------------------------------
        Another study showed that multinational companies in the
    pharmaceutical sector tend to locate their R&D facilities next to hubs
    of skilled workers. This finding underscores the importance of the NIH
    investments in sustaining a strong research infrastructure system in
    the United States and avoiding the loss of private sector investments
    in R&D that could be moved abroad.\5\
    ---------------------------------------------------------------------------
        \5\ Thursby, J. G., & Thursby, M. C. (2009). Is the US a Target of
    R&D Globalization? Location, Type and Purpose of Biomedical Industry
    R&D in New Locations: NBER. Report prepared for the NIH Office of
    Science Policy Analysis.
    ---------------------------------------------------------------------------
        Another study, Economic Impact of the Human Genome Project (http://
    www.battelle.org/publications/humangenomeproject.pdf), which was
    commissioned by the Life Technologies Foundation and prepared by the
    Battelle Technology Practice Foundation, assessed the benefits of the
    Federal investment of the Human Genome Project (HGP). Finding that the
    benefits are widespread and increasing over time, the report cites
    among other factors, the production of 3.8 million job-years of
    employment (one job-year for each $1,000 invested) and the generation
    of personal income (wages and benefits) exceeding $244 billion over the
    last 7 years, an average of $63,700 per job-year.
        With regard to whether there are other efforts underway at the NIH
    to capture the return-on-investment that taxpayers receive as a result
    of the Federal commitment to research, the NIH is also participating in
    the STAR METRICS Project.\6\ \7\ STAR METRICS is a collaboration
    between Federal science agencies and research institutions to document
    how Federal science investments support knowledge creation, economic
    growth, workforce development and a broad range of societal outcomes.
    The program's goal is to build a data infrastructure that will bring
    together inputs, outputs, and outcomes from a variety of sources in as
    open a fashion as possible.
    ---------------------------------------------------------------------------
        \6\ https://www.starmetrics.nih.gov/.
        \7\ Lane, J., & Bertuzzi, S. (2011). Research funding. Measuring
    the results of science investments. Science, 331(6018), 678-680.
    ---------------------------------------------------------------------------
        STAR METRICS has two levels and the NIH participates in both. Level
    I documents the initial effect of S&T investments on employment using
    administrative records from research institutions. This approach goes
    beyond the RIMSII model, capturing the actual, rather than estimated,
    number of jobs supported. Level II builds on Level I by connecting
    sources of funding, recipients of funding, interactions among
    scientists (in both the public and private sector) and the products of
    research over time ranging from the most proximal (such as meeting
    presentations and publications) to more distal (such as the development
    of a new drug).
                         congenital heart disease (chd)
        Question. Congenital Heart Disease (CHD) is one of the most
    prevalent birth defects in the United States and a leading cause of
    birth defect-associated infant mortality. Due to medical advancements
    more individuals with congenital heart defects are living into
    adulthood. Please provide an update of research within the NIH,
    particularly the National Heart, Lung, and Blood Institute (NHLBI)
    related to congenital heart defects across the life-span. The
    healthcare reform law included a provision, which I authored, that
    authorizes the CDC to track the epidemiology of congenital heart
    disease, with an emphasis on adults with CHD and expanding
    surveillance. If adequately funded, how could a population-surveillance
    system for adults with CHD support the NIH's ability to investigate CHD
    across the life-course and across subgroups?
        Answer. The NIH supports research on CHD across the lifespan. For
    example, as part of its Pediatric Heart Network, the NHLBI is following
    participants in an earlier study of the Fontan surgical procedure to
    assess functional health status, neurocognitive performance, and
    transitions from pediatric care to adult care for CHD. Through its
    Bench-to-Bassinet program, the NHLBI is examining the genetic causes of
    CHD and the effects of genetic variation on the long-term clinical
    outcomes of affected children as they grow older. The NHLBI also funds
    a research partnership between the Adult Congenital Heart Association
    and the Alliance of Adult Research in Congenital Cardiology that seeks
    to improve care delivery and long-term outcomes for adults with CHD and
    also to inform research designs for studies in adults. Through its
    Pumps for Kids, Infants, and Neonates (PumpKIN) program the NHLBI
    supports development of pediatric devices for congenital heart disease.
    In addition, an investigator-initiated project seeks to develop a blood
    pump for patients who have undergone the Fontan surgery. Patients who
    have had the surgery experience significant morbidity due to diminished
    blood flow, especially as they grow into adulthood, and a device to
    assist blood flow could dramatically improve care.
        An adequately funded population-surveillance system for adults with
    CHD could facilitate the NIH research. The surveillance data would help
    the NIH ensure that its research efforts address the full range of
    heart conditions, risk factors, and complications across the lifespan;
    provide the potential to link genetic and other biological information;
    permit monitoring of the effectiveness of new preventive and
    therapeutic strategies; and identify a potential pool of patients who
    could benefit from participation in various research activities.
    However, funding was not provided for this provision in the Affordable
    Care Act, and no funds have been requested within the budget for the
    Centers for Disease Control and Prevention to implement it.
                            the cancer genome atlas
        Question. The National Cancer Institute is making tremendous
    progress with the Cancer Genome Atlas (TCGA) in sequencing cancer
    genomes and then using scientific discoveries to further specific
    fields of cancer research. What is the status of the TCGA gastric
    cancer project? Specifically, the pilot project to utilize contiguous
    biopsies to sequence the genome for the diffuse gastric cancer subtype?
    How will the NCI utilize these groundbreaking discoveries to further
    the field of gastric cancer research? What other initiatives and steps
    is the NCI taking to investigate gastric cancer?
        Answer. TCGA staff and extramural researchers have been steadily
    working on identifying, collecting, and assessing the quality of
    gastric cancer biospecimens for inclusion into TCGA's genotyping and
    molecular characterization pipeline. However, due to the difficulty in
    obtaining qualifying biospecimens from patients with diffuse gastric
    cancer, the NCI began to explore a pilot project for collection of
    diffuse gastric cancer biospecimens. The challenges involved in this
    pilot project of multiple gastric biopsies was discussed in detail in
    May 2011 when the NCI hosted a workshop on gastric and esophageal
    cancer, bringing together a group of international experts to explore
    and discuss the basic biology, epidemiology, and clinical research
    aspects of these cancers across the world. There was tremendous
    interest in the pilot study from the gastric cancer researchers, and in
    June 2011 the NCI approved TCGA to proceed with the pilot study to
    collect biospecimens on a small number of diffuse gastric cancers from
    the United States. The extent of the project will depend on the cost
    per case and the number of centers willing to participate. We are
    hopeful that analysis of these biospecimens will yield valuable
    information that will stimulate novel research approaches for this
    challenging disease and will lead to advances in the prevention,
    diagnosis, and treatment of diffuse gastric cancer.
        In addition to the TCGA-related efforts, an NCI Genome-Wide
    Association Study (GWAS) on gastric adenocarcinoma and esophageal
    squamous cell carcinoma has already revealed a common cancer
    susceptibility region at PLCE1, and the NCI is funding follow-up
    mechanistic studies on the effect of the gene variations in this
    location. A second GWAS will be conducted in a mostly Caucasian cohort
    to provide further clues about susceptibility regions and whether they
    differ between populations that experience different rates of gastric
    cancer. The NCI also funds broad based research at four
    Gastrointestinal Cancer Specialized Programs of Research Excellence
    (SPOREs), two of which include a focus on esophageal cancers.
                   eosinophilic-associated disorders research
        Question. Eosinophilic-associated disorders were identified in the
    last decade. Consequently many people go undiagnosed for years, due to
    lack of information and awareness about these diseases. Please describe
    current efforts at the NIH, particularly the National Institute for
    Allergy and Infectious Diseases (NIAID) to investigate eosinophilic-
    associated disorders. Last year, the Senate budget included report
    language urging the NIAID to convene a working group to develop a
    research agenda aimed at improving the diagnosis and treatment of
    eosinophilic-associated disorders. What strides are the NIH and the
    NIAID making to develop a research agenda focused on these conditions?
        Answer. As the lead institute at the NIH responsible for research
    on immunologic and allergic disorders, the NIAID is committed to
    research to better understand the mechanisms that mediate tissue injury
    when eosinophils accumulate, including eosinophilic gastrointestinal
    disorders, a group of recently recognized allergic diseases associated
    with the production of IgE antibodies and other immune responses to
    food. The NIAID works closely with other NIH Institutes and Centers
    supporting research on eosinophilic disorders. Although these
    collaborations and communications do not occur through a formal working
    group or a predetermined research agenda, they have led to jointly
    sponsored workshops and research initiatives on eosinophilic disorders.
    In fiscal year 2012, the NIH, with the NIAID as the lead, will
    establish a working group with participation by relevant NIH Institutes
    and Centers, to develop a trans-NIH strategy to improve the diagnosis
    and treatment of eosinophilic disorders.
        As part of its overall research agenda on immunologic and allergic
    diseases, the NIAID pursues research on eosinophilic disorders through
    a variety of efforts and collaborations. For example, the Consortium of
    Food Allergy Research (CoFAR), co-funded with the National Institute of
    Diabetes and Digestive and Kidney Diseases (NIDDK), and renewed in
    fiscal year 2010, develops new approaches to treat and prevent food
    allergy. A new CoFAR project is examining the genetic aspects of
    eosinophilic esophagitis. The NIAID Asthma and Allergic Diseases
    Cooperative Research Centers (AADCRC) support basic and clinical
    research on the mechanisms, diagnosis, treatment, and prevention of
    asthma and allergic diseases, including food allergy and anaphylaxis.
    Many of these disorders are associated with eosinophilia. In addition,
    the NIAID-supported investigators are conducting a pilot clinical trial
    to determine the efficacy of swallowed glucocorticoids for the
    treatment of eosinophilic esophagitis, and developing novel noninvasive
    diagnostic tools for eosinophilic gastrointestinal diseases to reduce
    the number of endoscopies and biopsies that are currently performed.
    Also, on behalf of more than 30 professional organizations, Federal
    agencies, and patient advocacy groups, including the American
    Partnership for Eosinophilic Disorders, the NIAID coordinated the
    development of Guidelines for the Diagnosis and Treatment of Food
    Allergy in the United States. This document includes clinical practice
    guidelines for the diagnosis and management of eosinophilic esophagitis
    associated with food allergy. The guidelines were published in the
    December 2010 issue of the Journal of Allergy and Clinical Immunology
    and can be accessed at: http://www.ncbi.nlm.nih.gov/pubmed/21134576.
        The NIAID will continue its commitment to research and trans-NIH
    research collaborations on eosinophilic disorders to understand the
    mechanisms that mediate tissue injury when eosinophils accumulate. As
    part of this effort, in fiscal year 2011, the NIAID will recompete the
    AADCRC program.
                                     ______

                   Questions Submitted by Senator Mark Pryor
                           extramural research budget
        Question. What percentage of the NIH's funding leaves the greater
    Washington, DC area and goes to medical research in States and local
    communities?
        Answer. In fiscal year 2010, the NIH awarded 82 percent ($25.6
    billion of $31.2 billion) of its budget to more than 3,000 institutions
    and organizations across the United States, as well as several other
    countries throughout the world, 71 percent ($22.1 billion) in grants
    and 11 percent ($3.5 billion) in research and development contracts.
    The percentage of the fiscal year 2011 budget devoted to extramural
    research is also expected to be approximately 82 percent. An overview
    of the NIH funding allocations by Institute and Center in fiscal year
    2010, fiscal year 2011, and the fiscal year 2012 budget is available
    at: http://officeofbudget.od.nih.gov/pdfs/FY12/
    COPY%20of%20NIH%20BIB%20Chapter%202-9-11-%20FINAL.PDF.
                      personalized medicine as a priority
        Question. As you well know, we are currently in a very difficult
    economic time. The Congress is in the process of making many decisions
    related to addressing the Nation's budget problems. We are considering
    many ways to control our costs and minimize additional debt, but at the
    same time, we have to prioritize and ensure that important programs are
    adequately funded. Having said that, do you believe advances in
    personalized medicine could be threatened should the Congress enact
    cuts to the NIH's budget?
        Answer. Through the application of genomic research and high-
    throughput technologies, breakthroughs in our understanding of the
    causes of many diseases and the identification of new targets and
    pathways for the development of new therapeutics are within reach. For
    example, a decade ago, diagnosis of cancer was based on the organ
    involved and treatment depended on broadly aimed therapies that often
    greatly diminished a patient's quality of life. Today, research in
    cancer biology is moving treatment toward more effective and less toxic
    therapies tailored to the genetic profile of each patient's cancer. The
    NIH research is also identifying genetic markers that can predict
    whether an individual will respond well to a particular medication or
    will be at risk of having an adverse reaction. The NIH-funded
    researchers are also uncovering information about genes and the
    environment that will help point the way toward more personalized,
    targeted treatments for other diseases. The new National Center for
    Advancing Translational Sciences (NCATS) will provide the
    infrastructure and technologies to bring these critical basic
    discoveries to fruition through new diagnostics and therapeutics.
    Significant budget cuts could threaten the NIH's ability to continue to
    support these advances. However, the specific research areas that would
    be affected in the event that budget cuts materialize cannot be
    determined now since the NIH would need to re-evaluate its research
    priorities.
                                     ______

                Questions Submitted by Senator Richard C. Shelby
                        reorganization of ncrr programs
        Question. There remain concerns within the Congress and the
    research community with the decision to eliminate the National Center
    for Research Resources (NCRR). Can you explain the rationale behind
    this decision and where the National Center for Research Resources'
    assets will be moved?
        Answer. With the decision to move the Clinical And Translational
    Science Awards (CTSAs) into the proposed National Center for Advancing
    Translational Sciences (NCATS), it was necessary to consider the impact
    of its transfer on NCRR and whether there were long-range benefits that
    could be achieved by relocating its remaining programs within other NIH
    components. A task force was formed to determine if the remaining
    programs should be kept in a separate organization or if there was an
    opportunity for greater scientific synergies by moving the remaining
    programs to other NIH components. The task force was guided by the
    following considerations and principles in developing its
    recommendations:
      --The scientific synergies that could be achieved by placing the NCRR
            program in adjacency to existing (or in the case of the NCATS,
            proposed) portfolio/mission of the recipient IC versus the
            existing synergies among the NCRR programs.
      --The ``goodness of fit'' for the NCRR program within the recipient
            IC versus the negative effects of adding a program that is
            disproportionately large and/or not well aligned to the
            recipient IC's current (or in the case of the NCATS, proposed)
            mission.
      --The level of disruption to long-standing NCRR programs led by
            dedicated NCRR staff versus the disruptive innovation from
            reassigning NCRR staff to enable interactions with new
            colleagues and/or new programs.
        The Task Force agreed with the SMRB recommendation that the CTSAs
    be placed in the proposed Center. The Task Force then determined that
    the greatest scientific synergies could be achieved by placement of the
    remaining programs to other components of the NIH. The Research Centers
    in Minority Institutions (RCMI) program was proposed for placement in
    the National Institute for Minority Health and Health Disparities; the
    Institutional Development Award (IDeA) program was proposed for
    placement in the National Institute for General Medical Sciences
    (NIGMS); the Imaging and Point-of-Care Biomedical Technology Research
    Center (BTRC) grants, and Biomedical Imaging, and Point-of-Care
    research grants for Technology Research and Development were proposed
    for placement in the National Institute of Biomedical Imaging and
    Bioengineering; the remaining BTRCs and all other research grants for
    Technology Research and Development, and the BIRN network grants were
    proposed for placement in the NIGMS; the Gene Vector Repository was
    proposed for placement in the National Heart, Lung, and Blood
    Institute; and the Comparative Medicine Program, Extramural
    Construction and Animal Facilities Improvement, Shared and High-End
    Instrumentation, and Science Education Partnership Awards (SEPA) were
    proposed for placement in a new Office of Research Infrastructure
    Programs in the Division of Program Coordination, Planning, and
    Strategic Initiatives in the Office of the Director.
        The Task Force implemented a transparent process to collect and
    consider input from a wide range of internal and external experts, as
    well as stakeholders ranging from members of the public to members of
    the extramural research community. As the deliberations progressed, the
    NIH made information available to the public through a feedback page
    available on its website. The final Task Force recommendations were
    accepted by the NIH Director and the Secretary, and transmitted to the
    House and Senate Appropriations Committees in a letter dated June 6,
    2011. Additional budget details on the reorganization were provided to
    the subcommittees on June 23, 2011.
                       basic and applied research balance
        Question. How do you balance the NIH's goals in research aimed at
    knowledge generation (basic research) versus translation of that
    knowledge toward cures and improving human health (applied research)?
    Will the NCATS help to achieve a better balance?
        Answer. Basic research advances knowledge of fundamental biological
    processes and elucidates the molecular underpinnings of human health
    and disease. Basic research makes it possible to understand the causes
    of disease onset and progression and opens up new avenues for
    developing new and improved diagnostics, therapeutics, and preventive
    strategies. Realizing the benefits of fundamental biomedical
    discoveries depends on the translation of that knowledge into
    strategies and products that treat disease and sustain and improve
    health. It is important to understand that ``basic'' and
    ``translational'' research are inherently interrelated and comprise a
    cyclical process. There are important feedback loops between the fields
    so that advances in one ultimately yield new avenues for scientific
    inquiry and discovery in the other. Breakthroughs in our understanding
    of therapeutic targets and pathways also stimulate new avenues for
    basic scientific inquiry. By studying the process of developing new
    therapeutics and diagnostics in an open access environment, the NCATS
    will ultimately catalyze the cycle of discovery in order to advance
    public health.
        From a funding standpoint, 54 percent of the NIH budget is devoted
    to basic research and 46 percent to applied research, a ratio that has
    not varied appreciably for decades. The NIH does not intend to shift
    resources currently devoted to basic research to fund translational
    research. The NCATS will be formed through the realignment of existing
    translational research programs and, as such, will not affect the
    balance of basic and applied research supported by the NIH. It will
    certainly use discoveries made through basic research to advance its
    work while also providing important insights for basic scientists to
    pursue.
                molecular libraries program as part of the ncats
        Question. Dr. Collins, can you discuss the NIH Roadmap Molecular
    Libraries Probe Production Center Network component of the NCATS. I
    understand that this national network of centers provides for the first
    time a sophisticated infrastructure for drug discovery to the academic
    and nonprofit research community. What role will this program play in
    the NCATS going forward?
        Answer. The NIH Molecular Libraries Probe Production Center Network
    (MLPCN), a component of the NIH Molecular Libraries Program (MLP), is a
    collaborative research network that enables the generation of effective
    and useful small molecule chemical probes for the entire biomedical
    research community. Through support from the NIH Common Fund, the MLPCN
    offers biomedical researchers access to large-scale screening capacity,
    along with medicinal chemistry and informatics needed to convert the
    large number of active compounds identified by high-throughput
    screening into useful probes for studying the functions of genes,
    cells, and biochemical pathways. Traditionally, these resources and
    associated expertise have resided exclusively within the private
    sector.
        By providing early stage chemical compounds to the biomedical
    research community, the NIH anticipates that the components of the MLP
    can further enable researchers in both the public and private sectors
    to validate new drug targets, which could then move into the drug-
    development pipeline. This is particularly true for rare diseases,
    which may not be attractive for development by the private sector. For
    this reason, several components of the Common Fund's MLP are
    transitioning to be funded and managed through the NCATS. These include
    the Small Molecule Repository, Cheminformatics/PubChem, and the NIH
    Chemical Genomics Center (NCGC), an intramural high-throughput
    screening Center. The Common Fund will continue to provide support for
    the Chemical Diversity technology development program, the Imaging
    Probe Database, and the extramural Specialized Screening Centers.
                  the nih, academia, and industy relationship
        Question. Much of the country's translational research has been
    within the pharmaceutical industry and the biotechnology community. Can
    you elaborate on the relationship between the NCATS and these entities?
    Is there a change in roles in academia and the commercial world?
        Answer. The process of translating fundamental knowledge into new
    or better clinical applications is an exceedingly complex, costly, and
    risk-laden endeavor. Moreover, the average length of time from target
    discovery to FDA approval of a new drug is 14 years and the failure
    rate exceeds 95 percent, i.e., fewer than one out of twenty projects
    that enter the drug development pipeline will result in a new FDA-
    approved product. At the same time, recent progress in genomics,
    biotechnology, and other fields of biomedical research has advanced the
    potential for development of new diagnostics and treatments for a wide
    range of diseases, opening a wide door of opportunity in translational
    science.
        There is a growing recognition on the part of all those involved in
    translational medicine that the current model for development is not
    sustainable and that novel partnerships and collaborations are critical
    to progress. The NIH is uniquely positioned to help bring about the
    changes by complementing the translational efforts of each sector. To
    achieve this goal, the NCATS will bring together resources and skilled
    scientists to study the steps in the therapeutics development and
    implementation process, consult with experts in academia and the
    biotechnology and pharmaceutical industries to identify bottlenecks in
    the processes that are amenable to re-engineering, and develop new
    technologies and innovative methods for streamlining the processes.
    Cross-sector collaborations will be an essential part of how the NCATS
    operates.
                              future of r01 funds
        Question. Will the establishment of the NCATS result in the loss of
    R01 funds?
        Answer. No. Funds for research project grants will not be affected
    by the establishment of the NCATS, which is being created by realigning
    several existing NIH translational research programs. The NCATS will
    stimulate the pursuit of new avenues of scientific inquiry by
    facilitating and complementing translational research efforts carried
    out elsewhere at the NIH. It will not diminish the agency's commitment
    to basic science. Moreover, the NIH requested an additional $100
    million for the operation of the Cures Acceleration Network within the
    NCATS, some of which would be used for research project grants.
                        process innovation and the ncats
        Question. Dr. Collins, you have stated that ``process innovation''
    is an important component of the NCATS. Can you explain what this is
    and why it is important? How will process innovation relate to
    individual disease-focused projects the NCATS may do?
        Answer. Process innovation involves studying the therapeutics
    development process with the goal of developing new approaches and
    technologies that can strengthen and streamline the development
    pipeline itself. By approaching the development pipeline as a
    scientific question, the NCATS will identify bottlenecks in the
    processes that are amenable to re-engineering and develop new
    technologies and innovative methods for improving and advancing the
    discovery, testing, and implementation of new therapeutics. Among the
    specific developmental steps that may be addressed are target
    validation, preclinical toxicology testing, clinical trial design, and
    drug rescue and repurposing. In order to evaluate these innovations and
    new approaches, the NCATS will undertake targeted therapeutics
    development and implementation projects that may have relevance to
    individual disease-focused projects.
               reorganization of the comparative medicine program
        Question. I have heard from several elite schools of medicine,
    including Stanford, MIT, UAB, and Auburn that splitting the components
    of the National Center for Research Resources' Comparative Medicine
    program into different administrative entities would have a negative
    impact on the NIH's critical scientific infrastructure. Dr. Collins,
    can you address their concerns and share with the subcommittee a
    solution to ensure components of the Comparative Medicine program
    remains intact and together within the new organizational structure?
        Answer. Initially, we had considered a number of options with
    regard to the placement of the programs within the Division of
    Comparative Medicine, including dividing them among relevant institutes
    and centers. However, following extensive consultation with multiple
    stakeholders, including grantees, professional organizations, and the
    public, we concluded that it was important to keep the programs within
    the Division of Comparative Medicine together because of their
    intrinsic uniqueness and synergies. As such, the Division of
    Comparative Medicine is to be transferred in its entirety to the new
    Office of Research Infrastructure Programs in the Division of Program
    Coordination, Planning, and Strategic Initiatives within the Office of
    the Director.
                          broadening the idea program
        Question. The National Center for Research Resources' Institutional
    Development Award program broadens the geographic distribution of the
    NIH funding for biomedical and behavioral research. It is my
    understanding that the goal of the program is to expand biomedical
    research capabilities to areas that currently lack it through research
    and infrastructure funding opportunities and faculty development.
        In its entirety, Alabama is a significant recipient of the NIH
    funding, mainly due to the research funding received by its two medical
    schools. While they provide great benefit to my State and Nation
    through medical breakthroughs and economic investment, I am concerned
    that their success puts other Alabama institutions at a competitive
    disadvantage with similar institutions in IDeA-eligible States.
        Has the NIH considered ways to include institutions in this program
    from non-IDeA eligible States? If not, are there other avenues within
    the NIH that could serve a similar role to IDeA for schools in States
    where one or two universities' significant NIH funding limits their
    access to preliminary support?
        Answer. The current authorization language for the IDeA program
    limits participation in the program to institutions located in States
    with low aggregate success rates for obtaining NIH funding or States
    that do not attain a particular level of support from the NIH. It does
    not allow for participation by institutions from States with high
    success rates or States that receive substantial support from the NIH.
    In 2008, a working group of NCRR's advisory council, which was formed
    to review the eligibility criteria for the IDeA program, explored
    whether it would be possible to base eligibility on institutional or
    regional success rates. The group was unable to identify an alterative
    approach that met the intent of the law.
        In States that are not eligible for IDeA, institutions with limited
    NIH funding are encouraged to participate in are encouraged to apply
    for Academic Research Enhancement Awards (AREA) http://grants.nih.gov/
    grants/funding/area.htm which supports projects in the biomedical and
    behavioral sciences conducted by faculty and students in health
    professional schools, and other academic components that have not been
    major recipients of the NIH research grant funds. In addition,
    institutions could try to increase the NIH grant support by partnering
    with institutions with more significant NIH funding. Such partnerships
    can help build the experience and capacity necessary to successfully
    compete independently for the NIH funding in the future.
                     gulf oil spill health effects research
        Question. According to the NIH press statement, of the 40 known oil
    spills in the past 50 years, the health effects have been studied from
    only eight of those spills. I am pleased to see the NIH will begin to
    review health effects of people impacted by the Deepwater Horizon oil
    spill in the Gulf of Mexico. It is critical to understand how being
    exposed to the oil and the dispersants may have affected the health of
    cleanup workers and volunteers. Could you discuss how this study will
    be conducted and what you are hoping the GULF Study will help us learn?
        Answer. The Gulf Long-term Follow-up Study (GuLF STUDY) will help
    determine if oil spills and exposure to crude oil and dispersants
    affect physical and mental health. The National Institute of
    Environmental Health Sciences (NIEHS) is leading this research. A major
    facet of the study is to compare the health of clean-up workers and
    others who did not do clean-up work to learn if health problems are
    more common in workers. GuLF STUDY researchers will also examine other
    factors that may explain why some people are more likely than others to
    get sick and how stress affects health. The NIEHS will send
    approximately 90,000 invitation letters to people to be included in the
    study. Of this group it is expected that 55,000 will be enrolled and
    complete telephone interviews. Participants will be interviewed about
    their oil-spill clean-up jobs, demographic and socioeconomic factors,
    occupation and health histories, and current health, including stress
    and mental health. About half of the cohort will be asked to complete a
    brief clinical examination in their home. The home exam will include
    additional health questionnaires and collection of biological samples,
    such as blood and urine, and environmental samples, e.g., house dust.
    The exam will include basic clinical measurements such as height,
    weight, blood pressure and tests of lung function. The home exams will
    largely target workers residing in the four most affected Gulf States--
    Louisiana, Mississippi, Alabama, and Florida). All cohort members will
    be followed for development of a range of health outcomes. Follow-up of
    the entire cohort is initially planned for 10 years, with extended
    follow-up possible depending upon scientific and public health needs
    and the availability of funds.
        GuLF STUDY researchers are hoping to learn if exposure to
    constituents of oil, dispersants, and oil-dispersant mixtures during
    oil spill clean-up is associated with adverse health effects,
    particularly respiratory, neurological, hematologic, and mental health.
    In addition, this research is anticipated to reveal biomarkers of
    potentially adverse biologic effects associated with oil spill-related
    exposures. Results of the study will provide further insight into how
    stress and job loss can affect health, including mental health.
    Overall, the findings may influence long-term public health responses
    in Gulf communities or responses to other oil spills in the future.
                            cystic fibrosis research
        Question. In February, the NIH announced that federally funded
    research led to the development of a very promising therapy that
    targets the genetic defect that causes Cystic Fibrosis. How will the
    fiscal year 2012 NIH budget request support additional research on
    Cystic Fibrosis?
        Answer. Cystic fibrosis (CF) research continues to be a high-
    priority area. The NIH estimates the fiscal year 2012 budget request
    would support about $88 million for CF research, ranging from basic
    science studies through clinical trials. The results of our prior
    investments have provided enormous benefit to affected patients.
    Whereas years of life expectancy for children born with CF could once
    be counted on the fingers of one hand, today average survival is 37
    years and some patients live into their 50s and beyond. Evidence-based
    improvements in nutrition, infection control, and symptom management
    have substantially enhanced the quality of life of affected persons.
    Newborn screening for cystic fibrosis, now universal in the United
    States, is not only enabling early interventions but also providing
    unprecedented opportunities for effective translation of new research
    advances into clinical practice.
        With improved understanding of CF biology, advances in experimental
    methods, and growing availability of new targets for interventions, we
    anticipate that CF research will be especially productive in the next
    few years and that tangible improvement in patient outcomes will
    follow. The recent NHLBI workshop ``Future Research Directions in the
    Pathogenesis, Treatment, and Prevention of Early Cystic Fibrosis Lung
    Disease'' identified a number of important topics for future research
    that can be pursued as funding permits. They include work with animal
    models to understand how early lung disease develops, identification of
    genetic and environmental factors that modify the manifestations and
    course of CF, examination of the role of mutant CFTR (the defective
    gene product in CF) in airway growth and development, and exploration
    of the mechanisms that underlie CF-related diabetes and liver disease.
    The NIH will continue to adjust its research portfolio in CF to ensure
    that needs and opportunities for advancing research are addressed.
                           the nih-fda collaborations
        Question. The development of treatments for diseases, especially
    rare diseases, is an expensive and lengthy process. A very small
    percentage of potential medicines even make it to the clinical research
    stage, let alone to FDA review. What can the NIH do to reduce some of
    the regulatory requirements that both slow the pace and increase the
    cost of medical research, but that add little meaningful
    accountability?
        Answer. The NIH is taking a multi-pronged approach to promote
    efforts to address unnecessary, inconsistent, and duplicative
    regulatory requirements. We work closely with FDA and the Office for
    Human Research Protections to enhance the consistency of regulations
    governing clinical research. Through the NIH-FDA Joint Leadership
    Council, we are working with FDA to help ensure that regulatory
    considerations are a component of scientific research at all phases of
    development and they are informed by the most current science and
    technologies. Such efficiencies along with targeted support for the
    development of novel technologies including new and improved
    preclinical toxicology approaches for testing safety should quicken the
    pace and reduce the human-related costs of medical research. The
    proposed National Center for Advancing Translational Sciences will be
    focused on studying diagnostics and therapeutics development, testing,
    and implementation; identifying bottlenecks amenable to re-engineering;
    and formulating innovative methods to streamline the process.
                             clinical trial process
        Question. One of the priorities of the Joint NIH-FDA Leadership
    Council is to optimize and maximize data from clinical trials. Would
    you consider working with the FDA to grant greater flexibility
    regarding the approval of orphan drug therapies on the basis of a
    single, well-designed trial?
        Answer. The FDA and the NIH have complementary roles and
    functions--the NIH supports and conducts biomedical and behavioral
    research and the FDA ensures the safety and effectiveness of medical
    and other products. The NIH does not share regulatory authorities with
    the FDA, i.e., we do not make decisions about regulatory pathways or
    the approvability of investigational products. However, we certainly
    have common goals and are working closely in a number of ways to
    address issues related to therapeutics development and regulatory
    science. As you noted, the agencies are working at the leadership level
    through the NIH-FDA Leadership Council, formed in 2010, to help ensure
    that regulatory considerations form an integral component of biomedical
    research planning and that the latest science is integrated into the
    regulatory review process. The challenges associated with the
    development and review of therapies for rare and neglected diseases,
    such as the availability of alternative regulatory pathways for trials
    of rare diseases and the level of scientific evidence needed for
    approval of a new orphan therapy, are among the specific topics of
    mutual interest. We also collaborate closely on issues associated with
    the development of new cancer diagnostics and therapeutics through an
    interagency oncology task force and, in accord with the provisions the
    Best Pharmaceuticals for Children Act, to advance the development of
    preclinical and clinical methodologies that provide optimal approaches
    for treating diseases in childhood. We believe all of these efforts can
    go a long way toward achieving our common goal of advancing public
    health by promoting the translation of basic and clinical research
    findings into medical products and therapies.
                                     ______

                  Questions Submitted by Senator Thad Cochran
       transfer of the idea program to the national institute of general
                            medical sciences (nigms)
        Question. The NIH has proposed the elimination of the National
    Center for Research Resources (NCRR). I am particularly concerned that
    this elimination will affect the Institutional Development Award
    (IDeA), which has benefitted my home State of Mississippi. Under the
    proposal, the IDeA program will be moved to the National Institute of
    General Medical Sciences. There have been concerns expressed that the
    IDeA program should not be placed in an Institute with a defined
    constituency. Dr. Collins, can you elaborate on the decision process
    for moving IDeA to the National Institute of General Medical Sciences?
    Why do you think this is the best Institute to house the IDeA program?
        Answer. The IDeA program fosters research and enhances the
    competitiveness of investigators at institutions located in States in
    which the aggregate success rate for applications to the NIH has
    historically been low. By its nature, the IDeA program extends beyond
    traditional capacity building in supporting research projects that are
    designed to strengthen future investigator-initiated research
    applications, most of which are aimed at addressing basic science
    questions. The National Institute of General Medical Sciences (NIGMS)
    has a basic science mission as well as a longstanding focus on
    institutional capacity building and career development. Given these
    synergies, the NIGMS was determined to be the optimal new home for the
    IDeA program. The NIH reached this conclusion based on a careful
    analysis of existing NCRR programs as well as extensive consultation
    with stakeholders across the scientific community and input from the
    NIH Institutes and Centers, including NCRR leadership and staff.
                          jackson heart study impacts
        Question. African Americans are more likely to be diagnosed with
    coronary heart disease, and they are more likely to die from heart
    disease. Due to this greater prevalence, the Jackson Heart Study is
    exploring the reasons for this disparity and uncovering new approaches
    to reduce it. Can you discuss the impacts this study will have?
        Answer. The goals of the Jackson Heart Study (JHS) are to determine
    the roles of established risk factors such as obesity, dyslipidemia,
    and high blood pressure in the development and progression of
    cardiovascular disease (CVD) and to identify factors related to the
    emergence of such risk factors. Moreover, the study seeks to shed light
    on the contributions of sociocultural factors (e.g., stress, racism,
    discrimination, and coping strategies) and familial/hereditary factors,
    genetic variants, and gene--environment interactions to the development
    of CVD and its risk factors. Based on our experience with other NHLBI-
    funded epidemiological studies of CVD such as the Framingham Heart
    study, we expect the JHS to provide important information that will
    help researchers to generate new hypotheses and design studies to test
    interventions to prevent CVD. Ultimately, we expect the results of the
    JHS to benefit not only Mississippians but also African Americans
    beyond the participants in the study.
        The JHS also seeks to build research capabilities in minority
    institutions, address the critical shortage of minority investigators
    in epidemiology and prevention, and reduce barriers to dissemination
    and use of health information in a minority population. The JHS
    educational and community outreach components are very strong;
    consequently, the research findings will be efficiently disseminated
    among participants. The JHS training component continues to provide
    outstanding opportunities to inspire, motivate, and educate students to
    become research leaders and to study and disseminate important findings
    on prevention of CHD.
                        staffing the jackson heart study
        Question. The Jackson Heart Study is the largest epidemiologic
    investigation of Cardiovascular Disease among African Americans in the
    United States. The National Heart Lung and Blood Institute opened a
    field office in Jackson to provide scientific investigators and support
    staff to the study. It is my understanding that this one-person office
    will soon have no staff due to the staffer leaving Jackson. I am
    concerned that the National Heart Lung and Blood Institute may not fill
    the position quickly which would result in an adverse effect on the
    Jackson Heart Study. It is vital that the field site maintain strength
    to support scientific research at the Jackson Heart Study. Dr. Collins,
    can I have your assurance that the National Heart Lung and Blood
    Institute will replace this position in a timely manner?
        Answer. At present, the National Heart, Lung, and Blood Institute
    (NHLBI) medical officer stationed at the Jackson Heart Study site plans
    to remain there indefinitely. Should the position become vacant in the
    future, the NHLBI would promptly pursue recruitment via standard
    competitive procedures.
              geographic health disparities for stroke and obesity
        Question. Health disparities are persistent across ethnic
    populations as well as geographically. Geographic isolation,
    socioeconomic status, and health risk behaviors contribute to health
    disparities in these rural communities. Mississippi is part of the
    ``Stroke Belt'' and has the highest rate of obesity in the Nation. Both
    of these issues are persistent problems in the rural South, with 10 out
    of 11 States with the highest rates of obesity being in the South. Dr.
    Collins, how is the NIH addressing the geographic issues associated
    with many of the most serious diseases affecting our Nation?
        Answer. The NIH supports a broad portfolio of research to
    understand the complex factors that contribute to obesity, stroke, and
    related health problems, and to develop and evaluate prevention and
    treatment strategies for diverse populations.
        The Look AHEAD clinical trial, supported by the National Institute
    of Diabetes and Digestive and Kidney Diseases (NIDDK) and other NIH
    components, is determining whether lifestyle intervention improves
    health in overweight/obese people with type 2 diabetes, and in
    particular the impact of the intervention on the incidence of
    cardiovascular events, including stroke, heart attack, hospitalized
    angina, and cardiovascular-related death. For the first four years of
    this long-term study, participants in the lifestyle intervention group
    lost more weight and improved their blood pressure, fitness, glucose
    control, and good cholesterol, with less use of medication, compared
    with those in the control group. Look AHEAD includes sites across the
    country, including in Alabama, Louisiana, and Tennessee.
        A major National Institute of Neurological Disorders and Stroke
    (NINDS)-funded epidemiological study related to the ``Stroke Belt'' is
    the REGARDS study (REasons for Geographic and Racial Differences in
    Stroke) in which investigators are exploring the geographical and
    racial differences in stroke risk in a cohort of about 30,000
    individuals, about half of whom reside in the Stroke Belt region of the
    United States. This study also includes measures of functional
    cognitive decline, which may be a risk factor for stroke as well as a
    marker for unrecognized stroke. Data generated from this study has led
    to more than 70 publications, and will continue to help researchers
    pinpoint the reasons that the stroke death rate is higher in this
    region, and among African Americans, and to develop targeted strategies
    for intervention. Recent data from REGARDS indicated that overall time
    spent in the Stroke Belt is more predictive of hypertension--a powerful
    risk factor for stroke--than is current residence in the Stroke Belt.
    Data from the REGARDS study have also revealed that stroke survivors
    were more likely to have unrecognized hypertension and diabetes.
        To improve stroke care utilization and patient outcomes among
    vulnerable populations, the NINDS also invests in research to increase
    stroke awareness and reduce the time from symptom onset to hospital
    arrival, so that patients can be evaluated and treated in a timely
    manner.
        In one such study, a novel behavioral intervention will be tested
    in which children in high risk, minority communities are taught through
    Hip Hop Stroke (stroke rap songs and animated musical cartoons) to
    recognize and act on the five cardinal stroke symptoms and the
    importance of early treatment, with the hopes that they will
    communicate this information to their parents. Preliminary pilot data
    indicated that 74 percent of children communicated the material to
    their parents, which significantly improved their stroke knowledge.
        In the SWIFT (Stroke Warning Information and Faster Treatment)
    study, a culturally sensitive educational intervention focused on
    improving knowledge retention and time of arrival to the emergency
    department has been tested in minority communities. The outcome and
    results of this study are currently under review in a major medical
    journal.
        The ASPIRE program (Acute Stroke Program of Interventions
    addressing Racial and Ethnic disparities) is currently testing
    strategies to overcome community/socio-cultural and system barriers to
    stroke treatment with the goal of increasing the number of stroke
    patients treated with the clot-busting drug, tissue plasminogen
    activator (tPA), in six Washington, DC, hospitals.
        Ten years ago, the NINDS convened a Stroke Progress Review Group
    (SPRG) to identify and prioritize scientific opportunities in stroke
    research. In 2011, the NINDS will embark on a new stroke planning and
    evaluation effort, which will identify a specific set of high priority
    areas for advancing stroke research over the next 5-10 years. The topic
    of health disparities in stroke will be included as a cross cutting
    topic in this effort.
                        cardiovascular disease research
        Question. Cardiovascular Disease is the leading cause of death in
    Mississippi, accounting for more than 40 percent of all deaths. In
    2004, the State of Mississippi implemented a 10-year plan to address
    Cardiovascular Disease risk factors in a two-fold approach: prevention
    of potential risk factors and management of existing risk factors. In
    addition, the Jackson Heart Study is the largest investigation of
    causes of Cardiovascular Disease in an African-American population.
    While both initiatives are good starts to addressing this health issue
    in my home State, Cardiovascular Disease is the number one killer in
    the United States and we need comprehensive research to fight the
    disease nationwide. What plans do you have to increase research in the
    area of Cardiovascular Disease?
        Answer. The NHLBI is committed to supporting a comprehensive
    research program on the causes, prevention, diagnosis, treatment,
    monitoring, and management of cardiovascular disease (CVD). We invest
    63 percent of the NHLBI extramural budget in CVD research, and we
    intend to continue that high level of support. This year, the Institute
    has launched a number of new projects, including two major clinical
    trials:
      --The International Study of Comparative Health Effectiveness with
            Medical and Invasive Approaches (ISCHEMIA) addresses management
            of patients with stable coronary heart disease who have
            substantial ischemia on a cardiac stress test. The trial will
            evaluate whether an invasive approach (performing an angiogram
            and then opening or bypassing any blockages with stents or
            surgery) plus optimal medical therapy is better than optimal
            medical therapy alone in forestalling CVD events. Quality of
            life and cost-effectiveness will also be assessed.
      --The Cardiovascular Inflammation Reduction Trial (CIRT) addresses
            cardiovascular disease risk reduction in heart-attack survivors
            with persistently high levels of C-reactive protein, an
            indicator of inflammation. The trial will evaluate whether a
            very low dose of the anti-inflammatory drug methotrexate
            reduces rates of recurrent heart attack, stroke, and
            cardiovascular death. Several other conditions that have an
            inflammatory basis, such as diabetes, venous thromboembolism,
            and atrial fibrillation, will also be assessed.
        The NHLBI has responsibility for cardiovascular, lung, and blood
    diseases that affect millions of people worldwide. We will continue our
    longstanding emphasis on the support of a balanced research portfolio
    that addresses the many public health needs and scientific
    opportunities that fall within our mandate.
                                     ______

                 Questions Submitted by Senator Lamar Alexander
        reorganization of national center for research resources (ncrr)
                                    programs
        Question. In my State of Tennessee, the largest single Federal
    grant at one of the State's largest medical research institutions is a
    Clinical and Translational Science Award (CTSA), for $40 million. How
    will this program and others like it be affected by the dissolution of
    the NCRR, and the creation of the National Center for Advancing
    Translational Sciences (NCATS)?
        Answer. The NIH is committed to supporting each program currently
    housed within the NCRR; the proposed reorganization will not adversely
    affect the individual programs. Indeed, a careful programmatic
    evaluation concluded that important scientific synergies could be
    gained by moving NCRR programs to other NIH components with adjacent
    scientific missions. Staff responsible for administering and directing
    these programs will transfer with their respective programs to ensure
    continuity and oversight. With regard to the Clinical and Translation
    Science Awards (CTSA) program specifically, it is to be transferred to
    the proposed National Center for Advancing Translational Sciences
    (NCATS). The transfer was recommended by the NIH Scientific Management
    Review Board, a congressionally-mandated advisory committee to the NIH
    Director, and further supported by an internal NIH task force charged
    with assessing the optimal location for NCRR programs. The task force's
    analysis confirmed that the goals of the CTSA program were in close
    alignment with those of the new center. Decisions regarding the
    selection of individual CTSAs will continue to be made based upon each
    proposal's scientific merit and program relevance.
                              ctsa program mission
        Question. Given the established focus of the NCATS on drug
    development, will the CTSA's continue to be able to build on the
    programs of training, career development for young investigators,
    research informatics, community engagement and clinical research
    infrastructure?
        Answer. The focus of the NCATS is to develop new and innovative
    approaches to conducting research across the therapeutic development
    pipeline, in the context of strengthening and streamlining the process
    itself. The CTSAs have the infrastructure and diverse expertise that
    supports translational research, including training and career
    development for the next generation of clinical investigators,
    informatics, and community engagement, and they will be integral to
    fulfilling the NCATS mission. The CTSAs are making important
    contributions in transforming translational research across the
    country, and the NIH is committed to building upon the program's
    successful efforts. Ensuring that the pipeline of new investigators is
    sufficiently equipped to tackle the challenges associated with
    translational science through training and mentoring is an inherent
    part of the NCATS mission and will continue to be an essential
    component of the CTSAs.
                             personalized medicine
        Question. Physicians and researchers in Tennessee are investing a
    great deal in the science of personalized medicine. Can you tell us
    what the term ``personalized medicine'' means to you, and what role you
    see for the NIH?
        Answer. The concept of ``personalized medicine'' is based on the
    idea that one size does not fit all when it comes to the practice of
    medicine. Knowledge gathered from basic research and clinical studies
    have demonstrated that individuals are highly unique in their
    susceptibility to disease, reaction to medical treatments, and response
    to environmental and social factors. More than ever before, and largely
    thanks to research supported by the NIH, we now have the tools to
    understand, describe, and quantify these biological differences as well
    as the power to better predict which available treatments are optimal
    for certain patients and to design rationale-based new targeted-based
    therapies.
        The NIH will continue to play a pivotal role in the advancement of
    personalized medicine. For example, our support for pharmacogenomics
    research will advance understanding of the predictive roles and
    influences of genes in drug response. Findings from such research can
    help identify the right drug for the right patient at the right time.
    Increasingly, this information will help doctors calculate dosages that
    match a person's unique physiology. Pharmacogenomic information already
    is contained in approximately 10 percent of FDA-approved drug labels,
    helping to prevent the inappropriate use of diagnostics and therapies.
    Pharmacogenomic knowledge can also reduce the financial, emotional, and
    physical costs associated with the current trial-and-error based
    approach to treatment. Knowing each patient's DNA sequence is expected
    to add efficiencies and new research capabilities to current endeavors.
    As such, we are also fostering technological advances that are expected
    to bring down the cost of sequencing an individual genome to under
    $1,000. These advances will help make genetic analysis a routine part
    of medical care and a revolutionary factor in approaches to basic
    research and practice.
                                 dna databanks
        Question. Several major research institutions are creating
    databanks that allows researchers to access a large collection of human
    DNA. How does the NIH also plan to build on the mapping of the human
    genome by optimizing unique resources such as this?
        Answer. In support of its mission to improve public health through
    research, the NIH has a longstanding policy of making data publicly
    available from the research that it funds. The NIH recognizes that data
    sets are not only valuable for addressing the questions that the
    experiments that generated them were designed to ask, but also can be
    powerful resources when combined with other data sets or used to answer
    other scientific questions. This is particularly true of DNA data sets
    that consist of information across the full sequence of the human
    genome. Consequently, building on the data sharing practices that
    characterized the Human Genome Project, the NIH launched research
    programs to stimulate the creation of genomic resources and created
    policies and tools for facilitating the sharing of genomic data to
    capitalize on the databanks created by other institutions with or
    without the NIH funding.
        For example, under the leadership of the National Human Genome
    Research Institute (NHGRI) the International HapMap Project used the
    reference human genome sequence to build a comprehensive map (database)
    of the variation within human DNA sequences, so that ``spelling''
    differences in the DNA code of those with disease and those without
    disease could be identified and studied. The 1000 Genomes Project is
    now capitalizing on technological advances to extend and deepen the
    HapMap data. All data from each of these projects are publicly
    available to any investigator through the web with regular updates as
    new data are generated.
        In addition, to leverage the infrastructure and databank resources
    created at other research institutions, the NIH has introduced funding
    programs, such as the NHGRI-supported Electronic Medical Records and
    Genomics (eMERGE) Network. This consortium of U.S. medical research
    institutions has the primary goal of developing, disseminating, and
    applying approaches to research that combine existing DNA
    biorepositories with electronic medical record (EMR) systems for large-
    scale, high-throughput genomic research. eMERGE Network institutions
    use their own databanks (e.g., Vanderbilt University's BioVU DNA
    databank) for this program, but all data are shared through an NIH
    database, the database of Genotypes and Phenotypes (dbGaP), which
    provides centralized and consistent access to researchers around the
    globe. Importantly, dbGaP includes not only eMERGE data, but data from
    studies across the disease spectrum. Extremely rich databanks from
    studies such as the Framingham Heart Study, The Cancer Genome Atlas,
    and many other projects reside within dbGaP, enabling many more
    investigators to analyze the data as independent or combined data sets.
    The standardization of access supported by the NIH facilitates cross-
    study analyses, enables expansion of the study design beyond the
    initial research focus of the individual databanks, and increases the
    statistical power to identify the genetic contributors to common
    diseases that create substantial public health burden. And,
    importantly, all of these benefits are achieved through robust data
    sharing policies intended to protect the interests of the research
    participants who contribute their personal information to the
    individual databanks.
                    industry investment in genome sequencing
        Question. How does private investment in genome sequencing help to
    leverage the Federal investment of genomic research through the NIH
    funding?
        Answer. The sequencing of the human genome has rightly been
    regarded as one of the most important scientific undertakings of the
    modern era. The NIH's investment in genomics has been, and continues to
    be wide-ranging, from basic research to uncover and understand the
    structure of our genome to translational science aimed at using a
    patient's DNA code to tailor treatment. Enabling all of this research
    are innovative new tools for DNA sequencing that have precipitated a
    drop in the cost of sequencing an individual genome from hundreds of
    millions of dollars to $15,000 or less.\2\ In the process, an entire
    industry of genomics-focused companies has been created, one that,
    according to a recent study conducted by Battelle Technology
    Partnership Practice, has generated an economic contribution of almost
    $800 billion since the start of the Human Genome Project.\3\ \4\
    ---------------------------------------------------------------------------
        \2\ Additional information on sequencing costs is available at
    http://www.genome.gov/27541954.
        \3\ http://www.battelle.org/publications/humangenomeproject.pdf.
        \4\ Additional information on the economic impact of the human
    genome project is available at http://www.genome.gov/27544383.
    ---------------------------------------------------------------------------
        The field of genomics has benefited from a combination of public
    and private investment. During the course of the last 10 years, the
    National Human Genome Research Institute's Genome Technology Program
    has provided support for the development of almost all of the currently
    commercialized, as well as several yet-to-be-commercialized or
    emerging, sequencing technologies. Private investment during and since
    that initial period of the NIH support has and will continue to bring
    these innovative advances to the market. Newer and increasingly cheaper
    sequencing machines and reagents have increased both capacity and
    productivity, enabling the NIH grantees to answer more research
    questions in the same period of time and for the same cost as
    previously. Illumina and Life Technologies, for example, have now
    developed smaller and less expensive sequencing machines that are
    bringing DNA sequencing within reach of single-investigator research
    labs. Affordable access to these technologies will greatly amplify the
    number of researchers that can employ genomic sequencing within their
    research plans, expanding the benefit of the Federal investment in
    genomic sequencing into yet more basic, translational, and clinical
    research domains. Companies like Illumina and Complete Genomics are
    also offering sequencing services that the NIH-funded researchers have
    used to great effect, such as the discovery last year of the causative
    genes behind rare disorders like Miller syndrome, something that had
    eluded science until now.\5\
    ---------------------------------------------------------------------------
        \5\ http://www.sciencemag.org/content/328/5978/636.
    ---------------------------------------------------------------------------
                                     ______

                 Questions Submitted by Senator Lindsey Graham
                      eosinophilic disorders working group
        Question. I have heard from individuals in my State about the
    enormous challenges to children with eosinophilic disorders and their
    families. I understand that these conditions are often misdiagnosed and
    there is no cure for these children, many of whom suffer from extreme
    pain and are unable to eat normal food. This subcommittee has asked
    that the NIH convene a working group on this topic. When will this
    group meet and when can we expect to have a report of the group's
    recommendations?
        Answer. Eosinophilic gastrointestinal disorders (EGID) are a group
    of diseases characterized by a wide variety of gastrointestinal
    symptoms including abdominal pain, swallowing problems, food impaction
    (food lodged or wedged in the esophagus), vomiting, diarrhea, growth
    impairment and bleeding. EGIDs are associated with increased numbers of
    eosinophils, a type of white blood cell, in the gastrointestinal
    lining. The most common EGID, eosinophilic esophagitis, is
    characterized by inflammation and accumulation of eosinophils in the
    lining of the esophagus. This disease and other EGIDs are diagnosed by
    a patient's clinical history plus endoscopy with biopsy.
        As the lead Institute at the National Institutes of Health (NIH)
    responsible for research on immunologic and allergic disorders, the
    National Institute of Allergy and Infectious Diseases (NIAID) works
    closely with other NIH Institutes and Centers supporting research on
    eosinophilic disorders. Although these collaborations and
    communications do not occur through a formal working group or a
    predetermined research agenda, they have led to jointly sponsored
    workshops and research initiatives on eosinophilic disorders. In fiscal
    year 2012, the NIH, with the NIAID as the lead, will establish a
    working group with participation by relevant NIH Institutes and
    Centers, to develop a trans-NIH strategy to improve the diagnosis and
    treatment of eosinophilic disorders.
        As part of its overall research agenda on immunologic and allergic
    diseases, the NIAID pursues research on eosinophilic disorders through
    a variety of efforts and collaborations. For example, the Consortium of
    Food Allergy Research (CoFAR), co-funded with the National Institute of
    Diabetes and Digestive and Kidney Diseases (NIDDK), and renewed in
    fiscal year 2010, develops new approaches to treat and prevent food
    allergy. A new CoFAR project is examining the genetic aspects of
    eosinophilic esophagitis. The NIAID Asthma and Allergic Diseases
    Cooperative Research Centers (AADCRC) support basic and clinical
    research on the mechanisms, diagnosis, treatment, and prevention of
    asthma and allergic diseases, including food allergy and anaphylaxis.
    Many of these disorders are associated with eosinophilia. In addition,
    the NIAID-supported investigators are conducting a pilot clinical trial
    to determine the efficacy of swallowed glucocorticoids for the
    treatment of eosinophilic esophagitis, and developing novel noninvasive
    diagnostic tools for eosinophilic gastrointestinal diseases to reduce
    the number of endoscopies and biopsies that are currently performed.
    Also, on behalf of more than 30 professional organizations, Federal
    agencies, and patient advocacy groups, including the American
    Partnership for Eosinophilic Disorders, the NIAID coordinated the
    development of Guidelines for the Diagnosis and Treatment of Food
    Allergy in the United States. This document includes clinical practice
    guidelines for the diagnosis and management of eosinophilic esophagitis
    associated with food allergy. The guidelines were published in the
    December 2010 issue of the Journal of Allergy and Clinical Immunology
    and can be accessed at: http://www.ncbi.nlm.nih.gov/pubmed/21134576.
        The NIAID will continue its commitment to research and trans-NIH
    research collaborations on eosinophilic disorders to understand the
    mechanisms that mediate tissue injury when eosinophils accumulate. As
    part of this effort, in fiscal year 2011, the NIAID will recompete the
    AADCRC program.
                                     ______

                   Question Submitted by Senator Jerry Moran
                     budgetary effects on the nci programs
        Question. Dr. Collins, I recently visited the University of Kansas
    and was given a tour of the University's drug discovery, delivery, and
    development operation. This visit helped demonstrate to me not only the
    many elements that will become part of the application by the
    University for National Cancer Institute (NCI) comprehensive cancer
    center designation, but also the impressive role that the NCI's cancer
    centers play across the Nation. This network of centers drives basic
    research, brings individuals into clinical trials, and, most
    importantly, leads to the development of new treatment advances that
    will change the course of cancer for all Americans and individuals
    across the globe.
        While I understand that the University of Kansas' application for
    the NCI designation will be determined on its scientific merits, can
    you please explain how the NCI cancer center program will be affected
    by the proposed budgets of the NIH and the NCI?
        Additionally, considering possible scenarios for the fiscal year
    2012 budget, what will the effects of such scenarios be on current NCI
    programs and on the prospect for funding the review of new
    applications?
        Answer. The the NCI-designated Cancer Centers are an important part
    of the NCI's research portfolio, and they play a unique and valuable
    role in providing cutting-edge cancer care and access to the NCI-
    sponsored clinical trials across the country. The final fiscal year
    2011 appropriation has already necessitated a 5 percent reduction in
    funding below fiscal year 2010 for the cancer centers, and it is
    difficult to predict how they will be affected by the resolution of the
    fiscal year 2012 budget.
        The NCI's first priority must be to preserve funding for Research
    Project Grants (RPGs). Ensuring support for as many new RPGs as
    possible will enable investigators, especially new investigators, to
    pursue novel ideas that will preserve the pipeline of innovative cancer
    research. This year, nearly every NCI program budget has had to be
    trimmed in order to award adequate, though reduced, number of new RPGs.

                              SUBCOMMITTEE RECESS

        Senator Harkin. Is there anything else that any one of you
    would like to state for the record now? If not--Yes.
        Dr. Collins. Well, Senator, I'd just like to thank you and
    this subcommittee for your steadfast support for biomedical
    research.
        All of us involved in this enterprise sitting here at this
    table, and many others who are not at the table, but who are
    engaged every day in this effort to try to find interventions
    for people with disease appreciate your support and your strong
    voice that, even in difficult times, medical research is
    basically a societal good.
        I think a society ultimately will be judged by the ways in
    which, even in difficult times, priorities are chosen.
        We think, in terms of alleviating suffering as well as
    encouraging our American competitiveness and our economic
    growth, that what we are able to do through NIH is a very good
    story indeed, but we appreciate the fact that you have convened
    this hearing and given us a chance to tell some of that story.
        Senator Harkin. Well, thank you very much, Dr. Collins, and
    I can just reciprocate then I'll join all my colleagues in
    thanking you and all of you and all your colleagues at the NIH,
    all the Directors, the people who work there, and through you
    the whole network of researchers, young and old, some of who
    have just come on, some who have been there for many years, to
    thank you for your outstanding public service. All of you,
    every single person engaged in NIH, thank you.
        The subcommittee will stand recessed.
        [Whereupon, at 11:45 a.m., Wednesday, May 11, the
    subcommittee was recessed, to reconvene subject to the call of
    the Chair.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2012

                                  ----------

                            WEDNESDAY, JULY 27, 2011

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10:05 a.m., in room SD-124, Dirksen
    Senate Office Building, Hon. Tom Harkin (chairman) presiding.
        Present: Senators Harkin, Durbin, Landrieu, Reed, Pryor,
    Brown, Shelby, Cochran, Alexander, Moran, and Kirk.

                            DEPARTMENT OF EDUCATION

                            Office of the Secretary

    STATEMENT OF HON. ARNE DUNCAN, SECRETARY

                    OPENING STATEMENT OF SENATOR TOM HARKIN

        Senator Harkin. The Senate Appropriations Subcommittee on
    Labor, Health and Human Services, and Education will please
    come to order.
        Secretary Duncan, welcome back to the subcommittee. This is
    obviously a critical moment to be talking about education
    funding. The Nation will default on its loans in just 6 days
    unless Congress raises the debt ceiling; we all know that. I
    believe that to bring Federal deficits under control, we must
    be willing to make some tough, but necessary, budget choices.
    But we must be just as willing to say no to foolish and
    destructive choices. And this is especially true when it comes
    to funding for the education of our children.

             2011 CONTINUING RESOLUTION IMPACT ON EDUCATION BUDGET

        The fiscal year 2011 continuing resolution eliminated 37
    education programs totaling more than $900 million. Those cuts
    included the successful Striving Readers initiative, the
    Federal Government's only comprehensive literacy program.
    Meanwhile, cash strapped State and local governments are
    slashing school budgets and firing tens of thousands of
    teachers. Los Angeles public schools cut their budget for
    summer classes from $18 million last year to $3 million this
    year. Philadelphia recently issued layoff notices to more than
    1,500 of its 11,000 teachers. Many districts are shortening
    their academic calendar despite growing evidence that students
    should be spending more time in school, not less.
        From my perspective, as chairman of both this subcommittee
    and also the authorizing committee, I believe the combined
    Federal, State, and local budget cuts pose a grave threat--let
    me repeat that--pose a grave threat to education reform efforts
    across the country just as those efforts are reaching critical
    mass.
        Forty-eight States and the District of Columbia have
    collaborated to create high-quality, common education
    standards. Mr. Secretary, your Race to the Top initiative has
    jump started ambitious State-level reforms on teacher
    accountability, academic standards, and the better use of data
    in tracking student performance.
        In the HELP Committee, the authorizing committee, we hope
    to mark up the reauthorization of the Elementary and Secondary
    Education Act this year. However, it is wishful thinking--
    wishful thinking--to expect improvements in school quality when
    we are laying off teachers, increasing class sizes, and
    reducing instructional time. To demand reform without resources
    is to set up students and teachers to fail.

                             INVESTING IN EDUCATION

        Other countries understand this. China, for example, has
    tripled its investment in education. It is building hundreds of
    new universities. Even in times of austerity and shrinking
    budgets, smart countries do not just turn a chainsaw on
    themselves. They continue to invest in the future.
        A good case in point is early childhood education. Experts
    agree that high quality pre-kindergarten education gives a
    critical boost to students' long-term academic success. But the
    quality of early childhood education programs varies widely.
    Many States lack any coordination.
        The fiscal year 2011 appropriations bill addresses these
    challenges head on. And, Mr. Secretary, I applaud your efforts
    on this. We have provided $700 million for your Race to the Top
    initiative, and working together, you very wisely, I believe,
    have put $500 million of that into an early learning challenge
    grant program, in a competition. Studies have shown that high
    quality pre-school returns $7 for every $1 invested, but we
    will not be able to continue that investment if overall funding
    for domestic discretionary spending is slashed.
        At the other end of the learning continuum, we must do
    everything we can to preserve the fiscal integrity of the Pell
    Grant program. The 9 million students who rely on Pell grants
    to earn a postsecondary education each year need to be assured
    that this aid will not vanish in the middle of their college
    careers. So, I was very pleased that Senator Reid's plan would
    virtually close the Pell shortfall for the next 2 years. I want
    to engage with you on that aspect also in the question period.
    This will greatly improve our prospects of maintaining the
    maximum Pell grant at its current level of $5,550 per year.
        Mr. Secretary, I appreciate the work that you are doing not
    only to protect our Nation's investments in education, but to
    challenge the States to do better, and to make sure the money
    is spent in ways that will truly improve student learning.
        I also want to thank you for coming out to Iowa this last
    weekend, both for an event on Sunday regarding early childhood
    learning and also for Governor Branstad's education summit for
    Iowa. I could not be there because I had to come back here, but
    I read your remarks, and from all I hear, your presentation was
    both well received and challenging to the lawmakers and the
    policymakers in the State of Iowa.
        With that, I will yield to my ranking member, Senator
    Shelby.

                     STATEMENT OF SENATOR RICHARD C. SHELBY

        Senator Shelby. Thank you, Mr. Chairman. Thank you for
    calling this hearing.
        Mr. Secretary, I look forward to hearing your testimony
    today on the fiscal year 2012 budget request for the Department
    of Education.

                                 BUDGET SAVINGS

        But as we convene today's hearing, I am gravely concerned
    that the Department of Education has delayed some of the tough
    choices that are necessary to ensure national economic
    stability. We all understand the critical role of education in
    our society and its impact on our Nation's ability to compete
    in a global economic environment. However, our Nation is $14
    trillion in debt, and I think we must rein in spending.

            FISCAL YEAR 2012 DEPARTMENT OF EDUCATION BUDGET REQUEST

        In times of economic uncertainty, while every Department
    should be looking for savings and efficiencies within the
    budget, the Department of Education has requested a 13.3
    percent increase from 2011. In comparison to 2010, the 2012
    budget request is a 20.7 percent increase. Let me repeat that--
    20.7 percent increase since 2010.
        The Department of Education has requested 20.7 percent more
    funding in 2012 than it received 2 years ago. However, in your
    written statement, Mr. Secretary, you state, and I quote, ``Our
    request is a responsible budget that emphasizes both fiscal
    constraint and investment in education reforms that will
    deliver results.'' Mr. Secretary, how can you consider an over
    20 percent increase since 2010 a responsible budget that
    emphasizes fiscal restraints?

                         RACE TO THE TOP BUDGET REQUEST

        One of the key investments proposed by the Department of
    Education in 2012 is Race to the Top. The budget includes $900
    million for the program, an increase of $200 million or 28.6
    percent above 2011. According to the Department, Race to the
    Top funds are awarded to States that are leading education
    reform with ambitious, yet achievable plans. Specifically, Race
    to the Top creates incentives for State and local reforms that
    produce improvements in student achievement, while reducing
    achievement gaps.

                    ALABAMA AND RACE TO THE TOP COMPETITION

        I understand that education reform is never easy. However,
    it is made significantly more difficult when States must meet
    prescriptive requirements, in this case a de facto requirement
    for charter school legislation, to even compete for available
    funding. My State of Alabama has been a leader in innovative
    science, technology, engineering, and mathematics (STEM)
    initiatives. The Alabama math, science, and technology
    initiative has earned nationwide recognition as a model for
    increasing the math and science achievements of students, the
    very achievement that Race to the Top states it supports. Yet,
    Race to the Top only awarded STEM programming 15 points out of
    500. That is troubling, Mr. Secretary.
        Instead, the Department chose only States with charter
    schools as awardees. Despite its nationally recognized STEM
    program, a key component to our future workforce competing in a
    global economy, Alabama finished dead last in the latest round
    for Race to the Top funding. And although the Department of
    Education often states its objectives to be loose on means and
    tight on ends, the experience of the State--my State--clearly
    illustrates this is not the case.

                         STATE FLEXIBILITY TO INNOVATE

        As the United States continues to fall behind other
    developed countries in reading, math, and science, States
    should be given the flexibility, I believe, to implement
    critical reforms as identified on the State and local level.
    The Federal Government should not mandate initiatives, but
    assist States in implementing programs that they deem most
    important to improving their students' achievement.

                          PELL GRANTS--GROWTH IN COST

        A key component to this achievement is improving access to
    education. As a Nation, we are on the brink of breaking our
    commitment to students who wish to attend college because the
    Pell Grant program is on a fiscally unsustainable path. Since
    2008, the cost of the Pell Grant program more than doubled.
    Legislative changes that expanded eligibility, combined with
    the dramatic rise in the number of students seeking further
    education due to the economic recession, have caused costs to
    skyrocket.
        And while the 2012 budget request offers proposals to
    address the growth in costs, the administration also proposes a
    $5.6 billion increase in discretionary Pell Grant funding. We
    cannot continue to throw money at this problem. Access to
    higher education must be protected and immediate reforms are
    necessary to ensure the Pell Grant program continues as the
    basis of our commitment to helping low income students attend
    college.

                   DISTANCE LEARNING AND STATE AUTHORIZATIONS

        Finally, Mr. Secretary, I am concerned about State
    authorization provisions related to distance learning under the
    proposed program integrity regulations. While I understand the
    Department of Education has delayed the enforcement date
    related to distance learning until July 2014, as long as an
    institution is making a good faith effort to obtain the
    necessary State authorizations, I do not believe that this
    adequately addresses the underlying issue. Simply extending the
    deadline does not take into account the burdensome impact of
    these regulations on colleges and universities.
        In addition, the definition of what ``good faith'' means--
    good faith effort is vague, and the Department's proposed
    guidelines will prove costly and time-consuming.
        I hope, Mr. Chairman, that we can work together to find the
    appropriate balance between fiscal responsibility and
    meaningful education investments because we need this in
    America.
        Senator Harkin. Thank you very much.

                     OPENING STATEMENT OF SECRETARY DUNCAN

        Again, Mr. Secretary, welcome, and your statement will be
    made a part of the record in its entirety. Please proceed as
    you so desire.
        Secretary Duncan. Thank you so much, and good morning,
    Chairman Harkin and Ranking Member Shelby. Thank you very much
    for having me here today to talk about education, the economy,
    and the need to continue investing in our future, even as
    Congress and the administration work together to reduce overall
    spending and manage our Nation's deficit.

               KEY INVESTMENTS IN FISCAL YEAR 2012 BUDGET REQUEST

        Our Department of Education has submitted a formal
    statement on our 2012 budget proposal outlining our request to
    boost investments in education in order to secure America's
    future. Key investments include closing the Pell Grant
    shortfall both through efficiencies and more resources,
    protecting desperately needed title I and Individuals with
    Disabilities Education Act (IDEA) formula funds for students
    most at risk, expanding reform programs, including Race to the
    Top and Investing in Innovation, or i3, and our early learning
    and college completion programs. These programs support State
    and local policies to accelerate achievement for all students,
    particularly for students most at risk, and provide adequate
    funding for student aid administration, now that all Federal
    student loans are originated through the direct loan program.

                 BUDGET REQUEST IN CURRENT ECONOMIC CONDITIONS

        Recognizing the real fiscal challenges facing the country,
    we also propose efficiencies, consolidations, and cuts in
    programs that are not as effective as they should be. We
    understand that just as every family is doing more with less,
    so should we. But like America's hardworking families, we also
    understand that you cannot sacrifice the future to pay for the
    present, and nothing is more important to a family's future and
    to our future as a Nation than education.

                        INVESTING IN PROGRAMS THAT WORK

        Mr. Chairman, I was in Iowa earlier this week where I
    talked about the fact that your State had gone from being a
    national leader in education to being frankly in the middle of
    the pack. I know that was a difficult message for citizens in
    Iowa to hear, but I didn't want to sugarcoat the message
    because that would not be doing any favors to Iowa's children.
        And your State is not unique. In fact, America as a whole
    has gone from being a world leader in education to being in the
    middle of the pack. In this new century, the middle of the pack
    is simply not what we want for our children or for our country.
    We all have to get better, and in order to get better, we must
    continue to invest in programs that are working.

                               PELL GRANT PROGRAM

        The Pell Grant program is helping millions of young people
    and adults get new skills for the jobs of tomorrow. Demand has
    skyrocketed from 6 million to 9 million grants in 4 years.
    College has never been more necessary for success in the global
    economy, but it has also never been more expensive and out of
    reach for an increasing number of Americans. We cannot afford
    to go backward. We must once again lead the world in college
    graduates.

                WELL-ROUNDED CLASSROOM AND AFTER SCHOOL PROGRAMS

        We must continue to invest in programs like title I and
    IDEA, and programs that help support literacy, science, and
    mathematics, and other subjects necessary for a well-rounded
    education, and provide a rich offering of high quality after-
    school activities. They give struggling students the extra help
    they need to succeed. They promote equity and safety in
    schools, strengthen the teaching profession, and support
    English language learners, students with disabilities, rural
    students, and other special populations.

                  TEACHER PREPARATION AND CLASSROOM INNOVATION

        We also have to give States and districts the flexible
    dollars that allow for innovation and reform. Today in America,
    thanks to programs like Race to the Top and Investing in
    Innovation, States and districts are preparing teachers to
    teach to higher standards. They are integrating technology into
    classrooms, expanding arts programs for students with
    disabilities, and producing a new generation of teachers in
    science, technology, engineering, and math, the STEM fields.

                           SCHOOL TURNAROUND PROGRAM

        Today, thanks to our School Turnaround Program, low-
    performing schools across the country are undergoing dramatic
    changes--new leadership, new staff, new curriculum, longer
    school days, and fresh approaches to educating students at risk
    of failure.

                NEED TO KEEP EDUCATION SUPPORT IN TOUGH ECONOMY

        From big cities like New Orleans and Chicago to small towns
    in Tennessee and Kansas, educators are tackling our toughest
    challenges, exploring new approaches to education, and building
    new partnerships that are making a difference in the lives of
    our children. At the same time, we all know States and
    districts are facing more fiscal pressure than ever before.
    Recovery Act funding has largely dried up, and local and State
    revenues have yet to recover from the recession. The harsh
    result is that too many students are losing out--losing out on
    music, drama, sports, science, field trips, exchange programs,
    summer school, and many other unique and wonderful things that
    make education so worthwhile. Their generation, our children,
    are being cheated out of a world-class education because our
    generation is unable or unwilling to make the tough choices
    necessary to protect them.
        The current debate about the debt ceiling and the deficit
    is not just about budgets and numbers. It is really about the
    fundamental promise at the heart of the middle class American
    dream. For much of the last century, America was a country
    where if you worked hard, you and your family could enjoy the
    basic benefits of a secure and comfortable life--a job, a home,
    affordable healthcare, quality education, and a secure
    retirement. Today, for too many Americans, these building
    blocks of middle class life are increasingly beyond their
    reach, and that is creating uncertainty and anxiety. This is
    not good for the country, it is not good for our families, it
    is not good for children and for education.

                               PREPARED STATEMENT

        So, while I absolutely appreciate the hard work underway to
    cut spending and get our debt under control, I want all of us
    to work together to do this in a way that does not undermine
    the education of our Nation and the education of our children.
    They are counting--our children are counting on us to prepare
    them for the future. Business owners are counting on us to
    produce the workforce they need to compete in the new economy.
    Families are counting on us to open the doors to opportunity
    for every child, regardless of background, income, ability or
    disability. We cannot let them down. We cannot let ourselves
    down. The path to a strong future starts in our Nation's
    classrooms.
        Thank you.
        [The statement follows:]
                       Prepared Statement of Arne Duncan
        Chairman Harkin, Ranking Member Shelby, and Members of the
    Committee: Thank you for this opportunity to talk about President
    Obama's fiscal year 2012 budget to help America out-educate the rest of
    the world. While the President's overall request for 2012 reflects
    broad agreement that the Federal Government has to start living within
    its means, we believe it is absolutely essential to keep investing in
    education so that, as the President put it, ``every American is
    equipped to compete with any worker, anywhere in the world.''
                      final fiscal year 2011 appropriation
        I want to begin by thanking the Chairman, the Ranking Member, and
    other Members of this Subcommittee for your work on the fiscal year
    2011 appropriation for education. I know that you faced some tough
    decisions in reaching agreement on the 2011 budget, but I believe the
    final appropriation reflected a responsible mix of continued investment
    in high-priority activities as well as reductions in programs and
    activities based in large part on the recommendations in the
    President's 2012 budget.
        In particular, I want to thank you for your renewed support of the
    Race to the Top program, which now includes the Early Learning
    Challenge competition. In May, I was pleased to share the podium with
    Secretary of Health and Human Services Kathleen Sebelius to announce a
    $500 million competition that will reward States that create
    comprehensive plans to transform their early learning systems by
    coordinating services, raising standards, and increasing the
    effectiveness of pre-K teachers. I also announced separately that we
    will use the remaining $200 million in fiscal year 2011 Race to the Top
    funding to support a competition involving the nine States that were
    high-scoring finalists but did not receive funding in the first two
    rounds of Race to the Top.
        I'm also grateful that Congress provided $150 million for a second
    Investing in Innovation (i3) competition, as well as $30 million to
    keep moving forward with our Promise Neighborhoods initiative. In
    addition, Congress did the right thing by providing the significant
    funding and programmatic changes needed to maintain the $5,550 maximum
    Pell Grant award, as well as essential funding for the continued
    effective and efficient administration of the Department's
    postsecondary student financial aid programs.
                     president obama's 2012 budget request
        Turning to 2012, we recognize that the final 2011 appropriations
    bill will have an impact on the levels provided in fiscal year 2012,
    and we are aware of the ongoing bicameral, bipartisan discussions
    between the Administration and congressional leadership on the Nation's
    long-term fiscal picture, which may result in further adjustments to
    funding levels for 2012. Nonetheless, the 2012 budget request for the
    Department of Education reflects the Administration's policy priorities
    and remains a good starting point for developing these funding levels.
    The request represents both fiscal constraint and investment in
    education reforms that will deliver results. The overall discretionary
    request for the Department of Education, excluding Pell Grants, is
    $48.8 billion.
        As you know, financing the Pell Grant program, which is funded
    through a combination of discretionary and mandatory appropriations and
    has faced growing demand in recent years as more and more students and
    working adults seek to improve their knowledge and skills, has been a
    real challenge for the Department and for the Congress. The President's
    budget responds to this challenge by proposing a combination of tough
    choices to generate savings from Pell Grants and student loan programs
    and increased discretionary funding. The overall goal of our Pell Grant
    proposals is to protect the $5,550 maximum Pell Grant award, put the
    program on more sustainable financial footing in 2012 and beyond, and
    ensure that more than 9 million low-income students can continue to
    rely on Pell Grants to enter and complete a college education.
        Our 2012 request included a Pell Grant Protection Act that was
    designed to rein in Pell costs and place the program on more solid
    financial footing by eliminating the extra Pell Grant, ending the
    interest subsidy for graduate student loans, and allowing the
    conversion of guaranteed student loans to the Department. This
    proposal, combined with administrative action to implement enhanced
    income verification procedures for Pell Grant applicants as part of
    improvements in the processing of the Free Application for Federal
    Student Aid (FAFSA), would have produced an estimated $100 billion in
    discretionary Pell Grant savings over the next 10 years. The final 2011
    appropriations act ended the extra Pell Grant, achieving a significant
    portion of the savings proposed in our 2012 request, and we will be
    working with the Subcommittee to build on those savings in negotiations
    over the 2012 appropriation.
                              making tough choices
        Before I describe some of the key investments we are proposing for
    2012, I want to emphasize that our overall strategy for supporting
    effective education reform is fully consistent with the current fiscal
    environment. From the beginning, this Administration has envisioned a
    smaller Federal role focused on key priorities and structured to ensure
    the most productive use of the resources entrusted to us by taxpayers
    and the Congress. This is why, for example, our reauthorization
    proposal for the Elementary and Secondary Education Act (ESEA) would
    consolidate 38 existing programs into 11 more flexible authorities that
    would give communities more choices to implement their own research-
    based reform strategies.
        We also have worked hard to identify and eliminate duplicative,
    unnecessary, or ineffective programs, and Congress accepted many of
    these recommendations in its final action on the fiscal year 2011
    appropriation. Key eliminations included Even Start, Smaller Learning
    Communities, Educational Technology State Grants, Tech Prep Education
    State Grants, and Leveraging Educational Assistance Partnerships, as
    well as a number of smaller programs. While each of these programs
    undoubtedly provided meaningful benefits to students and schools over
    the years, we recognize that all levels of government are challenged to
    do more with less in these times of financial constraint. That's why
    our 2012 budget places a priority on spending smarter through cost-
    effective reforms that improve student outcomes, including by
    consolidating and, where appropriate, eliminating programs.
        But make no mistake; the President's request for education is about
    investing in our Nation's future. President Obama has said that to win
    the future, we have to win the education race, and his 2012 budget
    reflects what is needed to educate our way to a better economy. More
    specifically, the 2012 request for education is designed to promote
    reform, reward success, and support innovation at the State and local
    levels while maintaining strong support for students most at risk of
    educational failure. To meet these goals, our 2012 investments in
    education are divided into four significant priorities.
                           sustaining reform momentum
        First, our request includes an additional $900 million for Race to
    the Top, which already has demonstrated how competitive rewards create
    powerful incentives for State and local leaders to make groundbreaking
    education reforms. In the first two RTT competitions, 46 States created
    bold comprehensive reform plans that have buy-in from Governors,
    legislators, local educators, union leaders, business leaders and
    parents. As noted earlier, we will use 2011 Race to the Top funds to
    make awards to high-scoring but unfunded finalists from the first two
    rounds of Race to the Top. The 2012 request would focus on supporting
    district-level reform plans while also emphasizing cost-effective
    strategies that improve student achievement in a time of tight budgets.
    The Department would also carve out a portion of funds for rural school
    districts to ensure that communities of all sizes and from all
    geographic areas are able to compete for a fair share of Race to the
    Top funds.
        While we are very pleased that we will be able to launch the Early
    Learning Challenge Fund with fiscal year 2011 Race to the Top funds, we
    are seeking additional funding in 2012 to continue critical investments
    in early learning that will support model systems of high-quality early
    learning supports and services for children from birth to kindergarten
    entry. These investments would complement proposed 2012 increases for
    programs in the Department of Health and Human Services, including
    increases for Head Start and for quality child care.
        The 2012 request also would encourage reform and innovation through
    a $300 million request for the Investing in Innovation (i3) program to
    develop, evaluate, and scale up promising and effective models and
    interventions with the potential to improve educational outcomes for
    hundreds of thousands of students. The request includes priorities for
    science, technology, engineering, and mathematics (STEM) education and
    early learning, as well as an overall focus on increasing productivity
    to achieve better student outcomes more cost-effectively. The
    Department would include a refined rural priority in the i3 competition
    to ensure geographic diversity in the communities served by recipients,
    and would fund applications from providers and other entities proposing
    evidence-based approaches to address the unique needs and priorities of
    rural districts and schools. We also would take a page from the
    Department of Defense by creating a new Advanced Research Projects
    Agency: Education (ARPA-ED) that would use both discretionary and
    mandatory funds to pursue breakthrough developments in educational
    technology and learning systems, support systems for educators, and
    tools that improve outcomes from early learning through postsecondary
    education. We see this as a natural complement to the innovations found
    in the field through the i3 program.
        In addition, our request would significantly boost funding for the
    Promise Neighborhoods program to $150 million to support comprehensive,
    innovative and cost effective approaches to meeting the full range of
    student needs, drawing on the contributions of schools, community-based
    organizations, local agencies, foundations, and private businesses.
    Also, the request would maintain funding for safe school programming
    designed to reduce substance use, violence, and bullying while
    providing States with greater ability to adapt interventions to school
    needs and drive resources to the most unsafe schools.
                           great teachers and leaders
        Our second priority is teachers and school leaders. I think we can
    all agree that nothing is more important, or more likely to improve
    student achievement and other key educational outcomes, than putting a
    great teacher in every classroom and a great principal in every school.
    Our 2012 request, together with a proposed restructuring of teacher and
    leader recruitment and preparation programs as part of our ESEA
    reauthorization plan, is designed to support State and local reforms of
    systems for recruiting, preparing, supporting, rewarding, and retaining
    effective teachers and school leaders. For example, the budget includes
    funding for a Teacher and Leader Innovation Fund to support ambitious
    reforms, including innovative teacher evaluation and compensation
    systems, to encourage effective teachers, principals, and school
    leadership teams to work in high-need schools. We also are seeking
    funds for Teacher and Leader Pathways to expand high-quality
    traditional and alternative pathways into teaching, with an emphasis on
    recruiting, preparing, placing, and supporting promising teacher
    candidates for high-need (including rural) schools, subject areas, and
    fields. Included in this request is a set-aside to help prepare 10,000
    new STEM teachers over the next 2 years, as part of the President's
    plan to prepare 100,000 new STEM teachers over the next decade. In
    addition, the Presidential Teaching Fellows program (formerly the TEACH
    program), paid for with mandatory funds, would award $10,000
    scholarships to the best students attending our most effective teacher
    preparation programs who agree to work in high-need schools.
                               college completion
        Our third priority is college completion. I've already talked about
    the Pell Grant program, which is the foundation of Federal efforts to
    support both increased college access and completion for low-income
    students. Unfortunately, we know that far too many students who enroll
    in college drop out and never earn a degree. Currently, one-third of
    postsecondary students leave school without earning a degree and only
    one-half finish after 6 years. Clearly, access isn't enough, and we
    need a much stronger emphasis on attainment in postsecondary education.
    Through the $123 million ``First in the World'' competition, we'll
    provide venture capital to develop innovative approaches to increase
    college completion rates and improve educational outcomes while
    lowering costs and time to degree for students in higher education. And
    through our proposed College Completion Incentive Grants program, we
    would provide mandatory funding over the next 5 years in grants to
    States to reward institutions with exemplary college completion
    outcomes.
        The President's budget also would continue support for key existing
    programs supporting college access and completion, particularly for
    minority and disadvantaged students. The request includes funding for
    the Federal TRIO programs and the GEAR UP program, which helps an
    estimated 756,000 middle and high school students prepare for and
    enroll in college. The 2012 budget also provides discretionary and
    mandatory funding for the Aid for Institutional Development programs,
    which support institutions that enroll a large proportion of minority
    and disadvantaged students, and discretionary and mandatory funding for
    the Aid for Hispanic-Serving Institutions programs, which help ensure
    that Hispanic students have access to high-quality postsecondary
    education opportunities.
        We also look forward to working with Congress to strengthen the
    Perkins Act, which shapes the Career and Technical Education program,
    and improve its alignment with the education reform efforts at the core
    of our ESEA reauthorization proposal, so that the Perkins Act is a
    stronger vehicle for supporting the President's 2020 college completion
    goal and the Department's efforts to improve secondary schools.
                    support for at-risk students and adults
        Finally, the President's 2012 budget for education would maintain,
    and in some cases expand, the Federal Government's commitment to
    formula programs for students most at risk of educational failure. For
    example, our request for the reauthorized Title I College- and Career-
    Ready Students program (currently Title I Grants to Local Educational
    Agencies) includes increased funding to recognize and reward high-
    poverty districts and schools where disadvantaged students are making
    the most progress. The $600 million request for a reauthorized School
    Turnaround Grants program would expand support for school districts
    undertaking fundamental reforms in their persistently lowest-achieving
    schools, while the budget also provides funding to help English
    Learners meet the same college- and career-ready standards as other
    students.
        In Special Education, our request for Individuals with Disabilities
    Education Act Grants to States would help States and school districts
    pay the additional costs of educating students with disabilities, while
    our request for Grants for Infants and Families program would
    complement the proposed Early Learning Challenge Fund.
        The 2012 request also provides significant resources to help adults
    pursue educational and employment opportunities, including funding for
    Adult Basic and Literacy Education State Grants to help adults without
    a high school diploma or equivalent to become literate and obtain the
    knowledge and skills necessary for postsecondary education, employment,
    and self-sufficiency, and mandatory and discretionary funds for
    Vocational Rehabilitation (VR) State Grants to help States and tribal
    governments to increase the participation of individuals with
    disabilities in the workforce.
        We are looking forward to the reauthorization of the Workforce
    Investment Act (WIA) so that low-skilled adults and individuals with
    disabilities have access to the education and training they need to be
    successful in the 21st century economy. A reauthorized WIA would
    provide opportunities to upgrade the skills of our Nation's workers so
    that they are able to compete in this new economy. One of those
    opportunities includes a new Workforce Investment Fund, which we are
    proposing in partnership with the Department of Labor, to help provide
    flexibility for the connections necessary to get people into good jobs
    or the education needed for a better job. The Fund will also provide
    resources to evaluate and replicate best practices so that we better
    serve those who have the hardest time finding work--those with limited
    basic skills and individuals with disabilities.
                                   conclusion
        In conclusion, President Obama's 2012 budget for education is part
    of a comprehensive and responsible plan that will put us on the path
    toward fiscal sustainability in the next few years. Like every other
    agency across the Government, we are working hard to more efficiently
    steward the Department's resources. At the same time, education remains
    a priority for the Administration due to the critical importance of our
    education system for our continued economic prosperity. The
    Department's budget includes a responsible mix of savings and
    investments that will promote reform and innovation, support a
    comprehensive ESEA reauthorization, and encourage improved
    postsecondary outcomes. I look forward to working with the Committee to
    build support for the President's 2012 budget for education and to
    secure the best possible future for America by providing the best
    possible education for all of our children.
        Thank you. I would be happy to answer any questions you may have.

                 PELL GRANTS AND TOTAL EDUCATION BUDGET REQUEST

        Senator Harkin. Thank you very much, Mr. Secretary. We will
    start a round of 5-minute questions.
        Mr. Secretary, I want to talk about this 20 percent
    increase. I was quite surprised to hear that this budget had
    gone up 20 percent since 2010. So, I started looking at it, and
    when you look at the figures, excluding Pell grants, in fiscal
    year 2010, it was $46.64 billion, fiscal year 2012, the
    President's budget is $48.8 billion, which is about a 4 percent
    increase. So, why do we have a 20 percent increase that I heard
    my ranking member talk about? Is that not because of the
    increase in the Pell grants--the number of Pell grant money? Is
    that right, Mr. Secretary?
        Secretary Duncan. Yes, sir.

                   UNEMPLOYMENT IMPACT ON PELL GRANT PROGRAM

        Senator Harkin. Well, I would point out, of the $77.4
    billion request for fiscal year 2012, $28.6 billion is for Pell
    grants. Now, we might say, well, gee, what is going on here?
    Maybe we have got to cut back on Pell grants. What is going on
    is we have got over 20 million out of work. We've got an 18
    percent--not 9--almost 18 percent unemployment rate in this
    country.
        So, I guess what we are going to do is penalize the kids
    because their parents are out of work, and they have now fallen
    into the classification where they qualify for Pell grants,
    where before they probably would not have qualified for Pell
    grants.

                        INCREASED DEMAND FOR PELL GRANTS

        So, I hope we keep our eye on exactly what is happening
    here. Most of this increase is because of the increased use of
    Pell grants. We have an increased use of Pell grants because we
    have more poor people in this country, and we have more poor
    people because 18 percent of people are out of work and they
    are not working.
        So, I guess we have a choice to make. Do we cut these kids
    off at the knees?--Say, no, you qualify, but you are not going
    to get the money because we have to keep our budget down, you
    see, and our spending down. Well, as I said in my opening
    statement, that is like turning a chainsaw on yourself. Or up
    my way, we say, it is like eating your seed corn, when you are
    cutting education.

                               PELL MAXIMUM GRANT

        I can tell you, Mr. Secretary, this subcommittee and our
    committee, and I hope the Congress, will continue to be fully
    supportive of the maximum Pell grant.

              PELL SHORTFALL AFTER ELIMINATION OF YEAR ROUND PELL

        Now, again, we in the fiscal year 2011 continuing
    resolution, in order to free up money to make sure we had money
    for the basic Pell grant, we--Congress ended the year-round
    Pell Grant program known as ``two Pells'', which allowed
    students to receive two Pell grants in a single year. Well,
    that cut into some students, but it brought down the costs of
    the Pell Grant program. But even with that change, the
    shortfall for fiscal year 2012 is about $11 billion.

                               MAXIMUM PELL GRANT

        So, the other proposal that Senator Reid came up with--that
    we worked with him on--was to eliminate the in-school interest
    subsidy for graduate loans as another way of making sure we
    could keep the maximum Pell grant for the poorest students.
    This proposal was also in the President's budget.
        So, when you look at the options, why, Mr. Secretary, do we
    choose this one? Why do we choose eliminating the in-school
    interest subsidy for graduate loans? Why--could you just
    enlighten us why that is better than other options we might
    have?
        Secretary Duncan. Yes, Mr. Chairman. These are all very
    tough choices. In an ideal world, you know, better economic
    times, maybe you would not make any of these choices. But at
    the end of the day, we desperately want to preserve that
    maximum Pell grant.

                ELIMINATION OF TWO PELLS AND IN-SCHOOL SUBSIDIES

        And I think there are two factors at work here. One, as you
    said, is we simply have more young people around the country
    who qualify, who have need. Second, what is so critically
    important, I think, that we all understand is that our economy
    is changing. And to get the jobs of the future--there was a
    recent study that came out from the Georgetown University
    Center on Education and the Workforce. They estimate that going
    forward, we are going to be about 3 million college graduates
    short of what the economy needs--what the market is asking for.
    And so, at a time of increasing need, there is also increasing
    demand. And so, we have to keep that maximum Pell Grant at
    $5,550. We have had to make tough calls. Eliminating the two
    Pells in one year--in an ideal world, I would never want to do
    that. Eliminating in-school subsidies for graduate students,
    again, in an ideal world we'd never want to do that. But we are
    trying to be fiscally responsible and share the pain and make
    these tough choices. We think those are the lesser of the
    evils, and we want to at all costs maintain that Pell maximum
    award at $5,550.
        Senator Harkin. I appreciate that. And when we looked at
    that, the interest subsidy for graduate students, I mean, let
    us face it. If you are a graduate student, you are probably
    going to get a pretty good job when you get out. And so, in the
    whole spectrum of things, they could probably afford that
    interest payment--we hope so anyway, with all the unemployment.
    But hopefully our graduate students will lead us--help lead us
    out of this mess. But I can see where we would take on that
    rather than the poorer students in undergraduate school.
        Secretary Duncan. Yes, sir.
        Senator Harkin. So, it is a tough choice, but one that we
    supported.
        My time is up. Senator Shelby.

             STRONG EDUCATION SUPPORT NEEDED DESPITE TOUGH ECONOMY

        Senator Shelby. Thank you, Mr. Chairman.
        Mr. Secretary, I do not think any of us want to take a
    chainsaw to any program that is going to sustain our
    educational system and hope for our young people at all. But we
    are all taking a chainsaw to our budget right now to a certain
    extent because of our failure to act. We have a $14 trillion
    debt. You probably, in putting your budget together, made some
    tough choices.
        What we have got to do, I believe, is make some wise
    choices, and then carry them through. And what those all are, I
    am not sure, but I know that we cannot, as Senator Harkin said,
    we cannot starve the future. We cannot starve our children of
    food and sustenance. We cannot starve them of an education.

                 JOB AND EDUCATION REQUIREMENTS OF NEXT DECADE

        Where are the jobs going to be, in your judgment, in the
    next, say, 10 years? Where are the jobs in America going to be,
    and what kind of education process do we need to get there, to
    have our people ready for the workforce jobs that are needed?
    Because at the end of the day, we've got millions of people
    unemployed, and a lot of them are losing hope every day.

              INADEQUACY OF EDUCATION FOR CURRENT HIGH SKILL JOBS

        Secretary Duncan. Let me give you four different statistics
    that sort of get at this. One is that even in this tough
    economic climate, we have 3 million unfilled jobs in this
    country. Many of those are high-skilled, high-wage jobs, and we
    are simply not preparing the workforce for those jobs.

                    EDUCATION AND JOB DEMANDS OF NEXT DECADE

        Going forward, up until about 2018, we are going to need to
    fill 2.6 million job openings in the STEM fields--science,
    technology, engineering, and math. Going forward, there is an
    estimate that by 2018, if we stay on the current course, if we
    do not improve, we are going to be 3 million college graduates
    short of what the market demands.
        And then finally, by 2018, between now and then, 63 percent
    of job openings will require at least some college-level
    education. And these are not our facts; these are all facts
    from outside groups, the Bureau of Labor Statistics, and the
    Georgetown University Center on Education and the Workforce.
    So, we need an increasingly educated, high-skilled workforce
    with this particular emphasis on the STEM fields.

              PELL GRANTS--INTEGRAL TO EDUCATION BUDGET AND GOALS

        Senator Shelby. Mr. Secretary, as we think of Pell grants,
    do we not have to think of them in the overall budget process
    of the Department of Education? In other words, they are not
    separate from; they are part--an integral part of the budget.
    Is that correct?
        Secretary Duncan. I think, again, all of our work from, you
    know, early childhood education, which we will talk about----
        Senator Shelby. Everything----
        Secretary Duncan [continuing]. K to 12 reform, all of that
    is to what goal? The goal, as the President has laid out, is to
    lead the world in college graduates by 2020. We think that--we
    have to educate our way to a better economy. So, the Pell
    grants are absolutely vital, integral, critical to getting us
    as a country----
        Senator Shelby. But they are not the only part of the
    education part.
        Secretary Duncan. No, sir.
        Senator Shelby. An important part, yes.
        Secretary Duncan. Yes, sir.

                      PELL GRANTS--HOW DO WE PAY FOR THEM?

        Senator Shelby. Now, how are we going to pay for it? That
    is the bottom line. In other words, the growth--we have a lot
    of people unemployed. We know this, which we hate. But how are
    we going to pay for this, because that is going to be the
    bottom line up here this year and in the future. What are our
    priorities? What are our priorities in education? What are your
    priorities in the Department of Education? Could you list, say,
    the top three or four? You are going to have to make some
    decisions. So do we.

            SAVINGS FROM ELIMINATING TWO PELLS AND IN-SCHOOL SUBSIDY

        Secretary Duncan. So, we are making very tough decisions.
    We have talked about eliminating the grad school subsidies.
    That is going to save the country $18 billion over the next 10
    years.
        Senator Shelby. Eighteen billion dollars.
        Secretary Duncan. Over the next 10 years.
        Senator Shelby. Would that pay for the Pell Grant increase,
    for the, say, the undergraduates?
        Secretary Duncan. Short term, it helps. I mean, this is $18
    billion with a B, this is real money.
        Senator Shelby. Okay.
        Secretary Duncan. So, eliminating the second Pell----
        Senator Shelby. That is $1 billion here and $8 billion
    there, and it is real money?
        Secretary Duncan. Exactly. I am learning that here in
    Washington.
        Senator Shelby. Okay.
        Secretary Duncan. Eliminating the second Pell Grant each
    year, which again was a tough, tough call, that is $5 billion
    every single year. So, over 10 years that is $50 billion. So,
    these are very real savings. You know, tough calls, not calls
    we wanted to make, but we had to make, we think, to preserve
    that maximum funding for Pell grants.

                EDUCATION PRIORITIES--CRADLE-TO-CAREER CONTINUUM

        To answer your question, our priorities are continuing to
    strengthen early childhood education, to continue to drive K to
    12 reform, and to continue to invest in--to increase access to
    higher education. So, this is a cradle-to-career continuum, and
    those are the three steps along that pathway.
        Senator Shelby. But if you cannot have it all, and you
    cannot--I wish you could, and I wish that I were here when we
    owed no money as a Nation, because I think a lot of us could
    get together and have a lot of good ideas including investment
    in education. We are going to have to make tough decisions.
        And thank you. My time is up.
        Senator Harkin. Senator Reed.

                                EDUCATION REFORM

        Senator Reed. Thank you very much, Mr. Chairman, and thank
    you, Mr. Secretary. And certainly you have an extraordinarily
    challenging job, given the budget pressures. I think you
    rightly point out the central need to fundamentally reform our
    education system at the elementary and secondary level, and
    also support it at the higher education level.

            LARGE-SCALE COMPETITIVE VS. FORMULA-BASED GRANT PROGRAMS

        But let me take a moment because I am concerned that the
    overarching strategy at the Department has been to focus almost
    exclusively on these untested, large-scale competitive grant
    programs at the expense of some proven research-based programs
    that have a track record of success. Race to the Top is
    probably the signature program. That is a novel, and I think
    bold, way to sort of rethink education. But it has displaced
    programs, for example, like the school library program.

                           NEED FOR LIBRARY PROGRAMS

        And the Department's own evaluation has found these library
    programs to be extraordinarily effective over many decades. In
    fact, since 1965, more than 60 educational library studies have
    produced clear evidence that school libraries staffed by
    qualified librarians have a positive impact on student
    achievement. And I think it just follows that someone who knows
    about how to use the library and wants to use the library, is
    probably prepared for learning the rest of his or her life.
        There is no plan that I have seen or has been shared with
    me for the Department to replace either through Race to the Top
    or any other program the support that we have given to school
    libraries. So, frankly, those programs are not only on hold,
    but they very well might be lost. And I do not have to remind
    anyone around here, the first thing to go at the local school
    committee meeting is, well, we will not buy any library books
    this year. In fact, back in the 1990s when I got involved in
    this issue, librarians would come to me with books stamped
    ESEA, 1965, and that was 25 years after the legislation was
    passed. So, I am concerned about that.

                          TEACHER QUALITY PARTNERSHIPS

        Another example, too, is the Department has a program that
    is trying to develop support for teachers, but there is already
    a teacher quality partnership grant program that was included
    in the Higher Education Opportunity Act. This program has high
    bars for reform. You are consolidating that program into a
    broader, more flexible funding stream, which could water down
    reforms.

                  NEED FOR FULL RANGE OF STUDENT AID PROGRAMS

        And then we all are committed to maintaining student
    financial aid. And the President, I must admit, and your
    leadership has been instrumental in increasing the maximum Pell
    grant. However, the strength and resilience of our Federal aid
    programs comes through a combination of Pell, State grants,
    institutional aid, and student loans. And as we try to work the
    Pell Grant, it seems that we have done a lot to undermine the
    other programs. In fact, we have eliminated some of them
    effectively.
        And so, I do not know. They are not easy questions--with
    easy answers. I have specific questions I will submit to you in
    writing. But I would just in the remaining minute ask you to
    comment.

               FORMULA GRANT PROGRAMS FORM MAJORITY OF ED BUDGET

        Secretary Duncan. Sure. I will try and respond succinctly.
        So, the vast majority--let me be very clear--the vast
    majority of our funding has been, continues to be, and will be
    going forward, formula-based, not competitive-based. And in
    fact, 84 percent of our money is formula-based funding, the
    large--absolute large majority being title I and IDEA.

                     SUPPORT FOR INNOVATION AND ACHIEVEMENT

        We have asked for a small percentage of money to reward
    excellence and courage. And what has been so interesting to me
    in programs like to Race to the Top is it is not just within
    the States that won money, like your State, but it is in a
    State like Chairman Harkin's, where they did not receive a dime
    from us, that we have seen a massive amount of change. For the
    first time, States are raising standards, and that benefits
    disadvantaged children, and rural children more than anyone. We
    have dummied down standards in far too many places.
        And so, at the end of the day, it was not just about who
    received money; it was creating a climate in this country where
    folks started to do the right thing, started to think about
    high standards, or working together on better assessments, or
    finally turning around chronically under-performing schools
    that they hesitated to do before. And so, that work is going on
    nationwide whether States receive money or not.

                         SUPPORT FOR LITERACY PROGRAMS

        In terms of the literacy funding and school libraries, and
    you have been a strong advocate there, we were very
    disappointed that in our fiscal year 2011 budget, funding for
    literacy basically got decimated, went to zero in the
    continuing resolution. And so, we are asking for a very
    substantial increase in literacy funding because that is so
    fundamental, so foundational to student learning. And if
    students cannot read, if they cannot express their ideas
    verbally and on paper, frankly however much else we do does not
    matter. And so, we are, again, in tough economic times, asking
    for a significant boost in that funding.

                      INCREASING COLLEGE COMPLETION RATES

        And then again, just finally on the need for access to
    higher education. We want to continue, as I have said
    repeatedly, we want to continue to maintain that commitment.
    One thing we have not talked about is we are asking for some
    i3-like money, some creative money, to really reward
    institutions and States, and nonprofits that can increase
    college completion rates, and increase productivity, and do a
    better job of helping students with disabilities to graduate.
    So for me, access is desperately important, but it has got to
    be about more than access. It has got to be about attainment.
    It is about getting that college diploma. And we want to really
    invest in places that are going to build cultures around not
    just access, but around completion.
        Senator Reed. Mr. Secretary, I have specific questions I
    will submit to you. But I thank you again for your presence
    today and for your service. Thank you.
        Secretary Duncan. Thank you.

                   STRENGTHENING LITERACY IN THE EARLY GRADES

        Senator Cochran. Mr. Chairman. Mr. Secretary, thank you
    very much for your cooperation and participation in this
    hearing. I am pleased to be a co-sponsor with my friend from
    Rhode Island of S. 1328, The Strengthening Kids' Interest in
    Learning and Libraries Act. And that question that he put to
    you is one that I identify with.
        In our State, we have a financial problem because we do not
    have enough tax money coming into the State government
    agencies, and in county and local agencies that fund education
    programs to take care of all of our needs. So, we were really
    excited when the Elementary and Secondary Education Act was
    approved and funding under the various titles began coming to
    our State, and have provided some needed financial benefits
    that have been used to involve students who were not learning
    at the rates they should have been in innovative programs,
    literacy programs. And the school libraries played an active
    role in this.
        I was just curious to know what your assessment of the
    Department of Education's Learning and Libraries Act is having
    on that challenge.

                MISSISSIPPI'S GAINS IN LITERACY IN EARLY GRADES

        Secretary Duncan. Again, we want to do everything we can to
    enhance literacy through libraries, the classroom, and
    technology. That is just fundamental. And I have to tell you, I
    have been recently studying, Senator Cochran, Mississippi's
    results on increasing literacy in the early grades. And I think
    Mississippi is making as fast, if not faster, progress than any
    State in the country. And so, I am spending a lot of time
    talking to folks from your State, looking at what they have
    done right there.
        And Mississippi, as you know, historically has really been
    maybe 50th in so many indicators. And particularly in the early
    grade literacy, I think you have gone from 50th as a State to
    43rd. That is remarkable progress in a short amount of time.
    So, I think there are a lot of lessons to be learned about what
    you guys are doing as a State to create a culture of literacy,
    to better support teachers, to raise expectations.
        And, again, I am always looking not at just where you rank,
    but rates of progress. And the progress your State is making is
    very significant, very encouraging, and I think has national
    implications. So, I thank you for the leadership there. And I
    thank the State for taking on such a foundational issue and
    making remarkable progress in a short amount of time.

                           FEDERAL ROLE IN EDUCATION

        Senator Cochran. I am very proud of the fact that my
    parents were both involved in education. And my father was a
    school superintendent, and my mother was a mathematics teacher.
    And they both were very strong advocates for Federal assistance
    to education at a time in Mississippi when some people thought
    there were strings attached, and there were--it would
    strengthen the Federal role in education--and not necessarily
    to the benefit of the children, but to the control of the
    Federal Government over local decisionmaking.
        I think all of that has gotten sorted out, and there is not
    as much suspicion now as there used to be with Federal money
    coming into the State, and with it, strings being attached that
    might not be consistent with what was really best for the
    children and the atmosphere they were growing up in.

                       LITERACY THROUGH SCHOOL LIBRARIES

        But we want to continue to monitor the use of Federal
    dollars. And there is one program, I think it is called the
    Second Evaluation of the Improving Literacy Through School
    Libraries Program. What effect do you think this has had on the
    ability of school districts that do not have adequate resources
    for furnishing libraries? Has that provided meaningful benefits
    in your opinion?
        Secretary Duncan. I would have to look at the details of
    that. But, again, whatever we can do to support literacy, to
    support early literacy, in the classroom, after school, through
    print, and more and more going forward, digital resources, we
    want to do that, and we want to give students and communities
    who historically have been under-served or under-resourced--
    disadvantaged communities--we want to give them more
    opportunity.

                            TITLE I REWARDS PROGRAM

        Senator Cochran. Well, one area that has been brought to my
    attention is the title I program and a new--under new authority
    called Title I Rewards. I was going to ask you if you could
    submit for the hearing record your assessment of how that
    program is working.
        While Mississippi has the country's highest concentration
    of children in poverty, it received only $1,318 per title I
    eligible student. And we were looking at some comparisons with
    other States that had student populations about our size, and
    Wyoming received--and I am not fussing about the higher level,
    but three times as much funding for that program as our State
    did. I am just curious to know why is that, and if that is a
    disparity?
        Secretary Duncan. We would have to look at that and look at
    how States are allocating title I dollars. But to answer your
    question directly, our Title I Rewards Program hasn't been
    funded yet; that is a request, so there is nothing to evaluate.
    But our goal is very, very clear. There are certain high
    poverty, often high minority districts that do an amazing job
    of increasing student achievement. And we want to shine a
    spotlight on that, we want to recognize that, we want to learn
    from that, and we want to incentivize that, give them more
    resources.
        And so, I think, again, with everything we are doing, we
    are trying to put a spotlight on excellence. We spend billions
    and billions of dollars, you know, well over $10 billion a year
    on title I. I want to know which districts are doing an amazing
    job of helping disadvantaged students be successful, and give
    them additional resources and learn from them. That is the
    purpose of that program, but it has not been funded yet, so
    there is nothing to evaluate. That is part of our request.
        Senator Cochran. All right. Thank you very much. Mr.
    Chairman.

                FIRST GENERATION STUDENTS--COLLEGE DROPOUT RATE

        Senator Brown. Thank you very much, Chairman Harkin, and,
    Mr. Secretary, nice to see you again.
        Eighty-nine percent of first generation students--89
    percent leave college without a degree after 6 years, a
    terrible waste of human talent, a terrible waste of the future
    potentially, and a terrible waste of dollars.
        The Gates Foundation said 54 percent of students that leave
    during that 6 years cite the need to work and make money; 31
    percent cite an inability to afford the tuition and fees. And
    this is a direct result of Government not investing the way
    that we should. I appreciate the President's efforts there.
        You came a couple of years ago to speak to an annual--I
    have done it four times in my 5 years now in the Senate--annual
    presidents' conference. We bring in 50, 55 college presidents
    in Ohio, 2-year, 4-year, private, public. And you spoke 1\1/2\
    years ago, 1 year plus ago there. And trying to figure this
    whole issue out.
        What--talk to me--give me 2 or 3 minutes--what the
    Department is doing to target and eliminate barriers faced by
    first-generation students, especially community colleges.
        My wife was a first-generation. Her dad carried a union
    card for 35 years. She was one--the oldest of four children
    that went to college. She graduated with very little debt. It
    was--I guess I can say this--30 plus years ago. And she--but
    she talks about calling home those first 2 years, and her
    parents never had any real substantive useful advice for her
    about how to navigate their way through college.
        So, give me a couple of minutes of very specific, what this
    Department is doing to rescue--give those young people
    opportunities that they need.

                   HELPING FIRST GENERATION STUDENTS GRADUATE

        Secretary Duncan. First of all, thanks so much for your
    passionate leadership in this area. And as we become an
    increasingly diverse country, as the minority population
    becomes the majority, our ability to help those first-
    generation students, not just graduate from high school, but
    graduate from high school truly college- and career-ready, and
    then to graduate from college is critical. The fate of our
    Nation hangs on our ability to do that well, so I cannot
    overstate the importance.

                     MAINTAINING ACCESS THROUGH PELL GRANTS

        Three very specific things we are trying to do. One of the
    big emphases today is our desperate fight to maintain access
    for poor students to Pell grants, which by definition are
    students you are talking about. And if we scale back on Pell
    access based upon the research that the Gateses and many others
    have done, we will simply have a lot less people going on to
    college. And they are going to be at a huge disadvantage in
    this knowledge-based, globally competitive economy. So, we have
    to maintain that commitment and help more and more people have
    access.

                        INVESTING IN COMMUNITY COLLEGES

        Second, we have not talked enough today about community
    colleges. We think community colleges have been this unpolished
    gem along the education continuum. Many are doing a magnificent
    job, whether it is with 18-year-olds or 38-year-olds, or 58-
    year-olds, folks going back to retrain and retool, in areas
    like green energy jobs, healthcare jobs, technology jobs. We
    are making an unprecedented investment--$2 billion along with
    the Labor Department, to invest in community colleges that are
    building strong partnerships with the private sector. And,
    again, their work and their courses are leading to real jobs in
    the community.
        It has been a great partnership with Labor. My Under
    Secretary of Education, Martha Kanter, is a former president of
    a community college. We have never had someone at that level
    with that background. We did that very strategically because we
    thought that was so important.

           FIRST IN THE WORLD--BUILDING A COLLEGE COMPLETION CULTURE

        Finally, we want to invest in the fiscal year 2012 budget
    in what we are calling the First in the World Competition, and
    to really again put significant money, over $100 million behind
    States and universities and nonprofits that can show us what
    they are doing to build cultures around completion,
    particularly for first generation college goers, folks with
    disabilities, those who have been denied opportunities
    historically. So, those three, Pell access, a huge play in the
    community colleges in trying to invest in place, building
    cultures around completion would be the three I would give to
    you this morning.
        Senator Brown. Thank you, Mr. Secretary.
        Two other issues, one a comment, and then a last question.

                  FEDERAL DIRECT STUDENT LOAN ORIGINATION FEES

        It is my understanding that Speaker Boehner's latest
    deficit reduction plan proposes to eliminate the Department of
    Education's ability to offer incentives to borrowers who pay
    their loans on time. The Federal direct student loan program,
    which makes so much sense in terms of students dealing with
    interest rates, cost, debt all of that. I know that my
    colleagues do not--they think it is another big Government
    program. It is one that saves money and helps students, and
    kind of throws the middle man out, if you will, the banks, and
    has made such a difference. But under their deficit reduction
    plan, college students would have to pay a higher origination
    fee for their Federal direct loan. I would just like you to
    continue to do the right thing on the Federal direct loan
    program. It matters so much.

                 TITLE VI CULTURE AND FOREIGN LANGUAGE PROGRAMS

        My last question is this. The title VI international
    education and foreign language studies programs are, I think,
    especially important for us to enhance our capacity to
    understand foreign languages and cultures and people--
    increasingly important in both a globalized economy and in an
    uncertain world.
        For 50 years, the United States has invested in building
    this national capacity, which is vital to our economic and
    diplomatic efforts around the world. I was disappointed that
    fiscal year 2011 appropriations contained severe reductions to
    international programs.
        I think we--and my question is this. I would like more
    specifics about how you are measuring the effectiveness of this
    program, because I think if you really do measure it, including
    implementing the recommendations made by the 2007 National
    Academies report, the more accurately you measure this, the
    less likely you are going to want to, from my experience with
    this, be making any cuts to this program. So, if you would give
    me your thoughts on that.
        Secretary Duncan. No, I really appreciate you pushing on
    that. And we were disappointed those funds got cut
    substantially in fiscal year 2011. We are looking to restore
    funding for that program that we think is very important. And,
    again, in a smaller world and a more globalized world, in order
    to give young people those kinds of opportunities, we want to
    restore funding in fiscal year 2012. That is part of our
    request.
        Senator Brown. Thank you.
        Thank you, Mr. Chairman.
        Senator Moran. Mr. Chairman, thank you.

                    TEACHER AND STUDENT CLASSROOM EXPERIENCE

        Secretary, I appreciate the conversation you and I had last
    week, and look forward to working with you to see that good
    things happen in education, in our country, and particularly in
    Kansas.

                          STATE AND LOCAL FLEXIBILITY

        I voted against No Child Left Behind in its early creation
    back when I was a member of the House of Representatives for a
    number of reasons. I have genuine concern about what is
    happening in regard to teachers. And I am concerned that
    education becomes more of a bureaucracy as compared to a
    profession. I worry that the classroom experience is being
    diminished with focus on in-service teachers' meetings
    preparation as compared to that opportunity for teachers to do
    what they do best, teach our students in a classroom, in my
    view, as students learn with a teacher who loves to teach, with
    a student who wants to learn, and parents who encourage that
    through discipline and encouragement.
        And I want to make sure that the programs we create here in
    Washington, DC, do not impede upon that educational opportunity
    in the classroom.

              FEDERAL FUNDS AS PERCENT OF KANSAS EDUCATION BUDGET

        In Kansas, we receive just over 7 percent of our education
    funding from the Federal Government, and yet as I talk to
    educators--teachers, school administrators, superintendents,
    board members--the amount of time, effort, energy, and cost
    associated with trying to figure out what the Department of
    Education, what the Federal Government is doing in education
    consumes a much more substantive amount of their time than the
    7 percent of funding that is received. And I suppose one could
    answer, well, let us provide more money. I doubt that that is a
    realistic option.

                         STATE FLEXIBILITY AND WAIVERS

        I would love to hear from you the efforts that you are--
    your Department is pursuing to make sure that schools have the
    flexibility, that the focus is on the classroom, that it is not
    upon paperwork and bureaucracy. And in particular, you
    indicated that if we do not have ESEA reauthorized by
    September, that you had plans to offer waivers. And I am
    interested in knowing what those--what you would require--what
    those waivers would be and what you would require of States to
    actually receive a waiver. And also your thoughts about the
    growth model, which seems to be educators' kind of solution to
    AYP is changing the model, and what efforts in that regard do
    you see beneficial?
        Secretary Duncan. So, lots there, and I appreciate your
    leadership and thoughtfulness on these issues.

                  IMPROVING PARTNERSHIPS WITH STATES AND LEAS

        First of all, one of the biggest things I am trying to do,
    and I want you collectively to hold me accountable, is we want
    our Department to be a better partner. I was a school
    superintendent for 7\1/2\ years, and frankly, I often chafed at
    the restrictions of the Federal Government--I tell the story
    frequently that I had to have a huge battle with my Department
    of Education here for the right to tutor poor children after
    school in Chicago. I won that battle, but it made no sense that
    we had to fight the Federal Government to do the right thing by
    children.
        So, I am acutely aware of the history there. I cannot say
    we are doing it perfectly every day, but I just want to assure
    you we are trying. And I would encourage you to talk to supes
    and State school chief officers, and teachers to find out if we
    are being more receptive and doing a better job of listening.

               INCREASED EFFICIENCY THROUGH PROGRAM CONSOLIDATION

        We have tried to consolidate programs, to cut from 38 to
    11, to become more efficient and effective, but also just to
    have less points of contact, make it simpler for folks to deal
    with us.

                      FLEXIBILITY IN EXCHANGE FOR RESULTS

        And then for me, the tradeoff in all of this, whether it is
    in our education plans, Race to the Top, i3, Promise
    Neighborhoods, whether it is in, hopefully, reauthorization of
    ESEA, and if not, potentially waivers--to me, the real tradeoff
    is where States and districts are raising the bar, setting
    higher standards, and holding themselves accountable. I am a
    big believer in growth rather than absolute test scores. I want
    to know how much students are improving each year, not whether
    they are at some artificial cut point.
        Where States are doing the right thing, we want to provide
    a lot more resources and a lot more flexibility. Where folks
    are backing down, reducing standards, showing an unwillingness
    to close the achievement gap, we are going to challenge them
    very, very hard.

                              NO CHILD LEFT BEHIND

        But for me, the grand trade off philosophically in all
    these things is, if we can hold folks accountable to a high
    bar, then we should give them a lot more room to move. I think
    the current law, I have said repeatedly, is far too punitive.
    It is far too prescriptive. It led to a narrowing of the
    curriculum, and it led to a dumbing down of standards. None of
    those things are good for children or teachers or education in
    our country, and we want to fix the law in a common sense way.
    Chairman Harkin is working extraordinarily hard in a bipartisan
    manner. We are working very, very closely with Senator Enzi,
    and with the gentleman to your left, Senator Alexander, someone
    I have great, great respect for, who held my position. I listen
    very closely when he speaks.

                   BIPARTISANSHIP APPROACH TO EDUCATION BILL

        And we just hope, despite some of the dysfunction, frankly,
    that we see coming from our Congress, that we can think about
    education, while putting politics to the side, putting ideology
    to the side, to come up with a common sense, bipartisan bill.
    It is the right thing to do. And I desperately hope that will
    still happen.
        Senator Moran. I thank you for your answer, and I will
    follow up with questions in writing.

                 WAIVER FOR MC PHERSON USD SCHOOL DISTRICT 418

        But in that regard, as I indicated to you, I am very
    grateful for the waiver you provided McPherson USD School
    District 418. They have created their own set of tests and
    standards, and you granted the first waiver nationwide. It is
    an example of what is going on in Kansas. It is very
    beneficial.
        Secretary Duncan. And let me be very clear on that. That
    was not a gift; that was something McPherson earned. They
    basically said they were raising the bar above State standards.
    And whenever anyone is holding themselves to a higher level of
    accountability and challenging both adults and students to do
    more, we want to do everything we can to support that, and,
    frankly, to get out of the way. So, I appreciate their courage.
    That is tough, tough work. But if we had more districts and
    more States doing that, today education would be in a much
    better place. So, that was not a gift; that was something they
    absolutely earned. And I appreciate the example they are
    setting for the country.
        Senator Moran. I do criticize you for using my time to
    compliment Senator Alexander.
        Do that when he asks his questions, I would appreciate it.
        Thank you, Mr. Secretary.
        Secretary Duncan. I will use his time to compliment you.
        Senator Harkin. Senator Landrieu.
        Senator Landrieu. Mr. Secretary, let me begin by using some
    of my time to compliment Senator Alexander. I have worked with
    him on many issues.
        And I appreciate his continued support for our bipartisan
    reform efforts.
        I want to thank you, Mr. Secretary, for your passionate
    leadership and your inspirational leadership. I think you are
    exactly the right Secretary for the challenges before this
    Nation. And I thank you for being tough and not backing up and
    pushing this all forward.

                               TEACH FOR AMERICA

        But I wanted to raise just a couple of questions that are
    concerning to me.
        First, is because of the zeroing out of several critical
    and, in my view, superior programs, one of which, not the only
    one, but one of which is Teach for America. This subcommittee
    rallied in a bipartisan way because that program was zeroed out
    both by the President's budget and by a missed definition, in
    my view, of earmark. This subcommittee rallied, the chairman
    helped us, to identify 1 percent of title II-A funds last year
    so that some funding could move to Teach for America and other
    programs that were, in my view, in a very shortsighted way
    zeroed out.
        We have a plan--90 Members of Congress have sent a letter
    to you and the President, urging you to set aside 5 percent
    this year for these high-performing, effective programs. I am
    going to ask you this question in a minute. But I want to put
    on the record, Teach for America last year, there were 48,000
    applicants. Now, these applicants are the top 1 and 2 percent
    of students graduating from all of our universities. From 1,500
    colleges they applied. They only selected 5,000. Again, 48,000
    applied, 5,280 were selected by limits of budget.

                     LEVERAGING POWER OF TEACH FOR AMERICA

        TFA, for every $7 in non-Federal funding, they leverage $7
    in the private sector for every $1 that we fund them.

                     TEACH FOR AMERICA AND STEM INSTRUCTION

        In addition, TFA is the largest single provider of STEM--
    science, technology, engineering, and math--teachers in the
    country, so science, technology, engineering, math, STEM. They
    are providing more teachers, so we cut this program out
    entirely. It makes no sense to me.

                           TEACH FOR AMERICA FUNDING

        We have tried to say collectively, how do we get our best
    and brightest in the classroom? So, Teach for America comes up
    with a plan, mostly private sector driven, nonprofit driven. We
    put up a little money, they put up a lot of money, the public
    benefits.
        I am very confused as to how we zero out a program like
    this. So, we want to solve this problem.
        Are you committed to increasing 5 percent so that at least
    Teach for America has an opportunity to compete for decent
    enough money to get them back on track to continue to provide
    the technology, engineering, and math teachers this country
    desperately needs? If so, why? And if not, why not?

               TEACH FOR AMERICA--LEADERSHIP DEVELOPMENT BENEFITS

        Secretary Duncan. First of all, obviously I think Teach for
    America has done a remarkable job, not just at producing
    teachers and teachers in STEM areas and teachers in
    disadvantaged communities, but one of the huge residual
    benefits of the program is it has been an amazing leadership
    program. And many innovative superintendents, many leaders of
    nonprofits, many education entrepreneurs are Teach for America
    alums. And I think that is a benefit. When I ran Chicago Public
    Schools, I worked to bring TFA in. What I did not realize--I
    was not smart enough at the time, when we started opening
    really innovative new schools in disadvantaged communities--a
    wildly disproportionate number of the principals leading those
    efforts were Teach for America alumni. So, it was a really
    important lesson for me.

                     FUNDING INCREASE FOR TEACH FOR AMERICA

        Senator Landrieu. So, do you support the 5 percent----
        Secretary Duncan. So, we are adding--I am getting to that.
    We are right now, as you know, TFA successfully competed,
    again, not a gift, won, a $50 million grant to invest in
    innovation. Had great evidence, great data on effectiveness. We
    were happy to do the 1 percent set-aside. I would need to sort
    of sit down with my staff and think about the 5 percent set
    aside as we move forward. I understand the need, and to give
    more folks the chance to compete would be interesting to me.
    So, I am not willing to commit to it today, but----
        Senator Landrieu. Well, the nine of us are going to push
    you very hard to do that. And there are other programs, not
    just Teach for America, that are superior, effective, and
    extraordinary in their results. We should not be eliminating
    them.

                         RACE TO THE TOP ACCOUNTABILITY

        And my second question, Race to the Top----
        Secretary Duncan. I could not agree with that more.

                           RACE TO THE TOP AMENDMENTS

        Senator Landrieu. Okay. My second is, every State except
    Georgia that won Race to the Top in the first two rounds has
    now amended its State reform plan in some way, usually to push
    back timetables or scaling, you know, scale back initiatives.
    According to the list of approved amendments, there were 12
    winners that changed their plans 25 times.
        My question is, the administration has requested an
    additional $900 million for the Race to the Top, but before
    approving additional funding, are you going to continue to give
    out funding to States just to see their timelines, which they
    promise to meet, push back, or there are promises made, then
    modified, and not reach the goals that we all hope for them to
    do?
        Secretary Duncan. No, we are absolutely holding them
    accountable for outcomes, and we are never giving waivers for
    material changes in applications. We have asked them to take on
    very, very ambitious work. If it takes a little bit longer to
    get that work done well, we are happy to support that. If it is
    bypassing that work or avoiding it, we will never grant that
    waiver. And to be very clear, we will withhold funding if they
    take that step.
        I am not, frankly, seeing that. I am seeing huge amounts of
    courage. I am seeing extraordinarily hard work going on.
    Sometimes it takes a little longer, but I am interested in the
    outcome, in quality. And the second we see a State back away
    from that, we will stop funding them immediately. I want to let
    you know that, absolutely.
        Senator Landrieu. Okay. And I know my time is up, Mr.
    Chairman, but I do have other questions. I will just submit
    them for the record on the TRIO program and emergency
    preparedness for schools. And I thank you very much.
        Secretary Duncan. Thank you.

                           TEACH FOR AMERICA FUNDING

        Senator Harkin. I might just say to my friend from
    Louisiana that I have always been a big supporter of Teach for
    America. It was one of those earmarks that we used to do.
        Senator Landrieu. But it is a federally authorized program,
    so I am very confused about that definition.
        Senator Harkin. Well, we put a set-aside in there for
    everything at 1 percent. I would be delighted to visit with you
    about whether that should be increased at this level or not on
    that set-aside.
        Senator Landrieu. Thank you, Mr. Chairman, for your
    leadership.
        Senator Harkin. Well, for the competition.
        Senator Landrieu. And it is not just for Teach for America,
    but there are several effective programs out there. I mean, I
    understand eliminating programs that do not work, but when we
    start eliminating the best programs that are working at even a
    public/private partnership, I think we have gone way off the
    cliff.
        Senator Harkin. Well, I could not agree more. Thank you
    very much.
        Senator Pryor.
        Senator Pryor. Thank you, Mr. Chairman, and I want to thank
    the Secretary for being here today. It is great to see you. I
    think the last time you and I saw each other face to face was
    in Little Rock when you were at Little Rock Central High School
    doing your Courage in the Classroom kick off. I hope that was
    successful. We loved having you in Arkansas. Thank you very
    much for coming down.

                          PROMISE NEIGHBORHOOD PROGRAM

        I want to ask about the Promise Neighborhoods program. This
    is a program under which the University of Arkansas at Little
    Rock was successful in getting a planning grant for fiscal year
    2010. I am curious about your view of how the Promise
    Neighborhood projects are going. What kind of results you are
    seeing out there? What kind of end results you are looking for?
        Secretary Duncan. This is a hugely important initiative to
    me, particularly in our Nation's most distressed, most
    disadvantaged communities. The only way we strengthen those
    communities is by increasing the quality of education and
    building community support for that work, and building the kind
    of wrap-around services and nonprofit partnerships that help
    schools to be successful in very tough communities.

                         PROMISE NEIGHBORHOODS FUNDING

        We were fortunate to be able to fund 20 planning grants,
    that being one of them, around the country. We had 300
    applicants, and we had many more highly creative, thoughtful
    proposals that I would love to have funded that we simply did
    not have the money for. Fiscal year 2011, we have $30 million
    that we are going to use for a combination of purposes--
    starting to fund some programs, some communities for
    implementation and others to develop a plan. But we would like
    to see a significant increase in the investment in Promise
    Neighborhoods for fiscal year 2012 to really start to move to
    implementation across the country.
        And the grants are in very poor rural communities. We have
    one planning grant on an Indian reservation, Native American
    reservation, and others in distressed inner-city communities
    where we can get the kind of results that Geoffrey Canada has
    done in the Harlem children zone in New York, dramatically
    transforming the life chances of young people there.

             NEED FOR RECOGNIZING, FUNDING MORE PROMISING PROGRAMS

        We can prove, demonstrate, that communities can come
    together to help the most challenged children and families be
    very successful academically. So, we think this is the right
    investment. It is early on. There is much greater need and
    capacity out there than we are able to fund, and that is what
    is heartbreaking to me. There are people doing amazingly
    thoughtful work, collaborating, partnering in ways that they
    never would have done before. We support that effort to not
    scale back. And so we would respectfully ask for a significant
    increase in funding to move toward implementation to a wide
    variety of communities around the country.
        Senator Pryor. I think that is great. So, you are seeing
    what you would hope to see out there, which is communities
    coming together and really getting great things done. And now
    you are getting to the implementation stage.

                   PROMISE NEIGHBORHOOD APPLICANTS AND AWARDS

        Secretary Duncan. And we were blown away by the number of
    applicants, the quality of applicants. And, again, we were able
    to fund 20 or 21. There were probably over 100 that I would
    have felt great about investing in, and I was thrilled to do
    the ones we did. I would love to have had the chance to invest
    in many other communities.

                SCIENCE, TECHNOLOGY, ENGINEERING AND MATHEMATICS

        Senator Pryor. Well, thank you for that answer. Now let me
    also ask about STEM. This is an area that is very important.
    You have prioritized STEM education in your budget. My view is
    that focusing on STEM will absolutely translate into better
    jobs, better opportunities for many, many, many Americans
    around the country. Could you comment on that and talk about
    your vision for STEM education and how that impacts the future
    workforce?
        Secretary Duncan. So, at its heart as we go forward, we
    simply have to produce a lot more young people with skills,
    with competency, with a passion for the STEM disciplines. That
    is where the jobs of the future are. That is going to be the
    future creators, the innovators, the entrepreneurs who are
    going to create jobs in fields that do not even exist today.

                             STEM TEACHER SHORTAGE

        Right now, we have a shortage of teachers who are strong in
    STEM. We have had that shortage in this country probably for
    20, 25, 30 years, and I want to stop admitting the problem. I
    want to try and fix it. And we need teachers with great
    passion, great interest in the STEM fields, not just for AP
    calculus and physics, but in third, and fourth, and fifth grade
    where too often students start to turn away from that, lose
    interest because their teachers do not know the content area,
    and they start to back away.
        So, we have to invest significantly to get that next
    generation of teachers to come in to the STEM fields. The
    President has challenged us to recruit 100,000 new teachers in
    the STEM areas. We have to make sure that students in
    elementary school, eighth grade have access to classes like
    algebra I. We have to make sure that students--sophomores,
    juniors, and seniors--in high school have access to AP classes
    and college-level classes in the STEM fields.
        I think we--I am a little controversial on this but, I
    think particularly in disadvantaged communities, in rural and
    remote areas, we should be thinking about where there is a
    scarcity of great STEM teachers, and I think we should pay
    those teachers more money to take on those assignments in
    communities that just haven't had access. And we see across the
    Nation far too many young people--we just did a recent data
    survey--data collection with the Office of Civil Rights. There
    are far too many--hundreds of thousands of young people who do
    not have access to a class like algebra I in eighth grade. And
    if you want them taking, you know, AP physics or calculus down
    the road, you have to start them in that trajectory.
        So, we have a lot of hard work here. I do not want to keep
    admitting the problem. I want to try to fix it.
        Senator Pryor. Right. Mr. Chairman, thank you. Before I
    close, I would like to say to Secretary Duncan that I know we
    have picked on Senator Alexander today. But I know that Senator
    Alexander has great respect for you because the other day he
    was telling me that he thinks you are the second best secretary
    of education we have ever had.
        Thank you.
        Senator Harkin. Thank you, Senator Pryor. I must just add
    on the STEM stuff, Mr. Secretary, you pointed out it is so
    important to get down to first-, second-, third-graders who
    have a natural instinct and interest in science, and to
    encourage that at that level.
        Senator Kirk.

              EDUCATION SUPPORT FOR CHILDREN OF MILITARY FAMILIES

        Senator Kirk. Thank you. And, Mr. Secretary, it is great to
    see you in this job after what you did for the Chicago Public
    Schools.
        And I want to talk to you about--Senator Durbin and I are
    working on making sure that we are supporting the military
    families, especially around Great Lakes. We have a unique
    arrangement there. We are working with the chairman to make
    sure that we do not see a couple of school districts implode
    that support the military families there.

                                CHARTER SCHOOLS

        Then there is a unique charter school initiative that we
    are rolling, which I think will look a little bit like a DOD
    school, and further support military families that may be
    replicable throughout the rest of the country. I wonder if you
    could comment on those two initiatives.
        Secretary Duncan. Yeah. I do not know the details. I think
    you are working in the North Chicago community.
        Senator Kirk. Right.
        Secretary Duncan. And I will just say simply, we cannot do
    enough to support our military families. And as I talk to
    troops who are serving and who have come back from service in
    Iraq and Afghanistan, when I ask what can we do to help you,
    they consistently say, take care of my children. Educate my
    children. That is the least we can do.
        And so, I do not know the details of the proposal. Whatever
    I can do to support getting high quality options, strengthening
    education for the children of adults who are serving our
    country, I want to do everything I can to help that. I have
    tried to travel to as many bases and schools around military
    communities to really understand the challenges.

                   COMMON STANDARDS BENEFIT MILITARY FAMILIES

        This is a little bit off topic. There are huge benefits of
    the common standards that folks are doing, higher standards,
    for as you know, military families move very frequently, and
    they get devastated by those moves to different States doing
    different things, and children finding out they are far behind.
    So, they have been extraordinarily supportive of the work we
    have done to have college- and career-readiness common
    standards in the vast majority of States around the country.
    So, at the local level, nationally, whatever I can do to help
    support these children, please count me in.

                     EXPANDING CHARTER SCHOOL OPPORTUNITIES

        Senator Kirk. Thank you. Senator Durbin and I are also
    working on the Durbin-Kirk ALL-STAR legislation to expand
    charter school opportunities for kids. Right now, for example,
    in a community you know well, Chicago, only about 10 percent of
    families even have the ability to send their kids to a charter
    school. So, we would change the Federal funding law to allow us
    not just to start new charter schools, which is allowed under
    Federal law, but to expand current ones. And I think that would
    allow us to pick the winning charter systems. But can you
    comment on that?
        Secretary Duncan. I think, again, that is where I have been
    very, very clear. I am not pro-charter; I am pro great schools.
    And where you have great charters, giving them the chance to
    replicate, to serve more students, it is silly not to do that.
    I have also challenged the charter community, when schools are
    not working, we need to hold them accountable and close them
    down. But where you have high-performing charters, particularly
    in disadvantaged communities, to give them the chance to serve
    more children makes absolute sense to me.
        And where you have now not just sort of mom and pop charter
    models, you have some national models. You have folks that are
    replicating at a pretty significant scale in many communities
    and demonstrating this is not one amazing principal or one
    charismatic teacher, but systemically they are closing
    achievement gaps in very significant ways.
        And where we are seeing that, I just want every child in
    this country to have a chance to go to a great school.

                             ACADEMIC YEAR CALANDAR

        Senator Kirk. Yeah. Can I have you talk about a big picture
    item? Our basic school calendar was established two centuries
    ago, in the 19th century, to provide a summer break to bring in
    the harvest, which I think is particularly inappropriate for
    the now 80 percent of Americans who live in an urban or
    suburban area.
        We generally see in school performance that the summer
    break will set kids back at least 1 month if not more. Give me
    your views on all-year school in the 21st century.

                           LONGER SCHOOL YEAR NEEDED

        Secretary Duncan. I usually get booed by children when I
    talk about this, and adults usually--most adults cheer, not
    everyone.
        But I think we are crazy on this as a country. The fact
    that our school calendar is based upon an agrarian economy
    makes no sense to me whatsoever. And other countries that are
    out-educating us today--I do not think they are any smarter
    than us but, a lot of them are just going to school 30, 40, 50
    more days a year than we are.
        Senator Kirk. Right.
        Secretary Duncan. And they are just working a little bit
    harder and we need to work a little bit harder. All of you guys
    are in your positions because you work pretty hard. And we are
    just denying that opportunity to our young people. So, I am
    advocating everywhere I can, passionately, for longer days,
    longer weeks, and longer years.
        And let me be clear. Particularly in the summer, not that
    every child needs to do that. If you have a middle class
    child--a child that has access to libraries and summer camps
    and museums, that is okay. But if that child is going to be in
    the street or is going to sit in front of a TV all summer, that
    is a devastating loss. We are trying to close achievement gaps,
    not expand them.
        And so, to not give those students those kinds of
    opportunities makes no sense. So we can be, you know,
    thoughtful, we can be creative here, you can differentiate, you
    know, on what students need. But to just say we are going to
    stop learning in June and just hope for the best, particularly
    in disadvantaged communities, just makes no sense to me
    whatsoever.
        And, Senator, I have gone too long on this. But what really
    troubles me is you see some districts being really creative
    around the use of time and technology and doing some great
    things. You see other districts retrenching, going to 4-day
    weeks, shortening the school calendar. And I understand these
    are tough economic times, but those are horrendous decisions,
    and we need more time, not less. Our children need more
    structure, more opportunities to learn. And if we want them to
    compete and to compete successfully in a global economy, right
    now we are putting them at a competitive disadvantage from
    children in India and China who are going to school 30 to 50
    days more each year than children in the U.S. I do not know why
    we would want to put our children at a competitive
    disadvantage.
        Senator Kirk. And, Mr. Chairman, I know there are
    difficulties and we have to work out payer work arrangements,
    but the country, I think, should begin a debate on moving to
    all-year school. I think that would help our performance.
        And I would say the very controversial thing of joining
    Senator Landrieu on praising Secretary Alexander and his work.
        Senator Harkin. Thank you very much.
        Senator Alexander.
        Senator Alexander. Well, thanks. If I had known all these
    compliments were going to flow, I would have come on time.
        That gives me a chance to restate what I have said many
    times. I really compliment President Obama for his appointment
    of Secretary Duncan, who has a real heart for the job and a lot
    of experience, and is willing to challenge a lot of
    conventions. And despite the fact he is more of a basketball
    player than a politician, he is a better politician than most
    cabinet members and than most senators. So, all of us, I
    included, really respect your work.

                            EDUCATION ACCOUNTABILITY

        Let me use my time to talk with you for a few minutes about
    what we call accountability in the education business. And I
    want to read a letter--not a whole letter. I want to read a
    sentence from a letter or two and see whether you agree with
    it. I think you are generally familiar with the letter. This is
    a letter that the chief counsel of Chief State School Officers
    wrote to me and cc'd Senator Harkin, and Senator Enzi, and
    Senator Bingaman in May, talking about the work they have been
    doing, which you have been very much involved with. And I have
    asked, Mr. Chairman, this letter be included in the record.
        Senator Harkin. It will be.
        [The information follows:]

                        Council of Chief State School Officers,
                                          Washington, DC, May 19, 2011.
    The Honorable Lamar Alexander,
    455 Dirksen Senate Office Building,
    United State Senate, Washington, D.C. 20510.
        Dear Senator Alexander: In anticipation of our meeting, I wanted to
    share with you some information regarding the important work currently
    being led by the States on behalf of our Nation's students. We look
    forward to discussing our work with you in greater detail in hopes that
    we might be able to partner with you and work with the Senate Health,
    Education, Labor and Pensions Committee to inform reauthorization of
    the Elementary and Secondary Education Act (ESEA).
        Over the course of the past several years, and in the face of
    outdated and burdensome Federal requirements, States have led in
    developing policies and systems designed to ensure that all students
    graduate from high school ready for college and career. This is
    evidenced by myriad State-led reforms, including:
      --The development and adoption of college- and career-ready,
            internationally benchmarked standards, including the Common
            Core State Standards in reading/language arts and math that
            have been adopted by 45 States and territories;
      --The ongoing development of robust, internationally benchmarked,
            assessments aligned to rigorous standards, including through
            the two national assessment consortia (PARCC and SMARTER
            Balanced);
      --The design and implementation of growth models for accountability,
            which focus schools on ensuring that students meet the goal of
            college- and career-readiness; and
      --The development of improved standards for teacher and principal
            effectiveness, and teacher and principal evaluation systems
            focused on student achievement.
        In the light of this State leadership, CCSSO spearheaded a task
    force of chiefs in developing a roadmap for States in looking at next-
    generation accountability systems. Coming out of this task force are
    principles that would guide new models of school and district
    accountability designed to better drive school performance toward
    college- and career-readiness; more accurately and meaningfully
    identify and support the range of schools; and better provide
    actionable data to support districts, schools, principals, teachers,
    parents, students, and policymakers to dramatically improve student
    achievement. Beyond these core requirements, States may and will
    develop proposals that approach these issues in different ways. Each
    state's proposal would be guided by the following principles:
      --Fully align accountability expectations and measures to the goal of
            all students graduating from high school ready for college and
            career;
      --Make annual accountability determinations for all schools based on
            the performance of all students;
      --Base accountability determinations on student outcomes, including
            but not necessarily limited to improved, rigorous statewide
            assessments in reading and math (grades 3-8 and high school)
            and accurate graduation rates;
      --Base accountability determinations in part on disaggregated data of
            student performance across relevant subgroups;
      --Provide timely, transparent, disaggregated data and reports that
            can meaningfully inform policy and practice;
      --Include, as appropriate, deeper diagnostic reviews of school and
            district performance, particularly for low-performing schools,
            to create a tighter link between initial accountability
            determinations and appropriate supports and interventions;
      --Focus on building district and school capacity for significant and
            sustained improvement in student achievement toward college-
            and career-ready performance goals; and
      --Focus significant interventions on the lowest performing 5 percent
            of schools (elementary and middle, and high schools) and their
            districts (in addition to targeted interventions to address the
            lowest performing subgroups and/or schools with the greatest
            achievement gaps).
        A critical number of States are committed to moving forward in the
    design of accountability systems aligned to these principles and we
    expect a number of additional States to join in the next couple of
    weeks. States seek a reauthorization that supports this State
    leadership and innovation, and does not remain a barrier or seek to
    codify a single ``right'' answer for national education reform. We want
    to work with you in this effort and hope that our work helps to inform
    your conversations going forward. I look forward to meeting with you to
    discuss these issues in greater detail.
                Sincerely,
                                                          Gene Wilhoit.

              NO CHILD LEFT BEHIND--FLEXIBILITY AND ACCOUNTABILITY

        Senator Alexander. Thank you. Thank you.
        In this letter, it talks about the work that the different
    States have done in creating common core standards, in creating
    a test to see where children are meeting that standard, and
    creating what we call growth models, which have been discussed
    in this hearing before, and especially in working in there that
    you, and I, and others care a lot about, which is finding a way
    to measure teacher and principal effectiveness, and especially
    relating that to student achievement. And it is a very
    impressive record.
        And they go on to say this. And I had a conversation about
    this with one of your predecessors, Secretary Dick Riley, the
    former Governor of South Carolina, who supports this idea. The
    last--this is the sentence in the letter, it says, ``States
    seek a reauthorization of the Elementary and Secondary
    Education Act that supports this State leadership and
    innovation, and does not remain a barrier or seek to codify a
    single right answer for national education reform.'' Do you
    agree with that?
        Secretary Duncan. Yes.

                           FEDERAL ROLE IN EDUCATION

        Senator Alexander. Well, good. Then as we go down through
    these, one of the difficult issues that we have as we think
    about fixing No Child Left Behind is this accountability
    section. And to what extent should the Federal Government write
    anything about tests, write anything about a growth model,
    write anything about how to measure teacher performance,
    because whenever we put it in law, then the Department of
    Education, which you and I know something about, then goes
    through a process of rulemaking, establishes ``parameters,''
    which are what people in Washington think Chicago
    superintendents or Governors of Tennessee ought to be doing.
    And it all sounds good. By the time you get it all done, you
    have a superintendent flying in from Denver, Chicago, or
    Nashville seeking the Secretary's approval for some specific
    growth model, which is a big waste of everybody's time.
        So, what I am trying to get at--and let us take a specific
    example. Let us take the idea of relating student performance
    to teacher pay. I am a big advocate of rewarding outstanding
    teaching, master teachers. I think it is the Holy Grail of
    education. How do we reward outstanding school leaders and
    teachers with more pay, more honor?

                             TEACHER INCENTIVE FUND

        And I think many of us agree on that. But my fear is that
    if we put it into the law, and we write a rule about it, then
    suddenly we will be defining what 100,000 schools will be
    trying to do, and I do not think it works well that way. I
    think what has worked well is your teacher incentive fund where
    you give grants and money to local school districts who then
    work with their teachers or work with their community and come
    up with different models for rewarding outstanding teaching.
        So, what would your advice be as we work on fixing No Child
    Left Behind about how we accomplish this goal, which there is
    broad bipartisan support for, without running into the problem
    of violating what the Chief State School Officers have told us
    they do not want done.
        Secretary Duncan. Yeah. These are really, really thoughtful
    questions, and you and I have talked about this a multitude of
    times.

                               STATE FLEXIBILITY

        There is a balance we are trying to strike and where I
    think we are all trying to get to the same point and trying to
    figure out how to do that. The last thing we want to be is to
    be prescriptive or top down. We think the teacher incentive
    fund has been very effective. We think Race to the Top,
    frankly, was very effective. We said that student achievement
    had to be a significant part of teacher evaluations, but we did
    not say a number, and, frankly, we do not know that number. We
    have seen a huge amount of very creative and very, very hard
    work going on at the State level because we incentivize that in
    the right way.
        So, the Council of Chief State School Officers, Gene
    Wilhoit, has been an amazing profile in courage. All this work
    of higher standards, better assessments we talk about, that is
    not coming from you or I. That is coming from Governors and
    chief State school officers having the courage to do the right
    thing. And I cannot overstate what a great partner they have
    been.

                 ENSURING ACHIEVEMENT GAINS WITHIN FLEXIBILITY

        I think the vast majority of States are moving in the right
    direction now. My only concern is I do not want to give a pass
    to a State that somehow goes in the wrong direction. And we
    have a history of Governors, both Republican and Democrat, who
    dummied standards under No Child Left Behind, who did exactly
    the wrong thing for children for their State, because it was
    politically expedient, because it made them look good
    politically, but it hurt their children, hurt their education,
    ultimately hurt their State's economy. And nobody said anything
    about it. It was like they all got a great pass.
        So, I want to continue to reward courage, to incentivize
    that. But I also think as the Federal Government, we have an
    obligation to make sure if a State says, you know, we are not
    going to do accountability, we do not care about achievement
    gaps, we think poor children, black or brown children cannot
    learn--we have to think about what the Federal responsibility
    is there. And I think that is--we are trying to get that fine
    line worked out and, again, we continue to look to your advice
    and guidance of how best to do that.
        Senator Harkin. And, Senator Durbin.
        Senator Durbin. Thank you very much, Mr. Chairman.
    Secretary Duncan, Mr. Skelly, thank you for being with us.
        Mr. Secretary, thanks for the good job you are doing.

                     GROWTH IN RATE OF STUDENT INDEBTEDNESS

        In October of last year, we reached a milestone in America
    that most people did not know and did not hear about. For the
    first time in the history of our country, student loan debt
    exceeded credit card debt in America.
        The rate of growth of student indebtedness in our country
    is alarming. The indebtedness that students are incurring to go
    to school is holding them back in terms of their own personal
    ambitions and career goals, and creating a problem for us
    because should they default, ultimately the taxpayers will be
    the losers.
        I and many others have voted consistently for student
    assistance because that is why I am sitting here today. Were it
    not for the National Defense Education Act enacted by this
    Congress out of fear of Sputnik and the Russians, I do not know
    if I would have gone to college or to law school. So, I have
    always felt that I owed it to the next generation to give them
    the same chance.

                        PELL GRANTS VERSUS STUDENT LOANS

        And I have always felt the same way about Pell grants
    because, rather than loans, this is money that a student does
    not have to repay. The Pell Grant now is in the range of
    $5,500. The administration believes it is important and had
    made it part of our budget negotiations.
        And notwithstanding that, the next time I vote on Pell
    grants, I am going to have a very difficult time voting for
    them and looking at student loans the same way. And you know,
    because we have discussed it at length.

                               FOR-PROFIT SCHOOLS

        And the chairman of this committee has looked at a problem
    that we are facing that I think many Members of Congress are
    ignoring; that is the growth of for-profit schools.
        For-profit postsecondary education trains or educates 10
    percent of the students, claims 25 percent of all Federal aid
    to education, and accounts for 44 percent of all student loan
    defaults.
        What is going on is nothing short of scandalous. There are
    private companies that have found a way to game our system, to
    bring students out of high school into a so-called learning
    environment to burden them heavily with debt, to hand them
    worthless diplomas, and then watch while they fail.
        We have got to do something about this, Mr. Secretary.
        I cannot vote blindly for Pell grants and college student
    loans knowing that this Ponzi scheme is going on in the name of
    for-profit colleges. Now let me add, there are good ones, and I
    could name a few and you could, too. But there are so many bad
    ones, terrible schools, that are exploiting students these
    days.
        You looked at this. You have come up with a proposal. I
    think it moves in the right direction, but I think it moves too
    slowly.
        How can we in good conscience extend Pell grants and
    student loans knowing that this kind of predatory lending is
    going on, this kind of subprime mortgage pyramid is being
    created in the name of higher education?

               WORKING TO ENSURE EFFICACY OF FEDERAL STUDENT AID

        Secretary Duncan. Sir, your leadership in this issue and
    Chairman Harkin's absolute passion and leadership I think has
    changed the national conversation.
        And what we tried to do is very simple, and I think it is a
    significant step in the right direction. Is it perfect?
    Absolutely not, and we have had those conversations. But what
    we want to do is where you have good actors, as you said, we
    think that is a good investment. We think that is good for
    young people and folks who have not had those kinds of
    opportunities before to have the chance to increase their
    skills, if it is leading to meaningful work, if those skills
    and what they are learning are real. If it is not, we simply
    cannot continue to invest taxpayer money anytime, but
    particularly in tough economic times, in those places.
        So, we put in place some pretty significant rules and
    guidance that has been heavily challenged by many in the
    industry. Some of the good actors are actually supporting it,
    which has been interesting. But basically, trying to eliminate
    those programs that were not leading to good outcomes, where
    there is, you know, false advertising, where there are no jobs
    available, where you are under a mountain of debt that you
    cannot pay back. That is a horrendous investment. So, we have
    tried to move in the right direction.
        I would also add, I think we have seen pretty significant
    changes in behavior. We have seen a number of CEOs lose jobs.
    You have seen institutions start to behave in some very
    different ways. And so, I think this is going in the right way,
    and I feel much more comfortable about our investment in grants
    and loans, more comfortable today than I did before our
    regulation.

              ACCREDITATION AND TRANSPARENCY OF FOR-PROFIT SCHOOLS

        Senator Durbin. I have only a few seconds left. Here is
    what I think we have to do. You cannot expect a student or that
    student's family to know whether a school is worth investing
    in. There is no way they can tell whether the claims made by
    the school are true or not. It starts with the accreditation.
        I have been disappointed, sadly disappointed, by the
    limited, if negligible, standards for accreditation. Schools
    that are a laughing matter end up being accredited. How is a
    student supposed to know? How is a family supposed to know?
    They assume that if they are accredited and our Federal
    Government will send Pell grants and college student loans
    through those schools, that it is a good education. Why would
    they not assume that?
        Do we not have an additional obligation when it comes to
    evaluating these schools?
        Secretary Duncan. No, I think that is a great, great point.
    Absolutely. And we need to look at that. You have been very,
    very clear on that.
        I would only add one thing; what we are trying to do now is
    to really increase transparency so that young people and their
    parents can have a much better understanding of outcomes. And
    we think that transparency--we think there are lots of choices
    out there, and that transparency will hopefully drive behavior
    in the right way.
        But your basic question about accreditation is an
    absolutely real one, and I will take that to heart.

                         REPAYMENT OF STUDENT LOAN DEBT

        Senator Durbin. And the last point I will make, if you will
    bear with me for 5 seconds. Student loans are different than
    other debts. They are not dischargeable in bankruptcy. A
    student loan you will carry to the grave, and that is something
    we ought to remember and students should be advised of before
    they make these decisions.
        Thank you.
        [The statement follows:]
                Prepared Statement of Senator Richard J. Durbin
        I want to thank the Chairman for convening this hearing to review
    the fiscal year 2012 budget request for the Department of Education.
        We are engaged in a debate this week about our Nation's long-term
    fiscal outlook as we consider proposals to raise the debt ceiling. We
    can deal with our debt responsibly and in a balanced way.
        We have to reduce the debt and deficit. But investing in education
    and retraining is the best way to ensure our economic recovery now and
    our economic growth well into the future.
    President's Budget for Fiscal Year 2012
        The President's fiscal year 2012 budget recognizes the importance
    of education to sustained economic recovery by investing in key areas:
      --Early childhood education.--The President's budget includes $8.1
            billion for Head Start to serve an additional 1 million
            children and families.
          The budget also includes an additional $1.3 billion to support
            1.7 million children and families through the Child Care
            Development Block Grant Program.
      --High-quality schools.--The President's budget includes $26.8
            billion, an increase of 6.9 percent, for a reformed Elementary
            and Secondary Education Act that is focused on raising
            standards, encouraging innovation, and rewarding success.
      --Innovation and reform.--The budget would invest $1.4 billion in
            competitive programs that leverage scarce Federal dollars to
            bring about systemic reform in education.
        --The Early Learning Challenge Fund would spur States to improve
                the quality of early childhood programs.
        --A new Race to the Top program would bring resources to school
                districts willing to make needed reforms.
        --A new ``First in the World'' competition would encourage colleges
                and universities to demonstrate success in graduating more
                high-need students and preparing them for employment.
        These are the kinds of programs that use limited resources to
    inspire meaningful improvements. And it's the students who win.
    Pell Grants and For-Profit Colleges
        I would like to say a word about Pell Grant funding.
        The Department of Education expects demand for Pell grants to reach
    9.6 million students next year, up from 6 million in 2008.
        The President's budget would maintain a maximum Pell Grant award of
    $5,550 per year for these students.
        As a beneficiary of Federal investment in higher education, I have
    always voted to support Pell Grants and Federal student loans.
        But I have become deeply troubled by what I see happening in higher
    education today. The Federal financial aid system is in serious peril,
    largely because of the actions of many for-profit colleges.
        For-profit colleges educate less than 10 percent of students, take
    in 25 percent of all Federal financial aid, and account for 44 percent
    of all student loan defaults.
        We can't afford to see taxpayer dollars wasted by sending billions
    of dollars of Pell Grants to for-profit schools, many of which aren't
    providing a good return on that investment.
        If we want our economy to grow, we should help low-income students
    attend colleges that put them on a path to success.
        But it is irresponsible for us not to question whether the
    taxpayers are getting their money's worth at many for-profit colleges.
        And as we consider increasing funding for the Pell Grant program to
    meet our commitments to students, I think we should also have a serious
    conversation about how to ensure the value of that investment.
        Taxpayers deserve some assurance that a Pell Grant invested in a
    student is leading to a better career, a higher salary, and a greater
    potential to contribute to the economy--not wasted at a for-profit
    college that leads to little except debt.
    Conclusion
        Chairman Harkin, we can invest in education in a way that's
    fiscally responsible and will lead to stronger economic growth long
    into the future.
        The Administration has provided us a good start to that
    conversation, and I look forward to hearing from Secretary Duncan this
    morning.

                MISUSE OF STUDENT AID BY FOR-PROFIT INSTITUTIONS

        Senator Harkin. Well, thank you, Senator Durbin. And,
    again, I thank you for your great leadership in this area. You
    are the one who first started getting me focused on this a year
    and a half ago. And as you know, our authorizing committee has
    had a series of hearings and investigations into this going
    back 18 months. And what we have uncovered is just about what
    you just talked about. It is an invasion into the programs that
    we have developed to help poor kids get a decent education to
    prepare them for a career.
        And it has turned into almost an open spigot of taxpayers'
    dollars being siphoned off to hedge funds, Wall Street. You
    would be surprised how many of these for-profit schools are
    owned by Wall Street entities. And they are most interested--
    their interest is in the bottom line, not on education.
        Well, we do not mean to get into that, but thank you for
    your leadership.

                SPECIAL EDUCATION MAINTENANCE OF EFFORT WAIVERS

        Mr. Secretary, I do not mean to hold you any longer, but
    just one issue I wanted to raise with you relates to special
    education. Obviously you know this is a long-standing interest
    of mine. We have discussed this many times.
        Tight budgets are leading some States to ask for waivers
    for their maintenance of effort requirements under IDEA. I want
    to thank you for your close scrutiny of those requests, which
    should be granted only under exceptional circumstances. I also
    would encourage you to continue to take a close look at any
    additional requests and use all of the resources available to
    you to make sure a free and appropriate public education is not
    denied students with disabilities.

             SPECIAL EDUCATION--FREE, APPROPRIATE PUBLIC EDUCATION

        Whenever this issue comes up, I always take the opportunity
    for a little teachable moment perhaps and a little history
    lesson. I was here at the beginning of this when we did IDEA.
    And many States I know and some people think that IDEA, the
    Individuals with Disabilities Education Act, which superseded
    the Education of All Handicapped Children Act, was somehow a
    Federal mandate on States, requiring them to give a free,
    appropriate education to kids with disabilities.

                       FAPE--A CONSTITUTIONAL REQUIREMENT

        Well, that is absolutely wrong. The mandate on States to
    have a free, appropriate public education for kids with
    disabilities is a constitutional mandate--constitutional. PARC
    v. Board of Education, Pennsylvania Association of Retired
    Citizens v. Board of Education. That established the principle
    that if a State--first of all, as we all know, States do not
    have to provide free education. There is no constitutional
    requirement for any State--Alabama, Mississippi, or Iowa, or
    any other State to provide a free public education. What the
    Constitution does say is if a State--if a State decides to
    provide a free public education--or FAPE, it cannot then
    discriminate on the basis of race, or sex, or national origin,
    and PARC v. Pennsylvania--I am sorry, it was PARC v.
    Pennsylvania--that case said that a State cannot then
    discriminate either on the basis of disability.

               FEDERAL ASSISTANCE TO STATES IN PROVISION OF FAPE

        The Federal Government came along and said, okay, if that
    is the case, we will try to help States with IDEA to provide
    some help and support. And if you want this money, if a State
    wants to partake in IDEA, well, here are certain requirements.
    No State has to take one dime of IDEA money. But if they do,
    they have to meet certain requirements in terms of a free and
    appropriate public education.
        So, this is a constitutional matter. Even if we provided
    not one dime of IDEA money, States would still have to provide
    a free, appropriate public education to every kid with a
    disability.
        Now, I say all this, Mr. Secretary, I know you understand
    that, but I always like to take that time to reaffirm the fact
    that we have constitutional obligations to provide this kind of
    education to our kids. And when States ask for waivers from
    their constitutional obligation, that ought to be looked upon
    with very close scrutiny as to whether or not they need that
    kind of waiver.
        So, again, I say this in a way of thank you because I know
    you have looked at that with close scrutiny, and to make sure
    that you have continued to look at those waivers very, very
    closely in the future. So, I thank you for that.
        And I will turn to Senator Shelby.
        Senator Shelby. Secretary, you have been very patient, but
    I have three quick areas I would like to get into.

                  RACE TO THE TOP APPLICATION SCORING PROCESS

        I am concerned that the scoring process for the Race to the
    Top applications essentially mandates which interventions
    should be used by States and local school districts to improve
    student achievement and reduce achievement gaps. The Federal
    Government, I believe, should give States the flexibility to
    implement critical reforms as identified on the State and local
    level.
        If Race to the Top receives funding in 2012, can I have
    your commitment to review the scoring process for the Race to
    the Top applications, and specifically reevaluate the scoring
    measures on science, technology, engineering, and mathematics
    reform efforts? And will the Department consider changes to the
    Race to the Top program that allow States to be evaluated on
    their statewide vision and reform efforts identified at the
    State and local level? And if not, why not?
        Secretary Duncan. No, absolutely happy to continue to learn
    every single year----
        Senator Shelby. Okay.
        Secretary Duncan [continuing]. And to get that feedback. I
    thought we did a very, very good job. Did we do it perfectly?
    Of course not. And, you know, this is a work in progress, and
    I'm happy to have that conversation going forward.
        Senator Shelby. Do you disagree with some of my concerns
    here?
        Secretary Duncan. I do not know if I disagree. I welcome
    that conversation.
        Senator Shelby. Okay.
        Secretary Duncan. We want to continue in everything we do
    to emphasize STEM. We did it as a competitive priority on i3
    and Promise Neighborhoods and other things. So, STEM is a
    consistent thing there, and I think it is a fair, you know,
    question, and we will look at it very closely.
        Senator Shelby. So, you would review the scoring process.
        Secretary Duncan. Yeah, absolutely, no question, not just
    in that area, across the board. Again, we will take what worked
    and what did not, and learn from it, and try and get better.

               IMPACT OF COMPETITIVE-BASED FUNDING ON RURAL AREAS

        Senator Shelby. Mr. Secretary, formula versus competitive
    funding. The President's budget, your budget, proposal includes
    a substantial increase in the amount of discretionary funding
    that would be competitively awarded. This is a significant
    policy shift from the current formula grant structure. I am
    concerned that replacing formula-funded programs with so-called
    competitive programs will result in the redirection of critical
    Federal funds from smaller rural States or urban areas because
    they will not be able to compete for funding on a level playing
    field.

                          RACE TO THE TOP COMPETITION

        For example, Mr. Secretary, my State of Alabama, Iowa, and
    Mississippi, were all shut out from the competitive Race to the
    Top grants. These three States did not receive any funding in
    round one or in round two.
        Are you concerned at all that a shift from formula funding
    to competitive funding may not allow many high-need States and
    districts to receive Federal funding as illustrated in the Race
    to the Top?
        Secretary Duncan. Yeah. So, we have thought about that
    very, very carefully. Two answers just to think about. Again,
    to be very, very clear, the overwhelming majority of our money
    will continue to be, will always be, formula-based. So, in this
    budget, 84 percent is formula-based.
        Senator Shelby. You see my concern here?
        Secretary Duncan. Yes, I do.
        Senator Shelby. And I am sure it is a concern of the two
    colleagues of mine.
        Secretary Duncan. Yes, sir. And so, what we have tried to
    do in the Investing in Innovation fund, in the Promise
    Neighborhoods initiative, is to really make sure that rural
    States and communities could compete, and we think we did that
    better. So, we will continue to learn. And in all of these
    competitions, the goal is not a fancy PowerPoint presentation.
    We want to invest in places that have the courage and the
    capacity to do some things very, very differently.
        So, I am acutely aware of that, and we want to continue to
    strike that balance. We think in some of the other
    competitions, that went very well. And we want to continue to
    learn across the board in this area.

                      MATHEMATICS AND SCIENCE PARTNERSHIPS

        Senator Shelby. In the area of mathematics and science
    partnerships, the United States continues to fall behind, as we
    know, other developed countries in reading, math, and science
    education.
        According to the 2009 Performance Reporting Ranking, the 34
    countries of the Organization for Economic Cooperation and
    Development, the United States ranks 25th in math, 17th in
    science, and 14th in reading. It is unacceptable to all of us.
        I am concerned, and I am sure you are, that the 2012 budget
    proposal does not request funding for the mathematics and
    science partnership program. In Alabama, my State, funds from
    this formula program have helped finance the highly successful
    Alabama math, science, and technology initiative, a leading
    model for math and science education reform nationwide.
        In the place of the mathematics and science partnerships,
    the Department--your Department--proposes to create a new
    competitive grant program for science, technology, engineering,
    and math.
        How does the Department intend to ensure that all States
    will be able to compete for math and science funding when it is
    no longer distributed by a formula, as my understanding? And
    how will this program close the growing achievement gap between
    the United States and our global competition?

                             WELL-ROUNDED EDUCATION

        Secretary Duncan. We have talked about--a lot about STEM.
    Let me even broaden it a little bit further. One of my greatest
    concerns is that due to the current law and sometimes due to
    budget issues, we have seen a narrowing of the curriculum
    around the country. And that is probably the biggest complaint
    I hear as I travel, urban, rural, suburban, from students, from
    teachers, from parents across the board.
        So, we are asking for significant investment, not just in
    STEM, but in literacy, in arts, in PE, in all those things to
    give children what we call a world-class, well-rounded
    education. So, we want to invest at a different level there,
    getting behind those States and districts, again, whatever they
    look like, those that are committed to giving their children a
    well-rounded, world-class education. And this is not just at
    the high school level; this has to be for first and second and
    third and fourth graders----
        Senator Shelby. Absolutely.
        Secretary Duncan [continuing]. To give them a chance to
    build their skills. So, we are absolutely committed there, and
    want to put significant resources behind that effort.
        Senator Shelby. If we do not do this, where are the jobs
    going to come from in the future?
        Secretary Duncan. Well, the jobs will continue to migrate.
        Senator Shelby. Thank you.
        Thank you, Mr. Chairman.
        Senator Harkin. Senator Cochran. No other questions.
        There are no other questions, Mr. Secretary. Thank you very
    much. You have been very generous with your time, and we
    appreciate your appearance here.

                         ADDITIONAL COMMITTEE QUESTIONS

        And we will keep the record open for 10 days for any other
    questions that the Senators may have.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                   Questions Submitted by Senator Tom Harkin
                                  pell grants
        Question. Congress continues to make a significant investment in
    the Pell Grant program, in order to help make college more affordable
    for low-income students. The number of Pell Grant recipients has grown
    from 6.2 million in 2008 and is projected to reach 9.6 million in 2011.
    At the same time, 56 percent of all bachelor degree students graduated
    within 6 years and 28 percent of all associate degree students
    graduated within 3 years. For low-income students, these rates are even
    lower. Taking into account the difficult budget decisions Congress is
    facing in fiscal year 2012, what can be done to ensure that Congress'
    investment in Pell Grants is fully realized and low-income students
    complete their degrees at higher rates?
        Answer. The Department agrees that certain cost-cutting measures
    are necessary, but does not believe sacrificing the Pell Grant maximum
    award--especially considering current financial conditions--should be
    one of them. As evidenced in its fiscal year 2012 budget request, the
    Department has made maintaining the Pell Grant at its current $5,550
    maximum a priority. The Pell Grant will be an important piece of 9.6
    million students' financial aid packages in the 2012-2013 academic
    year. Ensuring these students have sufficient financial aid to remain
    in school is an important first step in helping lead them to college
    completion.
        Increasing college completion rates is another priority for the
    administration, and the fiscal year 2012 President's budget included a
    number of new programs--including College Completion Incentive Grants,
    First in the World, and College Access Challenge Grants--designed to
    help States and institutions focus on and adopt activities that are
    likely to contribute to higher completion rates. Some of the activities
    endorsed by these programs are: aligning high school graduation
    requirements with institutions' expectations for academic preparation;
    reducing a program's net price or time to degree; and providing low-
    income students assistance such as financial literacy training, need-
    based grant aid, or educational or career preparation.
                        workload of direct loan program
        Question. Since Congress passed the Student Aid and Fiscal
    Responsibility Act (SAFRA) of 2010, new volume in the Direct Loan
    program has increased to an estimated $124 billion in 2012, up from $29
    billion in 2009. What have been the implications of the increased
    workload on the Department's administration of the Direct Loan program
    and what has been the impact on customer service?
        Answer.
    Impact of SAFRA on Direct Loans Administration
        The Department has undertaken a number of administrative
    initiatives to manage increased workload resulting from SAFRA:
      --expansion of origination and disbursement capacity,
      --expansion of servicing capacity, and
      --addition of Government personnel to manage the increased workload.
            Each of these initiatives has driven increases in Department
            administrative costs. However, these initiatives have enabled
            over 2,500 domestic schools and 380 foreign institutions to
            smoothly transition to Direct Loans for the 2010-2011 award
            year, and millions of new Direct Loan borrowers to be
            successfully brought on by the Department's five private-sector
            loan servicers.
                Origination and Disbursement
        In anticipation of increased Direct Loan volume, in February 2010,
    the Department revised its Common Origination and Disbursement (COD)
    system contract to accommodate projected increases in Direct Loan
    originations. The Department further revised the COD contract in June
    2011 based on updated projections of Direct Loan volume. A Final
    Management Information Report issued on September 16, 2010, by the
    Department's Office of Inspector General, ``Federal Student Aid's
    Efforts to Ensure the Effective Processing of Student Loans Under the
    Direct Loan Program,'' notes that Federal Student Aid took all
    necessary actions to ensure processing of student loans as a result of
    SAFRA, and credits COD with successfully providing the capacity to
    transition to 100 percent Direct lending.
                Loan Servicing
        In order to accommodate expected increases in loan volume, foster
    improved performance through competition, and prepare for the eventual
    expiration of the existing loan servicing contract, the Department
    awarded four new servicing contracts in June 2009, known collectively
    as the Title IV Additional Servicers (TIVAS). The four vendors
    receiving awards were American Education Services/Pennsylvania Higher
    Education Assistance Agency (AES/PHEAA); Great Lakes Education Loan
    Services; Nelnet, Inc.; and Sallie Mae Corporation (SLM). These vendors
    began servicing FFEL loans purchased by the Department in September
    2009 and new Direct Loans starting June 2010. Together, these vendors
    provided a broad base of servicing capacity well equipped to handle the
    dramatic increase in workload post-SAFRA. As of June 2011, these four
    vendors held 50.4 percent of the total loan volume managed by the
    Department. In accordance with SAFRA, the Department is currently
    working on awarding additional performance-based Not-For-Profit loan
    servicer contracts, which will further expand loan servicing capacity.
                Government Personnel
        In order to properly manage the increased loan portfolio, the
    Department increased its FTE from fiscal year 2010 through fiscal year
    2011 after undergoing a 4 percent decrease in FTE from fiscal year 2008
    to fiscal year 2009. In response to SAFRA, over 100 new Federal staff
    have been added to handle an increased level of contract oversight,
    school reconciliation support, school training, and call center
    management. The increase represents a 9 percent rise from fiscal year
    2009 level; over the same period, the number of Direct Loan schools
    nearly doubled; the number of new Direct Loan originations grew by 158
    percent, and the Government-held servicing portfolio grew by 132
    percent.
        Additional Federal staff are needed in fiscal year 2012 to
    effectively manage up to 30 or more new Not-For-Profit contracts during
    fiscal year 2012 through fiscal year 2013.
                Budget Impact
        In order to meet the demands of the increased portfolio, the
    Student Aid Administration Account has required a budgetary increase of
    74 percent for COD and 198 percent in total servicing, including Not-
    For-Profit and For-Profit servicers, from 2009 to 2012. As the number
    of borrowers serviced continues to grow, servicing costs will continue
    to rise. These costs are not only necessary to manage effectively the
    student loan portfolio and provide quality customer service; they are
    essential for achieving approximately $67 billion in savings over the
    next 10 years, according to CBO estimates, for the transition of all
    Federal student loan originations to the Direct Loan program.
    Impact on Consumer Service
        There were no negative impacts to customer service during the
    transition. Schools have generally been highly satisfied with the
    Direct Loan process and the Department is aware of no students who have
    been unable to receive Federal Student Aid due to the transition. In
    fact, by uniting all Department-held loans for a single borrower with a
    single servicer, the Department has improved customer service for 1.6
    million student loan borrowers.
        In addition, increased workload stemming from SAFRA has not
    prevented the Department from continuing efforts to improve its service
    to students and borrowers who have been traditionally under-represented
    in postsecondary education. For example, the Free Application for
    Federal Student Aid (FAFSA) Completion program has allowed the
    Department to work with State and local education agencies and
    secondary schools to increase the number of completed FAFSA
    applications. Also, by reducing the number of questions an applicant
    must answer and streamlining financial information through the IRS Data
    Retrieval tool, FAFSA simplification efforts have made it much easier
    for applicants to apply successfully for Federal student aid.
      teacher incentive fund--vanderbilt and rand studies on performance-
                                   based pay
        Question. Last year, the Center for Performance Incentives at
    Vanderbilt University found little evidence to support a primary goal
    of the Teacher Incentive Fund (TIF)--that rewarding teachers for
    improved student test scores would cause scores to rise. This rigorous
    evaluation funded by the Department raises serious questions about the
    idea behind this program. And, just last week a RAND evaluation of New
    York City's program came to similar conclusions about performance-based
    pay. New York permanently canceled its program after the study's
    release.
        I understand that the Vanderbilt and RAND studies didn't examine
    all of the performance-based pay systems across the country. However,
    they raise the question whether we should continue to provide $400
    million per year for TIF given the need to reduce deficits and the
    significant amount of funding for these grants already.
        Mr. Secretary, what is your view of these evaluations of
    performance-based pay programs, and how will they shape your
    Department's thinking and priorities in fiscal year 2012?
        Answer. These evaluations provide important information about some
    of the challenges schools, districts, and States face when reforming
    human capital systems to focus on improving student outcomes. But the
    Teacher Incentive Fund (TIF) differs in important ways from the
    performance-pay programs studied by Vanderbilt and RAND. In addition,
    the Department plans to significantly strengthen TIF as part of the
    2012 new grant competition.
    Performance-based Compensation Systems
        While all of the 2010 TIF grant cohort projects include as one
    statutorily required element the development and implementation of
    performance-based compensation systems (PBCSs), these TIF projects
    support broader activities than just making performance-related
    payments to effective (as measured by student achievement gains and
    observations) teachers and principals. As you mentioned, the Vanderbilt
    study focused on awards to teachers based solely on increases in
    student achievement. Teachers received no additional support, such as
    mentoring or professional development, and the awards were not
    permanent or incorporated into district-wide human capital management
    systems. Finally, although about two-thirds of teachers participating
    in the study expressed support for the general notion that teachers
    should receive additional compensation if their students show
    outstanding achievement gains, a similar proportion felt that the
    program in which they participated did not do a good job of
    distinguishing effective and ineffective teachers. Likewise, large
    majorities agreed that the program ignored important aspects of
    performance not measured by test scores.
        In the 2010 TIF competition, on the other hand, in order to be
    eligible for a grant, applicants had to provide evidence that the
    proposed PBCS is aligned with a coherent and integrated strategy for
    strengthening the educator workforce, including the use of data and
    evaluations for professional development and retention and tenure
    decisions in the LEA or LEAs participating in the project during and
    after the end of the TIF project period. In addition, applicants could
    receive a competitive priority by demonstrating that their proposed
    PBCS is designed to assist high-need schools in:
      --serving high-need students,
      --retaining effective teachers in teaching positions in hard-to-staff
            subjects and specialty areas, such as mathematics, science,
            special education, and English language acquisition, and
      --filling vacancies with teachers of those subjects or specialty
            areas who are effective or likely to be effective.
        Applicants also had to provide an explanation for how they would
    determine that a teacher filling a vacancy is effective or likely to be
    effective, and demonstrate the extent to which the subjects or
    specialty areas they propose to target are hard-to-staff. Lastly,
    applicants had to demonstrate that they would implement a process for
    effectively communicating to teachers which of the LEA's schools are
    high-need and which subjects and specialty areas are considered hard to
    staff.
    New York City's Schoolwide Performance Bonus Program
        The RAND study similarly found that New York City's Schoolwide
    Performance Bonus Program had limited impact. The New York City
    Department of Education set annual performance targets for each
    participating school's ``Progress Reports,'' which are based in part on
    student growth. Schools meeting or exceeding those targets were
    eligible to receive a school-wide award of up to $3,000 per union-
    represented staff member. A committee at each school determined how to
    distribute the funds. However, the study noted that over one-third of
    teachers did not understand basic aspects of the program, ``including
    the target their school needed to reach, the amount of money their
    school would receive if they met their target, the source of the
    funding, and how committees decide on distribution plans.'' In
    addition, teachers reported that the bonus was too small to provide any
    incentive for changing behavior. Also, most compensation committees
    chose to distribute bonuses equally across all school staff members,
    further limiting the potential for such a policy to reward and motivate
    improved performance. Research suggests that performance-based
    incentive plans work best when participating individuals have a strong
    understanding of the program, when participants expect that their own
    effort can control the outcome, and when rewards are sufficient enough
    to drive action. New York City's teacher bonus program was not strong
    in these areas. Even the RAND report's authors question whether the NYC
    system was sufficiently designed to motivate or effect change.
    Teacher Incentive Fund Performance-based Compensation Systems
        In contrast, under TIF, a grantee must show that it has a plan for
    effectively communicating to teachers, administrators, other school
    personnel, and the community at-large the components of its PBCS.
    Grantees must also provide evidence of the involvement and support of
    teachers and principals and the involvement and support of unions in
    participating school districts (where they are the designated exclusive
    representatives for the purpose of collective bargaining) that is
    needed to carry out the grant. Finally, TIF emphasizes performance-
    based compensation systems that include compensation that is
    differentiated and substantial. The RAND study authors noted that these
    characteristics were integral to successful implementation of
    performance-based compensation reforms.
    Creating Innovative Human Capital and Evaluation Systems
        In the 2012 TIF competition, the Department will provide support
    for State and school district efforts to develop and implement
    innovative approaches to creating human capital and evaluation systems
    that improve teacher and leader effectiveness and student outcomes.
    This new competition would emphasize supporting, retaining, and
    rewarding teachers and principals who raise student achievement. The
    Department would continue to require TIF grantees to develop and
    implement these human capital and evaluation systems with meaningful
    input and support of teachers and school leaders.
                             promise neighborhoods
        Question. Promise Neighborhood grantees have been fully engaged and
    supported by State and city public officials, as well as private
    players. In fact, all 21 of the federally funded Promise Neighborhoods
    planning grantees have leveraged nearly $7 million in matching funds
    from public and private sources--including investment from foundations.
    Their planning efforts are progressing and generating a ground swell of
    local support.
        How are the current grantees planning to leverage existing
    resources to achieve the goals of their local communities?
        Answer. There are a number of examples where the 2010 Promise
    Neighborhoods grantees are leveraging existing resources to help meet
    the objectives of their planning grants. In Worcester, Massachusetts,
    the Main South Promise Neighborhood is partnering with Clark University
    in several ways. Clark is developing the longitudinal data system
    required by the program, and its students serve as formal and informal
    mentors to young residents in the neighborhood. Developed as a
    partnership between Clark and Worcester Public Schools, University Park
    School is an effective, comprehensive high school within the Main South
    neighborhood. Clark also waives tuition for any resident of Main South
    who has lived in the neighborhood for at least 5 years and who meets
    the university's entrance requirements.
        In the rural Mississippi Delta, the Indianola Promise Community is
    partnering with Mississippi State's National Strategic Planning and
    Analysis Research Center, a grantee of the Department's State
    Longitudinal Data Systems program. Mississippi is one of the few States
    with a data system that links K-12 and postsecondary data through the
    use of a unique identifier. The partnership with the Data Center,
    specifically the opportunity to leverage the Department's investment in
    the State's longitudinal data system, creates an opportunity for the
    Indianola Promise Community to manage outcomes at the student level
    from preschool through college.
                   maximizing public and private partnerships
        Question. Additionally, how can we maximize this public/private
    partnership moving forward?
        Answer. Peer reviewers of Promise Neighborhoods applications
    evaluate the extent to which applicants would leverage and integrate
    high-quality programs and related public and private investments into
    their work. We can maximize these types of partnerships by placing a
    similar priority in other Department grant programs. Moreover, guidance
    on productivity \1\ released by the Department's Office of Innovation
    and Improvement early this year identified additional opportunities for
    supporting such partnerships. State and local health and human services
    agencies, departments of public safety and parks and recreation,
    community-based organizations, businesses, and other entities have a
    significant stake in the success of our children and youth. Many have
    long provided academic and enrichment opportunities in the form of
    before- and after-school programming, apprenticeships, nursing, or
    counseling support. Breaking down barriers and better aligning and
    using community resources may also help school systems identify and
    access low-cost services or facilities. Governors, working with policy-
    makers and educators, can put in place State-level policies addressing
    these issues or issue guidance to districts, schools, nonprofits, and
    institutions of higher education that encourages collaboration and
    leverages public-private investments as part of school reform
    strategies.
    ---------------------------------------------------------------------------
        \1\ http://www.ed.gov/oii-news/increasing-educational-productivity.
    ---------------------------------------------------------------------------
            recovery act of 2009 and the education jobs fund of 2010
        Question. Mr. Secretary, I know that you share my concern about the
    state of the economy and the continuing challenges that many families
    are facing, especially when it comes to finding jobs. In my opinion,
    the best way to solve our debt crisis is to get more people working,
    because when people are working they pay more taxes, buy more goods,
    and keep our economy growing.
        Jobs are a particular concern in our Nation's schools, where we're
    hearing more reports every day of possible teacher layoffs. It's
    timely, therefore, to take a look back at the Recovery Act of 2009 and
    the Education Jobs Fund of 2010. Some have said that today's
    unemployment figures prove those investments were a waste of money.
    However, in my home State of Iowa, these bills have helped save or
    create almost 4,000 education-related jobs (960 Ed Jobs through March
    2011 plus almost 2,800 education-related jobs through the Recovery
    Act).
        That's the story in Iowa. What is your assessment of these bills
    from a national perspective?
        Answer. I share your concern about our economy and how it affects
    our Nation's families and children. To do our part to minimize the
    effects of these difficult times on students, we worked with you to
    provide States and school districts with unprecedented resources in the
    Recovery Act and through the Education Jobs Fund to save and create
    education jobs. Based on State-reported data, we estimate that the
    Recovery Act and the Education Jobs Fund have funded over 400,000
    educator jobs since February 2009. We know that the strain of the
    economy continues to force States and school districts to make
    difficult choices, and we know that these two efforts helped to save
    our students from an even heavier burden that would have been felt in
    our Nation's schools.
    cost savings and efficiencies initiated by the department of education
                    in fiscal year 2009 and fiscal year 2010
        Question. The fiscal year 2012 budget request identifies savings in
    program administration related to decreased travel costs generated by a
    greater use of teleconferencing. In fiscal years 2009 and 2010, what
    actions did the Department take to create efficiencies in its programs,
    eliminate lower-priority spending and realize other cost savings?
        Answer. The Department took a variety of actions in 2009 and 2010
    to create efficiencies in its programs, eliminate lower-priority
    spending, and realize other cost savings. These included the following
    items:
      --In 2009, the Department closed its office at the U.S. Mission to
            the United Nations Educational, Scientific, and Cultural
            Organization in Paris, France and eliminated its attache
            position.
      --In 2009, the Department closed the National Institute for Literacy,
            which provided national leadership on issues related to
            literacy, and coordinated literacy services and policy. Funding
            for the Institute ended in fiscal year 2009. The Institute's
            broad mission and lack of clear management oversight led to a
            diffuse and incoherent system of delivery, as well as
            duplication of efforts with other Department of Education and
            Federal offices. The functions of the Institute are more
            efficiently being carried out by other Department offices,
            primarily the Office of Vocational and Adult Education.
      --The Department eliminated the Secretary's Regional and Deputy
            Regional Representatives in the Department's 10 regional
            offices. These positions were primarily used for communication
            and outreach, which may be done as effectively by other
            personnel.
      --The Department undertook two steps to reduce the cost of
            information technology equipment it leases. The number of
            computers used per person was reduced from 1.5 to 1.1, with a
            total reduction of 1,600 computers. In addition, the number of
            printers on employees' desktops was reduced from 5,700 to
            1,400.
      --Starting in fiscal year 2010, the Department required any
            conference or meeting occurring in Washington, DC with an
            attendance of 250 or less to take place in either of the
            Department's two large capacity auditorium facilities.
      --In fiscal year 2010, the Department negotiated with one of its
            Direct Loan servicing vendors to eliminate transfer fees for
            migrating servicing accounts between this vendor and any other
            Direct Loan servicing vendor.
         cost savings planned for fiscal year 2011 and fiscal year 2012
        Question. What additional steps will be completed in fiscal year
    2011, and what other steps are proposed in the fiscal year 2012 budget
    request?
        Answer. The Department will complete additional cost savings
    actions in 2011 and is planning more in 2012, as follows:
      --The Department plans to save 7 percent of contract spending by the
            end of 2011, using 2008 acquisition expenditures as a base.
            Some actions already taken have been described in the response
            for fiscal year 2009 and fiscal year 2010. The Department will
            continue to achieve contract savings by ending contracts that
            do not meet program needs or projects that are no longer
            needed, restructuring high-risk cost reimbursement contracts as
            fixed price contracts, improving contract terms and conditions,
            improving the procurement process, and investing in a highly
            skilled acquisition workforce.
      --In 2011, the Department partially implemented an initiative to use
            double-sided printing as the default printing option.
            Currently, 25 percent of printing is two-sided. The Department
            is moving towards using double-sided printing 50 percent of the
            time.
      --Due to the elimination of several programs administered by the
            Office of Safe and Drug-Free Schools (OSDFS), and to maximize
            limited resources, the Department is planning to move the
            remaining programs administered by OSDFS programs into the
            Office of Elementary and Secondary Education (OESE). This
            change will provide new opportunities for staff from OESE and
            OSDFS to work together to improve school environments and
            support children's learning, health, and well-being.
      --The Grant Award Notification (GAN) process provides the
            Department's grantees with official documentation of their
            Federal grant award and instructions for grants management.
            This process is currently paper-based, requiring a traditional
            signature from the Department's representative and mailing the
            2 copies of the signed GAN to the grantee. In fiscal year 2012,
            the Department will provide mechanisms for:
        --Electronically signing the GAN documentation sent from the
                Department to grantees;
        --Electronically transmitting the GAN documentation from the
                Department to grantees; and
        --Electronically filing and retrieving the GAN documentation.
                                     ______

                Questions Submitted by Senator Daniel K. Inouye
                    ethnic and immigrant student performance
        Question. In Hawaii, Filipino Americans represent the second
    largest ethnic group in the public school systems but are consistently
    ranked second to last in the Hawaii State Assessments. These tests, in
    which Filipino students in 2010 scored only 69 percent in reading and
    51 percent in math proficiencies, indicate that these students are in
    need of additional assistance throughout their primary, K-12,
    education. Furthermore, a study conducted by the John A. Burns School
    of Medicine, in Honolulu, indicated a significant connection between
    low Filipino cultural identification and low family support with
    delinquency. What new creative efforts are being considered by your
    administration to improve student performance within large ethnic and
    recently immigrated communities, such as the Filipinos, while
    maintaining the integrity of their cultural values?
        Answer. The Department is focusing much of its current efforts on
    improving student performance, as detailed below. Most of these efforts
    are not focused on particular ethnic or recently immigrated
    communities, but are designed to improve performance in a wider range
    of student populations.
        Many of the top priorities of the Department are found in A
    Blueprint for Reform, which proposes a reauthorized Elementary and
    Secondary Education Act intended to help give all children the world-
    class education that they deserve and that America needs to ensure
    future economic prosperity. The Blueprint focuses on key priorities
    aimed at improving educational outcomes for all students, including:
      --recognizing and rewarding student academic growth and school
            progress;
      --ensuring that students complete high school prepared for college
            and a career, based on rigorous, State-developed standards;
      --putting a great teacher in every classroom and a great principal in
            every school; and
      --focusing intensive support and interventions on our lowest-
            performing schools that serve our neediest students and
            communities, including the ``dropout factories'' that account
            for one-half of the estimated 1 million students who leave
            school each year without a high school diploma.
        Together, these changes support the goal of ensuring that, by 2020,
    the United States will once again have the highest proportion of
    college graduates in the world--a key goal not only for restoring and
    increasing our economic prosperity, but also for securing the more
    equal, fair, and just society envisioned by our Nation's founders.
        More specifically, the Department is emphasizing the following
    goals:
        Sustaining Reform Momentum.--The Department will reform America's
    public schools to deliver a 21st century education that will prepare
    all children for success in the new global workplace, building on the
    achievements already gained by the Race to the Top and Investing in
    Innovation (i3) programs. Race to the Top will focus on supporting
    district-level reform plans while also emphasizing cost-effective
    strategies that improve student achievement in a time of tight budgets.
    The i3 program will prioritize science, technology, engineering, and
    mathematics (STEM) education and early learning, as well as focus
    overall on increasing productivity to achieve better student outcomes
    more cost-effectively. The Department also will place high priority on
    Promise Neighborhoods to support comprehensive, innovative and cost
    effective approaches to meeting the full range of student needs,
    drawing on the contributions of schools, community-based organizations,
    local agencies, foundations, and private businesses.
        Great Teachers and Leaders.--Nothing is more important, or more
    likely to improve student achievement and other key educational
    outcomes, than putting a great teacher in every classroom and a great
    principal in every school. To help achieve this goal, the Department
    will support ambitious reforms, including innovative teacher evaluation
    and compensation systems, to encourage effective teachers, principals,
    and school leadership teams to work in high-need schools. Emphasis will
    also be placed on expanding high-quality traditional and alternative
    pathways into teaching and preparing 10,000 new STEM teachers over the
    next 2 years, as part of the President's plan to prepare 100,000 new
    STEM teachers over the next decade.
        College Completion.--The Department is committed to ensuring that
    America will once again lead the world in college completion by 2020.
    Regardless of their intended educational path after high school, all
    Americans should be prepared to enroll in at least 1 year of higher
    education or job training to ensure we have a better prepared workforce
    for a 21st century economy.
                         access to 4-year institutions
        Question. Super rural and isolated communities, such as those
    existing on some of the neighboring islands of Hawaii, face many
    obstacles when it comes to accessing higher education. On the Hawaiian
    island of Kauai, for example, residents have access to a local 2-year
    community college but would have to relocate to another island to be
    able to attend a 4-year institution. How is the Department of Education
    improving access to 4-year higher education programs for potential
    university students residing in super rural and isolated areas, such as
    Kauai, without diverting funds from existing local community colleges?
        Answer. The Department provides aid to students based on their
    estimated family contribution, not their location. If a student chooses
    to attend a more expensive school, attend a degree or certificate
    program that would keep him in school for a longer period of time, or
    attend a school in a different location, the total Federal and State
    financial aid he would be able to receive would be influenced by these
    circumstances.
        Additionally, a student may find useful the net price calculator on
    his desired institution's website, to see the potential costs of
    attending that school. In accordance with the Higher Education
    Opportunity Act of 2008, all postsecondary institutions are required to
    have a version of this calculator on their websites by October 29,
    2011. The net price number produced from the calculator will be able to
    help the student see the full cost of attending that school, and help
    him evaluate and make a more informed decision about whether it is
    financially possible for him to attend that institution.
                           student health initiatives
        Question. Nurses in schools provide a vital service to the
    educational system. As your Department has established, proper health
    and nutrition are key to students being considered ``ready to learn''
    and maximizing their educational opportunities. How is your Department
    supporting and funding initiatives in States, such as Hawaii, that lack
    a robust school health nursing infrastructure and what other creative
    initiatives have been put forward to provide access to school-based
    nurse managed health centers in these targeted States?
        Answer. The administration's Elementary and Secondary Education Act
    reauthorization proposal includes the Successful, Safe, and Healthy
    Students program. This new program would provide resources and
    increased flexibility for States and districts to design and implement
    strategies that best reflect the needs of their students and
    communities, which may include programs that support student physical
    health. Depending on the activity, projects that support the efforts of
    school-based nurses could be funded. Additionally, the administration
    is working to improve student health outside of the Department of
    Education. Under the Affordable Care Act, the Department of Health and
    Human Services awarded $95 million in July 2011 to school-based health
    center programs across the country. These grants will help improve the
    health and wellness of children through screenings, health promotion,
    and disease prevention activities.
                    carol m. white physical educaton program
        Question. Your Department has found that students who come to
    school ready to learn perform better in their classes and on
    standardized tests. Good health is a vital component of being
    considered ``Ready to Learn.'' In light of the increasing prevalence of
    chronic conditions, how is the Department of Education supporting
    health screening, prevention and treatment of obesity, and support for
    students with diabetes, asthma, and other increasingly prevalent,
    chronic conditions so that they may be best prepared to get the most
    out of their education?
        Answer. Currently, the Department's primary contribution to the
    physical wellness of students is the Carol M. White Physical Education
    program. Through rulemaking in fiscal year 2010, the Department
    established a competitive priority for the Physical Education program
    for projects that incorporate the collection of body mass index data as
    part of a comprehensive assessment of health and fitness for the
    purposes of monitoring the weight status of their student population
    across time. In addition, the administration's ESEA proposal for the
    Successful, Safe, and Health Students program would provide funding for
    States and districts to design and implement strategies that best
    reflect the needs of their students and communities, which may include
    programs that support student physical health.
                    21st century community learning centers
        Question. How would changing the 21st Century Community Learning
    Centers (CCLC) program to a competitive grant program affect Hawaii? If
    Hawaii can no longer rely on a consistent funding formula for the 21st
    CCLC program, program administration and planning for future years may
    become more difficult for the State.
        Answer. We believe that transforming the 21st CCLC program from a
    formula to a competitive grant program will improve program quality.
    States developing high-quality plans to compete for the 21st CCLC funds
    would lead to more of a focus on improved outcomes for students. If we
    encourage all States to submit high-quality applications, we believe
    that would drive more improvements in the field in general.
    Additionally, we believe that numerous States would continue to receive
    funding under a competitive 21st CCLC program.
        Question. How can States maintain consistent program administration
    without formula funds?
        Answer. Those States that would not receive funding under a
    competitive 21st CCLC program would be in the best position to
    determine whether local programs that had received 21st CCLC formula
    funds are worth investing in if 21st CCLC funds are not available.
    States could, for example, choose to invest more State funds in
    programs currently funded by the 21st CCLC program. Another option
    could be that States could encourage school districts to dedicate more
    title I funds to lengthening the school day and providing services
    outside of regular school hours.
        teach grants and proposed presidential teaching fellows program
        Question. The Education Department's fiscal year 2012 budget
    proposal would replace the TEACH Grant program for institutions of
    higher education (IHEs) with a new Presidential Teaching Fellows grant
    program for States. Under the TEACH Grant program, many eligible
    students do not receive grants either because the schools they attend
    do not participate in the program or they anticipate being unable to
    fulfill the program's employment requirements. Did these shortcomings
    prompt the administration to propose replacing the program with its new
    proposal; are there other reasons why the administration wants to
    effectively end the TEACH Grant program?
        Answer. Yes, based on preliminary data, it does not appear that the
    program is fulfilling its intended purpose of encouraging students to
    enter, and remain in, the teaching profession. As many as 75 percent of
    students receiving a TEACH Grant fail to fulfill its requirements.
    Additionally, many of the students receiving a TEACH Grant may be doing
    so in lieu of other institutional aid, which often does not need to be
    repaid.
        The Presidential Teaching Fellows program is designed specifically
    to target students who demonstrate an interest in teaching later in
    their undergraduate career, as well as those individuals in programs
    that have a proven ability to produce quality teaching candidates.
                institutional participation in the teach program
        Question. According to the Education Department, five institutions
    for higher education (IHE) in Hawaii are TEACH Grant eligible. Can you
    explain why some IHEs did not participate?
        Answer. There are many reasons why an institution may not
    participate in this program, but it would be reasonable to say their
    decision is likely based, at least in part, on the decision that
    nonparticipation is in the best interest of their students and
    institution. Many of the problems with the nature of the TEACH Grant
    program, as described earlier, may be contributing factors into an
    institutions' reasoning when choosing whether or not to participate.
                         presidential teaching fellows
        Question. How many of Hawaii's institutions will be considered
    eligible for the Presidential Teaching Fellows program?
        Answer. Any Hawaiian institution's participation would be dependent
    upon if the State chose to participate in the program. In order for the
    institutions in a State to be eligible, the State must first agree to
    embrace certain reforms, including making licensure and certification
    systems more rigorous, measuring the effectiveness of teacher
    preparation programs based on multiple outcomes, including their
    graduates' success in improving student achievement, and to be willing
    to shut down persistently low-performing programs.
                         career and technical education
        Question. The President has set a goal of having the United States
    improve college completion rates and become the Nation with the highest
    percentage of college graduates among its adults by 2020. The Carl D.
    Perkins Career and Technical Education Improvement Act of 2006 is the
    principal source of Federal funding to the States for the improvement
    of secondary and postsecondary career and technical education programs.
    The Department of Education's (ED's) fiscal year 2012 budget proposes
    reducing Federal funding to States under the act from $1.124 billion in
    fiscal year 2011 to $1 billion in fiscal year 2012, following a $140
    million reduction from fiscal year 2010 to fiscal year 2011. Hawaii's
    $6.121 million allocation in fiscal year 2010 will be reduced an
    estimated $595,000 in fiscal year 2011 and an additional $608,000 in
    fiscal year 2012. How will this proposal support the administration's
    goal and the Nation's projected employment needs?
        Answer. While career and technical education (CTE) is vitally
    important to America's future, the Perkins CTE program as it is
    currently structured is not operating in a way that produces optimal
    results for students. ED is currently engaged in developing our
    reauthorization proposal for the Carl D. Perkins Career and Technical
    Education Act. Our intent is to develop a proposal that will improve
    the statute by ensuring that all CTE programs become viable and
    rigorous pathways to postsecondary and career success, providing
    students with the career skills necessary to compete in a global
    marketplace, and collecting better program performance data.
                    career and technical education in hawaii
        Question. What effect will this funding decrease have for Hawaii,
    in particular?
        Answer. While the State of Hawaii would receive a reduced grant
    award under the administration's $1 billion request for the CTE State
    Grants program, the State would still continue to benefit from the .25
    percent set aside under section 116(h) of the Perkins Act for programs
    that benefit Native Hawaiian individuals. The State could also
    supplement the funds distributed to local agencies and institutions of
    higher education by taking advantage of the authority in section 112(c)
    of the Act that allows it to reserve State funds for awards in rural
    areas or areas with high percentages or numbers of CTE students.
                         distance education regulations
        Question. Mr. Secretary, Hawaii has a large number of military
    members assigned to bases throughout our State. I am concerned that the
    new regulations on distance education may have potential negative
    impacts on the ability of our military members to access distance
    learning opportunities, particularly since they frequently change duty
    location. What effect will this regulation have on military members?
        Answer. The Department's regulations governing State authorization
    of distance education programs simply required institutions to comply
    with State laws where they exist. It imposed no additional requirements
    beyond being able to demonstrate that they complied with State law
    where those State laws exist. A Federal court recently took action to
    strike the provision of the Department's regulation, but did not
    overturn State law.
                                     ______

                  Questions Submitted by Senator Patty Murray
                           early childhood education
        Question. I was pleased with the investment in early childhood
    education you decided to make with the fiscal year 2011 Continuing
    Resolution Race to the Top funding. However, I think we both know there
    is much more that should be done. Early childhood education is one of
    the most important investments we can make in a child's education. Can
    you tell me your thoughts and plans for continued funding and
    investments to improve the quality of early childhood education for
    children in Washington State and across the country?
        Answer. The administration wants to ensure that there continues to
    be funding to support the important work of improving the quality of
    early learning programs and services. We are excited about the RTT-ELC
    competition, which is focused on improving the early learning and
    development of young children by supporting States' efforts to increase
    the number and percentage of low-income and disadvantaged children in
    each age group of infants, toddlers, and preschoolers enrolled in high-
    quality early learning and development programs, and on States' efforts
    to design and implement an integrated system of high-quality early
    learning and development programs and services. We expect that the
    States that win these grants will serve as models for others, leading
    to improved quality of early learning and development programs across
    the Nation.
                                literacy funding
        Question. I am very troubled by the elimination of almost all
    Federal aid for literacy programs and what it could mean for the future
    of the Federal commitment to literacy. Providing high-quality literacy
    programs for children across the country has always been a priority for
    me. How does the Department plan to support further investments in
    literacy, given its importance in the educational success of students?
        Answer. The fiscal year 2011 compromise agreement included many
    painful cuts, and the reductions for literacy programs were
    particularly difficult. The administration requested increased funding
    for literacy in fiscal years 2011 and 2012, so we are very concerned
    about the cuts to literacy programs. We want to work with you to find a
    way to restore funding for literacy programs.
        The President's fiscal year 2012 budget request included funding
    for the proposed Effective Teaching and Learning: Literacy program,
    which would replace the previously fragmented literacy programs to
    support States in carrying out a comprehensive, pre-kindergarten
    through grade 12 literacy strategy. States would target funds to high-
    need districts to implement high-quality evidence-based literacy
    instruction. States and districts would have the flexibility to target
    funds on the activities and grade spans where local need and the
    potential impact on student learning are greatest. In addition, the
    Department just made awards under the Striving Readers Comprehensive
    Literacy (SRCL) program using fiscal year 2010 funds. That competition
    is aligned in many ways with the proposed Effective Teaching and
    Learning: Literacy program. The President's budget request includes
    continuation funds for the SRCL grants in the request for the new
    literacy program.
                    21st century community learning centers
        Question. The budget proposal you submitted proposes adding new
    purposes and programs to the existing 21st Century Community Learning
    Centers initiative, including summer school and longer school days. In
    this budget environment, I am very concerned that diverting afterschool
    funds to schools to extend the regular school day will inevitably mean
    fewer afterschool programs and fewer communities being served. How can
    you guarantee that these proposed changes will not result in fewer
    children being served by afterschool programs that keep our students
    safe and give them enriching educational activities?
        Answer. The fiscal year 2012 request for the 21st Century Community
    Learning Centers program, which is aligned with the administration's
    proposal to reauthorize the Elementary and Secondary Education Act
    (ESEA), would allow local recipients to use program funds to expand
    learning time by significantly increasing the number of hours in a
    regular school schedule and comprehensively redesigning the school
    schedule for all students in a school. The administration's ESEA
    reauthorization proposal would continue to allow funds to be used for
    before- and after-school programs, summer enrichment programs, and
    summer school programs, and, additionally, would permit States and
    eligible local entities to use funds to support expanded-learning-time
    programs and full-service community schools. This enhanced flexibility
    would allow communities to determine the best strategies for enabling
    their students and teachers to get the time and support they need.
                     extended-day and after-school programs
        Question. Many extended-day programs only keep students in school
    until 4 PM, or earlier. And, since the majority of afterschool programs
    end between 5 pm and 7 pm and sometimes later, how is extending the
    school day going to fill that gap, ensuring students are off the
    streets, until their working parents get home?
        Answer. I agree that it is critically important that children have
    a safe, enriching place to go between the time that they are dismissed
    from school and when they are supervised at home. The administration's
    reauthorization proposal assumes that local communities are best suited
    to determine how best to provide such support for children and their
    families, whether through afterschool programs, expanding the regular
    school day, week, or year, or a combination of these strategies. Under
    our reauthorization proposal, all of these options would be allowed,
    including afterschool programs.
              initiatives and investment in educational technology
        Question. As you know, the first round of Race to the Top
    Assessments are scheduled to be performed online in 2014. Many States
    and districts are unprepared technologically and in terms of training
    people to administer them and yet funding for classroom technology was
    cut from this and last year's budget proposals. Can you explain the
    Department's rationale for failing to invest in classroom technology,
    and, are there any plans to assist States and districts in ramping up
    to meet the technology challenges of implementing the Common Core
    assessments?
        Answer. The administration believes that technology is integral in
    improving educational quality for students, and that technology can be
    a valuable tool for enhancing student learning and better supporting
    teachers. For that reason, instead of continuing to fund a separate,
    narrowly defined formula program for education technology, the
    administration is proposing, through the Elementary and Secondary
    Education Act (ESEA) reauthorization and fiscal year 2012 budget
    request, new ways of investing and integrating technology across ESEA
    programs. We believe that this new approach would offer more
    flexibility and provide greater support to States, districts, and
    schools in their efforts to integrate technology into curricula and
    instruction and also would encourage the replication of effective
    technology-based practices.
    Educational Technology in the Fiscal Year 2012 Budget Request
        As you are aware, the President's fiscal year 2012 budget request
    includes $835 million for the proposed Effective Teaching and Learning
    for a Complete Education initiative, which would address the need to
    strengthen instruction and increase student achievement, especially in
    high-need local educational agencies, through three programs focused on
    literacy; science, technology, engineering, and math; and ensuring a
    well-rounded education. Under this proposed initiative, the Department
    would support States and districts in developing strategies and
    practices to meet the needs of their students and teachers across
    subject areas, including through innovative uses of technology in
    classroom instruction and professional development. The initiative's
    national activities authority also would support States in
    strengthening their use of technology in the core academic subjects,
    including the development and implementation of technology-enabled
    curriculum, assessments, professional development, and tools and
    resources.
        The fiscal year 2012 budget request also includes $300 million for
    a reauthorized Investing in Innovation Fund and $90 million for the new
    Advanced Research Projects Agency--Education (ARPA-ED). The Investing
    in Innovation Fund would support the use of technology to drive
    improvements in educational quality and productivity. The ARPA-ED
    initiative would pursue breakthrough developments in educational
    technology and learning systems, support systems for educators, and
    tools that result in improvements in student outcomes. Other programs
    that would encourage the integrated use of technology in classrooms
    include Expanding Educational Options, College Pathways and Accelerated
    Learning, Effective Teachers and Leaders State Grants, Teacher and
    Leader Pathways, Assessing Achievement, and English Learner Education.
    The administration is also proposing to allow States and districts to
    set aside a sizable percentage of the $14.8 billion request for Title
    I, Part A, College- and Career-Ready Students program to support
    capacity-building activities, including for technology.
    Computer-based Assessments
        In addition to these new ways of investing and emphasis on the
    integration of technology across programs, the administration is
    committed to supporting States and districts as they begin to make
    greater use of computer-based assessments. Under the Race to the Top
    Assessments competition, the Department awarded grants to consortia of
    States to develop reading-English language arts and mathematics
    assessments that are aligned with standards that are held in common by
    participating States. The administration's ESEA reauthorization
    proposal and fiscal year 2012 budget request include support for the
    Assessing Achievement program (currently titled State Assessments),
    which would allow States to use program funds to administer assessments
    that are aligned with college- and career-ready standards, as well as
    for other activities relating to implementation of such assessments and
    reporting of assessment data. The administration believes that these
    resources would increase the number of States implementing assessment
    systems that measure whether students are on track to being college-
    and career-ready by the time they graduate from high school, and they
    also would help States align their standards and high school graduation
    requirements with college and career expectations.
                         career and technical education
        Question. Across America, unemployment levels remain high, but we
    know there are jobs available for individuals who have the right skill
    sets. Career and Technical Education (CTE) programs work to ensure that
    students have the academic, technical and employability skills
    necessary for real career readiness. And at the Federal level, it is
    important that we support programs that help our workforce gain the
    skills necessary to be successful. Can you discuss how schools can
    offer CTE programs to help students attain these skills without Perkins
    funding?
        Answer. The Perkins Act funding assists States in expanding and
    implementing CTE education in high schools, technical schools, and
    community colleges. While it constitutes a small percentage of the
    total funding used by States, districts, and institutions of higher
    education for CTE programs, targeted Federal funding can continue to
    spur reform and innovation.
        The majority of the funding for CTE programs comes from State and
    local sources. Therefore, as long as students, school systems, and
    business leaders find that these programs are valuable and provide
    students with relevant and useful skills, these programs are likely to
    continue to exist.
         reauthorization of perkins act--career and technical education
        Question. The Department has mentioned that one reason for cutting
    Perkins funding is an inconsistency in the quality of programs across
    the country. However, I think that cutting funding for Perkins will
    likely exacerbate program quality inconsistencies. Furthermore, due to
    the nature of this formula grant, even high-quality programs will lose
    a significant amount of funding. Can you discuss how the Department
    expects CTE programs to succeed under this loss of funding?
        Answer. The administration's intent is to work with Congress during
    the upcoming reauthorization of the Perkins Act to improve the program
    and ensure that it provides students with the career and technical
    skills necessary to compete in a global marketplace. The current
    accountability system under the act cannot effectively differentiate
    between low- and high-quality CTE programs, nor does it provide
    incentives to distribute funds to schools and postsecondary
    institutions based on performance. We need to ensure that we invest in
    high-quality CTE programs, those that provide multiple pathways to
    success in careers and postsecondary education or training and align
    academic and technical coursework with challenging postsecondary
    expectations, industry needs, and certifications, and respond to the
    changing needs of the global economy.
                               impact aid funding
        Question. Impact Aid is an important education program for many
    schools around the country and, specifically, in my home State of
    Washington. Impact Aid remains a bipartisan priority of the United
    States Senate. Could you please explain for me your plan for continued
    investment in the Impact Aid program?
        Answer. The Department is committed to maintaining funding for the
    Impact Aid program. Since 2001, funding for the Impact Aid program has
    increased by over 28 percent. The administration's budget request would
    maintain the current level of funding and provide over $1.2 billion in
    financial assistance to school districts affected by Federal
    activities. Our request would maintain the Department's commitment to
    over 937,000 federally connected students and ensure that sufficient
    funding remains available for Basic Support Payments, Payments for
    Children with Disabilities, Facilities Maintenance, Construction, and
    Payments for Federal Property.
                           impact aid payment process
        Question. Additionally, how does the Department plan to rectify
    ongoing, consistently late Impact Aid payments to districts?
        Answer. With regard to late payments to districts, as you may know,
    the Impact Aid program is not fully funded and as a result we follow
    payment proration rules that are set by statute. In order to make final
    payments for any fiscal year, all data for all applicants must be
    complete and approved. When we begin making payments for any fiscal
    year, this is not the case. There are a number of reasons why this
    happens, such as amendments submitted by some applicants in September,
    incomplete field reviews (the monitoring process), pending property or
    Indian policy and procedure reviews, eligibility determinations that
    are not final, data questions regarding total current expenditures,
    attendance or local contribution rate figures, and submissions for
    military base housing undergoing renovation that have not been
    approved. As a result of these pending questions, we have to set the
    payment level at a lower level for the first year to avoid making
    overpayments to a large number of districts. In addition, we must set
    an initial payment rate in our system in May or June in order to be
    prepared to begin making payments on October 1, when funds become
    available for the new fiscal year. As this is well before an
    appropriation is enacted, we must consider the possibility that the
    program will not receive an increase or even be level funded for the
    next fiscal year. When we operate under a continuing resolution for
    part of the fiscal year, as we have for many recent years, we have
    limited funds to distribute and try to provide funding to as many
    applicants as possible, which is another reason for setting the initial
    payments at a lower rate. Once we have an appropriation for the full
    fiscal year, we raise that rate and issue another set of payments.
        Under the Impact Aid statute, we actually have 6 years to complete
    payments, the year of the appropriation and 5 more. However, our goal
    is to get this down to only 2 years so that we can get our funds out to
    the LEAs as soon as possible. What generally happens during a fiscal
    year is that we make initial and interim payments for the current year
    and the prior year, and final payments for the second prior year.
    Together these payments are usually equal to approximately the full
    amount of the payments for the current year. The LEAs with the highest
    percentages of federally connected students in their enrollments have
    received the highest proportions of their final payments in the first
    year, which we feel is an appropriate outcome. We continually strive to
    improve and expedite our payment processing while ensuring that our
    payments to all applicants are accurate.
                                     ______

                Questions Submitted by Senator Mary L. Landrieu
                               teach for america
        Question. Because of the zeroing out of several critical education
    programs, worthwhile organizations like Teach For America have been
    struggling to find alternative sources of Federal funding. To support
    this effort, this subcommittee recently approved a competitive funding
    stream to be set aside for national programs that recruit, train, and
    professionally develop teachers at an amount of 1 percent of title IIa
    funds. Meanwhile, the programs eligible to compete for these funds were
    awarded over $100 million last year, and they will be left to vie for a
    slice of merely $25 million if this set aside is left at 1 percent.
    Nearly 90 Members of Congress--from both parties and chambers--have
    written in support of increasing this competitive funding pot to 5
    percent of title IIa.
        Mr. Secretary, do you support this increase; if so, why, and if
    not, why not?
        Answer. Under the President's fiscal year 2012 budget request,
    Teach For America, along with other nonprofit organizations, States,
    local educational organizations, and institutions of higher education,
    would be eligible to apply for $250 million in competitive grant awards
    under the Teacher and Leader Pathways program, for which the creation
    or expansion of high-quality alternative pathways into the teaching
    profession would be an authorized activity. In addition, Teach For
    America would also be eligible to compete for funding under the
    Investing in Innovation program, through which Teach For America
    received $50 million in 2010 and for which $300 million was requested
    for 2012. Finally, Teach For America could partner with States and
    districts to use funds awarded under the Effective Teachers and Leaders
    State grants program to support Teach For America projects. The
    Department believes that the funds requested for these programs would
    significantly expand the resources available for Teach For America and
    other States, local educational agencies, nonprofit organizations, and
    institutions of higher education to compete for funding to support
    their efforts to recruit, prepare, and develop, and retain effective
    and highly effective teachers.
                      race to the top funding competition
        Question. Every State (except Georgia) that won Race to the Top in
    the first two rounds has now amended its State reform plan in some
    way--usually to push back a timeline or scale back an initiative.
    According to the list of approved amendments listed on the U.S.
    Department of Education's Web site, 12 winners have changed their plans
    25 times, overall.
        Delaware, the District of Columbia, Florida, Georgia, Hawaii,
    Maryland, Massachusetts, New York, North Carolina, Ohio, Rhode Island,
    and Tennessee won Race to the Top funding based on their ambitious
    plans for reform. Now, nearly all of these States and the District of
    Columbia are making changes to their plans.
        The administration has requested an additional $900 million for
    Race to the Top. Before appropriating additional funding to this
    competition, it's worth asking if the Department of Education is
    learning any lessons from the first two rounds.
        Could you address any improvements the Department of Education
    intends to make to Race to the Top to ensure that only the States truly
    committed to their bold reform plans win the funds?
        Answer. We are working closely with States to ensure that the only
    changes they make to the plans in their winning applications are those
    that preserve the ambitious work they set out to do. We are open to
    revisions so long as they preserve the long-term trajectory of the work
    while addressing short-term implementation challenges. If a State fails
    to follow through on the commitment in their application, we will
    freeze or take back its grant award.
        Question. Additionally, can you please discuss the specifics of the
    administration's proposal to expand the Race to the Top competition to
    regions and cities, not just States?
        Answer. We still have details to work out, but it is our intention
    that districts in States that received Race to the Top grants, as well
    as those in all the other States, would be eligible to compete in the
    district competition. In States that won Race to the Top grants last
    year, we do not want to get in the way of the great work these States
    are already doing. District plans should be aligned with the State's
    plans, and we would seek input from the field on how best to ensure
    that alignment. We also recognize the concern that districts in Race to
    the Top States may be further ahead in developing comprehensive reform
    plans. We would explore the best way to ensure a level playing field
    for all districts, whether they are in Race to the Top States or not.
                            race to the top phase 3
        Question. Finally, could you also provide a status update on the
    $200 million fiscal year 2011 Race to the Top competition for the nine
    high-scoring finalists that did not receive funds in the first two
    rounds of the competition?
        Answer. The Department will dedicate (for what we are calling
    ``Race to the Top Phase 3'') approximately $200 million for the nine
    highest-ranked but unfunded finalist States from the 2010 Race to the
    Top Phase 2 competition. The grant application for Race to the Top
    Phase 3 will be available in early fall for the nine eligible States:
    Arizona, California, Colorado, Illinois, Kentucky, Louisiana,
    Pennsylvania, New Jersey, and South Carolina. We are working on the
    final details of the grant opportunity, but the focus will be on
    supporting the States' 2010 Race to the Top applications in order to
    drive continued education reform in those States. The Department plans
    to make awards in December 2011.
                       emergency preparedness in schools
        Question. According to the National Commission on Children and
    Disasters, in its October 2010 Report to the President and Congress, a
    major concern is the lack of comprehensive disaster planning and
    preparedness for schools across the country. The Commission echoes a
    2007 GAO Report that identified many gaps in aligning school emergency
    plans with federally-recommended practices.
        The U.S. Department of Education manages the Readiness and
    Emergency Management for Schools (REMS) grant competition to improve
    emergency preparedness in schools. It is the only Federal grant program
    solely dedicated for this purpose. In fiscal year 2010, the Department
    received $30 million and awarded grants to about 120 school districts
    (local educational agencies). The fiscal year 2011 budget request was
    again $30 million.
        The Commission noted that $30 million is insufficient to improve
    emergency preparedness for over 130,000 public and private schools in
    our country. For fiscal year 2011, the Department intends to spend just
    $4 million and provides only $6 million in its fiscal year 2012 budget
    request.
        Given the concerns of the Commission and GAO, why isn't improving
    emergency preparedness for schools a higher priority to the Department,
    and worthy of greater investment?
        Answer. The Department remains committed to emergency preparedness
    planning, and believes that a more cost-effective and efficient
    strategy is to build State-level capacity for emergency preparedness
    planning. Instead of funding grants for Readiness and Emergency
    Management for Schools (REMS) to school districts, the Department plans
    to award grants in 2012 to States to provide support to districts and
    schools, including those that face unique challenges in implementing
    emergency management activities, that will help them prepare to address
    a variety of potential hazards and crises.
        REMS currently does not enable the Department to achieve meaningful
    progress towards sustainable, continuous improvement in K-12 emergency
    management. The REMS grants program has served a small fraction of all
    school districts and is too small to have a significant impact on
    emergency preparedness nationally. Since 2003, the Department has
    distributed 823 grants to districts, a small proportion of the 14,200
    public school districts nationwide.
    State Grants for Emergency Management
        Supporting statewide efforts will ultimately allow the Department
    to reach more districts. Also, moving to this new approach will allow
    the Department to support State efforts to develop best practices and
    innovative models that can be shared with and adapted or adopted by
    other States.
        Further, the National Commission on Children and Disasters 2010
    Report to the President and Congress recommended the approach we have
    proposed, stating, ``the Commission recommends that competitive
    disaster preparedness grants be awarded to States through the REMS
    program as an initial step toward developing innovative models designed
    to ensure a higher level of school preparedness statewide.'' This
    approach also would align our emergency preparedness efforts with the
    Department's overall priority to build the capacity of State
    educational agencies across the country.
        We had hoped to initiate the State Grants for School Emergency
    Management in 2011 but, due to the $98 million cut in funding for Safe
    and Drug-Free Schools and Communities (SDFSC) National Activities under
    the fiscal year 2011 full-year continuing resolution, the Department
    did not have enough 2011 funds to make any new SDFSC grant awards.
        Also, in 2012 under SDFSC National Activities the Department plans
    to award additional Safe and Supportive Schools grants to States to
    support statewide measurement of, and targeted programmatic
    interventions to improve, conditions for learning in order to help
    schools improve safety and reduce substance use. Promoting readiness
    and emergency management for schools would be among the programmatic
    interventions supported with those grants.
                             federal trio programs
        Question. Over the last 5 years, Federal TRIO programs have lost
    37,000 participants as a result of stagnant funding. The $26.6 million
    cut in fiscal year 2011 may result in as many as 107,000 fewer
    participants. The administration has requested $920 million for TRIO in
    fiscal year 2012. This funding is critical to growing the capacity of
    TRIO and thereby increasing the rate of college completion for students
    from lower socioeconomic backgrounds. Could you discuss how the
    administration will support and defend its recommended funding level
    for TRIO in fiscal year 2012?
        Answer. The administration believes that the Federal TRIO programs
    play an important role in assisting low-income students and students
    whose parents never completed college with support and preparation to
    enter and complete postsecondary education programs. In designing the
    TRIO competitions for 2012, particularly Upward Bound, the Department
    is focused on ensuring that grantees pursue strategies and activities
    that will maximize the number of students to which they can provide
    high-quality services. The Department also believes that the TRIO
    programs can play an important role in ensuring that our investment in
    Pell Grants results in more students persisting and completing because
    they enroll in postsecondary education better prepared to succeed.
        The administration remains committed to increasing college
    enrollment and completion rates among traditionally underrepresented
    populations. In demonstration of this commitment, we have prioritized
    protecting the $5,550 maximum Pell Grant award in fiscal year 2012 and
    beyond, with the goal of ensuring that more than 9 million low-income
    students can continue to rely on Pell Grants to enter into, and
    complete, a postsecondary education. However, low-income students need
    more than just financial support to enter and complete college; they
    also need supportive services like those provided by our Federal TRIO
    programs.
                     educational stability for foster youth
        Question. Children in the foster care system face unique challenges
    on their path to high school graduation and college success. On
    average, foster children move one to two times per year, and often
    change schools when they move. When students change schools, they lose
    4 to 6 months of educational progress. Only about half of foster
    children graduate from high school, and a mere 3 percent earn
    bachelor's degrees. As the Co-Chair of the Senate Caucus on Foster
    Youth and an advocate for foster youth, I am concerned that children in
    the foster care system do not have the educational stability they need
    to graduate from high school--on time and with the strong educational
    foundation they need to access and complete college.
        Mr. Secretary, do you believe the U.S. Department of Education
    should invest in promoting educational stability for the nearly 450,000
    children in foster care, and, if so, what would that investment look
    like? Might this investment include school vouchers for youth in care
    over 18 months; stronger collaboration between State Educational
    Agencies and State child welfare agencies; Federal funding for the
    transportation needed to keep foster youth in their school of choice;
    or other solutions?
        Answer. All students, especially those in foster care, need
    educational stability in order to succeed in school. We certainly need
    to do more for youth in foster care, who are more likely to repeat a
    grade, and score lower on standardized tests, than youth who are not in
    foster care. Between one-quarter and almost one-half of all children in
    foster care are also in special education, well above the average for
    the general population.
        Collaboration among State educational agencies (SEAs), State child
    welfare agencies, local educational agencies (LEAs) and schools is key
    to tackling these challenges. In letters to Chief State School Officers
    and State Child Welfare Directors, we are planning to encourage States
    and LEAs to develop or review and, if appropriate, revise their
    policies and guidelines for serving children in foster care, in order
    to minimize the disruptions to education that can come from being
    placed in foster care. We have encouraged SEAs, LEAs, and child welfare
    agencies to collaborate during this process and to publicize these
    policies and guidelines so that school administrators, teachers, social
    workers, and parents understand and can replicate and reinforce their
    efforts to increase the educational success of foster children. ED has
    also urged child welfare agencies to collaborate with LEAs on policies
    and procedures to ensure that foster children remain in and receive
    transportation to their school of origin in cases where this is in the
    best interest of the foster child, using funding under title IV, part E
    of the Social Security Act and other available resources for such
    purposes. We have pushed for all States and LEAs to have any revised
    policies and guidelines in place prior to the start of the 2011-2012
    school year.
        ED is also collaborating with the Department of Health and Human
    Services (HHS) on this issue, by providing HHS with the information and
    technical assistance needed to successfully carry out that agency's
    work under the Fostering Connections to Success and Increasing
    Adoptions Act of 2008 (FCA). For example, we have worked closely with
    HHS in providing input and assistance as it develops guidance and other
    material on the FCA. ED has also shared with HHS resources developed by
    the National Center for Homeless Education (NCHE), our technical
    assistance contractor for the McKinney-Vento Education for Homeless
    Children and Youth program. NCHE provides technical assistance to ED on
    issues related to homeless students, but it has also put together
    information and recommendations on the education of students who are
    eligible for homeless services while they are awaiting foster care
    placement.
    Foster Care and Education National Meeting in 2011
        Finally, ED and HHS will co-host a Foster Care and Education
    National Meeting on November 3 and 4 of 2011 to bring together State
    teams, representing each State's educational, child welfare, and court
    systems, to discuss how to promote educational stability and improve
    educational outcomes for children in foster care. Our goals for this
    meeting are to expand participants' understanding of each system and of
    the individual and collective opportunities that can contribute to
    improving educational outcomes for children in foster care; gain
    insight into foster youths' perspectives on what supports have aided in
    their educational success; familiarize participants with the
    educational provisions of the FCA; and showcase meaningful
    collaborative initiatives that have demonstrated positive educational
    outcomes. During the meeting, each State team will also create an
    action plan for cross-system collaboration to be implemented following
    the conference. All conference attendees will have access to additional
    technical assistance, such as webinars, on topics related to the FCA
    leading up to this national meeting.
                high school dropout recovery/prevention programs
        Question. A June 2011 MDRC report, ``Staying on Course: Three-Year
    Results of the National Guard Youth ChalleNGe Evaluation,'' shows that
    the National Guard Youth ChalleNGe program is effectively reducing our
    Nation's high school dropout rate. According to the report, 3 years
    after entering the program, Youth ChalleNGe graduates were more likely
    to earn their high school diploma or GED, obtain college credits, be
    employed, and have substantially higher earnings than high school
    dropouts who were eligible, but did not participate in the ChalleNGe
    Program.
        Are you aware of any comparable high school dropout recovery/
    prevention programs, and if so, how is the U.S. Department of Education
    investing in these programs?
        Answer.
    Dropout Prevention Guidance
        Reducing our Nation's high school dropout rates is a key Department
    goal, and we have been actively engaged in identifying and
    disseminating information on effective dropout prevention and recovery
    practices. In fall 2008, the Institute of Education Sciences (IES)
    released Dropout Prevention: A Practice Guide, which provides
    recommendations for dropout interventions using evidence from
    previously implemented programs that positively affected students'
    progress and persistence in school. Using material from this guide, the
    Department developed a Dropout Prevention section for the Doing What
    Works Web site, which provides practitioners with research-based
    information and tools for improving outcomes. The Office of Elementary
    and Secondary Education has also recently initiated an effort to
    identify a set of promising dropout prevention and recovery models. In
    addition, IES continues to fund research on dropout prevention
    programs, currently including a study of the Check & Connect dropout
    prevention model.
    Departmental Dropout Prevention and Reentry Programs
        The Department has invested in dropout prevention and reentry
    efforts through the High School Graduation Initiative (HSGI, formerly
    School Dropout Prevention) program, which received $48.9 million in
    fiscal year 2011 and provides competitive grants to States and local
    school districts to implement, at schools with below-average graduation
    rates, effective, sustainable dropout prevention and reentry
    activities, including activities similar to those of the National Guard
    Youth ChalleNGe program. In our proposal to reauthorize the Elementary
    and Secondary Education Act, we propose to consolidate this and two
    other programs that seek to improve outcomes for high school students
    or offer accelerated learning opportunities into a single authority,
    the College Pathways and Accelerated Learning program. This program
    would support comprehensive efforts to increase high school graduation
    rates and preparation for college matriculation and success by
    providing college-level and other accelerated courses and instruction
    in middle and high schools with concentrations of students from low-
    income families and in high schools with low graduation rates. It would
    also allow considerable local flexibility for activities including
    efforts to prevent students from dropping out and to reengage out-of-
    school youth, including early warning systems and comprehensive
    prevention and reentry plans. The President's fiscal year 2012 request
    includes $86 million for this program.
        In addition, high schools with high dropout rates receive
    significant assistance through the Title I School Turnaround Grants
    (formerly School Improvement Grants) program. Under the
    administration's recent program regulations and ESEA reauthorization
    proposal, Title I secondary schools with a graduation rate below 60
    percent may receive priority for School Turnaround funds. These school
    turnaround grants will provide hundreds of millions of dollars to help
    restructure significant numbers of the Nation's ``dropout factories.''
        Also, the Department will continue to invest in efforts to keep
    students in school and on the path to college through programs
    authorized under the Higher Education Act, including the TRIO-Talent
    Search and GEAR UP programs.
                                     ______

                Question Submitted by Senator Richard J. Durbin
                 study abroad and foreign language instruction
        Question. Currently, only about 1 percent of college students study
    abroad each year, few of whom are minority students, community college
    students, or students studying in the STEM fields or to be teachers.
    Less than 10 percent of students enrolled in higher education
    institutions in the U.S. are taking foreign languages. Given the
    increasingly global nature of our economy, what plans does the
    Department have to help more students graduate college with the global
    mindset and foreign language skills necessary to be successful in
    today's global economy?
        Answer. The Department agrees that a world-class education must
    integrate global competencies and is committed to increasing the global
    competency of all U.S. students, including those from traditionally
    disadvantaged groups. The Department expects these objectives to be
    reflected in a strategy it is currently developing that would govern
    all its international activities. The Department currently administers
    18 discretionary grant programs authorized under the Higher Education
    Act and the Mutual Educational and Cultural Exchange Act of 1961 that
    are designed to strengthen the capability and performance of American
    education in foreign languages and in area and international studies,
    and to improve secondary and postsecondary teaching and research
    concerning other cultures and languages, as well as the training of
    specialists, and the American public's general understanding of the
    peoples of other countries. The Department intends to further align
    activities to be supported in fiscal year 2012 under these programs
    with the Department's goals to advance global educational competency
    for American citizens and to increase access and quality in
    postsecondary education.
                                     ______

                    Questions Submitted by Senator Jack Reed
                                school libraries
        Question. Given that more than 60 education and library studies
    have shown evidence that effective school libraries are linked to
    increased student achievement and knowing that digital literacy skills
    are essential to being college and career ready, what is the
    administration's plan to ensure that students in title I schools have
    access to effective school library programs?
        Answer. The administration's proposed Effective Teaching and
    Learning: Literacy program would address the need to comprehensively
    strengthen instruction and increase student achievement in literacy in
    high-need districts and schools. The administration believes that this
    new program would help ensure that States and high-need districts have
    in place a solid infrastructure across the grade levels to support
    high-need schools in implementing high-quality, developmentally
    appropriate, and systematic literacy instruction (which may include
    programs that support school libraries).
        Question. What changes does the administration plan to make to
    competitions such as Race to the Top to encourage States and school
    districts to provide effective school library programs?
        Answer. Race to the Top provides significant flexibility to States
    and encourages them to pursue approaches that improve student outcomes
    and best meet State and local needs. Depending on the strategies
    adopted by individual States (and by local educational agencies, if we
    are able to hold a district-level RTT competition), the approaches may
    include activities to strengthen school libraries. In addition, the
    proposed Effective Teaching and Learning: Literacy program would
    encourage States and LEAs to implement high-quality literacy
    instruction, which could include support for school libraries.
                       teacher quality partnership grants
        Question. The President's fiscal year 2012 budget calls for the
    Teacher Quality Partnership program to be consolidated, along with four
    others, into a new authority called Teacher and Leader Pathways.
    Teacher Quality Partnership Grants are currently the Federal
    Government's only investment in reforming teacher preparation at
    institutions of higher education, which prepare nearly 90 percent of
    all teachers. Why is the administration planning to switch course
    before full implementation of the Teacher Quality Partnership Grants?
        Answer. In its March 2011 report entitled ``Opportunities to Reduce
    Potential Duplication in Government Programs, Save Tax Dollars, and
    Enhance Revenue,'' the Government Accountability Office (GAO)
    specifically identified the Teacher Quality Partnerships Grants program
    as a current teacher quality program that overlaps with another program
    in the Department based on its allowable activities or shared
    objectives and target groups. The GAO report noted that the
    administration had already proposed to reform the current fragmented
    approach to improving teacher quality through its Blueprint for the
    reauthorization of the Elementary and Secondary Education Act.
        By consolidating several overlapping and sometimes narrowly
    targeted programs, the administration has proposed an integrated
    approach to recruiting, preparing, developing, rewarding, and retaining
    effective teachers and school leaders that builds on the best elements
    of existing programs and approaches at the Federal, State, and local
    level. The President's fiscal year 2012 budget requests $250 million
    for the Teacher and Leader Pathways program to support the preparation
    of new teachers, with particular emphasis on the preparation of
    science, technology, engineering, and mathematics, or STEM, teachers.
    Institutions of higher education, along with States, local educational
    agencies, and nonprofit organizations, would be eligible for
    competitive grants to support the creation or expansion of high-quality
    traditional and alternative pathways into the teaching profession.
            projects funded under teacher quality partnership grants
        Question. What are the preliminary results from the current Teacher
    Quality Partnership Grants?
        Answer. The Department is currently administering 40 grants under
    the Teacher Quality Partnership Grants program, including 19 teacher
    residency projects, 12 pre-baccalaureate teacher preparation projects,
    and 9 projects that support both a teacher residency project and pre-
    baccalaureate teacher preparation. Although it is too early to know if
    these teacher preparation programs are producing more effective
    teachers as a result of the reforms they are implementing through these
    grants, the annual performance reports for the second year of these
    grants indicate that most projects are implementing their projects as
    planned.
        The grants supporting teacher residency projects prepared 620
    teacher candidates last year. These projects focused on preparing
    candidates who will be certified to teach elementary education,
    mathematics, science, or special education. The graduates of these
    residency projects will be teaching in high-need schools in high-need
    districts in the 2011-2012 school year. Due to reductions in State and
    local funding, some of the partnering high-need districts for the
    residency projects have been unable to meet their original commitments
    to hire as many residents to teach in high-need schools. Since grantees
    are required to place successful graduates of residency projects in
    teaching positions in high-need schools, these grantees have had to
    reduce the number of candidates they admitted. The Department is
    hopeful that the partnering districts will be able to commit to hiring
    more teacher residents in the remaining years of these grants and will
    continue to work with grantees to ensure that these projects are as
    successful as possible despite the challenging economic conditions.
        For the pre-baccalaureate teacher preparation grants, six
    institutions of higher education have incorporated information into
    their traditional course offerings to ensure that their teacher
    preparation candidates are prepared to teach students in urban, high-
    need schools more effectively. Four pre-baccalaureate projects are
    focused on preparing candidates to teach students in high-need rural
    schools and rural education is an area of emphasis for several other
    projects. Both pre-baccalaureate and residency projects reported that
    they are establishing or expanding clinical experience requirements for
    teacher candidates. In addition to preparing teachers to enter the
    classroom, six projects also have reported that they are offering
    professional development for teachers in partnering schools.
             federal partnerships and need-based student grant aid
        Question. Does the administration see a need for a Federal-State
    partnership to support need-based grant aid for students? What are the
    administration's plans to rebuild such a partnership now that the
    Leveraging Educational Assistance Partnerships, or LEAP, program has
    been defunded?
        Answer. Cooperation between the Department and States is vital to
    achieve good educational outcomes. This is why the 2012 President's
    budget included proposals for new Federal-State partnerships in the
    form of the College Completion Incentive Grant (CCIG) program, and the
    College Access Challenge Grant program. CCIG is designed for twofold
    activity: to encourage States to engage in reforms to increase college
    completion rates (and ensure these students are well-prepared), and to
    reward institutions that are successful at achieving these goals.
    States must apply to receive funding, and include with their
    application a plan of how they will make certain reforms.
        The College Access Challenge Grant Program, as proposed, would
    provide formula aid to States to bolster access, persistence, and
    completion activities, specifically targeted toward low-income
    students. This program would fund activities to ensure low-income
    students are prepared to enter and succeed in postsecondary education,
    such as providing them need-based grant aid, promoting financial
    literacy and debt management, and providing postsecondary education and
    career preparation for students and their families.
        Question. Does the administration see a need for a Federal-
    institutional partnership to provide need-based grant aid for students?
    How can we strengthen the current aid programs to improve these
    partnerships?
        Answer. Besides the funding that is able to be granted to
    institutions from States via the College Completion Incentive Grants
    and College Access Challenge Grant programs, the First in the World
    program, included in the 2012 President's budget request, would go
    directly to programs that are evidence-based and willing to undergo
    rigorous evaluation. This would be a competitive grant program, and
    would place priority in the first year on projects that could reduce
    net price, improve outcomes, reduce time to degree or instructional
    costs; and/or improve access and completion rates.
                      race to the top funding and vendors
        Question. With billions of dollars awarded, Race to the Top is the
    largest competitive grant program at the Department of Education. It is
    essential that the use of these funds is fully transparent. Please
    provide information on which vendors States are using to implement
    their grants and the amount of Race to the Top dollars that are being
    awarded to the top vendors across the States.
        Answer. We have not aggregated the information about the vendors
    with whom the Race to the Top States are working to implement their
    plans. All of the States and school districts that received Race to the
    Top funds must meet the reporting requirements set forth in section
    1512 of the Recovery Act. Those requirements include identifying any
    vendors that receive payment of $25,000 or more in a given quarter, and
    that information is publicly available on Recovery.gov. In addition,
    States must follow State procurement laws, which may require the public
    release of the names of entities that are awarded contracts and other
    awards under the program.
                                     ______

                   Questions Submitted by Senator Mark Pryor
           level playing field for rural areas in grant competitions
        Question. You testified that over 80 percent of the Department of
    Education's funding allocations remain formula based. However, I have
    heard from many of my constituents that are concerned that they do not
    have the ability or the resources necessary to effectively compete for
    the remaining 20 percent of funding in competitive grants. What steps
    is the Department of Education taking to ensure that poor and rural
    school districts are able to apply for competitive grants and compete
    on a level playing field?
        Answer. The Department recognizes that capacity constraints in
    remote and rural areas can make applying for competitive grants
    difficult. To help level the playing field for rural districts, the
    Department is using absolute and competitive priorities to award
    additional points to applications from these districts or other
    applicants serving rural areas. For example, the Department included a
    rural priority and a tribal priority in the Promise Neighborhoods grant
    competition. The Department also has proposed structuring new
    competitions for the Race to the Top and i3 programs to reflect the
    needs of rural districts. Our goal would be to ensure that rural
    districts are able to compete for Race to the Top funds in our proposed
    district-level competition, and that i3 recipients serve geographically
    diverse communities. Under i3, for example, we hope to fund providers
    proposing evidence-based approaches to addressing the unique needs of
    rural districts and schools. Also under i3, we plan to recruit peer
    reviewers experienced in working with rural students and schools, and
    to improve our training methods so that all peer reviewers are aware of
    the unique needs of students and schools in rural communities and our
    expectations for applications that respond effectively to the rural
    priority.
        The Department also is using its Comprehensive Centers to provide
    technical assistance designed to increase the capacity of rural
    districts, working with Rural Education Achievement Program (REAP)
    State coordinators to increase awareness of competitive grant
    opportunities for rural areas, and encouraging the development and
    expansion of consortia and partnerships to help make rural districts
    more competitive. Finally, the Department's recent experience with the
    School Improvement Grants (SIG) program suggests that rural districts
    can hold their own in properly structured competitive grant
    competitions. Rural schools made up just under 20 percent of all
    schools eligible for SIG funds in the fiscal year 2009 State SIG
    competitions, but totaled 23 percent of grant recipients in that year.
       race to the top application process and rural district applicants
        Question. The President has requested $900 million for fiscal year
    2012 for Race to the Top. Can you take me through the process of
    selecting applications for award?
        Answer. We have not yet developed the specific process for the
    district-level competition, but would do so with input from
    stakeholders in a diverse array of districts.
        Question. Additionally, what metrics or criteria do you have in
    place to ensure that rural and underserved States and school districts
    will be evaluated on a level playing field with States and school
    districts that may have more resources?
        Answer. While we do not have specific metrics or criteria in place,
    we would develop the competition with rural districts in mind. If a
    single set of criteria are not appropriate for both rural and non-rural
    districts, we may develop different criteria. We have not yet decided
    what approach we would use.
                            education and employment
        Question. I am increasingly concerned about the ability of students
    with a degree or certification from a high school, technical or
    vocational school, or community college to find gainful employment. How
    can we make sure these students graduate with the knowledge and skills
    that employers are looking for?
        Answer.
    Ensuring All Students Graduate College- and Career-Ready
        President Obama and I share your commitment to ensuring that all
    students graduate college- and career-ready, both to expand individual
    opportunity for further education and success in the job market and to
    ensure our Nation's continued competitiveness in the global economy. We
    recognized early on that one of the unintended consequences of No Child
    Left Behind was that it encouraged States to lower the quality of their
    K-12 academic standards, primarily to avoid the law's overly
    prescriptive school improvement requirements. This is why all of our
    key initiatives in elementary and secondary education have emphasized
    the development and adoption of more rigorous college- and career-ready
    academic standards and aligned assessments. In particular, the Race to
    the Top program has had a tremendous impact in this area, encouraging
    the vast majority of States to adopt a common set of State-developed
    college- and career-ready standards and supporting State consortia as
    they develop the next generation of high-quality assessments aligned
    with these standards.
        The development and implementation of college- and career-ready
    standards is also at the core of our proposal to reauthorize title I of
    the Elementary and Secondary Education Act (ESEA), which would provide
    resources to States and school districts for this purpose. It is
    important to recognize, however, that the Department cannot prescribe
    or impose particular standards or curricula on America's schools, and
    that the States bear the primary responsibility for developing,
    adopting, and successfully implementing high-quality academic standards
    linked to success in college and careers. Our role is to highlight the
    need for such standards and, wherever possible, create the incentives
    for States to do the right thing for their students and for our Nation.
    College Pathways and Accelerated Learning Program
        Our ESEA reauthorization proposal would create other new programs
    that aim to improve student college and career readiness including the
    College Pathways and Accelerated Learning program, which would
    consolidate several current ESEA programs into a single, more
    comprehensive and flexible authority that supports State and local
    efforts to better prepare students for college and the workforce by
    providing college-level and other accelerated courses and instruction,
    including dual enrollment and early college high school programs, in
    secondary schools with concentrations of students from low-income
    families and with low graduation rates. The President's fiscal year
    2012 request includes $86 million for this program.
    Carl D. Perkins Career and Technical Education Act
        The Department is also in the process of developing a
    reauthorization proposal for programs under the under the Carl D.
    Perkins Career and Technical Education Act (Perkins Act). We are
    looking at options for making the Perkins Act a better vehicle for
    ensuring that all career and technical education programs are viable
    and rigorous pathways to postsecondary and career success. College and
    career pathways provide multiple pathways to the same destination:
    achievement of both success in college and an upwardly mobile career.
    These pathways must align academic and technical coursework with
    challenging postsecondary expectations, as well as industry needs and
    certifications, and be designed and implemented in close collaboration
    with employers in order to respond to the changing needs of the global
    economy. The President's fiscal year 2012 request includes $1 billion
    for this program.
          public-private partnerships as tool in ensuring college- and
                                career-readiness
        Question. In your opinion, would public-private partnerships be an
    effective tool? If so, how can we incentivize educational institutions
    to create partnerships with businesses to develop effective programs?
        Answer. Public-private partnerships can definitely be a valuable
    tool for helping young people acquire the knowledge and skills that
    employers are looking for. Surveys of business leaders show that,
    despite the high unemployment rate, they are having difficulty finding
    sufficiently skilled workers to fill many job openings. However, few
    business leaders report that they are working with postsecondary
    institutions to help them improve programs that prepare individuals for
    careers.
        The Department is currently developing its reauthorization proposal
    for the Carl D. Perkins Career and Technical Education Act. One of the
    issues we are considering is how to create incentives for educational
    institutions and businesses to work together to ensure that students
    acquire the knowledge and skills they need to get good jobs and succeed
    in high-wage, high-skill careers.
                  supplemental educational services oversight
        Question. Many educators in my State have voiced concern about the
    lack of proper oversight of title I funds for supplemental educational
    services (SES). How can we ensure that these valuable funds are being
    used effectively and in the best interest of students?
        Answer. Under the ESEA, States are responsible for approving SES
    providers and monitoring provider performance in providing tutoring and
    other academic enrichment services to eligible students. To help States
    carry out these responsibilities, the Department in recent years has
    provided extensive technical assistance to States on questions and
    issues related to the provision of SES, including questions regarding
    the allowable use of title I funds by providers for specific activities
    and incentives. The Department also monitors the implementation of SES,
    sometimes including the delivery of services by particular providers,
    as part of the title I monitoring process.
                  supplemental educational services evaluation
        Question. What level of evaluation of the impact of SES on student
    achievement is currently underway?
        Answer. The Department is currently completing a rigorous
    evaluation of the impact of supplemental educational services on
    individual student achievement in six school districts with
    approximately 24,000 students eligible for SES. The study also will
    examine whether the impact of SES on student achievement is associated
    with particular characteristics of services, providers, students, or
    practices in the school district. This study currently is undergoing
    peer review and is expected to be released by the end of 2011.
                          common core state standards
        Question. What do you think about the new Common Core State
    Standards and the corresponding Partnership for Assessment of Readiness
    for College and Careers assessment system?
        Answer. The administration believes the adoption of State-
    developed, college- and career-ready academic standards is an essential
    first step toward developing next generation accountability systems
    that will help students prepare more effectively for college and
    careers and ensure that our Nation is able to compete successfully in
    the global economy of the 21st century. As a result of the leadership
    of our Governors and Chief State School Officers, the vast majority of
    States have now voluntarily adopted common, college- and career-ready
    standards. The administration also believes that the development and
    implementation of new State assessments linked to these standards,
    including the work currently under way by the Partnership for
    Assessment of Readiness for College and Careers, will be a game-changer
    in public education. These new assessments will, for the first time,
    effectively measure whether America's students are on track for college
    and careers while providing teachers with timely, high-quality
    formative assessments that measure student academic growth and help to
    improve teaching and learning.
           funds for implementing academic standards and assessments
        Question. Are you concerned about resources for teachers and
    schools to implement these Common Core State standards?
        Answer. The Department, as enunciated in both its budget requests
    and in our proposal for reauthorizing the ESEA, intends to continue
    providing State formula grant funding to help States implement high-
    quality standards and assessments, as well as competitive grants for
    States and LEAs to support instruction aligned with college- and
    career-ready standards. For fiscal year 2012, the President's request
    includes $420 million under a reauthorized Assessing Achievement
    program, as well as $835 million under a reauthorized Effective
    Teaching and Learning for a Complete Education program. In addition,
    the Department believes that the near-universal voluntary adoption of
    common academic standards by the States is evidence of a commitment to
    make available the State and local resources required to implement
    these standards as well as aligned assessments.
                               ayp waiver request
        Question. In March 2011, Arkansas requested that you waive a
    requirement of NCLB to allow its AYP targets to be held at the 2011-
    2012 levels until it fully implements the Common Core State Standards
    (2014-2015 school year). I understand that their request was denied.
    Did you grant any AYP waivers?
        Answer. No, we have not granted any waivers of adequate yearly
    progress (AYP) targets. Several States have submitted amendments to
    their Accountability Workbooks that are consistent with the ESEA
    statute and regulations, but these are not waivers.
               no child left behind requirements flexibility plan
        Question. The reason given for the waiver denial was that these
    issues should be addressed in an Elementary and Secondary Education
    Authorization bill. As we all know, it is highly unlikely that we will
    see such a bill this year. Based on that information, will you take a
    second look at Arkansas's request for a waiver?
        Answer. The Department is developing a plan to provide flexibility
    regarding NCLB requirements for those States that are moving forward
    with reforms that will increase the quality of instruction and improve
    student achievement. Final details on the flexibility package will be
    available in mid-September, and we encourage all interested States,
    including Arkansas, to request it.
                                     ______

                  Questions Submitted by Senator Sherrod Brown
          elimination of in-school subsidy for undergraduate students
        Question. Last year, the Deficit Reduction panel proposed the
    elimination of the in-school subsidy for undergraduates as a way to
    find savings. It is my understanding that this was on the table during
    debt ceiling recent negotiations. Eliminating the in-school subsidy for
    undergraduates would have an extremely negative impact on students. How
    does the administration plan to balance the needs of middle class
    students who may qualify for the in-school subsidy, but not the Pell
    Grant?
        Answer. While the Budget Control Act of 2011 eliminated subsidized
    loans for graduate and professional students--which the administration
    endorsed as part of its 2012 budget proposal--undergraduate students
    still retain the ability to take out subsidized loans. Students who are
    not interested in a Stafford loan, and are not otherwise Pell-eligible,
    should consider the campus-based aid programs--Supplemental Educational
    Opportunity Grants (SEOG), Work-Study grants, and Perkins loans--as a
    good source of aid. Part of the 2012 budget request was to maintain the
    current level of funding for SEOG and Work-Study, and to reform the
    Perkins program with $8.5 billion in volume--eight and one-half times
    the current volume--which could enable it to reach over 3 million
    students at over 2,700 institutions.
                            student loan conversion
        Question. In May, I introduced the Student Loan Simplification and
    Opportunity Act which was a part of the Presidents' Pell Grant
    Protection Act. This legislation would allow students with both Federal
    Family Education Loan Program (FFELP) loans and Direct Loans to
    simplify their loan repayment process and provide borrowers with 2
    percent off of their FFELP principal for converting their loans, while
    saving the Government $1.8 billion. Does the administration support
    this policy included in the bill?
        Answer. The administration supports the policy as presented in its
    fiscal year 2012 budget proposal to Congress. The administration
    believes this policy will make loan repayment simpler for the estimated
    6 million split borrowers--those with loans both in the Direct Loan and
    FFEL programs--and make it less likely they will default as a result.
               race to the top--early learning challenge program
        Question. In July, Senator Hagan and I introduced the Ready Schools
    Act of 2011. This legislation is based off of the great work of the
    Spark Partnership in Ohio and the North Carolina Ready Schools
    Initiative. This legislation focuses on the importance of school
    readiness in addition to the student readiness. Early childhood
    education plays an important role in the short- and long-term success
    of students. I appreciate your efforts in establishing the Early
    Learning Challenge Grant Program but am concerned that this funding
    will only benefit a limited number of children. As childhood poverty
    rates continue to grow, it is important that we invest in all young
    children. Why did the Department decide to spend $500 million for this
    program when the success of the Race to the Top model is still unknown?
    What is included in the budget to improve the systematic alignment and
    delivery of early childhood education?
        Answer. The Race to the Top--Early Learning Challenge program will
    support States that demonstrate their commitment to integrating and
    aligning resources and policies across all of the State agencies that
    administer public funds related to early learning and development.
    Winning States will serve as models of how to build a more unified
    approach to supporting young children and their families--an approach
    that increases access to high-quality early learning and development
    programs and services, and helps ensure that children enter
    kindergarten with the skills, knowledge, and dispositions toward
    learning they need to be successful.
        All States can undertake this work by using existing funds that
    support early learning and development from Federal, State, private,
    and local sources, such as the Child Care and Development Fund, title I
    and II of the ESEA, the Individuals with Disabilities Act, State-funded
    preschool programs, and Head Start.
                             federal trio programs
        Question. In your fiscal year 2012 budget request, you recommend a
    $67 million increase to the TRIO programs. As you know, this is not
    really an ``increase'' but rather it provides funding to ensure that
    the 180 Upward Bound programs funded by the College Cost Reduction and
    Access Act--including three programs in Ohio--would not have to close
    their doors in December 2011. In light of recent funding cuts to TRIO
    in fiscal year 2011, could you reaffirm your commitment to TRIO,
    particularly the administration's fiscal year 2012 funding request for
    the program?
        Answer. The administration believes that the Federal TRIO programs
    play an important role in assisting low-income students and students
    whose parents never completed college with support and preparation to
    enter and complete postsecondary education programs. In designing the
    TRIO competitions for 2012, particularly Upward Bound, the Department
    is focused on ensuring that grantees pursue strategies and activities
    that will maximize the number of students to which they can provide
    high-quality services. The Department also believes that the TRIO
    programs can play an important role in ensuring that our investment in
    Pell Grants results in more students persisting and completing because
    they enroll in postsecondary education better prepared to succeed.
        The administration remains committed to increasing college
    enrollment and completion rates among traditionally underrepresented
    populations. In demonstration of this commitment, we have prioritized
    protecting the $5,550 maximum Pell Grant award in fiscal year 2012 and
    beyond, with the goal of ensuring that more than 9 million low-income
    students can continue to rely on Pell Grants to enter into, and
    complete, a postsecondary education. However, low-income students need
    more than just financial support to enter and complete college; they
    also need supportive services like those provided by our Federal TRIO
    programs.
                               tech prep program
        Question. The Tech Prep program provides college and career
    training for students beginning in high school so that they are
    prepared for success in business and industry. This program also helps
    to ensure more students are on the path to complete higher education
    and thus the United States is on the path to compete in a global
    economy. Why did the administration choose to merge the Tech Prep State
    Grant with the title I basic State grant and then reduce the overall
    appropriation?
        Answer. The Tech Prep program duplicates activities authorized
    under the Career and Technical Education (CTE) State Grants program.
    The purpose of the Tech Prep program is to support development and
    implementation of programs of non-duplicative, sequential courses of
    study that incorporate secondary education and postsecondary education
    with work-based learning experiences. However, the CTE State Grants
    program also requires States to develop these types of programs, and to
    do so within the larger context of CTE programs within the State. In
    addition, 28 States consolidated at least a portion, and generally all,
    of their Tech Prep funds into State Grants during school year 2010-
    2011.
        In order to maintain fiscal discipline by placing a priority on
    programs that are most aligned with the President's reform agenda and
    most likely to demonstrate results, the Department did request a
    reduction in funding for CTE for fiscal year 2012. While CTE is vitally
    important to America's future, the Perkins CTE program as it is
    currently structured is not operating in a way that produces optimal
    results for students. The Department is currently engaged in developing
    our reauthorization proposal for the Carl D. Perkins Career and
    Technical Education Act. Our intent is to develop a proposal that will
    improve the statute by ensuring that all CTE programs become viable and
    rigorous pathways to postsecondary and career success, providing
    students with the career skills necessary to compete in a global
    marketplace, and collecting better program performance data.
             family engagement in educational outcomes for children
        Question. I have heard a lot of discussion about family engagement
    in education from the administration, which is a step in the right
    direction. In your blueprint for ESEA reauthorization, you propose the
    establishment of a Family Engagement and Responsibility Fund, along
    with an increase in the title I set-aside for family engagement
    initiatives. However, the Parent Information Resource Center (PIRC)
    funds are consolidated in the Department 2012 budget. Parental
    Information and Resource Centers exist to work in partnership with, and
    build the capacity of, State and local educational agencies and provide
    technical assistance on implementing research-based and effective
    family engagement strategies.
        How does the administration plan to ensure that districts and
    States build their capacity to carry out this work without the PIRC
    program?
        Answer. Enhancing family engagement is crucial to improving
    educational outcomes for children, and the administration's budget and
    Elementary and Secondary Education Act (ESEA) reauthorization proposals
    reflect our commitment to making sure that families are informed of and
    better involved in the educational opportunities available in their
    community. The Department is also committed to pursuing actions that
    will help build the capacity of States, school districts, and schools
    to effectively leverage resources for strengthening family engagement
    in education. As you mentioned, the administration's ESEA
    reauthorization proposal for the renamed College- and Career-Ready
    Students (CCRS) program (currently title I grants to local educational
    agencies) would significantly increase State and local spending on
    parent and family engagement activities, ensuring that every district
    receiving title I funds is developing and implementing a family
    engagement plan focused on raising student achievement and developing
    promising new strategies to engage parents and families. States would
    be permitted to reserve up to 5 percent of their title I, part A
    allocations to carry out activities to build State and local capacity
    to improve student achievement, including by improving capacity to
    carry out effective family engagement strategies.
    Family Engagement and Responsibility Fund
        States also would be permitted to set aside up to 1 percent of
    their title I, part A allocations to fund programs that support family
    engagement and to identify and disseminate best practices in this area.
    This Family Engagement and Responsibility Fund would support and expand
    district-level best practices, with a priority for evidence-based
    parental involvement activities. PIRCs, along with districts,
    community-based organizations, and other nonprofit organizations, would
    be eligible to compete for these funds.
    Title I Set-aside and Family Engagement
        Our reauthorization proposal would also double the local title I
    set-aside for parent and family engagement, from 1 to 2 percent,
    increasing the total from about $145 million to approximately $270
    million. PIRCs would be eligible to partner with school districts or
    consortia of school districts in implementing activities funded under
    this set-aside. Additional elements of the administration
    reauthorization proposal (including our proposals for Safe and Healthy
    Students, Promise Neighborhoods, and Expanding Educational Options)
    would also focus specifically on issues related to family engagement.
    Capacity Building and Technical Assistance for Family Engagement
            Activities
        Finally, you asked about the Department's plan to provide capacity-
    building and technical assistance to States and districts on family
    engagement in education. We will continue to support these goals
    through our new Implementation and Support Unit (ISU), in the Office of
    the Deputy Secretary, and through programs like the Comprehensive
    Centers. The ISU provides technical assistance directly to States
    implementing comprehensive reforms under the Education Jobs Fund, Race
    to the Top, Race to the Top Assessment, and State Fiscal Stabilization
    Fund programs. The Comprehensive Centers also help increase State
    capacity to assist districts and schools in meeting their student
    achievement goals. In fiscal year 2012, the Department will make
    approximately 21 new competitive grant awards to support the first year
    of a second cohort of Comprehensive Centers. Because family engagement
    is a priority for the administration and for the Secretary, it will be
    one of the key issues addressed through these efforts.
                        school-based counseling programs
        Question. School counselors, school psychologists, and school
    social workers provide counseling and other learning support services
    to students who are struggling with issues that create barriers to
    learning. The Elementary and Secondary School Counseling Program is the
    only Federal grant specifically targeted to providing assistance to
    school districts to establish and enhance school counseling programs,
    including ensuring access to these highly trained professionals to
    address students' social and emotional needs. Given the serious impact
    on students' academic success that children can face because of anxiety
    related to a parent's military deployment, issues related to
    homelessness, or other types of mental illness, as well as the need for
    prevention and early intervention to avoid more serious problems, how
    will the priorities of the Elementary and Secondary School Counseling
    Program be preserved under the proposed consolidation program?
        Answer. The administration is committed to addressing student
    mental health issues and believes that school-based counseling programs
    offer great promise for improving prevention, diagnosis, and access to
    treatment for children and adolescents.
    Successful, Safe, and Healthy Students Program
        Under the proposed Successful, Safe, and Healthy Students program,
    State educational agencies (SEAs), high-need local educational agencies
    (LEAs), and their partners, that are interested in establishing or
    expanding elementary and secondary school counseling programs would be
    eligible to apply for competitive grant funding to develop and
    implement programs that measure and improve conditions for learning
    based on local needs. The administration believes that this broader,
    more flexible approach, through which grantees could address students'
    mental health and related social needs comprehensively, rather than a
    narrowly focused program, would be more successful in building State,
    district, and school capacity and in providing the resources necessary
    to design and implement strategies for promoting healthy development
    and successful students.
                       promise neighborhoods applications
        Question. There were 339 communities who applied for $10 million in
    Promise Neighborhoods funding in fiscal year 2010. More than 80 of
    these communities scored 80 or higher on the application process. Nine
    of these communities were in Ohio. Many of these communities would have
    been awarded planning grants if additional funding were available. I am
    pleased that for fiscal year 2011, there is $30 million available for
    Promise Neighborhoods, and that ED is offering implementation grants,
    in addition to a second round of planning grants. I understand that the
    notice of intent for this second round was due last week; do you have a
    sense of how many communities applied for the new implementation?
    Specifically, do you know how many communities are seeking
    implementation verse planning grants?
        Answer. As of the July 22 deadline for Intents to Apply in the
    fiscal year 2011 competition, 501 entities had submitted their intent
    for the planning grant competition and 161 entities had submitted their
    intent for the implementation grant competition. The deadline to submit
    a full application for both the planning and implementation grant
    competitions is September 6, 2011.
                         promise neighborhoods funding
        Question. What is the Department of Education doing to meet the
    national need and demand for Promise Neighborhoods?
        Answer. The President's fiscal year 2012 budget request includes
    $150 million to provide continued funding to fiscal year 2011
    implementation grantees in addition to funding a new round of planning
    and implementation grants. We consider this a priority within our 2012
    budget request. In addition, as part of the White House Neighborhood
    Revitalization Initiative (NRI), the Department is partnering with
    other Federal agencies to provide comprehensive technical assistance to
    additional communities, many of which have expressed interest in the
    Promise Neighborhoods program, as part of the NRI's Building
    Neighborhood Capacity program. This program will support organizations
    with limited capacity, but serving high-poverty neighborhoods, through
    hands-on technical assistance. Designed to serve an initial cohort of
    five neighborhoods, the program will provide an online resource center
    and leverage assistance from multiple Federal agencies and other
    sources in support of local neighborhood revitalization initiatives.
             technical assistance to promise neighborhoods grantees
        Question. For those communities who did receive planning grants,
    how is the Department providing the necessary coaching and technical
    assistance needed to ensure success?
        Answer. The fiscal year 2010 appropriation did not provide Federal
    resources to support coaching or technical assistance for the planning
    grantees. Nevertheless, the Promise Neighborhoods Institute (PNI), an
    independent, foundation-supported nonprofit resource, is meeting many
    of the needs of the communities. PNI offers tools, information, and
    strategies to assist any community interested in participating in the
    Promise Neighborhoods program. In addition, PNI provides technical
    support directly to the program's grantees for planning, identifying
    quality approaches, building partnerships, assessing needs, and many
    more essentials for successfully building a Promise Neighborhood. The
    $30 million fiscal year 2011 appropriation will support national
    activities, including technical assistance for the first cohort of
    Promise Neighborhood implementation grantees.
                                     ______

                Questions Submitted by Senator Richard C. Shelby
                              pell grants funding
        Question. The unsustainable growth in the costs of the Pell Grant
    program continues to be an anchor dragging down the entire budget for
    the Department of Education. While the fiscal year 2012 budget request
    does propose some policy changes to address the growth in Pell Grant
    costs, the administration also proposes a $5.6 billion increase in
    discretionary funding. How will the fiscal year 2012 budget request
    address the fiscally unsustainable path of the Pell Grant program?
        Answer. The President's budget for fiscal year 2012 seeks to
    protect the $5,550 maximum award for those students with the greatest
    need, while also finding ways to reduce the overall cost impact of the
    Pell Grant program. One way the request does this is by not seeking to
    raise the maximum award, instead keeping it level with the prior 2
    years. Additionally, in the President's budget, the administration
    outlined a comprehensive plan to cover rising Pell Grant costs and help
    close the program's shortfall through changes to other student aid
    programs, and changes to the administration of Pell itself. In total,
    these changes are estimated to save $100 billion over 10 years.
                           reducing pell grants costs
        Question. Specifically, how is the administration proposing to
    reduce the overall rapid cost growth in the Pell Grant program?
        Answer. The Department's plan for reducing Pell Grant costs
    specifically includes eliminating the availability of a second Pell
    Grant in an award year, FAFSA simplification, creating easier student
    repayment through a debt conversion plan, expanding and modernizing the
    Perkins Loan program so it can assist more students, replacing the
    TEACH Grants program with Presidential Teaching Fellows, creating the
    College Completion Incentive Grants program to achieve better outcomes
    for students, and eliminating subsidized loans for graduate and
    professional students. Two of these policy proposals--the elimination
    of the second Pell Grant in an award year, and the elimination of
    subsidized loans to graduate and professional students--have already
    been adopted by Congress. In total, the Department estimates these
    changes will reduce Pell's discretionary appropriations need by $13.2
    billion in 2012 alone.
               state authorization of distance education programs
        Question. There continues to be concerns raised by colleges and
    universities regarding State authorization provisions under the
    proposed Program Integrity regulations and the potential impact on
    access to distance education at higher education institutions. At the
    risk of losing Federal financial aid, colleges and universities will be
    required to request permission to offer their distance education
    programs in every State in which a student is located while receiving
    instruction. Many States already have legislation that requires
    registration. Why is the Department of Education moving forward with
    regulations where States already have efficient and equitable policies
    in place regarding distance learning?
        Answer. The Department's regulations governing State authorization
    of distance education programs simply required institutions to comply
    with State laws where they exist; it imposed no additional requirements
    beyond being able to demonstrate that they complied with State law
    where those laws exist. A Federal court recently took action to strike
    the provision of the Department's regulation but did not overturn State
    law. The United States is still evaluating whether to appeal.
        With that said, Alabama has set high standards and imposed
    significant charges on institutions that offer distance learning in the
    State. While we do not endorse these requirements, we do acknowledge
    that each State has the ability to regulate higher education
    institutions operating in the State.
        Question. How will the Department ensure universities that have
    already been approved by their home State's Higher Education Commission
    and accredited by the relevant regional accrediting authority that they
    will not be unduly burdened by duplicative, costly, time consuming, and
    academically unnecessary regulations?
        Answer. The Department's regulations governing State authorization
    of distance education programs simply required institutions to comply
    with State laws where they exist; it imposed no additional requirements
    beyond being able to demonstrate that they complied with State law
    where those laws exist. A Federal court recently took action to strike
    the provision of the Department's regulation but did not overturn State
    law. The United States is still evaluating whether to appeal.
        With that said, Alabama has set high standards and imposed
    significant charges on institutions that offer distance learning in the
    State. While we do not endorse these requirements, we do acknowledge
    that each State has the ability to regulate higher education
    institutions operating in the State. So, States, including Alabama, can
    take steps to reduce the burden imposed on institutions of higher
    education if they believe those burdens are duplicative, costly, time
    consuming, and academically unnecessary. The Federal Government ought
    not to limit the authority of States but if that were to be done it
    would involve preempting State laws. Such preemption would require
    either congressional action or a regulatory action. Such regulations
    would need to be developed consistent with the Executive Order of
    Federalism signed by President Reagan.
        high school graduation initiative and the college pathways and
                          accelerated learning program
        Question. The fiscal year 2012 Department of Education budget
    request proposes to consolidate 38 programs into 11 new authorities in
    line with the administration's Elementary and Secondary Education Act
    reauthorization proposal. Beginning in 2010, the Mobile County School
    System will receive nearly $9 million over 5 years under the High
    School Graduation Initiative to support the implementation of
    effective, sustainable, and coordinated dropout prevention and reentry
    efforts in high schools. However, the fiscal year 2012 budget request
    would eliminate the High School Graduation Initiative and replace the
    program with a new College Pathways and Accelerated Learning program.
    How will the Department of Education ensure that schools who have been
    awarded funding under the High School Graduation Initiative continue to
    receive their promised funding under the budget request?
        Answer. The administration's proposal for the College Pathways and
    Accelerated Learning program would require the Secretary to reserve
    funds to pay for grants made under the High School Graduation
    Initiative and Advanced Placement programs through the grants'
    completion.
                                     ______

                  Questions Submitted by Senator Thad Cochran
            targeting of title i funds to local educational agencies
        Question. It is clear that the funds appropriated for title I could
    be distributed in a more equitable manner that targets those for whom
    the program is intended: children in concentrated poverty. Is the
    Department of Education actively pursuing potential changes to title I
    distribution formulas to ensure Federal education funding better
    reaches disadvantaged children?
        Answer. The administration is strongly committed to ensuring that
    title I funds are targeted to high-poverty schools, regardless of
    geographic location, and stands ready to work with the Congress,
    through the reauthorization process, on ways to improve the targeting
    of title I funds.
    national not-for-profit organizations and the improving teacher quality
                              state grants program
        Question. There continues to be concern with the consolidation of
    existing programs into 11 new authorities in the administration's
    reauthorization proposal for the Elementary and Secondary Education
    Act. Specifically, the Department of Education budget appears to direct
    funding to programs for States and localities without a path for
    national not-for-profit organizations with a proven track record to
    compete. In fiscal year 2011 Congress addressed this concern by
    including a 1 percent set aside under the Improving Teacher Quality
    State Grants program for a competition for national not-for-profit
    organizations that provide teacher training or professional development
    activities. When does the Department of Education intend to have a
    competition for national not-for-profit (NFP) organizations under the
    Improving Teacher Quality State Grants program?
        Answer. A notice inviting applications for new awards under this
    set-aside was published in the Federal Register on September 8, 2011.
    Our goal is to make awards in early 2012, well before the period of
    availability ends on September 30, 2012.
                national nfp organizations set-aside competition
        Question. Can you please provide details to this subcommittee on
    how the Department intends to conduct a competition for these funds,
    including any expected priorities for the competition?
        Answer. Through the new Supporting Effective Educator Development
    competition, the Department will make grants to national non-profit
    organizations to support projects that are supported by at least
    moderate evidence, as defined in the notice inviting applications.
    Grantees will use the funds to recruit, select, and prepare or provide
    professional enhancement activities for teachers or for teachers and
    principals.
    Supporting Effective Educator Development Competition Absolute
            Priorities
        An applicant may apply under any of three absolute priorities:
      --Under Absolute Priority 1, the Department will support the creation
            or reform of practices, strategies, or programs that are
            designed to increase the number or percentage of teachers (or
            teachers and principals) who are highly effective, especially
            teachers (or teachers and principals) who serve concentrations
            of high-need students, by identifying, recruiting, and
            preparing highly effective teachers or teachers and principals.
            To meet this priority, an applicant must propose a plan
            demonstrating that teacher or principal participation in the
            applicant's proposed activities will be determined through a
            rigorous, competitive selection process.
      --Under Absolute Priority 2, we will support projects that will
            increase the quality of student literacy and writing by
            creating or reforming practices, strategies, or programs that
            improve teachers' knowledge, understanding, and teaching of
            English language arts with a specific focus on writing through
            high-quality professional development or professional
            enhancement programs.
      --Under Absolute Priority 3, the Department will fund projects that
            encourage and support teachers or teachers and principals
            seeking advanced certification or advanced credentialing
            through high-quality professional enhancement programs designed
            to improve teaching and learning for teachers or for teachers
            and principals. To meet this priority, an applicant must
            demonstrate or propose a plan to demonstrate that the award of
            the advanced certification or advanced credential will be
            determined on the basis of a rigorous evaluation with multiple
            measures that include measures of student academic growth.
        The Department will also award points in this competition based on
    two competitive preference priorities. An applicant may receive
    additional points by proposing:
      --a project that is supported by strong evidence of effectiveness (as
            defined in the notice inviting applications), or
      --a project that is designed to significantly increase efficiency in
            the use of time, staff, money, or other resources while
            improving student learning or other educational outcomes.
            Projects that receive points under the second competitive
            preference priority may include innovative and sustainable uses
            of technology, modification of school schedules and teacher
            compensation systems, use of open educational resources, or
            other strategies.
            national nonprofit competitions and esea reauthorization
        Question. Will the Department of Education commit to supporting a
    dedicated funding stream for the same purpose in fiscal year 2012?
        Answer. Our proposal for ESEA reauthorization includes several
    competitions in which many national nonprofit organizations would be
    eligible to participate. For example, organizations such as Teach for
    America, the National Writing Project, and the National Board for
    Professional Teaching Standards, the organizations no longer receiving
    earmarked assistance, could partner with schools to apply for an
    Investing in Innovation grant. In addition, Teach for America could
    compete for funds under the proposed new Teacher and Leader Pathways
    program. The National Board for Professional Teaching Standards could
    partner with States in the Teacher and Leader Innovation Fund to
    strengthen State standards for certification and licensure. The
    National Writing Project could receive funding under the national
    activities set-aside in the new Effective Teaching and Learning
    initiative and could also partner with States on comprehensive literacy
    strategies.
        promise neighborhoods competition--absolute priority for rural
                                  communities
        Question. The fiscal year 2012 budget request includes $150 million
    for the Promise Neighborhoods program, which supports projects designed
    to improve education and life outcomes for children and youth within a
    distressed geographic area. The Indianola Promise Community in
    Mississippi was awarded one of the first Promise Neighborhood grants in
    fiscal year 2010. However, there are concerns that as the process moves
    forward the Indianola Promise Community will have to compete on a
    national scale with large, urban school districts for implementation
    grant funding. Please provide details on the steps that the Department
    has taken under the Promise Neighborhoods program to ensure rural
    communities can compete for grant funding to implement reform efforts.
        Answer. In fiscal year 2010, the Department included an absolute
    priority for rural communities applying for Promise Neighborhood
    grants. The Delta Health Alliance in Indianola applied for and received
    a planning grant under this rural community priority. The fiscal year
    2011 competition again includes an absolute priority for rural
    communities as well as tribal communities, for both planning and
    implementation grants, in order to ensure that communities such as
    Indianola are able to compete on a national scale for Promise
    Neighborhood funding.
    improving competitive stance of rural communities for education funding
        Question. Does the Department plan to take similar steps in the
    future to ensure that rural communities are less disadvantaged under
    competitive grant opportunities, as it has with the Promise
    Neighborhoods and Investing in Innovation programs?
        Answer. Through the rulemaking process, the Secretary has created
    supplemental priorities to target funds to high-priority areas. These
    priorities include a priority for improving the achievement and high
    school graduation rates of students in rural school districts. The
    Department is considering applying this priority in competitions for
    absolute or competitive preference in a number of programs for fiscal
    year 2012.
                    innovative strategies in early learning
        Question. The Department recently announced that $500 million of
    the fiscal year 2011 funding for the Race to the Top program will be
    awarded to States to help build comprehensive early learning systems.
    For fiscal year 2012, the administration requested an additional $900
    million for the Race to the Top program and $350 million for a new
    Early Learning Challenge Fund. What plan does the Department have in
    place to ensure that funding awarded through Race to the Top or the
    Early Learning Challenge Fund prioritizes innovative strategies for
    early learning, including the implementation and expansion of full-day
    kindergarten?
        Answer. We want to provide funding to support the important work of
    transforming early learning programs and services from a patchwork of
    disconnected programs with uneven quality into a coordinated system
    that prepares children for success in school and in life. The purpose
    of the Race to the Top-Early Learning Challenge (RTT-ELC) program,
    which we are implementing with about $500 million of the fiscal year
    2011 appropriation for Race to the Top, is to improve the quality of
    early learning and development and close the achievement gap for
    children with high needs. The overarching goal is to make sure that
    many more children, especially children with high-needs, enter
    kindergarten ready to succeed. The competition for RTT-ELC grants also
    includes an invitational priority to encourage States to sustain
    positive early learning program effects in the early elementary grades.
                              geography education
        Question. According to results from the National Assessment of
    Educational Progress that were released on July 19, 2011, fewer than
    one-third of the Nation's students achieve at or above the proficient
    level in geography. As the sponsor of S. 434, the ``Teaching Geography
    Is Fundamental Act,'' which would create a dedicated program to improve
    geographic literacy, these recent results are gravely concerning. Will
    the Department of Education commit to do more to ensure that funding is
    directed to geographic education activities?
        Answer. The Department is committed to ensuring that our Nation's
    students have access to high-quality instruction across academic
    content areas. Our proposal to reauthorize the Elementary and Secondary
    Education Act (ESEA) includes the Effective Teaching and Learning for a
    Well-Rounded Education program, which would support efforts to improve
    instruction in a wide range of subjects, including geography, while
    providing States and local school districts with greater flexibility to
    meet the needs of their students and teachers. The President's fiscal
    year 2012 request includes $246 million for this new program.
        Although geography is included among the subjects in the current
    ESEA definition of ``core academic subjects,'' geography education is
    not the focus of any current ESEA program and, thus, most likely does
    not receive significant Federal support under current law. Enactment of
    the Effective Teaching and Learning for a Well-Rounded Education
    program would give the Department and grantees a better vehicle for
    supporting the evaluation and expansion of geography education programs
    as well as efforts to integrate geography more prominently in
    instruction in other subject areas.
                         career and technical education
        Question. Across the country, unemployment levels are still high,
    but there are jobs available for individuals with the right skill sets.
    The Career and Technical Education program works to ensure that
    students have the academic, technical and employability skills
    necessary for career readiness in the current workforce. In fiscal year
    2012, the Department of Education budget request proposes an almost
    $125 million reduction to the Career and Technical Education State
    Grants. How will the Department of Education ensure that schools can
    continue to offer Career and Technical Education programs to help
    students attain these skills with a decrease in funding?
        Answer. While CTE is vitally important to America's future, the
    Perkins CTE program as it is currently structured is not operating in a
    way that produces optimal results for students. The Department is
    currently engaged in developing our reauthorization proposal for the
    Carl D. Perkins Career and Technical Education Act. Our intent is to
    develop a proposal that will improve the statute by ensuring that all
    CTE programs become viable and rigorous pathways to postsecondary and
    career success, providing students with the career skills necessary to
    compete in a global marketplace, and collecting better program
    performance data.
                                     ______

                 Questions Submitted by Senator Lindsey Graham
                       incentive compensation regulations
        Question. It is my understanding that recent sub-regulatory
    language related to incentive compensation rules issued by your
    Department would prohibit one or two entities from providing support
    services to other colleges and universities, services that other
    companies can provide without reservation. If this is accurate, this
    regulation would be arbitrarily picking winners and losers. It is
    difficult to comprehend either the statutory grounds or rationale for
    interfering with the provision of services to educational institutions.
        In order to better understand the intent of the regulation, I
    respectfully request clarity on the statutory grounds and why the
    Department would choose to include some institutions under the
    regulation while leaving others out.
        Answer. On March 17, 2011, the Department issued guidance related
    to several areas of program integrity, including the issue of incentive
    compensation. This guidance was designed to assist institutions in
    understanding the regulations and provide examples of permissible
    activities. The guidance provided in this letter, and the regulations
    in general, seek to ensure title IV aid at all institutions is used to
    successfully train students.
        Please be aware that there is no prohibition upon any entity
    providing support services to another entity. The only prohibition is
    upon the manner in which compensation may be provided should one of
    those services involve student recruitment. Pursuant to section
    487(a)(20) of the HEA an ``institution will not provide any commission,
    bonus, or other incentive payment based directly or indirectly on
    success in securing enrollments or financial aid to any persons or
    entities engaged in any student recruiting or admission activities or
    in making decisions regarding the award of student financial
    assistance.'' It is that statutory provision which the Department is
    enforcing when it monitors the manner in which student recruitment
    activities are compensated.
     title vi centers for international business education (ciber) program
        Question. For fiscal year 2011, your Department cut the title VI
    Centers for International Business Education and Research (CIBER)
    program by 55 percent. Over two decades, CIBERs have been engaged in
    cutting-edge activities to strengthen the Nation's global economic
    competitiveness on many levels.
        I respectfully request detailed information on CIBERs' recent role
    in supporting an increase in our country's exports, including
    collaboration with business and government on the President's National
    Export Initiative. I also request information on how CIBERs have
    enhanced institutes of higher education, including underrepresented
    institutions such as HBCUs, MSIs, and community colleges, in meeting
    global demand for a competitive workforce.
        Answer. In response to President Obama's recent announcement of the
    National Export Initiative, which calls for increased resources to
    expand international trade, the U.S. Commercial Service--the trade
    promotion arm of the U.S. Department of Commerce's International Trade
    Administration--plans to increase its efforts to move U.S. companies
    into new and emerging markets. The CIBERs have a good track record with
    the U.S. Department of Commerce and will work with President Obama's
    National Export Initiative, either directly or indirectly, by holding
    conferences and assisting businesses to improve their export
    strategies.
        In the 2010 CIBER competition, the Department encouraged the
    applicants to help improve internationalization at minority-serving
    institutions (MSIs). Many applicants responded to the priority by
    incorporating activities into their 2010-2013 CIBER projects. For
    example, Michigan State University hosts a bi-annual training program
    for community colleges where the Commerce Department's teaching
    materials are featured.
        As outreach to other constituencies, a number of CIBERs have
    developed 4-year training programs for faculty from HBCUs. The program
    includes mentoring institutions as well as individual faculty and
    providing for faculty study abroad. The program will be extended to
    Hispanic-Serving Institutions, and three CIBERS--Colorado, Hawaii, and
    Washington--will work with Alaska Native, Native Hawaiian, and Native
    American students and faculty during the 2010-2014 cycle.
        In partnership with the University of Memphis, CIBERs and the
    Institute of International Public Policy, which is operated by the
    United Negro College Fund Special Programs Corporation, have been
    working with 46 Historically Black Colleges and Universities (HBCUs) to
    enhance understanding of interdisciplinary international business
    education. The consortium has been engaged in equipping HBCU faculty
    with discipline specific international knowledge, pedagogical tools,
    research methodologies, and study abroad experiences to incorporate
    international content into existing business courses and/or develop new
    courses, and to increase international business research. An integral
    component of the program is one-on-one assistance provided by the
    sponsoring CIBERs to their respective HBCUs in the implementation of
    international business education programs on HBCU campuses and in
    acquiring Federal grants to support these efforts.
        CIBERs at Brigham Young University and the University of Colorado
    at Denver support a consortium of 36 community colleges and
    universities across 10 western States to provide CIBER programs to the
    region's small and medium-sized rural institutions and to facilitate
    the sharing of resources among regional schools with developing
    international business expertise. The consortium is now reaching out to
    Tribal Colleges and Universities (TCUs) recognized by the American
    Indian Higher Education Consortium, as 23 TCUs are located in 10 States
    with a significant number of Native American students.
           national impact of fiscal year 2011 budget cuts on cibers
        Question. Lastly, what has been the impact of the cuts on CIBERs
    nationally and their ability to continue their legislative mandates?
        Answer. Besides producing the majority of internationally prepared
    business students and entrepreneurs, CIBERs are designed to serve as
    regional and national resources to businesses, students, and academics.
    The CIBERs are the equivalent of the National Resource Centers (NRCs)
    in Schools of Business. Most are located at major U.S. universities.
        The most recent competition for new awards was held in fiscal year
    2010 and 33 grants averaging $386,576 were awarded. The CIBER
    allocation in 2011 is $5.7 million, a reduction of $7 million or 55
    percent, below the 2010 funding. The reduced funding in 2011 will
    likely hamper activities supported by the CIBER program. Outreach to
    business, including export development; business language training and
    other interdisciplinary programs; outreach and faculty development to
    minority-serving institutions, community colleges, other colleges and
    universities, and K-12 schools in the 50 States; practical, policy-
    oriented international business research; and study abroad and
    international internships could be eliminated or reduced.
               plan for ciber program funding in fiscal year 2012
        Question. What is your plan for CIBER program funding in fiscal
    year 2012?
        Answer. The Department is currently supporting 33 universities,
    designated as CIBERS, who were awarded multi-year grants in fiscal year
    2010. Fiscal year 2012 funds would be used to cover, to the extent
    possible, funding for the third year of the 4-year grants.
        Currently funded CIBERS institutions are: Brigham Young University,
    Columbia University, Duke University, Florida International University,
    George Washington University, Georgia Institute of Technology, Georgia
    State University, Indiana University, Michigan State University, Ohio
    State University, Purdue University, San Diego State University, Temple
    University, Texas A&M University, University of California, LA,
    University of Colorado at Denver, University of Connecticut, University
    of Florida, University of Hawaii at Manoa, University of Illinois at
    Urbana-Champaign, University of Maryland, University of Memphis,
    University of Miami, University of Michigan, University of Minnesota,
    University of North Carolina--Chapel Hill, University of Pennsylvania,
    University of Pittsburgh, University of South Carolina, University of
    Southern California, University of Texas--Austin, University of
    Washington, and University of Wisconsin--Madison.
                                     ______

                   Questions Submitted by Senator Jerry Moran
                     possible waivers of esea requirements
        Question. Secretary Duncan, you have stated recently that if
    reauthorization of the Elementary and Secondary Education Act (ESEA) is
    not completed by this September, you will look to issue States
    conditional waivers from No Child Left Behind's most troublesome
    requirements provided that States agree to make certain changes to
    their education systems. Specifically, what No Child Left Behind
    requirements would you waive for States and what changes would you
    require of States to receive such waivers?
        Answer. The Department is still working out the details of possible
    flexibility from ESEA requirements pending the completion of
    reauthorization, and expects to announce the specifics in mid-
    September.
                       measuring student academic growth
        Question. Mr. Secretary, last March, your Department released its
    Blueprint for the Reauthorization of ESEA, which outlined in broad
    terms proposed changes to the current law, including the development of
    new assessments of student growth. What do you see as the ideal
    ``growth models'' for States to measure individual student performance
    and how will these models be different from current ``adequate yearly
    progress'' (AYP) standards?
        Answer. The Department believes that there are a number of valid
    and reliable methods for measuring student academic growth that States
    would be able to choose from to meet the requirements of our
    reauthorization proposal. The key benefit of growth models is that they
    will track the academic progress of individual students over time, as
    opposed to simply measuring the percentage of students who have reached
    grade-level proficiency in a particular subject at a particular point
    in time, as under most assessment and accountability systems used by
    States under current law. The Department's reauthorization proposal
    would continue to require States to set performance targets for
    schools, similar to current AYP requirements, but schools would be able
    to meet such targets either by demonstrating that students are ``on
    track'' to college- and career-readiness or making adequate progress
    toward being on track to college- and career-readiness.
                   impact of the esea on student achievement
        Question. We all know that education is a primary key to increasing
    our country's global competitiveness. Knowledge and human capital are
    what drive innovation, entrepreneurship, and growth. We talk a lot
    about holding our schools and teachers accountable for creating our
    leaders of tomorrow, but we also need to hold ourselves accountable.
    Since the ESEA was enacted more than 45 years ago, Federal per-pupil
    spending has nearly tripled. However, our national graduation rates and
    other academic achievement measures have remained relatively flat and
    we have fallen in international education ranking. Considering these
    measures, why have we failed to improve and what are some examples you
    have seen in your travels across the country that represent a fresh
    approach where schools are raising the bar for student achievement?
        Answer. I believe a number of factors have been holding us back
    educationally despite decades of effort to improve academic and other
    outcomes at the Federal, State, and local levels. First, I believe we
    have set the bar too low. We all know that young people tend to perform
    up to expectations, and our expectations for academic achievement in
    core subjects, as reflected in State standards and assessments, have
    simply been lower than many of our strongest economic competitors have
    for their students. In part this ``dumbing down'' of standards and
    assessments has been due to flawed and overly prescriptive
    accountability requirements, such as those we have experienced over the
    past decade under No Child Left Behind. The administration's response
    to these problems has been to encourage and create incentives for
    States to raise their standards, and thanks to the leadership of our
    Nation's Governors and Chief State School Officers, we have seen great
    success in this area with the voluntary adoption of common, State-
    developed, college- and career-ready standards by the vast majority of
    States over the past 2 years. And we are proposing to create, through
    the reauthorization of the ESEA, more nuanced accountability systems
    that ask States and school districts to focus their attention and
    support on the lowest-performing schools and schools with the largest
    achievement gaps, while also giving them considerable flexibility to
    develop and implement their own improvement strategies for most
    schools.
    Teacher Recognition and Academic Achievement
        Another issue is that we have not treated our teachers like the
    professionals that they are: we must provide needed support, reward
    excellence, and create incentives for our best teachers to work in our
    toughest schools. A key first step toward elevating the teaching
    profession is the development and implementation of rigorous and fair
    teacher evaluation systems that will help us identify, support, learn
    from, and reward effective teachers. We have been promoting the
    creation of those systems in several of our key initiatives, including
    Race to the Top, the Teacher Incentive Fund, School Improvement Grants,
    and our ESEA reauthorization proposal.
    Examples of Innovative Approaches to Ensuring Academic Success
        Despite these challenges to excellence in our education system,
    many districts and schools are finding innovative ways to make
    extraordinary progress in preparing their students for success in
    college and careers as well as for lifelong and active participation in
    our democracy. For example, Mooresville Graded School District in North
    Carolina has launched a Digital Conversion Initiative to promote the
    use of technology to improve teaching and learning. The district has
    provided laptops to every 4th to 12th grade student and interactive
    SMART Boards and Slates and Response Devices have been employed in
    every K-3 classroom. In addition to the use of computers as
    instructional tools, the Digital Conversion Initiative has resulted in
    a shift to digital textbooks with content that is aligned with State
    standards. Traditional textbooks may still be used, but generally as
    supplemental materials. The use of digital textbooks and other
    technology can increase student achievement and enhance the learning of
    21st century skills.
        In Florida, the Florida Virtual School also taps into technology to
    provide online learning options for students in grades K-12. The school
    has modified the way most traditional public school systems work by
    moving to a completely results-based funding model in which a school
    receives funding only for students who successfully complete courses.
    It allows students to progress at their own pace--usually faster than
    normal seat-time classes would allow--and provides many traditional
    schools economical options for providing courses they would have
    difficulty staffing locally.
        And in Mobile, Alabama, George Hall Elementary School underwent a
    restructuring plan that involved hiring a new principal and replacing a
    majority of school staff. The new staff signed contracts to stay at the
    school for at least 5 years. The principal focused on developing staff
    cohesion, a positive culture, and a curriculum that was aligned with
    State standards and connected from one grade level to the next. Since
    then student achievement has risen sharply. In reading, the percentage
    of students scoring at or above the proficient level almost doubled
    from 24 percent in 2003-2004 to 43 percent in 2004-2005; math gains
    were even larger, rising from 34 percent to 69 percent. By 2008-2009,
    the percentage of students who scored proficient or above reached 90
    percent in reading and 94 percent in math.
                         career and technical education
        Question. In Kansas and many other States, career and technical
    education is critical to economic growth and expansion of a competitive
    workforce. Your Department's Blueprint for the Reauthorization of ESEA
    references developing and implementing new statewide assessments for
    career and technical subjects. Specifically, what role do you see
    career and technical education playing in a reauthorized ESEA?
        Answer. For too long, career and technical education (CTE) has been
    a neglected part of the education reform movement. That neglect must
    end, and CTE must change its mission to play a key role in the goal of
    ensuring that all students graduate high school ready for college and
    careers. President Obama has suggested that every American earn both a
    high school diploma and a degree or an industry-recognized
    certification. CTE can and must help ensure that young adults receive
    those two credentials, both of which are essential to securing a good
    job.
                     esea title i accountability structure
        Question. Also, how do we successfully incorporate career and
    technical education and other learning that may take place outside the
    traditional classroom into ESEA's accountability structure?
        Answer. The ESEA title I accountability structure is based on
    student performance on assessments in reading/language arts and
    mathematics, as well as additional academic indicators such as high
    school graduation rates. Students who participate in career and
    technical education are included in those assessments, but they
    typically are assessed in the 10th grade, before they begin taking CTE
    coursework, and the assessments do not measure their progress in CTE.
        Many observers of the current title I accountability structure have
    criticized it as being too focused on reading/language arts and
    mathematics, which may have resulted in a narrowing of the curriculum.
    The administration's ESEA reauthorization blueprint includes a number
    of proposals that would seek to ensure that students have access to a
    broad, well-rounded curriculum that is not dominated by the tested
    subjects.
    Accountability in Career and Technical Education Programs
        In addition, in the context of the upcoming reauthorization of the
    Carl D. Perkins Career and Technical Education Act, we are seeking to
    develop mechanisms for holding career and technical education programs
    appropriately accountable for results-- mechanisms that would track
    student programs in CTE as well as in the academic subjects. We believe
    that this type of strategy is likely to be more successful than trying
    to incorporate CTE skill and knowledge acquisition within the title I
    framework.

                             CONCLUSON OF HEARINGS

        Senator Harkin. And with that, the--we are done. The
    subcommittee will stand in recess.
        [Whereupon, at 11:40 a.m., Wednesday, July 27, the hearings
    were concluded, and the subcommittee was recessed, to reconvene
    subject to the call of the Chair.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2012

                                  ----------

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

        [Clerk's note.--The subcommittee was unable to hold
    hearings on departmental and nondepartmental witnesses. The
    statements and letters of those submitting written testimony
    are as follows:]

                             DEPARTMENTAL WITNESSES

         Prepared Statement of the Corporation for Public Broadcasting
        Chairman Harkin, Ranking Member Shelby, and members of the
    subcommittee, thank you for allowing me to submit testimony on behalf
    of our Nation's public media system.
        Every day across the country, people turn to public radio and
    television for programs that inform and inspire; for lifelong
    education; for local news and information; for arts and cultural
    content, and for a variety of other services. Public broadcasting, or
    what should more accurately be called ``public media,'' has many faces,
    and employs around 24,000 people, but is best-known by the 1,300 local
    public radio and television stations across the country that provide
    unique local service to their communities. These stations collectively
    reach more than 98 percent of the U.S. population with free, over-the-
    air television and radio programming and other services. When Congress
    appropriates money to the Corporation for Public Broadcasting (CPB), it
    is benefitting the 170 million Americans who use public broadcasting
    each month by supporting the stations that serve them.
        CPB distributes Federal funds in accordance with a statutory
    formula contained in the Public Broadcasting Act of 1967, under which
    more than 70 percent of our funds go directly to local public
    television and radio stations. CPB also supports the creation of
    programming for radio, television, and digital media. The statute
    ensures diversity in this programming by requiring CPB to fund
    independent and minority producers. CPB fulfills these obligations by
    funding the Independent Television Service and the five Minority
    Consortia in television (which represent African American, Latino,
    Asian American, Native American, and Pacific Islander producers) and
    similar organizations in radio. CPB funds the National Program Service
    at PBS, which supports signature programs like ``PBS NewsHour'',
    ``NOVA'' and ``American Experience''; as well as educational,
    scientifically researched, impactful and trusted children's programming
    like ``Sesame Street'', ``Curious George'', and ``Word Girl''.
        In addition, CPB spends 6 percent of its funds on projects that
    benefit the entire public broadcasting community, befitting its role as
    the only entity responsible for and answerable to the entirety of the
    public media system. CPB negotiates and pays music royalties for all of
    public broadcasting, for example, and funds research to explore
    audience needs and technological opportunities. Added together, these
    efforts account for 95 percent of the funds appropriated to CPB (which
    is limited by law to an administrative budget of no more than 5
    percent).
        Some have suggested that public broadcasting can easily do without
    Federal funding. Let me briefly explain the critical importance of
    Federal funding to public media as it exists today, and what the impact
    would be if it were to go away. Congress designed the public media
    system in this country as a public-private partnership, where minimal
    Federal dollars are leveraged to the maximum extent to ensure universal
    service to every American and every community. While CPB's
    appropriation accounts for around 15 percent of the entire cost of
    public broadcasting, this ``lifeblood'' funding leverages critical
    investments from State and local governments, universities, businesses,
    foundations and from viewers and listeners of local stations. Put
    simply, CPB funding is the foundation on which the entire system is
    built. Undermining the foundation puts the entire structure in
    jeopardy.
        CPB funding is particularly important to minority-owned public
    stations and stations in rural areas, which are more challenging to
    operate due to low population density of viewers and listeners; the
    need to operate multiple transmitters to reach far-flung populations;
    and the limited disposable incomes and potential for private support
    often found in rural America. In fiscal year 2009, individual donations
    represented 17 percent of an average rural station's total revenue,
    versus almost 28 percent for the industry as a whole. The
    disproportional importance of Federal funding to stations in rural
    areas is clear--in fiscal year 2009, 108 rural stations relied on CPB
    for at least 25 percent of their revenue; while 22 rural stations, many
    on Native American reservations, relied on CPB funding for at least 50
    percent of their revenue.
        Finally, CPB funding is also the only funding source without a
    station cost associated with it--all other fundraising costs money (for
    stations and for any nonprofit). For example, in fiscal year 2008 it
    costs the average station 40 cents on the dollar to raise funds from
    individuals and local businesses.
        Numerous studies, including one conducted by the Government
    Accountability Office (GAO), have shown that the loss of Federal
    funding would create a void not easily filled by other sources of
    funding. For the vast majority of stations, this would mean a drastic
    and immediate cutback in service, local programming and personnel, and
    in many cases stations would ``go dark.'' Further, the loss of Federal
    funding would have a severe impact on a station's ability to acquire
    national programming, such as ``The Electric Company'', ``Super Why!'',
    ``NOVA'', ``American Experience'', ``Frontline'', ``PBS NewsHour'',
    Marketplace and many others, from PBS, NPR, American Public Media and
    other sources. Federal funding has been the basis for this highly
    successful public media model since CPB was created nearly 45 years
    ago. Without it, public media ceases to exist as its creators intended.
    Core System Support
        One of CPB's core responsibilities is to preserve, protect, and
    advance public media. Public television and radio stations are facing
    an unprecedented array of challenges. These include the challenging
    economy, reductions in Federal and State support, shifting community
    demographics, fracturing audiences and emerging patterns in the way
    content is delivered and consumed. Public television has been hit
    especially hard. Over the past two years, the public television economy
    has declined by $250 million, and CPB projects a further $250 million
    decline over the next two years. In addition, while the digital
    conversion in public television has provided exciting new opportunities
    for service, digital equipment becomes obsolete much more quickly than
    the analog equipment it replaced. The more or less constant cost of
    equipment replacement is further affecting public television. To cope
    with declining revenue and increasing equipment expenses, many stations
    have been forced to cut local service. As a result, the need to
    maintain infrastructure is draining resources from content and local
    service at stations.
        CPB is working in two areas to help the system begin to facilitate
    collaboration and operational efficiencies: mergers and consolidations,
    and joint master control operations.
        Mergers and Consolidation.--Most communities are served by one or
    more stand-alone public broadcasting stations. While independent local
    stations theoretically have a great deal of flexibility in choosing how
    to serve their community, the limited scale of many stand-alone
    operations drives up operating costs and constrains stations' ability
    to offer local service.
        State networks like Iowa Public Television and Alabama Public
    Television have demonstrated the advantage of taking an alternative
    approach. Combining management and back office operations to serve
    multiple communities can increase efficiency and free resources for
    additional local service. CPB plans to continue to work with stations
    to explore operating models that bring multiple stations together as an
    important focus of our work. Our efforts include offering informal
    advice to stations considering mergers and, once stations issue a
    formal intent to merge, providing some financial assistance with
    merger-related costs.
        Central Master Control.--A master control room is the central hub
    of a television station's technical operation, the point where content
    sources come together to be routed to the station transmitter. In the
    past, each television station has needed a master control room. Digital
    technology now allows the master control function to be provided from a
    remote location. A single master control facility can now serve
    multiple stations. This is important because master controls are
    expensive; they are both capital- and people-intensive. Combining
    master control operations can yield significant cost savings, increase
    productivity, and encourage station collaboration in other back-office
    areas.
        CPB is supporting the design and construction of multi-station
    master control facilities. We are also exploring the practicality of
    creating a nationwide ``master plan'' for master control facilities. As
    the specifics of a new consolidated master control function evolve,
    there is an opportunity to realize cost savings, reduce the capital
    burden on stations, and improve efficiency for public television.
    American Graduate
        In the words of our statute, ``[I]t is in the public interest to
    encourage . . . the use of [public] media for instructional,
    educational, and cultural purposes.'' Education continues to be a core
    value of the public broadcasting community, as it has been since its
    inception. For over 40 years, public broadcasting stations have made a
    robust and vital contribution to education and an informed and
    strengthened civil society, and these contributions are reflected in
    CPB's recently-launched American Graduate initiative.
        American Graduate is a significant new public media initiative to
    help improve our Nation's high school graduation rates. Every year,
    more than 1 million students drop out of high school. If that trend
    continues, over the next 10 years, it will cost the Nation more than $3
    trillion in lost wages, productivity and taxes. American Graduate
    expands on public media's record of success in early childhood
    education to reach students in middle school--a critical point when the
    disengagement that leads to dropping out in high school often begins.
    Local public radio and television stations are at the core of this
    initiative and are uniquely positioned to educate and engage various
    stakeholders on the dropout problem, rally support and help coordinate
    efforts in communities, something experts say is crucial to a solution.
    CPB's Requests for Appropriations
        Public media stations continue to evolve, both operationally and
    more importantly in the myriad ways they serve their communities.
    Stations are committed to reaching viewers and listeners on whatever
    platform they use--from smart phones to iPads to radios to television
    sets. While stations can and will continue to adapt and thrive in the
    digital age, without sufficient support they cannot provide service on
    evolving platforms. As the Federal Communications Commission's National
    Broadband Plan noted, ``Today, public media is at a crossroads . . .
    [it] must continue expanding beyond its original broadcast-based
    mission to form the core of a broader new public media network that
    better serves the new multi-platform information needs of America. To
    achieve these important expansions, public media will require
    additional funding.''
        CPB Base Appropriation (Fiscal Year 2014).--CPB has requested a
    $495 million advance appropriation for fiscal year 2014, to be spent in
    accordance with the Public Broadcasting Act's funding formula. The two-
    year advance appropriation for public broadcasting, in place since
    1976, is the most important part of the ``firewall'' that Congress
    constructed between Federal funding and the programs that appear on
    public television and radio. President Gerald Ford, who initially
    proposed a 5-year advance appropriation for CPB, said it best when he
    said that advance funding ``is a constructive approach to the sensitive
    relationship between Federal funding and freedom of expression. It
    would eliminate the scrutiny of programming that could be associated
    with the normal budgetary and appropriations processes of the
    government.''
        Our fiscal year 2014 request balances the fiscal reality facing our
    Nation with the stark fact that stations are struggling to maintain
    service to their communities in the face of shrinking non-Federal
    revenues--a $218 million, or 9.2 percent, drop between fiscal year 2008
    and 2009 alone. Even with these challenges, public broadcasting
    contributes to American society in many ways that are worthy of greater
    Federal investment. In fiscal year 2014, CPB will continue to support a
    range of programming and initiatives through which stations provide a
    valuable and trusted service to millions of Americans.
        CPB Digital Funding (Fiscal Year 2012).--CPB requests $48 million
    for CPB Digital for fiscal year 2012, $11.5 million less than requested
    in fiscal year 2011. The digital conversion of public media is a much
    more extensive process than simply replacing analog with digital
    equipment. Digital conversion requires the development of new
    organizational models optimized for the digital environment, with new
    workflows, multi-channel services, and multi-platform distribution. CPB
    Digital funding, which can fund a wider range of projects than our
    formula-governed main account, has led to some of the most important
    innovation in public broadcasting's history. The continuing
    availability of this funding is critical to public broadcasting's
    progress toward a true, digital public service media.
        Ready To Learn (Fiscal Year 2012).--CPB requests that the U.S.
    Department of Education's Ready To Learn (RTL) program be funded at
    $27.3 million, the same level as fiscal year 2011. A partnership
    between the Department, CPB, PBS and local public television stations,
    RTL leverages the power of digital television technology, the Internet,
    gaming platforms and other media to help millions of young children
    learn the reading and math skills they need to succeed in school. The
    partnership's work over the past few years has demonstrably increased
    reading scores particularly among low-income children and has erased
    the performance gap between children from low-income households and
    their more affluent peers. An appropriation of $27.3 million in fiscal
    year 2012 will enable RTL to develop tools to improve children's
    performance in math as well as reading and bring on-the-ground,
    station-convened early learning activities to more communities.
        All told, the Federal contribution to public media through CPB
    amounts to $1.39 per American per year and, in a model private-public
    partnership, the public media system takes each of these dollars and
    raises six dollars more. The returns for taxpayers are exponential.
    They include in-depth news and public affairs programming on the local,
    State, national and international level; unmatched, commercial-free
    children's programming; formal and informal educational instruction for
    all ages; and inspiring arts and cultural content.
        Mr. Chairman and Ranking Member, thank you again for allowing CPB
    to submit this testimony. We are under no illusions about the pressures
    you face on a daily basis as Congress works to address our country's
    perilous fiscal situation. As such, on behalf of the public
    broadcasting community, including the stations in your states and those
    they serve, we sincerely appreciate your support.
                                     ______

              Prepared Statement of the Railroad Retirement Board
        We are pleased to present the following information to support the
    Railroad Retirement Board's (RRB) fiscal year 2012 budget request.
        The RRB administers comprehensive retirement/survivor and
    unemployment/sickness insurance benefit programs for railroad workers
    and their families under the Railroad Retirement and Railroad
    Unemployment Insurance Acts. The RRB also has administrative
    responsibilities under the Social Security Act for certain benefit
    payments and Medicare coverage for railroad workers. During the past 2
    years, the RRB has also administered special economic recovery payments
    and extended unemployment benefits under the American Recovery and
    Reinvestment Act of 2009 (Public Law 111-5). More recently, we have
    administered extended unemployment benefits under the Worker,
    Homeownership, and Business Assistance Act of 2009 (Public Law 111-92),
    and the Tax Relief, Unemployment Insurance Reauthorization, and Job
    Creation Act of 2010 (Public Law 111-312).
        During fiscal year 2010, the RRB paid $10.8 billion, net of
    recoveries, in retirement/survivor benefits to about 582,000
    beneficiaries. We also paid $156.3 million in net unemployment/sickness
    insurance benefits to some 38,000 claimants. Unemployment benefits
    included $19.4 million under Public Law 111-92, and about $0.8 million
    under Public Law 111-5. In addition, the RRB paid benefits on behalf of
    the Social Security Administration amounting to $1.3 billion to about
    116,000 beneficiaries.
                   proposed funding for agency administration
        The President's proposed budget would provide $112,239,000 for
    agency operations, which would enable us to maintain a staffing level
    of 902 full-time equivalent staff years (FTEs) in 2012. The proposed
    budget would also provide $1,810,000 for information technology (IT)
    investments. This includes $700,000 for costs related to systems
    modernization and e-Government, and $654,000 for improvements related
    to cyber security and continuity of operations. The remaining $456,000
    would be used for network operations, infrastructure replacement and
    emergency restoration services.
                                agency staffing
        The RRB's dedicated and experienced workforce is the foundation for
    our tradition of excellence in customer service and satisfaction. Like
    many Federal agencies, however, the RRB has a number of employees at or
    near retirement age. Nearly 70 percent of our employees have 20 or more
    years of service at the agency, and about 40 percent of our current
    workforce will be eligible for retirement by January 1, 2013. To help
    prepare for the expected staff turnover in the near future, we are
    placing increased emphasis on strategic management of human capital.
    Our human capital plans provide for employee support and knowledge
    transfer, which will enable the RRB to continue achieving its mission.
    In addition, with the agency's formal human capital plan, succession
    plan and various action plans in place, we are ensuring that succession
    management supports a systematic approach to ensuring a continuous
    supply of the best talent through helping individuals develop to their
    full potential.
        In connection with these workforce planning efforts, our budget
    request includes a legislative proposal to enable the RRB to utilize
    various hiring authorities available to other Federal agencies. Section
    7(b)(9) of the Railroad Retirement Act contains language requiring that
    all employees of the RRB, except for one assistant for each Board
    Member, must be hired under the competitive civil service. We propose
    to eliminate this requirement, thereby enabling the RRB to use various
    hiring authorities offered by the Office of Personnel Management.
                      information technology improvements
        We are actively pursuing further automation and modernization of
    the RRB's various processing systems to support the agency's mission to
    administer benefit programs for railroad workers and their families.
    Key capital initiatives for fiscal year 2012 include projects to add
    new reporting services to our Employer Reporting System, and to
    continue with long-term system modernization efforts. In recent years,
    the agency has moved to a relational database environment and optimized
    the data that reside in the legacy databases. In fiscal year 2012, our
    staff will work with an experienced DB2 Database Administrator to
    ensure that the master database remains platform independent and to
    develop stored procedures that will be used by reengineered mainframe
    programs that access the master database. We also plan to move forward
    with reengineering the applications to the agency's LAN enterprise
    program platform, several of which are programmed in outdated,
    commercially unsupported technologies.
        Our budget request also provides for cyber security improvements to
    ensure that the RRB continues to control the risks that threaten the
    agency's critical assets and to meet the security requirements set
    forth in the Federal Information Security Management Act (FISMA) of
    2002, and infrastructure investments to maintain our operational
    readiness and provide a firm foundation for our target enterprise
    architecture.
                            other requested funding
        The President's proposed budget includes $51 million to fund the
    continuing phase-out of vested dual benefits, plus a 2 percent
    contingency reserve, $1,020,000, which ``shall be available
    proportional to the amount by which the product of recipients and the
    average benefit received exceeds the amount available for payment of
    vested dual benefits.'' In addition, the President's proposed budget
    includes $150,000 for interest related to uncashed railroad retirement
    checks.
                      financial status of the trust funds
        Railroad Retirement Accounts.--The RRB continues to coordinate its
    activities with the National Railroad Retirement Investment Trust
    (Trust), which was established by the Railroad Retirement and
    Survivors' Improvement Act of 2001 (RRSIA) to manage and invest
    railroad retirement assets. Pursuant to the RRSIA, the RRB has
    transferred a total of $21.276 billion to the Trust. All of these
    transfers were made in fiscal years 2002 through 2004. The Trust has
    invested the transferred funds, and the results of these investments
    are reported to the RRB and posted periodically on the RRB's website.
    The net asset value of Trust-managed assets on September 30, 2010, was
    approximately $23.8 billion, an increase of $0.5 billion from the
    previous year. As of April 2011, the Trust had transferred
    approximately $11 billion to the Railroad Retirement Board for payment
    of railroad retirement benefits.
        In June 2010, we released the annual report on the railroad
    retirement system required by Section 22 of the Railroad Retirement Act
    of 1974, and Section 502 of the Railroad Retirement Solvency Act of
    1983. The report addressed the 25-year period 2010-2034, and included
    projections of the status of the retirement trust funds under three
    employment assumptions. These indicated that barring a sudden,
    unanticipated, large decrease in railroad employment or substantial
    investment losses, the railroad retirement system would experience no
    cash flow problems for the next 23 years. Even under the most
    pessimistic assumption, the cash flow problems would not occur until
    the year 2033. The report did not recommend any change in the rate of
    tax imposed by current law on employers and employees.
        Railroad Unemployment Insurance Account.--The RRB's latest annual
    report on the financial status of the railroad unemployment insurance
    system was issued in June 2010. The report indicated that even as
    maximum daily benefit rates rise 39 percent (from $64 to $89) from 2009
    to 2020, experience-based contribution rates are expected to keep the
    unemployment insurance system solvent, except for small, short-term
    cash-flow problems in 2010 and 2011. Projections show a quick repayment
    of loans even under the most pessimistic assumption.
        Unemployment levels are the single most significant factor
    affecting the financial status of the railroad unemployment insurance
    system. However, the system's experience-rating provisions, which
    adjust contribution rates for changing benefit levels, and its
    surcharge trigger for maintaining a minimum balance, help to ensure
    financial stability in the event of adverse economic conditions. No
    financing changes were recommended at this time by the report.
        Due to the increased level of unemployment insurance payments
    during fiscal years 2009 and 2010, loans from the Railroad Retirement
    (RR) Account to the RUI Account became necessary beginning in December
    2009. The balance of loans from the RR Account was $47.4 million at the
    end of fiscal year 2010, including $0.9 million in accrued interest.
    The estimated loan balance at the end of fiscal year 2011, is $3.0
    million, and full repayment of the loans is expected during fiscal year
    2012.
        Thank you for your consideration of our budget request. We will be
    happy to provide further information in response to any questions you
    may have.
                                     ______

     Prepared Statement of the Inspector General, Railroad Retirement Board
        My name is Martin J. Dickman and I am the Inspector General for the
    Railroad Retirement Board. I would like to thank you, Mr. Chairman, and
    the members of the Subcommittee for your continued support of the
    Office of Inspector General.
                                 budget request
        I wish to inform you of our fiscal year 2012 appropriations request
    and describe our planned activities. The Office of Inspector General
    (OIG) respectfully requests funding in the amount of $9,259,000 to
    ensure the continuation of its independent oversight of the Railroad
    Retirement Board (RRB). During fiscal year 2012, the OIG will focus on
    areas affecting program performance; the efficiency and effectiveness
    of agency operations; and areas of potential fraud, waste and abuse.
                             operational components
        The OIG has three operational components: the immediate Office of
    the Inspector General, the Office of Audit (OA), and the Office of
    Investigations (OI). The OIG conducts operations from several
    locations: the RRB's headquarters in Chicago, Illinois; an
    investigative field office in Philadelphia, Pennsylvania; and five
    domicile investigative offices located in Arlington, Virginia; Houston,
    Texas; San Diego, California; Miami, Florida; and New York, New York.
    These domicile offices provide more effective and efficient
    coordination with other Inspector General offices and traditional law
    enforcement agencies with which the OIG works joint investigations.
                                office of audit
        The mission of the Office of Audit is to promote economy,
    efficiency, and effectiveness in the administration of RRB programs and
    detect and prevent fraud and abuse in such programs. To accomplish its
    mission, OA conducts financial, performance, and compliance audits and
    evaluations of RRB programs. In addition, OA develops the OIG's
    response to audit-related requirements and requests for information.
        During fiscal year 2012, OA will focus on areas affecting program
    performance; the efficiency and effectiveness of agency operations; and
    areas of potential fraud, waste, and abuse. OA will continue its
    emphasis on long-term systemic problems and solutions, and will address
    major issues that affect the RRB's service to rail beneficiaries and
    their families. OA has identified four broad areas of potential audit
    coverage: Financial Accountability; Railroad Retirement Act & Railroad
    Unemployment Insurance Act Benefit Program Operations; Railroad
    Medicare Program Operations; and Security, Privacy, and Information
    Management.
        During fiscal year 2012, OA must accomplish the following mandated
    activities with its own staff: Audit of the RRB's financial statements
    pursuant to the requirements of the Accountability of Tax Dollars Act
    of 2002 and evaluation of information security pursuant to the Federal
    Information Security Management Act (FISMA).
        During fiscal year 2012, OA will complete the audit of the RRB's
    fiscal year 2011 financial statements and begin its audit of the
    agency's fiscal year 2012 financial statements. OA contracts with a
    consulting actuary for technical assistance in auditing the RRB's
    ``Statement of Social Insurance'', which became basic financial
    information effective in fiscal year 2006. In addition to performing
    the annual evaluation of information security, OA also conducts audits
    of individual computer application systems which are required to
    support the annual FISMA evaluation. Our work in this area is targeted
    toward the identification and elimination of security deficiencies and
    system vulnerabilities, including controls over sensitive personally
    identifiable information. OA will also conduct an audit of employer
    compliance with the provisions of the Railroad Retirement and Railroad
    Unemployment Insurance Acts. Our work in this area is designed to
    verify the completeness and accuracy of the external reviews performed
    by the RRB's compliance group.
        OA undertakes additional projects with the objective of allocating
    available audit resources to areas in which they will have the greatest
    value. In making that determination, OA considers staff availability,
    current trends in management, Congressional and Presidential concerns.
                            office of investigations
        The Office of Investigations (OI) focuses its efforts on
    identifying, investigating, and presenting cases for prosecution,
    throughout the United States, concerning fraud in RRB benefit programs.
    OI conducts investigations relating to the fraudulent receipt of RRB
    disability, unemployment, sickness, and retirement/survivor benefits.
    OI investigates railroad employers and unions when there is an
    indication that they have submitted false reports to the RRB. OI also
    conducts investigations involving fraudulent claims submitted to the
    Railroad Medicare Program. These investigative efforts can result in
    criminal convictions, administrative sanctions, civil penalties, and
    the recovery of program benefit funds.

                  OI INVESTIGATIVE RESULTS FOR FISCAL YEAR 2010
    ------------------------------------------------------------------------

    ------------------------------------------------------------------------
    Civil Judgments.........................................              19
    Indictments/Informations................................              47
    Convictions.............................................              50
    Recoveries/Receivables..................................     $29,296,188
    ------------------------------------------------------------------------

        OI anticipates an ongoing caseload of about 450 investigations in
    fiscal year 2012. During fiscal year 2010, OI opened 244 new cases and
    closed 210. To date in fiscal year 2011, OI has opened 188 new cases
    and closed 135. At present, OI has cases open in 47 States, the
    District of Columbia, and Canada with estimated fraud losses of over
    $37 million. Disability fraud cases represent the largest portion of
    Ol's total caseload. These cases involve more complicated schemes and
    often result in the recovery of substantial amounts for the RRB's trust
    funds. They also require considerable resources such as travel by
    special agents to conduct surveillance, numerous witness interviews,
    and more sophisticated investigative techniques. Additionally, these
    fraud investigations are extremely document-intensive and require
    forensic financial analysis.
        During fiscal year 2012, OI will continue to coordinate its efforts
    with agency program managers to address vulnerabilities in benefit
    programs that allow fraudulent activity to occur and will recommend
    changes to ensure program integrity. OI plans to continue proactive
    projects to identify fraud matters that are not detected through the
    agency's program policing mechanisms.
                                   conclusion
        In fiscal year 2012, the OIG will continue to focus its resources
    on the review and improvement of RRB operations and will conduct
    activities to ensure the integrity of the agency's trust funds. This
    office will continue to work with agency officials to ensure the agency
    is providing quality service to railroad workers and their families.
    The OIG will also aggressively pursue all individuals who engage in
    activities to fraudulently receive RRB funds. The OIG will continue to
    keep the Subcommittee and other members of Congress informed of any
    agency operational problems or deficiencies.
        The OIG sincerely appreciates its cooperative relationship with the
    agency and the ongoing assistance extended to its staff during the
    performance of their audits and investigations. Thank you for your
    consideration.
                                     ______

                           NONDEPARTMENTAL WITNESSES

              Prepared Statement of the ADAP Advocacy Association
        Thank you on behalf of the ADAP Advocacy Association (aaa+) and its
    board of directors for the opportunity to submit our written testimony
    to the Senate Committee on Appropriations, Subcommittee on Labor,
    Health and Human Services and Education (LHHSE) about the AIDS Drug
    Assistance Programs (ADAPs). aaa+ is a national 501(c)(3) nonprofit
    organization incorporated in the District of Columbia to promote and
    enhance the AIDS Drug Assistance Programs and improve access to care
    for persons living with HIV/AIDS. We appreciate the opportunity to
    share our testimony on fiscal year 2010 appropriations.
        State ADAPs are primarily federally funded under Part B of the Ryan
    White Comprehensive AIDS Resources Emergency (CARE) Act. ADAPs provide
    medications to treat HIV disease and prevent and treat AIDS-related
    opportunistic infections to low income, uninsured and underinsured
    individuals living with HIV/AIDS in the 50 States, District of
    Columbia, Puerto Rico, Guam, U.S. Virgin Islands, American Samoa,
    Marshall, and Northern Marianas Islands. Additional funding is directed
    toward State ADAPs from other Ryan White CARE Act funds, including Part
    A Eligible Metropolitan Area (EMA) funds. Many States also directly
    contribute funding. ADAPs represent the ``access to treatment'' window
    for the community-based continuum of HIV/AIDS healthcare so carefully
    built and supported by all the parts of the Ryan White CARE Act, which
    was reauthorized for 4 years by both Houses of Congress and signed into
    law by President Barack Obama on October 30, 2009. The law in general
    has enjoyed strong bipartisan support since it was first passed in the
    1990s, and ADAPs specifically have been a Return on Investment (ROI)
    model since the Federal Government began pumping money into them when
    President Bill Clinton and Speaker Newt Gingrich were in office.
        At the time when our testimony is being submitted to the
    subcommittee for its consideration, there are 7,553 people living with
    HIV/AIDS in 11 States on ADAP waiting lists--including 31 people in
    Arkansas, 3,848 people in Florida, 1,221 people in Georgia, 11 people
    in Idaho, 816 people in Louisiana, 21 people in Montana, 177 people in
    North Carolina, 303 people in Ohio, 560 people in South Carolina, 563
    people in Virginia and 2 people in Wyoming. Overall, 95.54 percent of
    these people reside in the South. Additionally, it is being submitted
    for the people living with HIV/AIDS who are the ``invisible'' waiting
    lists because they have been kicked-off the program due to changes in
    eligibility requirements--including 99 people in Arkansas, 257 people
    in Ohio, and 89 people in Utah, as well as the 6,500+ people in Florida
    who have been transitioned off the program.
        Faced with the ``Perfect Storm'' that is being fueled by high
    unemployment, record number of uninsured, State budgetary cutbacks,
    high cost of medications and inadequate Federal funding, there are a
    historic number of people being denied access to treatment. Without the
    subcommittee's leadership and fortitude to recognize the ROI from
    ADAPs, several thousand people living with HIV/AIDS will be at risk of
    developing Opportunistic Infections (OIs), and thousands of others who
    are HIV-negative will be at greater risk of contracting the virus
    because their HIV-positive counterparts are more infectious when not
    taking Highly Active Anti-Retroviral Therapy (HAART).
        Each year a sophisticated pharmacoeconomic model is employed by the
    ADAP Coalition--a unique coalition of AIDS advocates, community-based
    organizations and representatives of research-based pharmaceutical and
    biotechnology companies--referencing the data collected from ADAPs from
    the previous 2 years to forecast the dollar resources that will be
    needed for the coming 2 years to enable ADAPs to provide HAART
    (combination antiretroviral therapy) to Americans living with HIV
    disease.
        Many are familiar with this process and its remarkable accuracy
    over the past 12 years. The Congress and White House have provided us
    with support very close to the amounts we projected in fiscal year
    1996, 1997, 1998, 1999, 2000, always in amounts above the original
    Administration budget requests; funding in subsequent fiscal year 2001-
    05 was sustainable, but often short of the necessary amounts needed to
    avert waiting lists. Between 2000 and 2008, States increased their
    share of the ADAP budget by 155 percent while the Federal Government
    increased its share by only 46 percent overall. The chart shows the
    increase by each party each year over the previous fiscal year in
    percentage points. States have basically increased--as well as
    pharmaceutical rebates--while the Federal commitment has gone down!

        The ongoing ADAP crisis is being fueled, by in large, because
    Federal spending has been inadequate--despite small budget increases
    under both President George W. Bush and President Obama since 2005. The
    Federal share of ADAP funding has fallen steadily over the last several
    years. In fiscal year 2003 the Federal earmark was 72 percent of the
    overall ADAP budget. In fiscal year 2009, the Federal share had fallen
    to 49 percent of the ADAP budget. ADAPs have long had a strong State-
    Federal partnership; however despite the economic downturn many States
    have increased funding in fiscal year 2010 by an additional $121
    million for a total of $346.2 million. Pharmaceutical manufacturers
    have also helped to alleviate fiscal challenges for ADAP by agreeing to
    lower drug prices and enhance rebates, which amounted to $259 million
    in saving for fiscal year 2009. Supplemental agreements will save an
    additional $160 million per year starting in July 2010.\1\
    ---------------------------------------------------------------------------
        \1\ The ADAP Coalition, ADAP Need Fiscal Year 2012, January 2011.
    ---------------------------------------------------------------------------
        ADAPs truly need an increase of $410 million in fiscal year 2012 to
    maintain their programs and fill the structural deficits that have
    built up over the last several years. In fiscal year 2012, the HIV/AIDS
    community is asking for an increase of $131 million to continue to
    serve an average of 1,312 new clients per month. The funding level of
    $991 million is the authorized level in the Ryan White reauthorization
    of 2009.\2\
    ---------------------------------------------------------------------------
        \2\ The ADAP Coalition, ADAP Need Fiscal Year 2012, January 2011.
    ---------------------------------------------------------------------------
        A large gap remains for ADAPs in fiscal year 2010. Included in the
    fiscal year 2011 need number was a revised estimate for the ADAP
    Federal need number for fiscal year 2010 of $961 million, an increase
    of $126 million over the current funding level. The fiscal year 2010
    need number was revised based upon new survey data. Coupled with
    estimated State funding, this funding will provide continued services
    to a total of 153,875 clients in fiscal year 2010, including the
    ability to enroll 15,760 new clients and eliminate waiting lists. This
    includes individuals who are fully covered by ADAP and those who
    receive assistance with Medicare Part D cost sharing requirements or
    private insurance continuation. The fiscal year 2010 need number has
    been adjusted from the previous level to account for the $20 million
    already received through the fiscal year 2010 Congressional
    appropriations process.\3\ This problem is only worsens moving into
    fiscal year 2012.
    ---------------------------------------------------------------------------
        \3\ The ADAP Coalition, ADAP Need Fiscal Year 2010 & Fiscal Year
    2011, January 2010.
    ---------------------------------------------------------------------------
        The problem of growing ADAP waiting lists is exacerbated because we
    are facing an American HIV/AIDS epidemic of devastating proportion.
    According to some estimates, the number of people living with HIV/AIDS
    in the United States was approximately 2 million by the end of 2010.
    These numbers are not due to decrease in the near future. In 2006
    alone, the Centers for Disease Control and Prevention (CDC) estimated
    that there have been more than 56,000 new HIV infections per year for
    the last decade. If this was not severe enough, the disease is far from
    color blind. Currently, the incidence rate of new HIV infection among
    African American men and women is seven times that of the Caucasian
    population. Furthermore, racial disparities are echoed regionally as
    the epidemic has seen its most recent unfettered growth in southern
    States, which often times have smaller State budgets and fewer access
    points to comprehensive care.
        The ADAP need is being driven by simple factors. As we all know
    HAART AIDS treatments has dropped U.S. death rates from AIDS by about
    75 percent starting in 1996. Whereas annual AIDS deaths use to run
    about 40,000 a year, now 15,000 to 17,000, even less in areas of very
    good medical care.
        While dramatic improvements in lifespan and quality of life are
    almost miraculous, HAART treatments must continue for ADAP patients.
    Therefore patients living longer will likely require ADAP services for
    medications longer. There are 200,000 to 300,000 Americans who are
    unaware that they are HIV+. Extensive multi-million dollar efforts for
    outreach and HIV testing are going on all over the country, and the CDC
    now urges routine testing for those at risk for HIV. Funded by
    churches, foundations, Minority Health Initiatives, pharmaceutical
    companies and AIDS service groups, these efforts are identifying ``hard
    to reach'' populations many of whom lack adequate health insurance.
    These individuals, when identified, must look to ADAP to cover the
    costs of their drugs. For most, access to Medicaid is limited. State
    Medicaid programs typically require disease progression to full-blown
    AIDS to meet the Social Security definition of disabled. U.S.
    Government treatment guidelines consider progression to full-blown AIDS
    to be months and years too late for optimum treatments. As we decided
    in Congress to allow timely early treatment of breast and cervical
    cancers in women, so too should we allow States the option to provide
    early treatments for HIV through Medicaid to both men and women.
        While we hope that Congress will pass the Early Treatment for HIV
    Act (ETHA) to allow States the option to provide HIV care and
    treatments through Medicaid early in the disease process when health
    benefits are greater and costs are less, for now we are stuck with
    folks who can't qualify for Medicaid looking to ADAP for basic
    coverage. Increases in private sector health insurance costs forces
    steady streams of HIV+ patients from private health insurance programs
    to State ADAPs. This is a result of rising costs in premiums and co-
    payments that become unaffordable, and in some instances by HMO-type
    providers with drug benefits leaving the market for more profitable
    locations. These factors together, ensure need for State ADAPs for the
    coming years. The increasing rate of need will be substantial until key
    provisions of the Patient Protection and Affordable Care Act (PPACA)
    can provide adequate benefits to our entire senior, elderly and
    disabled populations. As the profile of the American AIDS epidemic has
    expanded further into communities of color, marginalized populations,
    rural areas, and particularly to women of color in their child bearing
    years, ADAPs feel these additional strains from groups which
    traditionally may work low-paying jobs with inadequate health insurance
    or no healthcare benefits.
        In the past 12 months, 20 State ADAPs have instituted other cost-
    containment strategies. ADAPs with other cost-containment strategies
    instituted since April 1, 2009, as of February 2, 2011) include:
    Arizona: Reduced formulary, Arkansas: Reduced formulary, lowered
    financial eligibility to 200 percent of FPL, (disenrolled 99 clients in
    September 2009), Colorado: Reduced formulary, Florida: Reduced
    formulary, lower financial eligibility to 300 percent FPL, transition
    clients to Welvista from 2/14-3/31/11, Georgia: Reduced formulary,
    implemented medical criteria, continued participation in the
    Alternative Method Demonstration Project (AMDP), Idaho: Capped
    enrollment, Illinois: Reduced formulary, instituted monthly expenditure
    cap, Kentucky: Reduced formulary, Louisiana: Discontinued reimbursement
    of laboratory assays, North Carolina: Reduced formulary, North Dakota:
    Capped enrollment, instituted annual expenditure cap, lowered financial
    eligibility to 300 percent FPL, Ohio: Reduced formulary, lowered
    financial eligibility to 300 percent of FPL (disenrolled 257 clients),
    Puerto Rico: reduced formulary, South Carolina: Lowered financial
    eligibility to 300 percent FPL, Utah: Reduced formulary, lowered
    financial eligibility to 250 percent of FPL (disenrolled 89 clients),
    Virginia: Reduced formulary, only distribute 30-day prescription
    refills, Washington: Instituted client cost sharing, reduced formulary
    (for uninsured clients only), only pay insurance premium for clients
    currently on antiretrovirals, and Wyoming: Reduced formulary,
    instituted client cost sharing.
        As previously stated, ADAP waiting lists--as well as the
    aforementioned cost-containment strategies put the lives of people
    living with HIV/AIDS at risk (e.g., developing OIs), as well as put
    HIV-negative people at higher risk of becoming infected (e.g., HIV-
    positive people are more infectious when not properly treated with
    HAART). Without congressional leadership and adequate Federal funding,
    current circumstances could easily lead to a public health emergency
    that will only cost the taxpayers much more.
        In hindsight, it becomes easy to argue that ADAPs have historically
    been underfunded. In reality however, it is the emergence of highly
    active anti-retroviral therapy over the past 7 years and the successes
    of these treatment options that have made dramatic changes in people's
    lives; that have made access to HIV treatment and care such a dramatic
    national policy concern. We now understand how HIV replicates in the
    body, beginning its destructive impact on the immune system from the
    moment of infection. Where in the recent past we divided people into
    categories such as asymptomatic and symptomatic in order to make
    treatment decisions, current treatments dictates that we no longer make
    these distinctions in our approach to therapy. The latter simply
    reflects a more advanced state of immune damage.
        The standard of care today recommends that patients start on
    antiretroviral therapy with a combination of drugs earlier in the
    disease in order to preserve immune function. It also presumes the
    earliest possible knowledge of HIV status and informed medical care to
    decide the exact timing of treatment commencement and treatment type
    selection. Improved immune function has a direct impact on those topics
    you are most likely interested in today, saving and improving the
    quality of lives and cost savings to the healthcare system.
        By now it is really not necessary to explain the benefits of
    antiretroviral treatments or even its cost effectiveness. Everyone
    knows these things. In fact thousands of people are dedicated to seeing
    that the ``AIDS miracles'' of the last few years available in the
    United States are delivered to the rest of the world before societal
    damage in excess of the plagues of the Middle Ages is inflicted upon
    whole countries in the Caribbean, Africa, Asia and parts of the former
    Soviet Union. In sharing the wealth of the medical knowledge and
    expertise, which the United States have lead in developing we must not,
    and should not forget the homeland. We must make sure that no American
    with HIV is forgotten and allowed to fall through the cracks. The time
    has come to end the wait for people living with HIV/AIDS.
        In closing the following two hypothetical examples demonstrate the
    ROI of the AIDS Drug Assistance Program:
      --Charlie is a 29-year old black single father living in Gadsden
            County Florida. He and his wife found out they were infected
            with HIV when she died from complications of AIDS related
            pneumonia the previous year. Charlie is on a waiting list to
            receive AIDS drugs but between his depression and efforts to
            care for his children he is unable to access the help he needs
            to navigate the Patient Assistance Programs. He himself gets
            sick. He enters an emergency room in Tallahassee, Florida and
            is subsequently admitted for a 5-day stay. His emergency room
            visit is near the average for this hospital at $2,783 (source
            Florida Heath Finder.org.) The hospital stay is near the
            national average of $24,000. He receives additional bills from
            doctors, radiologists and therapists for $750. You can compare
            this total to the cost of the AIDS drug he would need for an
            entire year. Charlie is what is known as therapy naive so the
            most inexpensive combination therapy drugs would be effective
            in reducing the virus to undetectable levels. The annual drug
            cost would be around $15,000 per year. Compare that to $33,830
            in 6 days for hospitalization.
      --Now consider Patricia. She has had AIDS for 20 years and the AIDS
            virus she carries is resistant to all but the most expensive
            AIDS drugs. She has fallen out of care and is now getting
            progressively sicker. She goes to ADAP at the nearest county
            health department which is 20 miles away only to be told that
            she has been wait listed due to budget shortfalls. Patricia
            falls ill while trying to navigate assistance programs and is
            hospitalized. Her ER costs are similar to that of Charlie's but
            she stays in the hospital for 20 days and then dies. Her costs
            are well over $100,000 not including funeral and burial costs.
            Her drugs would have cost $30,000 per year.
        We urge to you fully fund the ADAP program in fiscal year 2012 with
    an increase of $131 million. No one need be denied the new standard of
    care for HIV disease. We have come too far as a Nation to turn our
    backs on HIV/AIDS now. Please make sure that the resources are there
    for every HIV-positive American to be treated regardless of their
    financial resources or ability to access adequate health insurance
    coverage.
                                     ______

          Prepared Statement of the Ad Hoc Group for Medical Research
        The Ad Hoc Group for Medical Research is a coalition of more than
    300 patient and voluntary health groups, medical and scientific
    societies, academic and research organizations, and industry. The Ad
    Hoc Group appreciates the opportunity to submit this statement in
    support of enhancing the Federal investment in biomedical, behavioral,
    and population-based research supported by the National Institutes of
    Health (NIH).
        We are deeply grateful to the Subcommittee for its long-standing,
    bipartisan leadership in support of NIH. These are difficult times for
    our Nation and for people all around the globe, but the affirmation of
    science is the key to a better future. To improve Americans' health and
    strengthen America's innovation economy, the Ad Hoc Group for Medical
    Research recommends $35 billion for NIH in fiscal year 2012.
        The partnership between NIH and America's scientists, medical
    schools, teaching hospitals, universities, and research institutions
    continues to serve as the driving force in this Nation's search for
    ever-greater understanding of the mechanisms of human health and
    disease. More than 83 percent of NIH research funding is awarded to
    more than 3,000 research institutions located in every State. These are
    funded through almost 50,000 competitive, peer-reviewed grants and
    contracts to more than 350,000 researchers.
        The foundation of scientific knowledge built through NIH-funded
    research drives medical innovation that improves health and quality of
    life through new and better diagnostics, improved prevention
    strategies, and more effective treatments. NIH research has contributed
    to dramatically increased and improved life expectancy over the past
    century. A baby born today can look forward to an average life span of
    nearly 78 years--almost three decades longer than a baby born in 1900,
    and life expectancy continues to increase. People are staying active
    longer, too: the proportion of older people with chronic disabilities
    dropped by nearly a third between 1982 and 2005. Thanks to insights
    from NIH-funded studies, the death rate for coronary heart disease is
    more than 60 percent lower--and the death rate for stroke, 70 percent
    lower--than in the World War II era.
        NIH research continues to create dramatic new research
    opportunities, offering hope to the millions of patients awaiting the
    possibility of a healthier tomorrow. For example, a new ability to
    comprehend the genetic mechanisms responsible for disease already is
    providing insights into diagnostics and identifying a new array of drug
    targets. We are entering an era of personalized medicine, where
    prevention, diagnosis, and treatment of disease can be individualized,
    instead of using the standardized approach that all too often wastes
    healthcare resources and potentially subjects patients to unnecessary
    and ineffective medical treatments and diagnostic procedures.
        Peer-reviewed, investigator-initiated basic research is the heart
    of NIH research. These inquiries into the fundamental cellular,
    molecular, and genetic events of life are essential if we are to make
    real progress toward understanding and conquering disease. The
    application of the results of basic research to the detection,
    diagnosis, treatment, and prevention of disease is the ultimate goal of
    medical research. Clinical research not only is the pathway for
    applying basic research findings, but it also often provides important
    insights and leads to further basic research opportunities. Additional
    funding is needed to sustain and enhance basic and clinical research
    activities, including increasing support for current researchers and
    promoting opportunities for new investigators and in those areas of
    science that historically have been underfunded.
        Ongoing efforts to reinvigorate research training, including
    developing expanded medical research opportunities for minority and
    disadvantaged students, continue to gain importance. For example, the
    volume of data being generated by genomics research, as well as the
    increasing power and sophistication of computing assets on the
    researcher's lab bench, have created an urgent need, both in academic
    and industrial settings, for talented individuals well-trained in
    biology, computational technologies, bioinformatics, and mathematics to
    realize the promise offered by modern interdisciplinary research.
        To move forward, it will be essential to maintain the talent base
    and infrastructure that has been created to date. Large fluctuations in
    funding will be disruptive to training, to careers, long range projects
    and ultimately to progress. The research engine needs a predictable,
    sustained investment in science to maximize our return.
        Further, NIH-supported research contributes to the Nation's
    economic strength by catalyzing private sector growth and creating
    skilled, high-paying jobs; new products and industries; and improved
    technologies. Industries and sectors that benefit include the high-
    technology and high value-added pharmaceutical and biotechnology
    industries, among others. In particular, the NIH funds ``enabling
    science'' that explores and identifies discoveries at a point earlier
    than businesses often invest, stoking and sustaining the discovery
    pipeline.
        The investment in NIH not only is an essential element in restoring
    and sustaining both national and local economic growth and vitality,
    but also is essential to maintaining this Nation's prominence as the
    world leader in medical research. As Raymond Orbach, former Under
    Secretary for Science at the Department of Energy for President George
    W. Bush, noted in a recent editorial in Science, ``Other countries,
    such as China and India, are increasing their funding of scientific
    research because they understand its critical role in spurring
    technological advances and other innovations. If the United States is
    to compete in the global economy, it too must continue to invest in
    research programs.'' To succeed in the information-based, innovation
    driven world-wide economy of the 21st century, we must recommit to
    long-term sustained growth in medical research funding.
        The ravages of disease are many, and the opportunities for progress
    across all fields of medical science to address these needs are
    profound. In this challenging budget environment, we recognize the
    painful decisions Congress must make. The community appreciates that
    this subcommittee always has recognized that discoveries gained through
    basic research yield the medical advances that improve the fiscal and
    physical health of the country. Strengthening the Nation's commitment
    to medical research is the key to ensuring the future of America's
    medical research enterprise and the health of her citizens.
        The Ad Hoc Group for Medical Research respectfully requests that
    NIH be recognized as an urgent national priority as the subcommittee
    prepares the fiscal year 2012 appropriations bills.
                                     ______

              Prepared Statement of the AIDS Healthcare Foundation
        On behalf of the over 1 million Americans with HIV/AIDS, and the
    over 56,000 Americans who will become infected with HIV this year, AIDS
    Healthcare Foundation (AHF) submits the following recommendations and
    proposals for funding domestic HIV/AIDS programs for fiscal year 2012.
        AHF is the largest HIV/AIDS nonprofit in the United States. For
    over 20 years, it has delivered high quality medical care, pharmacy
    services, research, and HIV prevention and testing services throughout
    the country. It currently provides medical care to over 150,000 people
    with HIV/AIDS in 22 countries around the world.
        Based on this experience, it is clear to AHF that the battle
    against HIV/AIDS is winnable, and that the keys to winning this fight
    are:
        Find those Americans who have HIV, but don't know it.
        It is estimated that approximately 20 percent of all Americans who
    have HIV do not know they are infected. It is not surprising that this
    group unwittingly is the source of up to 70 percent of all HIV
    infections in the United States--if you don't know you have HIV, you
    don't take steps to protect others, and you don't get treatment.
        Provide AIDS drug treatment to all Americans with HIV/AIDS who need
    it.
        It cannot be stressed enough--treatment is prevention. AIDS
    treatment is one of the most effective tools we have to prevent new
    infections. The point of treatment is to reduce the amount of the HIV
    virus in a person. People with HIV/AIDS who are on treatment are less
    infectious, and simply are far less able to transmit the virus. AIDS
    treatment is 92 percent effective in preventing new infections.
        If we could find those who don't know they have HIV, and get them
    treatment, new HIV infections would plummet. Not only would these
    people be healthier and able to work and care for their families, but
    we would save tens of billions per year in future medical costs.
        Currently, there are approximately 56,000 new HIV infections in the
    United States every year. As the lifetime medical cost (the majority of
    which will be borne by the Federal Government via Medicare, Medicaid,
    or the Ryan White CARE Act) for each HIV infection is over $600,000,
    the United States accrues over $36 billion in future medical costs
    every year due to new HIV infections.
        Therefore, effectively battling the AIDS epidemic requires
    prioritizing scarce funds into two main areas: Testing (to find those
    who are unaware they have HIV) and treating (providing AIDS drugs and
    medical care to the newly diagnosed, to prevent new infections).
        AHF recognizes the prevailing economic and budget climate, and
    understands that finding new money to pay for these necessary programs
    is extremely challenging. AHF therefore makes the following
    recommendations that would free up existing funding to focus more on
    testing and treatment:
        Re-prioritize AIDS prevention funding within the Centers for
    Disease Control toward HIV testing.
        Yearly new HIV infections have not declined for well over a decade.
    As a result, it is time to re-think the CDC's approach to HIV
    prevention. In recent times CDC has spent approximately 30 percent of
    its HIV prevention budget on HIV testing. AHF recommends that, for
    fiscal year 2012 and beyond, the CDC be required to spend at least 50
    percent of its prevention budget on testing. The more tests the CDC
    performs, the more people who are unaware of their HIV status will be
    found, which is the first step in preventing new infections.
        Increase funding for the AIDS Drug Assistance Program (ADAP) by
    $108 million.
        ADAP is a lifeline for thousands of Americans who cannot afford
    AIDS treatment, which can cost well in excess of $12,000 per year.
    Nationwide, ADAP serves over 165,000 people, approximately one-third of
    all people on AIDS treatment in the United States.
        Ensuring access to treatment is the backbone in our fight against
    HIV/AIDS. Without treatment, people with AIDS become sicker. Without
    treatment, new infections will increase, and every new infection
    carries with over $600,000 in lifetime medical costs. For these
    reasons, it is of grave concern that access to care for thousands of
    Americans is now at risk.
        Currently, there are over 7,800 Americans on ADAP waiting lists
    across the country--7,800 people who cannot get access to these drugs
    due to budgetary constraints. This list continues to grow as infections
    continue, State financial support is reduced, and drug prices increase.
        To reverse this trend, AHF supports the consensus of the AIDS
    community that ADAP funding should be increased by $108 million for a
    total of $991 million. In the absence of new money, AHF proposes
    funding this increase via the following means:
        Implement administrative and overhead caps within CDC, HRSA, and
    NIH AIDS programs, and redirect the savings to ADAP.
        In tight budgetary times, Government must become more cost
    effective. Currently, Government agencies like HRSA require that
    contractors spend no more than 10 percent of grants on administrative
    overhead. These agencies, which are tasked with implementing ADAP and
    other AIDS programs, spend a combined $2.3 billion on administration
    and overhead. As a recipient of Government funds that has operated
    under these requirements, AHF submits that these caps should be applied
    to these agencies as well. Controlling administrative costs will free
    up money that can be spent on services, not bureaucracy.
        Secure additional drug price discounts/rebates from AIDS drug
    manufacturers.
        Drug price increases are one of the main causes of the current ADAP
    crisis. Additional discounts would mean ADAPs could serve everyone who
    needs it without new funding. Moreover, given the unique nature of
    ADAP, these discounts would not have any significant impact on drug
    company profitability, as they would not impact price calculations for
    other drug programs or reduce drug company revenues.
        AIDS Healthcare Foundation (AHF) supports increasing Federal
    funding for ADAP. However, additional funding must go hand in hand with
    changes to ADAP that protect the program from high drug prices. To
    achieve this, AHF proposes that for every dollar of additional Federal
    funding drug companies contribute $2 in additional rebates or price
    cuts. This would effectively triple the purchasing power of each
    additional ADAP dollar, and ensure the sustainability of this vital
    program. Congress can implement this solution by directing the
    Secretary of Health and Human Services to negotiate the drug company
    contribution as a condition of receiving new money for ADAP.
        Call for the National Institutes of Health to make an independent
    review of prevention interventions being supported by CDC to determine
    their effectiveness.
        Even though the AIDS epidemic is over 25 years old, there is still
    very little evidence concerning what prevention programs work, and are
    cost effective. In order to better target scarce resources to the most
    effective interventions, AHF recommends that $1 million of NIH's fiscal
    year 2012 AIDS research budget be spent on determining which HIV
    prevention methods are in fact cost-effective ways of reducing HIV
    infections.
        The implementation of the recommendations would forcefully re-
    orient America's AIDS response in a way that would significantly reduce
    new infections, save billions of dollars, and improve the health of
    hundreds of thousands of Americans.
                                     ______

                       Prepared Statement of AIDS United
        On behalf of AIDS United and our diverse partner organizations I am
    pleased to submit this testimony to the Members of this Subcommittee on
    the urgency of needed funding for the fiscal year 2012 domestic HIV/
    AIDS portfolio. AIDS United is a national organization that seeks to
    end the AIDS epidemic in the United States by combining private-sector
    fundraising, philanthropy, coalition building, public policy expertise,
    and advocacy--as well as a network of passionate local and State
    partners--to effectively and efficiently respond to the HIV/AIDS
    epidemic in the communities most impacted by it. Through its unique
    Community Partnerships program, Public Policy Committee and targeted
    special grant-making initiatives, AIDS United represents over 400
    grassroots organizations. These organizations provide HIV prevention,
    care, treatment, and support services to underserved individuals and
    populations most impacted by the HIV/AIDS epidemic including
    communities of color, women and people living with HIV/AIDS in the
    United States as well as education and training to providers of
    treatment services.
        June 5, 2011 marks the 30th year since the Centers for Disease
    Control and Prevention (CDC) reported the first cases of what later
    became identified as HIV disease. Sadly, the HIV/AIDS epidemic in the
    United States is characterized by needless mortality, inadequate access
    to care, persistent levels of new infection, and stark population and
    regional disparities. Although improved treatment has made it possible
    for people with HIV disease to lead longer and healthier lives, these
    stark realities remain.
    HIV Remains a Major Public Health Danger
        More than 1.2 people are living with HIV or AIDS; nearly one-half
    living with HIV/AIDS are not in care.
        56,300 people are estimated to have been newly infected with HIV in
    the United States in 2006, the year for which the most recent data is
    available--one new infection every 9\1/2\ minutes. According to the
    Centers for Disease Control and Prevention (CDC) the HIV infection rate
    has not fallen in 16 years.
        There is neither a cure nor a vaccine for HIV and current
    treatments do not work for everyone.
    HIV Severely Affects African Americans, Latinos, Women and Gay Men
        African Americans represent 13 percent of the United States
    population but nearly 50 percent of all newly reported HIV infections.
        Hispanics/Latinos represent 13 percent of the United States
    population but account for 18 percent of newly reported cases of HIV.
        The percentage of newly reported HIV/AIDS cases in the United
    States among women tripled from 8 percent to 27 percent between 1985
    and 2007. AIDS is a leading cause of death among black women aged 15-
    54.
        Gay, bisexual, and other men who have sex with men, especially in
    communities of color, are the population most severely affected by HIV.
    AIDS United Supports the Goals of the National HIV/AIDS Strategy
        The Federal Government has created a first ever National HIV/AIDS
    Strategy that commits to four basic goals: reducing the number of
    people who become infected with HIV; increasing access to care and
    optimizing health outcomes for people living with HIV; reducing HIV-
    related health disparities; and achieving a more coordinated national
    response to the HIV Epidemic.
        AIDS United strongly supports achievement of these goals and
    strongly urges the Labor, Health and Human Services, and Education
    Subcommittee of the Senate Appropriations Committee to ensure that
    meeting these goals is a top priority. Unfortunately given the growth
    in the epidemic, meeting these goals, particularly lowering the new HIV
    infection rate, will require greater funding than has been made
    available. The Federal Government's commitment to HIV domestic funding
    is even more important this year as we see many States lowering their
    State funding contributions due to the economic realities States are
    facing. AIDS United strongly urges Congress to meet this challenge
    through the good work of this subcommittee and to recognize and address
    the true funding needs of the programs in the HIV/AIDS portfolio.
    AIDS Budget and Appropriations Coalition HIV Community Fiscal Year 2012
            Request (Increases Over Fiscal Year 2010)
        The HIV community has come together under the umbrella of the AIDS
    Budget and Appropriations Coalition with the community funding request
    for the HIV/AIDS domestic portfolio for fiscal year 2012, the
    comparisons are based on fiscal year 2010 finals. We fully understand
    the budgetary constraints that are impacting this time, but we feel it
    is imperative to let this subcommittee know of the true needs in the
    HIV community.
        HIV Prevention.--According to CDC estimates contained in the
    agency's 2009 HIV/AIDS Surveillance Report, since the beginning of the
    epidemic there have been 1,142,714 AIDS cases reported with a total of
    617,025 deaths in the United States. Based on previous CDC estimates
    more than 1.2 million people are living with HIV/AIDS and that an
    estimated 21 percent of people living with HIV are unaware of their HIV
    status and could unknowingly transmit the virus to another person.
    Prior to fiscal year 2010 funding had remained flat for more than 8
    years. As a result, grants to States and local communities have
    decreased significantly even as the United States seeks to increase
    prevention and testing services. To begin to reach the goals of the
    National HIV/AIDS Strategy the Congress must give the CDC the necessary
    funding to invest in meaningful prevention. AIDS United requests an
    increase of at least $57.2 million to $857.6 million in fiscal year
    2012 to address the true need of $1,324.6 billion.
        Education.--The National HIV/AIDS Strategy acknowledges the need to
    educate all Americans about the threat of HIV and how to prevent it.
    The United States must invest in programs that provide our young people
    with complete, accurate, and age-appropriate sex education that helps
    them reduce their risk of HIV, other STDs, and unintended pregnancy.
    AIDS United supports the Administration's teen pregnancy prevention
    initiative but urges Congress to find opportunities to fund true,
    comprehensive sex education that promotes healthy behaviors and
    relationships for all young people, including LGBT youth. Negative
    health outcomes are related to lack of knowledge and we must provide
    youth with the information and services they need to make responsible
    decisions about their sexual health. AIDS United requests that the teen
    pregnancy prevention initiative funding increase by $6.7 million to a
    level of $161.4 million. AIDS United also requests an increase of $10
    million, for a total of $50 million, for the Division of Adolescent and
    School Health's HIV Prevention Education at the CDC. AIDS United is
    pleased that the President's budget includes zero funding for failed
    abstinence-only-until-marriage programs and urges the subcommittee also
    to ensure that funding is not included for these ineffective programs.
        Policy Rider, Syringe Exchange.--CDC estimates that approximately
    13 percent of all HIV cases and 60 percent of all hepatitis C cases in
    the United States are related to intravenous drug use. Eight Federal
    studies and numerous scientific peer reviewed papers have conclusively
    established that syringe exchange programs reduce the incidence of HIV
    among people who inject drugs and their sexual partners and that
    syringe exchange reduces drug abuse. Syringe exchange programs connect
    people who use drugs to healthcare services including substance abuse
    treatment, HIV and viral hepatitis prevention services and testing,
    counseling, education, and support. AIDS United recommends that the
    Subcommittee maintain the current compromise language letting local
    jurisdictions make their own decision about using Federal funds to
    prevent HIV and viral hepatitis through the use of proven syringe
    exchange programs.
        HIV/AIDS Treatment.--The Ryan White HIV/AIDS Treatment Extension
    Act, administered by the Health Resources and Services Administration
    (HRSA) provides services to more than 529,000 people living with and
    affected by HIV throughout the United States and its territories. It is
    the largest source of Federal funding solely focused on the delivery of
    HIV services and has provided the framework for our national response
    to the HIV epidemic. In recent years, funding for the Ryan White
    Program has not kept pace with the growing epidemic leading to waiting
    lists and other cost containment measures for the AIDS Drug Assistance
    Program (ADAP), increasing wait times to receive medical appointments
    and loss of some support services. Ryan White Programs are designed to
    compliment each other. As such, all parts of the Ryan White Program
    require substantial increased funding to address the true needs of the
    hundreds of thousands of people living with HIV who are uninsured,
    underinsured, or who lack financial resources for healthcare and
    require Ryan White Program services. AIDS United recommends that the
    Ryan White Program funding level be increased by $369.7 million to a
    total of $2.686 billion in fiscal year 2012.
        Ryan White Programs, Part A.--This Part of the Ryan White Programs
    provides physician visits, laboratory services, case management, home-
    based and hospice care, and substance abuse and mental health services
    in the jurisdictions most affected by HIV/AIDS. These core medical and
    supportive services are critical to ensuring patients have access to
    and can effectively utilize life-saving therapies. AIDS United
    recommends funding for Part A at $751.9 million, an increase of $73.8
    million in fiscal year 2012.
        Ryan White Programs, Part B (base).--This program ensures a
    foundation for HIV related healthcare services in each State and
    territory, including the critically important ADAP. Part B base grants
    (excluding ADAP). AIDS United recommends funding for Part B base grants
    at $495.0 million, an increase of $76.2 million in fiscal year 2012.
        Ryan White Programs, Part B (ADAP).--The AIDS Drug Assistance
    Program provides medications for treating people with HIV who cannot
    access Medicaid or private health insurance. According to the 2011
    National ADAP Monitoring Project, ADAP provided drugs to about 190,936
    clients in fiscal year 2009, including 33,672 new clients. As of April
    15, 2011, 11 State ADAPs had waiting lists of 7,885 individuals and an
    additional 8 States had taken or were considering taking cost-
    containment measures. According to a respected pharmacoeconomic study
    that measures the funds needed to let State ADAPs provide a minimum
    clinical standard formulary the actual need for increases last year was
    more than $370.1 million. The community recognizes the difficult budget
    environment and asks for a much lower amount. AIDS United recommends
    $991 million, the authorized amount for ADAP, an increase of $131
    million, in fiscal year 2012.
        Ryan White Programs, Part C.--This Part awards grants to community-
    based clinics and medical centers, hospitals, public health
    departments, and universities in 22 States and the District of Columbia
    under the Early Intervention Services program. These grants are
    targeted toward new and emerging sub-populations impacted by the HIV
    epidemic. Part C funds are particularly needed in rural areas where the
    availability of HIV care and treatment is still relatively new. AIDS
    United requests $272.2 million, the authorized amount for Part C an
    increase of $65.8 million, in fiscal year 2012.
        Ryan White Programs, Part D.--Part D awards grants under the
    Comprehensive Family Services Program to provide comprehensive care for
    HIV positive women, infants, children, and youth and their affected
    families. These grants fund the planning of services that provide
    comprehensive HIV care and treatment and the strengthening of the
    safety net for HIV positive individuals and their families. AIDS United
    requests $83.1 million, an increase of $5.5 million, for Part D.
        Ryan White Programs, Part F, the AIDS Education and Training
    Centers (AETCs).--The AETCs train Ryan White program doctors, advanced
    practice nurses, physicians' assistants, nurses, oral health
    professionals, and pharmacists about HIV treatment, testing, viral
    hepatitis and more. The AETCs also ensure that education is available
    to primary healthcare providers who do not specialize in HIV but are
    asked to treat the increasing numbers of HIV positive patients who
    depend on them for care. AIDS United requests a total of $50 million, a
    $15.2 million increase in fiscal year 2012.
        Ryan White Programs, Part F, Dental Care.--Dental care is a crucial
    service needed by people living with HIV disease. Oral health problems
    are often an early manifestation of HIV disease. Unfortunately oral
    health is often neglected by those who cannot afford, or do not have
    access to, proper medical care creating missed opportunities to find
    early HIV infections. AIDS United request $19 million, a $5.4 million
    increase, for this program in fiscal year 2012.
        Department of Health and Human Services, Minority AIDS
    Initiative.--The Minority AIDS Initiative directly benefits racial and
    ethnic minority communities that are the most deeply affected by HIV/
    AIDS infection rates with grants to provide technical assistance,
    infrastructure support and strengthen the capacity of minority
    community based organizations to deliver high-quality HIV healthcare
    and supportive services. Communities of color are deeply affected by
    the HIV epidemic. The Minority AIDS Initiative funds needed programs
    throughout HHS agencies and is included in every Part of the CARE Act.
    It was authorized within the Ryan White Program for the first time in
    2006. AIDS United requests a total of $610 million for the Minority
    AIDS Initiative.
        HIV/AIDS Research.--Research to prevent, treat and ultimately cure
    HIV is vital to the domestic and global control of the disease. The
    United States through the National Institute of Health (NIH) must
    continue to take the lead in the research and development of new
    medicines to treat current and future strains of HIV. The NIH's Office
    of AIDS Research must continue its groundbreaking research in both
    basic and clinical science to develop a preventative vaccine,
    microbicides, and other scientific, behavioral, and structural HIV
    prevention interventions. Commitment to research will ultimately help
    to bring the epidemic under control decreasing the funds that must be
    spent on care and treatment of HIV. AIDS United requests that the NIH
    be funded at $35 billion in fiscal year 2012 and the AIDS portfolio be
    funded at $3.5 billion, a $410 million increase.
        The HIV epidemic is a continuing health crisis in the United
    States. We must expand resources for our domestic HIV prevention,
    treatment and care, and research efforts to meet the goals of the
    National HIV/AIDS Strategy. On behalf of our more than 400
    participating organizations, HIV positive Americans and those affected
    by this disease, AIDS United urges the subcommittee help us save lives
    by to fully funding the domestic response to the ongoing, tragic, HIV
    epidemic in the United States.
                                     ______

          Prepared Statement of the Adult Congenital Heart Association
    Introduction
        The Adult Congenital Heart Association (ACHA)--a national non-for-
    profit organization dedicated to improving the quality of life and
    extending the lives of adults with congenital heart disease (CHD)--is
    grateful for the opportunity to submit written testimony regarding
    fiscal year 2012 funding for congenital heart research and
    surveillance. We respectfully request $3 million for CHD surveillance
    at the Centers for Disease Control and Prevention (CDC) as well as
    additional CHD research at the National Heart, Lung and Blood Institute
    (NHLBI).
    Adult Congenital Heart Disease
        Congenital heart defects are the most common group of birth defects
    occurring in approximately 1 percent of all live births, or 40,000
    babies a year. These malformations of the heart and structures
    connected to the heart either obstruct blood flow or cause it to flow
    in an abnormal pattern. This abnormal heart function can be fatal if
    left untreated. In fact, congenital heart defects remain the leading
    cause of birth defect related infant deaths.
        Many infants born with congenital heart problems require
    intervention in order to survive. Intervention often includes one or
    multiple open-heart surgeries; however, surgery is rarely a long-term
    cure. The success of childhood cardiac intervention has created a new
    chronic disease--CHD. Thanks to the increase in survival, of the nearly
    2 million people alive today with CHD, more than half are adults,
    increasing at an estimated rate of 5 percent each year. Few congenital
    heart survivors are aware of their high risk of additional problems as
    they age, facing high rates of neuro-cognitive deficits, heart failure,
    rhythm disorders, stroke, and sudden cardiac death, and many survivors
    require multiple operations throughout their lifetime. 50 percent of
    all congenital heart survivors have complex problems for which life-
    long care from congenital heart specialists is recommended, yet less
    than 10 percent of adult congenital heart patients receive recommended
    cardiac care. Delays in care can result in premature death and
    disability. In adults, this often occurs during prime wage-earning
    years.
    ACHA
        ACHA serves and supports the more than 1 million adults with CHD,
    their families and the medical community--working with them to address
    the unmet needs of the long-term survivors of congenital heart defects
    through education, outreach, advocacy, and promotion of ACHD research.
        In order to promote life-saving research and accessible,
    appropriate and quality interventions which, in turn, will reduce the
    public health burden of this chronic disease, ACHA advocates for
    adequate funding of CDC initiatives relating to CHD, and encourages
    funding within the National Institutes of Health (NIH) for CHD
    research. ACHA continues to work with Federal and State policy makers
    to advance policies that will improve and prolong the lives of those
    living with CHD.
        ACHA is also a founding member of the Congenital Heart Public
    Health Consortium (CHPHC). The CHPHC is a group of organizations
    uniting resources and efforts to prevent the occurrence of CHD and
    enhance and prolong the lives of those with CHD through targeted public
    health interventions by enhancing and supporting the work of the member
    organizations. Representatives of Federal agencies serve in an advisory
    capacity. In addition to ACHA, the Alliance for Adult Research in
    Congenital Cardiology, American Academy of Pediatrics, American College
    of Cardiology, American Heart Association, March of Dimes Foundation,
    National Birth Defects Prevention Network, and the National Congenital
    Heart Coalition are all members of the CHPHC.
    Federal Support for Congenital Heart Disease Research and Surveillance
        Despite the prevalence and seriousness of the disease, CHD data
    collection and research are limited and almost non-existent for the
    adult CHD population. In 2004, the NHLBI convened a working group on
    CHD, which recommended developing a research network to conduct
    clinical research and establishing a national database of patients.
        In March 2010, the first CHD legislation passed as part of Patient
    Protection and Affordable Care Act (ACA).\1\ The ACA calls for the
    creation of The National Congenital Heart Disease Surveillance System,
    which will collect and analyze nationally representative, population-
    based epidemiological and longitudinal data on infants, children, and
    adults with CHD to improve understanding of CHD incidence, prevalence,
    and disease burden and assess the public health impact of CHD. It also
    authorized the NHLBI to conduct or support research on CHD diagnosis,
    treatment, prevention and long-term outcomes to address the needs of
    affected infants, children, teens, adults, and elderly individuals.
    These provisions included in the ACA were originally in the Congenital
    Heart Futures Act (H.R. 1570/S.621, 111th Congress), which garnered bi-
    partisan support in both the House and Senate and was championed by
    Senators Richard Durbin (D-IL) and Thad Cochran (R-MS), Representative
    Gus Bilirakis (R-FL) and former Representative Zack Space (D-OH).
    ---------------------------------------------------------------------------
        \1\ Patient Protection and Affordable Care Act, Sec. 10411(b).
    ---------------------------------------------------------------------------
        Recently, the National Center on Birth Defects and Developmental
    Disabilities included preventing congenital heart defects and other
    major birth defects, in its recently published 2011-2015 Strategic
    Plan, specifically recognizing the need for understanding the
    contribution of birth defects to longer term outcomes (i.e., beyond
    infancy) and the economic impact of specific birth defects.
    The National Congenital Heart Disease Surveillance System at CDC
        As survival improves, so does the need for population-based
    surveillance across the lifespan. Funding to support the development of
    the National Congenital Heart Disease Surveillance System through both
    a pilot adult surveillance program, and the enhancement of the existing
    birth defects surveillance system will be instrumental in driving
    research, improving interventional outcomes, improving loss to care,
    and assessing healthcare burden. In turn, the National Congenital Heart
    Disease Surveillance System can serve as a model for all chronic
    disease states.
        The current surveillance system is grossly inadequate. There are
    only 14 States currently funded by the CDC to gather data on birth
    defects, presenting limitations in generalizing the information across
    the entire population. Thus, there are significant inconsistencies in
    the methods of collection and reporting across the various State
    systems which limits the value of the data. Given the absence of
    population-based data across the lifespan, the data we do have excludes
    anyone diagnosed after the age of one, as well as those who are lost to
    care. It is this population, those lost to care, that is of greatest
    concern, and most difficult to identify. Evidence indicates that those
    with CHD are at significant risk for heart failure, rhythm disorders,
    stroke, and sudden cardiac death as they age, requiring ongoing
    specialized medical care. For those who are lost to care, for reasons
    such as limited access to affordable or appropriate care or poor
    education about the need for ongoing care, they often return to the
    system with preventable advanced illness and/or disability. Population
    based surveillance across the life span is the only method by which
    these patients can be identified, and, as a result, appropriate
    intervention can be planned. ACHA is currently working with the CDC to
    address these concerns through the National Congenital Heart Disease
    Surveillance System.
        ACHA requests that Congress provide the CDC $3 million in fiscal
    year 2012 to support data collection to better understand CHD
    prevalence and assess the public health impact of CHD. This level of
    funding will support a pilot adult surveillance system and allow for
    the enhancement of the existing birth defects surveillance system.
    Funding of Research Related to Congenital Heart Disease at NIH
        Our Nation continues to benefit from the single largest funding
    source for CHD research, the NIH. Yet, as a leading chronic disease,
    congenital heart research is significantly underfunded.
        The NHLBI supports basic and clinical research to establish a
    scientific basis for the prevention, detection, and treatment of
    congenital heart disease. The Bench to Bassinet Program is a major
    effort launched by the NHLBI to hasten the pace at which heart research
    on genetics and basic science can be developed into new treatments
    across the life span for people with congenital heart disease. The
    overall goal is to provide the structure to turn knowledge into
    clinical practice, and use clinical practice to inform basic research.
        ACHA urges Congress to support the NHLBI in efforts to continue its
    work with patient advocacy organizations, other NIH Institutes, and the
    CDC to expand collaborative research initiatives and other related
    activities targeted to the diverse life-long needs of individuals
    living with congenital heart disease.
    Summary
        Thank you for the opportunity to highlight this important disease.
    We know that you face many difficult funding decisions for fiscal year
    2012 and hope that you consider addressing the life-long needs of those
    with CHD. By making an investment in the research and surveillance of
    CHD, the return will be seen through reduced healthcare costs,
    decreased disability and improved productivity in a population quickly
    approaching 2 million.
                                     ______

             Prepared Statement of the Alliance for Aging Research
        Chairman Harkin and members of the Subcommittee, for 25 years the
    not-for-profit Alliance for Aging Research has advocated for medical
    research to improve the quality of life and health for all Americans as
    we grow older. Our efforts have included supporting Federal funding of
    aging research by the National Institutes of Health (NIH), through the
    National Institute on Aging (NIA) and other NIH institutes and centers.
    The Alliance appreciates the opportunity to submit testimony
    highlighting the important role that the NIH plays in facilitating
    aging-related medical research activities and the ever more urgent need
    for increased Federal investment and focus to advance scientific
    discoveries to keep individuals healthier longer.
        Research toward healthier aging has never been more critical for so
    many Americans. In January 2011, the first of the baby boomers began
    turning age 65. Older Americans now make up the fastest growing segment
    of the population. According to the U.S. Census Bureau, the number of
    people age 65 and older will more than double between 2010 and 2050 to
    88.5 million or 20 percent of the population; and those 85 and older
    will increase three-fold, to 19 million, according to the U.S. Census
    Bureau. Late-in-life diseases such as type 2 diabetes, cancer,
    neurological diseases, heart disease, and osteoporosis are increasingly
    driving the need for healthcare services in this country. Many diseases
    of these aging are expected to become more prevalent as the number of
    older Americans increases. Preventing, treating or curing chronic
    diseases of the aging, is perhaps the single most effective strategy in
    reducing national spending on healthcare.
        Consider that the number of Americans age 65 and older with
    Alzheimer's disease is projected to more than double by 2030. A report
    in the Journal of Clinical Oncology projected cancer incidence will
    increase by about 45 percent from 2010-2030, accounted for largely by
    cancer diagnoses in older Americans and minorities, and by 2030, people
    aged 65 and older will represent 70 percent of all cancer diagnoses in
    the United States. Currently, the average 75-year old has three chronic
    health conditions and takes five prescription medications. Six
    diseases--heart disease, stroke, cancer, diabetes, Alzheimer's and
    Parkinson's diseases--cost the United States over $1 trillion each
    year. In the absence of new discoveries to better treat and prevent
    osteoporosis, it is estimated to cost the United States $25.3 billion
    per year by 2025. According to an Alzheimer's Association report from
    2010, research breakthroughs that slow the onset and progression of
    Alzheimer's disease could yield annual Medicare savings of $33 billion
    in 2020 and as much as $283 billion by 2050.
        The rising tide of chronic diseases of aging threatens to overwhelm
    the U.S. healthcare system in the coming years. Research which leads to
    a better understanding of the aging process and human vulnerability to
    age-related diseases could be the key to helping Americans live longer,
    more productive lives, and simultaneously reduce the need for care to
    manage costly chronic diseases. Scientists who study aging now
    generally agree that aging is malleable and capable of being slowed.
    Rapid progress in recent years toward understanding and making use of
    this malleability has paved the way for breakthroughs that could
    increase human health in later life by opposing the primary risk factor
    for virtually every disease we face as we grow older--aging itself.
    Better understating of this ``common denominator'' of disease could
    usher in a new era of preventive medicine, enabling interventions that
    stave off everything from dementia to cancer to osteoporosis. As we now
    confront unprecedented aging of our population and staggering increases
    in chronic age-related diseases and disabilities, a modest extensions
    of healthy lifespan could produce outsized returns of extended
    productivity, reduced caregiver burdens, lessened Medicare spending,
    and more effective healthcare in future years.
        The NIA leads national research efforts within the NIH to better
    understand the aging process and ways to better maintain the health and
    independence of Americans as they age. NIA is poised to accelerate the
    scientific discoveries. The science of aging is showing increasing
    power to address the leading public health challenges of our time.
    Leaders in the biology of aging believe it is now realistically
    possible to develop interventions that slow the aging process and
    greatly reduce the risk of many diseases and disabilities, including
    cancer, diabetes, Alzheimer's disease, vision loss and bone and joint
    disorders. While there has been great progress in aging research, a
    large gap remains between promising basic research and healthcare
    applications. Closing that gap will require considerable focus and
    investment. Key aging processes have been identified by leading
    scientists as potentially yielding crucial answers in the next 3-10
    years. These include stress response at the cellular level, cell
    turnover and repair mechanisms, and inflammation.
        A central theme in modern aging research--perhaps its key insight--
    is that the mutations, diets, and drugs that extend lifespan in
    laboratory animals by slowing aging often increase the resistance of
    cells, and animals, to toxic agents and other forms of stress. These
    discoveries have two main implications, each of which is likely to lead
    to major advances in anti-aging science in the near future.
        First is the suggestion that stress resistance may itself be the
    facilitator (rather than merely the companion) of the exceptional
    lifespan in these animal models, hinting that studies of agents that
    modulate resistance to stress could be a potent source of valuable
    clinical leverage and preventive medicines. Second is the observation
    that the mutations that slow aging augment resistance to multiple
    varieties of stress--not just oxidation, or radiation damage, or heavy
    metal toxins, but rather resistance to all of these at the same time.
        The implication is that cells have ``master switches,'' which, like
    rheostats that can brighten or dim all lights in a room, can tweak a
    wide range of protective intracellular circuits to tune the rate of
    aging differently in long-lived versus short-lived individuals and
    species. If this is correct, research aimed at identifying these master
    switches, and fine-tuning them in ways that slow aging without unwanted
    side-effects, could be the most effective way to postpone all of the
    physiological disorders of aging through manipulation of the aging rate
    itself. Researchers have formulated, and are beginning to pursue, new
    strategies to test these concepts by analysis of invertebrates, cells
    lines, laboratory animals and humans, and by comparing animals of
    species that age more quickly or slowly.
        One hallmark of aging tissues is their reduced ability to
    regenerate and repair. Many tissues are replenished by stem cells. In
    some aged tissues, stem cell numbers drop. In others, the number of
    stem cells changes very little--but they malfunction. Little is
    currently known about these stem cell declines, but one suspected cause
    is the accumulation of ``senescent'' cells. Cellular senescence stops
    damaged or distressed cells from dividing, which protects against
    cancer. At advanced ages, however, the accumulation of senescent cells
    may limit regeneration and repair, a phenomenon that has raised many
    questions. Do senescent cells, for instance, alter tissue
    ``microenvironments,'' such that the tissue loses its regenerative
    powers or paradoxically fuel the lethal proliferation of cancer cells?
        A robust research initiative on these issues promises to illuminate
    the roots of a broad range of diseases and disabling conditions, such
    as osteoporosis, the loss of lean muscle mass with age, and the age-
    related degeneration of joints and spinal discs. The research is also
    essential for the development of stem cell therapies, the promise of
    which has generated much public excitement in recent years. This is
    because implanting stem cells to renew damaged tissues in older
    patients may not succeed without a better understanding of why such
    cells lose vitality with age. Importantly, research in this area would
    also help determine whether interventions that enhance cellular
    proliferative powers would pose an unacceptable cancer risk.
        Acute inflammation is necessary for protection from invading
    pathogens or foreign bodies and the healing of wounds, but as we age
    many of us experience chronic, low-level inflammation. Such insidious
    inflammation is thought to be a major driver of fatal diseases of
    aging, including cancer, heart disease, and Alzheimer's disease, as
    well as of osteoporosis, loss of lean muscle mass after middle age,
    anemia in the elderly, and cognitive decline after 70. Just about
    everything that goes wrong with our bodies as we age appears to have an
    important inflammatory component, and low-level inflammation may well
    be a significant contributor to the overall aging process itself. As
    the underlying mechanisms of age-related inflammation are better
    understood, researchers should be able to identify interventions that
    can safely curtail its deleterious effects beginning in mid-life,
    broadly enhancing later-life, and with negligible risk of side effects.
        While important advances have been made toward the goal of adding
    healthy years to life, it cannot be achieved in a timely way without
    significant financial support. In stark contrast to the rapidly rising
    costs of healthcare for the aging, we as a Nation are making a
    miniscule, and declining, investment in the prevention, treatment or
    cure of chronic diseases of aging. Out of each dollar appropriated to
    NIH only 3.6 cents goes toward supporting work of the NIA. Between
    fiscal year 2003 and fiscal year 2010, NIA-funded scientists saw a
    series of nominal increases and cuts that amounted to a 14.7 percent
    reduction in constant dollars. The November 11, 2010 issue of Nature
    notes that ``[a]lthough the funding situation is tight all around for
    NIH-supported investigators, the NIA is in an exceptional predicament .
    . . . As both the United States and global populations age, the
    prevalence of chronic diseases such as cancer, heart disease and
    diabetes will also grow, along with neurodegenerative ailments . . .
    The NIA deals with age-related aspects of all of these.''
        An increase in funding for aging research is urgently needed to
    enable scientists to capitalize on the field's recent exciting
    discoveries. Advocates for age-related diseases like Alzheimer's
    disease and cancer in the past have called for congressional
    appropriations of $2 billion annually in order to achieve major
    breakthroughs in treating and curing those diseases. Thus, a goal of $2
    billion annually in Federal funding for aging research on the basic
    underpinnings of aging over the next 3 to 10 years seems modest
    considering its great potential to lower overall disease risk
    (including Alzheimer's, cancer, and more) and add healthy years to
    life. For the NIA in particular, an increase in funding would enable
    flexibility in supporting high-quality grant proposals that fall within
    the 20th percentile of submitted grants. In recent years, the percent
    of grant applications receiving funding by the NIA has dropped
    precipitously and currently only the top 9 percent are being funded.
    This means that many valuable projects are being set aside due to
    budget constraints, and many talented scientists who might make major
    contributions to aging research are being dissuaded from making this
    their life's work.
        In addition to increased resources, the field would also benefit
    greatly from the creation of a trans-NIH initiative that could improve
    the quality and pace of research that advances the understanding of
    aging, its impact on age-related diseases, and the development of
    interventions to extend human healthspan. The initiative would be most
    effective if it included the representatives from the National
    Institute on Aging (NIA) and the major-disease focused institutes that
    have some role in aging research such as the National Institute of
    Neurological Disorders and Stroke (NINDS), National Heart, Lung, and
    Blood Institute (NHLBI), National Institute of Diabetes and Digestive
    and Kidney Diseases (NIDDK), and the National Cancer Institute (NCI).
        The field of aging research is poised to make transformational
    gains in the near future. Few if any areas for investing research
    dollars offer greater potential returns for public health. The Alliance
    for Aging Research supports funding the NIH at $35 billion in fiscal
    year 2012 with a minimum of $1.4 billion in funding for the NIA
    specifically. This level of support would allow the NIH and the NIA to
    adequately fund new and existing research projects, accelerating
    progress toward findings which could prevent, treat, slow the
    progression or even possibly cure conditions related to aging. With a
    Silver Tsunami of age driven chronic ailments looming as our population
    grows older, an increased emphasis on NIH's aging research activities
    has never been more urgent, with potential to impact so many Americans.
        The payoffs from such focused attention and investment would be
    large and lasting. Therapies that delay aging would lessen our
    healthcare system's dependence on the relatively inefficient strategy
    of trying to redress diseases of aging one at a time, often after it is
    too late for meaningful benefit. They would also address the fact that
    while advances in lowering mortality from heart attack and stroke have
    dramatically increased life expectancy, they have left us vulnerable to
    other age-related diseases and disorders that develop in parallel, such
    as Alzheimer's disease, diabetes, and frailty. Properly focused and
    funded research could benefit millions of people by adding active,
    healthy, and productive years to life. Furthermore, the research will
    provide insights into the causes of and strategies for reducing the
    periods of disability that generally occur at the end of life.
        Mr. Chairman, the Alliance for Aging Research thanks you for the
    opportunity to outline the challenges posed by the aging population
    that lie ahead as you consider the fiscal year 2012 appropriations for
    the NIH and we would be happy to furnish additional information upon
    request.
                                     ______

     Prepared Statement of the Alliance of Information and Referral Systems
        The Alliance of Information and Referral Systems (AIRS) thanks you
    for providing the opportunity to submit testimony as you consider an
    fiscal year 2012 Labor-HHS, Education Appropriations bill. AIRS is the
    national voice of Information and Referral/Assistance (I&R/A) services
    and we provide a professional umbrella for over 1,200 I&R/A providers
    in both public and private organizations. Our primary purpose for
    submitting this testimony is to urge you not to cut Title IIIB funding
    of the Older Americans Act (OAA) as this provides Federal funding to
    the States for I&R. President Obama's proposed fiscal year 2012 budget
    emphasizes an increase in funding of $48 million for Title IIIB of the
    OAA.
        Information and Referral brings people and services together. When
    people don't know where to turn, I&R/A is there for them. Last year,
    AIRS members answered more than 20 million calls for help.
    Comprehensive and specialized I&R/A programs help people in every
    community and operate as a critical component of the health and human
    services delivery system. I&R/A organizations have databases of
    programs and services and disseminate information through a variety of
    channels to individuals and communities. People in search of critical
    services such as, food, shelter, child care, work and job training,
    mental health support often do not know where to begin. More often than
    not, I&R/A organizations provide the answers.
        We encourage you to support a $48 million increase in funding for
    Title III of the Older Americans Act and at a very minimum, not cut
    funding for I&R/A services. Thank you for your consideration.
                                     ______

                       Prepared Statement of Alluviam LLC
        As a small business, we're writing to you today to bring to your
    attention what we feel is an urgent issue regarding the National
    Library of Medicine (NLM) decision to enter and unfairly compete with
    private industry in the market for software for firefighters and other
    emergency responders.
        It has come to our attention that NLM has been funding development
    of a software program (``WISER'') that they then give away at no cost
    to first responders. Apparently, NLM has been funding this effort for
    the last several years; in spite of the fact that there are at least 6
    other companies within this market segment that provide similar
    decision support tools for first responders, and have been doing so
    prior to NLM entering the marketplace.
        Providing government funding to a program that competes with an
    established segment of private industry kills jobs, stifles innovation
    and seems inherently unfair and contrary to the long term best interest
    of the emergency response community and a poor use of taxpayer money.
    With NLM's continued practices, there will cease to be any private
    industry R&D, innovation or other commercial investment in this market
    segment, effectively killing innovative technologies like ours, and the
    other companies currently providing products to this market. We have
    attempted to raise this issue to the attention of NLM without success,
    even though OMB circular A-76 (revised), supra note 182 at A-3
    articulates a ``Red Light for On-Line and Informational Government
    Activity: Principle 10: The government should exercise substantial
    caution in entering markets in which private-sector firms are active.''
        We feel that NLM is acting far outside its charter as a library
    information service. While we certainly applaud their efforts to
    provide concise and useful chemical and health related information to
    emergency responders and the public, it seems clear that with the
    development of software that they then give away, NLM has crossed the
    line of what it has been chartered to do, and is in conflict with OMB
    A-76, whose basic tenets are that ``in the process of governing, the
    Government should not compete with its citizens'' and that ``a
    commercial activity is not a governmental function.'' These principles
    provide fundamental policy direction to agencies that the Government
    should not be in the business of providing commercial goods and
    services in competition with private markets.
        We've attempted to contact NLM directly, but their position has
    been that they are fulfilling their duty of publishing Government
    information. We feel that developing and distributing analytical
    software, running focus groups to solicit user feedback, then promoting
    the software at the same industry trade shows that we attend is not
    consistent with publishing Government data. In fact, it is quite
    disingenuous, as if their intent was to publish the information, they
    could make the information widely available in any number of portable
    document or html formats that would be accessible from a range of
    devices, from laptops to smartphones, and would not put them in direct
    competition with private industry.
        The Government doesn't provide emergency responders free emergency
    response vehicles, protective clothing, respirators, radios or chemical
    detectors, and neither should the Government be competing with
    established private industry companies that are already providing
    decision support software to emergency responders. I'm sure that
    Microsoft would take umbrage with the Department of Commerce if
    Commerce decided to develop and then give away a free spreadsheet
    program simply because they thought it would benefit U.S. business.
        We respectfully request that you look into defunding this NLM
    program and get NLM out of the business of competing with private
    industry for this type of software. Since NLM started promoting their
    software, we've had existing customers and potential clients wonder why
    they should pay for software that NLM makes available for free.
        By way of background, as part of the Homeland Security Act of 2002,
    Public Law 107-296, known as the SAFETY ACT, Congress passed the Act as
    a mechanism to foster and support the development of innovative and
    effective anti-terrorism technology. Today, our company is one of a few
    companies in the United States that has a CBRNE/IED decision support
    system that has earned SAFETY ACT certification and designation as an
    approved anti-terrorism technology. We've spent over 5 years, and
    nearly 25,000 man hours--all at our own private expense, developing,
    fielding and deploying our technology. Today our technology,
    HazMasterG3 is deployed with the FBI, the Secret Service Presidential
    Protective Detail, every CST/WMD team in the country, the USMC's CBIRF,
    DHS, US Special Forces, and many civilian fire departments, HAZMAT
    teams and bomb squads throughout the United States.
                                     ______

        Prepared Statement of the American Academy of Family Physicians
        The American Academy of Family Physicians representing 97,600
    family physicians, residents, and medical students nationwide, is
    pleased to submit this statement for the record in support of our
    funding priorities for inclusion in the fiscal year 2012 appropriations
    bill.
        The AAFP urges the Senate Appropriations Subcommittee on Labor,
    Health and Human Services, and Education to make a robust fiscal year
    2012 investment in our Nation's primary care physician workforce in
    order to ensure that it is adequate to provide efficient, effective
    healthcare delivery addressing access, quality and value.
        We recognize the difficult decisions which our Nation's budgetary
    pressures present and remain confident that wise Federal investment
    will help to transform healthcare to achieve optimal, cost-efficient
    health for everyone. Specifically, we recommend that the Committee
    provide the Health Resources and Services Administration and the Agency
    for Healthcare Research and Quality with the fiscal year 2012 funding
    levels called for in the President's budget request.
    Health Resourses and Services Administration
        HRSA is the Federal agency chiefly responsible for improving access
    to healthcare services for Americans who are uninsured, isolated or
    medically vulnerable. HRSA's mission also calls for a skilled health
    workforce, and the AAFP supports their efforts to train the necessary
    primary care physician workforce. Primary care physicians will serve as
    a strong foundation for a more efficient and effective healthcare
    system.
        The AAFP recommends that the Committee provide at least $449.5
    million for all of the Health Professions Training Programs authorized
    by Title VII of the Public Health Service Act and administered by the
    Health Resources and Services Administration (HRSA) as requested in the
    President's fiscal year 2012 budget.
        Within that line, we urge you to provide at least:
      --$140 million for Health Professions Primary Care Training and
            Enhancement authorized under Title VII, Section 747 of the
            Public Health Service Act;
      --$10 million for Teaching Health Centers development grants
            authorized by Title VII, Section 749A; and
      --$4 million for Title VII, Section 749B Rural Physician Training
            Grants.
                Title VII Health Professions Training Programs
        As the only medical specialty society devoted entirely to primary
    care, the AAFP appreciates this Committee's commitment to a strong
    primary care physician workforce. We are concerned that a failure to
    provide adequate funding for the Title VII, Section 747, the Primary
    Care Training and Enhancement (PCTE) program, would destabilize ongoing
    efforts to increase education and training support for family
    physicians, exacerbating primary care shortages and further straining
    the Nation's healthcare system.
        Title VII, Section 747 primary care training grants to medical
    schools and residency programs have for decades helped to increase the
    number of physicians who select primary care specialties and work in
    underserved areas. A study published in the Annals of Family Medicine
    on the impact of Title VII training programs on community health center
    staffing and national health service corps participation found that
    physicians who work with the underserved in CHCs and NHSC sites are
    more likely to have trained in Title VII-funded programs.\1\ Title VII
    primary care training grants are vital to departments of family
    medicine, general internal medicine, and general pediatrics; strengthen
    primary care curricula; and offer incentives for training in
    underserved areas.
    ---------------------------------------------------------------------------
        \1\ Rittenhouse DR, et al. Impact of Title VII training programs on
    community health center staffing and National Health Service Corps
    participation. Ann Fam Med. 2008;6(5):397-405.
    ---------------------------------------------------------------------------
        In the coming years, medical services utilization is likely to rise
    given the increasing and aging population as well as the insured status
    of more of the populace. These demographic trends will cause primary
    care physician shortages to worsen. We urge the Committee to increase
    the level of Federal funding for primary care training to reinvigorate
    medical education, residency programs, as well as academic and faculty
    development in primary care to prepare physicians to support the
    patient centered medical home.
                Teaching Health Centers
        The AAFP has long called for reforms to graduate medical education
    programs in order to encourage the training of primary care residents
    in non-hospital settings where most primary care is delivered. An
    excellent first step is the innovative Teaching Health Centers program
    authorized under Title VII, Section 749A to increase primary care
    physician training capacity now administered by HRSA.
        Federal financing of graduate medical education has led to training
    which occurs mainly in hospital inpatient settings in spite of the fact
    that most patient care is delivered outside of hospitals in ambulatory
    settings across the Nation. The Teaching Health Center program provides
    resources to any qualified community based ambulatory care setting that
    operates a primary care residency program including federally Qualified
    Health Centers or federally Qualified Health Centers Look Alikes, Rural
    Health Clinics, Community Mental Health Centers, a Health Center
    operated by the Indian Health Service, or a center receiving Title X
    grants.
        We were pleased that the Patient Protection and Affordable Care Act
    authorized a mandatory appropriations trust fund of $230 million over 5
    years to fund the operations of Teaching Health Centers. However, if
    this program is to be effective, there must be funds for the planning
    grants to establish newly accredited or expanded primary care residency
    programs.
                Rural Health Needs
        Another important HRSA Title VII grant program is the Rural
    Physician Training Grants program to help medical schools to recruit
    students most likely to practice medicine in rural communities. This
    modest program authorized by Title VII, Section 749B will help provide
    rural-focused training and experience and increase the number of recent
    medical school graduates who practice in underserved rural communities.
                National Health Service Corps
        The National Health Service Corps (NHSC) recruits and places
    medical professionals in Health Professional Shortage Areas to meet the
    need for healthcare in rural and medically underserved areas. The NHSC
    provides scholarships or loan repayment as incentives for practitioners
    to enter primary care and provide healthcare to Americans in Health
    Professional Shortage Areas. By addressing medical school debt burdens,
    the NHSC also helps to ensure wider access to medical education
    opportunities.
        The Government Accountability Office (GAO-01-1042T) described the
    NHSC as ``one safety-net program that directly places primary care
    physicians and other health professionals in these medically needy
    areas.'' Currently most of the more than 7 million people who rely on
    NHSC clinicians for their healthcare needs would not have access to
    care without the NHSC.
        Since its inception in 1972, the NHSC has helped place 37,000
    primary care health professionals in underserved communities across the
    country, many of whom remain in these areas following the completion of
    their service. According to the fiscal year 2009 Health Resources and
    Services Administration budget justification, over 75 percent of the
    clinicians placed by the NHSC in underserved areas continued to serve
    in their position for at least 1 year after the completion of their
    service obligation.
        Today, there are over 9,000 vacancies at NHSC approved sites across
    the country with more added every day, yet funding is inadequate to
    fill all of these needed slots.
        The AAFP recommends that Committee provide at least the President's
    requested level of $418.5 million for the National Health Service Corps
    for fiscal year 2012 to include $295 million in funds made available
    for NHSC operations, scholarships and loan repayments by the Affordable
    Care Act.
    Agency for Heatlhcare Research and Quality
        The mission of the Agency for Healthcare Research and Quality
    (AHRQ)--to improve the quality, safety, efficiency, and effectiveness
    of healthcare for all Americans--closely mirrors the AAFP's own
    mission. AHRQ is a small agency with a huge responsibility for research
    to support clinical decisionmaking, reduce costs, advance patient
    safety, decrease medical errors and improve healthcare quality and
    access. Family physicians recognize that AHRQ has a critical role to
    play in patient-centered outcomes research also known as comparative
    effectiveness research.
                Patient-Centered Outcomes Research
        AHRQ's investment in patient-centered outcomes research will help
    Americans make the informed decisions we must make to focus on paying
    for quality rather than quantity. By determining what has limited
    efficacy or does not work, this important research can spare patients
    from tests and treatments of little value. Today, patients and their
    physicians face a broad array of diagnostic and treatment options
    without the scientific evidence needed to know what procedure or which
    drug is most likely to succeed or how best to time a given therapy.
    AHRQ is supporting research to answer those questions so that
    physicians and their patients can make the choices about care that are
    most likely to succeed. AHRQ also supports the essential research into
    the prevention of medical errors and reducing hospital-acquired
    infections.
                Medical Liability Demonstrations
        Solving the professional medical liability has long been one of the
    AAFP's highest priorities. Although the medical liability
    demonstrations announced by AHRQ in fiscal year 2010 are quite modest,
    we support the effort to find alternatives to the current medical tort
    system.
                Primary Care Extension Program
        The AAFP supports the Primary Care Extension Program to be
    administered by AHRQ to provide support and assistance to primary care
    providers about evidence-based therapies and techniques so that
    providers can incorporate them into their practice. As AHRQ develops
    more scientific evidence on best practices and effective clinical
    innovations, the Primary Care Extension Program will disseminate them
    to primary care practices across the Nation in much the same way as the
    Federal Cooperative Extension Service provides small farms with the
    most current information and guidance.
        The AAFP recommends that the Committee provide at least $405
    million for AHRQ in fiscal year 2012. In addition, we ask that the
    Primary Care Extension program receive the authorized level of $120
    million in fiscal year 2012.
                                     ______

       Prepared Statement of the American Academy of Physician Assistants
        On behalf of the nearly 80,000 clinically practicing physician
    assistants in the United States, the American Academy of Physician
    Assistants is pleased to submit comments on fiscal year 2012
    appropriations for Physician Assistant (PA) educational programs that
    are authorized through Title VII of the Public Health Service Act.
        AAPA believes that the Title VII Health Professions Programs are
    essential to placing health professionals in medically underserved
    communities. According to the Health Resources and Services
    Administration, an additional 301,000 healthcare practitioners are
    needed to alleviate existing professional shortages. One of three
    healthcare professions providing primary medical care in the United
    States, the PA profession is deemed by many economists to be among the
    fastest growing professions. Title VII will not only encourage greater
    numbers of students to enter PA educational programs; it will also help
    increase access to care for millions of Americans who live in medically
    underserved areas.
        As a member of the Health Professions and Nursing Education
    Coalition (HPNEC), AAPA respectfully supports the coalition's request
    to fund Title VII health professions education program at the
    President's request of $449,454,000.
        AAPA recommends that Congress continue its support to grow the PA
    primary care work force. The U.S. healthcare system will require a
    much-expanded primary healthcare workforce, both in the private and
    public healthcare markets. For example, the National Association of
    Community Health Centers' March 2009 report, Primary Care Access: An
    Essential Building Block of Health Reform, predicts that in order to
    reach 30 million patients by 2015, health centers will need at least an
    additional 15,585 primary care providers, just over one-third of whom
    are non-physician primary care professionals.
        A review of PA graduates from 1990-2009 demonstrates that PAs who
    have graduated from PA educational programs supported by Title VII are
    67 percent more likely to be from underrepresented minority populations
    and 47 percent more likely to work in a rural health clinic than
    graduates of programs that were not supported by Title VII.
    Additionally, a study by the UCSF Center for California Health
    Workforce Studies found a strong association between physician
    assistants exposed to Title VII during their PA educational preparation
    and those who reported working in a federally qualified health center
    or other community health center.
        Title VII programs are essential to the development and training of
    primary healthcare professionals and, in turn, provide increased access
    to care by promoting healthcare delivery in medically underserved
    communities. Title VII funding is especially important for PA programs
    as it is the only Federal funding available on a competitive
    application basis to these programs.
        We wish to thank the members of this subcommittee for your
    historical role in supporting funding for the health professions
    programs, and we hope that we can count on your support to maintain
    funding to these important programs in fiscal year 2011 at the
    President's request.
    Overview of Physician Assistant Education
        Physician assistant educational programs are located within schools
    of medicine or health sciences, universities, teaching hospitals, and
    the Armed Services. All PA educational programs are accredited by the
    Accreditation Review Commission on Education for the Physician
    Assistant.
        The typical PA program consists of 26 months of instruction, and
    the typical student has a bachelor's degree and about 4 years of prior
    healthcare experience. The first phase of the program consists of
    intensive classroom and laboratory study. More than 400 hours in
    classroom and laboratory instruction are devoted to the basic sciences,
    with over 75 hours in pharmacology, approximately 175 hours in
    behavioral sciences, and nearly 580 hours of clinical medicine.
        The second year of PA education consists of clinical rotations. On
    average, students devote more than 2,000 hours, or 50 to 55 weeks, to
    clinical education, divided between primary care medicine--family
    medicine, internal medicine, pediatrics, and obstetrics and
    gynecology--and various specialties, including surgery and surgical
    specialties, internal medicine subspecialties, emergency medicine, and
    psychiatry. During clinical rotations, PA students work directly under
    the supervision of physician preceptors, participating in the full
    range of patient care activities, including patient assessment and
    diagnosis, development of treatment plans, patient education, and
    counseling.
        After graduation from an accredited PA program, physician
    assistants must pass a national certifying examination developed by the
    National Commission on Certification of Physician Assistants. To
    maintain certification, PAs must log 100 continuing medical education
    hours every 2 years, and they must take a recertification exam every 6
    years.
    Physician Assistant Practice
        By design, PAs always practice in teams with physicians, extending
    the reach of medicine and the promise of improved health to the most
    remote and in-need communities in our Nation. The PA profession's
    patient-centered, team-based approach reflects the changing realities
    of healthcare delivery and fits well into the patient-centered medical
    home model of care, as well as other integrated models of care
    management.
        PAs practice in various medical setting across the country and in a
    recent survey conducted by the AAPA it is estimated that:
      --Nineteen percent of all PAs practice in non-metropolitan areas
            where they may be the only full-time providers of care (State
            laws stipulate the conditions for remote supervision by a
            physician);
      --41 percent of PAs work in urban and inner city areas;
      --40 percent of PAs are in primary care;
      --44 percent of PAs worked in group practices or solo physician
            offices: and
      --80 percent of PAs practice in outpatient settings.
        Nearly 300 million patient visits were made to PAs in 2009. PAs
    often provide autonomous medical care, have their own patient panels,
    and are granted prescribing authority in all 50 States.
    Critical Role of Title VII Public Health Service Act Programs
        Title VII programs promote access to healthcare in rural and urban
    underserved communities by supporting educational programs that train
    health professionals in fields experiencing shortages, improve the
    geographic distribution of health professionals, increase access to
    care in underserved communities, and increase minority representation
    in the healthcare workforce.
        Title VII programs are the only Federal educational programs that
    are designed to address the supply and distribution imbalances in the
    health professions. Since the establishment of Medicare, the costs of
    physician residencies, nurse training, and some allied health
    professions training have been paid through Graduate Medical Education
    (GME) funding. However, GME has never been available to support PA
    education. More importantly, GME was not intended to generate a supply
    of providers who are willing to work in the nation's medically
    underserved communities--the purpose of Title VII.
        Furthermore, Title VII programs seek to recruit students who are
    from underserved minority and disadvantaged populations, which is a
    critical step toward reducing persistent health disparities among
    certain racial and ethnic U.S. populations. Studies have found that
    health professionals from disadvantaged regions of the country are
    three to five times more likely to return to underserved areas to
    provide care.
    Title VII Support of PA Educational Programs
        Federal support for Title VII is authorized through section 747 of
    the Public Health Service Act. It is the only Federal funding available
    to PA educational programs. This funding is specifically targeted for
    primary care education and training programs and is designed to train
    PAs for practice in urban or rural medically underserved areas. The
    program is essential to the development and training of the Nation's
    health workforce and is critical to providing continued health services
    to both underserved and minority communities. It also encourages PAs to
    return to these environments with the greatest need after they have
    completed their training, being one of the best recruitment tools to
    date.
        Title VII was last reauthorized in 2010 under the Patient
    Protection and Affordable Care Act. Now there is a critical need to
    fund the Title VII program through the appropriations process to
    increase the supply, diversity, and distribution of PAs and primary
    care practitioners in medically underserved communities.
        Support for educating PAs to practice in underserved communities is
    particularly important given the market demand for physician
    assistants. Without Title VII funding to expose students to underserved
    sites during their training, PA students are far more likely to
    practice in the communities where they were raised or attended school.
    Title VII funding is a critical link in addressing the natural
    geographic maldistribution of healthcare providers by exposing students
    to underserved sites during their training, where they frequently
    choose to practice following graduation. Currently, 36 percent of PAs
    met their first clinical employer through their clinical rotations.
        Changes in the healthcare marketplace reflect a growing reliance on
    PAs as part of the healthcare team. Currently, the supply of physician
    assistants is inadequate to meet the needs of society, and the demand
    for PAs is expected to increase. A 2006 article in the Journal of the
    American Medical Association (JAMA) concluded that the Federal
    Government should augment the use of physician assistants as physician
    substitutes, particularly in urban Community Health Centers (CHCs)
    where the proportional use of physicians is higher. The article
    suggested that this could be accomplished by adequately funding Title
    VII programs. Additionally, the Bureau of Labor Statistics projects
    that the number of available PA jobs will increase 39 percent between
    2008 and 2018.
        Title VII funding has provided a crucial pipeline of trained PAs to
    underserved areas. Recognizing that the PA educational programs
    received significantly less funding than other programs in the cluster
    on primary care medicine and dentistry, the 111th Congress established
    a 15 percent set-aside for PA education within the section 747 cluster
    on primary care during reauthorization of the Title VII Programs.
    Recommendations on Fiscal Year 2012 Funding
        The American Academy of Physician Assistants urges members of the
    Appropriations Committee to consider the inter-dependency of all public
    health agencies and programs when determining funding for fiscal year
    2012. For instance, while it is critical, now more than ever, to fund
    clinical research at the National Institutes of Health (NIH) and to
    have an infrastructure at the Centers for Disease Control and
    Prevention (CDC) that ensures a prompt response to an infectious
    disease outbreak or bioterrorist attack, the good work of both of these
    agencies will go unrealized if the Health Resources and Services
    Administration (HRSA) is inadequately funded.
        HRSA administers the ``people'' programs, such as Title VII, that
    bring the results of cutting edge research at NIH to patients through
    providers such as PAs who have been educated in Title VII-funded
    programs. Likewise, the CDC is heavily dependent upon an adequate
    supply of healthcare providers to be sure that disease outbreaks are
    reported, tracked, and contained.
        Thank you for the opportunity to present the American Academy of
    Physician Assistants' views on fiscal year 2012 appropriations.
                                     ______

          Prepared Statement of the American Academy of Sleep Medicine
        Dear Chairman Harkin and Members of the Committee: The American
    Academy of Sleep Medicine (AASM), an organization composed of over
    9,700 sleep care professionals and the accrediting agent for over 2,200
    accredited sleep care centers, is pleased to provide our views on the
    HHS research budget for fiscal year 2012. As the leader in setting
    standards and promoting excellence in evidence-based sleep medicine
    healthcare, education, and research, we can attest to the fact that the
    work of the National Institutes of Health (NIH) has proven to be vital
    in allowing our members to provide effective sleep care services.
        The AASM supports funding levels for the NIH that will allow the
    careful continuation of the current research agenda. Savings should be
    realized from speeding the research process, vigilant screening of new
    research proposals, and an honest examination of spending for ongoing
    research. Key criteria in reviewing ongoing research should include
    both the potential patient benefit and whether a stoppage today will
    result in a restart on some future tomorrow that will duplicate the
    initial research and correspondingly duplicate the previously incurred
    expenses.
        Even in this economic climate, the value of the NIH as an incubator
    for advancing scientific and healthcare knowledge has to be recognized.
    Efforts need to be made to continue spending that: Enhances our ability
    to identify and provide beneficial patient care services; moves
    information from the white coats of the research laboratory to the
    white coats at the patient's bedside; and ensures a continual pipeline
    of research professionals.
        Even with this realization, however, we are not blind to the
    reality of the need to pare the Federal budget. We accept the fact that
    the totality of NIH spending is not immune to budget cuts. The key in
    looking at this budget is to take steps that do not fall into the
    category of being unexamined cuts that are made without taking into
    account the repercussions of these budget-based actions. While across-
    the-board cuts provide a clean and arguably simple process for trimming
    the budget, taking a budget axe to the NIH has the very real counter-
    productive potential of stopping prominent, patient oriented research
    in mid-stream and creating a gap in the research field. These
    unintended consequences carry significant negative implications that
    our patients and our society can ill afford.
        Examples of ongoing sleep related and other research recently
    funded by the NIH illustrate the difficulty of budget slashing that
    fails to take into account the three above noted bullet points. The
    sleep related research identified at this site (set out below) provides
    clear examples of ongoing research with indisputable patient care
    implications. This is the type of research that needs to be completed
    and not simply restarted at some future point with duplicated expenses.
    It also bears noting that the research funding on the connection
    between sleep apnea treatment and cardiovascular disease resulted in 12
    new jobs. These are the types of jobs that build the cadre of future
    key researchers. The importance of this cannot go unnoticed. For the
    future vitality of our society, we can ill afford another ``Sputnik
    moment'' by failing to maintain the research pipeline and the personnel
    that are essential to its maintenance and growth.
        The American Academy of Sleep Medicine urges careful consideration
    when addressing budget issues; the Academy is available as a resource
    on how those issues are connected with care for patients with sleep
    disorders. Please feel free to direct questions for the AASM to Bruce
    Blehart, Director of Health Policy and Government Relations, at
    BBlehart@aasmnet.org.

    Nirinjini Naidoo, Ph.D.
    Research Assistant Professor of Medicine, University of Pennsylvania,
            Philadelphia, PA
    Biomarker for Sleep Loss: A Proteomic Determination
    Administered by the NHLBI Division of Lung Diseases, Lung Biology and
            Disease Branch
    Fiscal Year 2009 Recovery Act Funding: $500,000
    Additional Funding
        Biomarker for Sleep Loss: A Proteomic Determination
        Administered by the NHLBI Division of Lung Diseases, Lung Biology
    and Disease Branch
        Fiscal Year 2010 Recovery Act Funding: $500,000
        Total funding: $1,000,000
        Dr. Nirinjini Naidoo grew up in South Africa, where she drew daily
    inspiration from her family. Her father, a classical scholar, fed the
    young Dr. Naidoo's desire to read voraciously. Over time, she was drawn
    to books about energetic, creative women in science like Marie Curie
    and Rosalind Franklin. ``Those stories really stuck with me,'' Dr.
    Naidoo said, noting that she is intensely curious and always ``wants to
    know.'' The attributes suit her well as a frontier scientist in the
    world of sleep research. They may be at odds with her getting sleep,
    though, she admitted. ``I sometimes wake up at 3 a.m. and send myself
    an e-mail about a newly hatched experiment.''
        Research Focus.--Humans spend about one-third of their lives
    asleep. But according to Dr. Naidoo, many of us do not appreciate that
    sleep is a vital part of healthy living and that our bodies accomplish
    several important tasks during that time. ``Sleep is definitely not
    just an `off' state,'' Dr. Naidoo said. ``Research is telling us that
    our bodies are actually very busy when we sleep--re-stocking cellular
    components, consolidating memories, and strengthening connections
    between nerve cells in the brain.'' Dr. Naidoo's research interest in
    sleep came fairly recently. A chemist who specializes in studying the
    structures and functions of proteins, she did postdoctoral research in
    the area of circadian rhythms--the 24-hour cycles that tune body
    systems with the light-and-dark cycle of our environment. Matching her
    scientific skills to what she saw as a fascinating question, Dr. Naidoo
    decided to look at the molecular features of sleep. What proteins are
    talking to each other? Which genes and molecules are active . . . or
    asleep themselves?
        Grant Close-Up.--Dr. Naidoo's Recovery Act grant is a comprehensive
    search for ``biomarkers'' of sleep loss. Biomarkers are substances that
    indicate a particular state or process. They can be used to signify
    health problems--high cholesterol is one, for example. Or, biomarkers
    can denote a normal activity, like growth or sleep. But as useful as
    they sound, accurate biomarkers can be very difficult to find. That's
    because so many factors can affect how the body functions: our diet,
    whether we exercise, what medicines we take, and our genetic make-up.
    All these components can influence body systems independently of each
    other, which makes finding telltale biomarkers challenging.
        You could think of Dr. Naidoo's approach as a variant on the
    childhood matching game ``same and different.'' In earlier experiments,
    she and other researchers identified people who were different types of
    sleepers. Some recovered quickly and fully from sleep deprivation and
    could easily pass a question-and-answer knowledge test. Others, Dr.
    Naidoo explained, reacted very differently and made several mistakes on
    the same relatively simple test. In that earlier experiment, she and
    leading sleep researcher Allan I. Pack, Ph.D., also at the University
    of Pennyslvania, collected blood samples from all the study
    participants. They will now use a high-tech chemical analytical tool
    called mass spectrometry to search for molecules that differ between
    the two different types of sleepers.
        After 2 years, Dr. Naidoo plans to have a profile of sleepiness--a
    snapshot of all the proteins and other molecules in blood that define
    sleepy or non-sleepy. In general, biomarkers can useful non-invasive
    tools for detecting illness and spotting disease risk. She hopes the
    sleep biomarkers will help researchers and physicians track sleep
    deprivation or the role of sleep loss in various diseases.
        Economic Impact.--Dr. Naidoo used Recovery Act funds to buy several
    pieces of state-of-the-art scientific equipment, such as a powerful
    microscope and machines that screen blood and other fluids for their
    component proteins. She is especially excited about the fact that this
    funding is enabling her to bring new blood into the field of sleep
    research. ``One of my new research specialists working on this
    project--a recent chemistry graduate--is now applying to graduate
    school to study sleep,'' said Dr. Naidoo. ``It's so important that we
    get new thinking and new methods into understanding one of the most
    fundamental processes in our daily lives.''

          By Alison Davis, Ph.D.--Last Updated: August 10, 2010

    Susan Redline, M.D., M.P.H.
    Professor, Case Western Reserve University, Cleveland, Ohio
    PHASE II Trial of Sleep Apnea Treatment to Reduce Cardiovascular
            Morbidity
    Administered by the NHLBI Division of Lung Diseases, National Center on
            Sleep Disorders Research
    Fiscal Year 2009 Recovery Act Funding: $2,190,865
        Research Focus.--More than 12 million American adults have sleep
    apnea, a disorder where breathing repeatedly pauses or becomes shallow
    during sleep. The condition can double or even quadruple a person's
    risk of heart disease, high blood pressure, and stroke. Despite sleep
    apnea's prevalence and risks, an estimated 1 in 10 patients isn't
    diagnosed or treated. One reason for the low treatment rate is that
    doctors lack evidence about which sleep apnea therapies actually reduce
    cardiovascular disease risk. On top of that, some patients who do get
    diagnosed may not follow through with their prescribed treatment
    because they think it's uncomfortable or awkward-looking.
        Grant Up Close.--Supported by an NHLBI Recovery Act funded Grand
    Opportunity grant, Susan Redline, M.D., M.P.H., is leading the first
    large-scale study in the United States to determine whether two common
    sleep apnea treatments reduce patients' risk of cardiovascular disease.
    Her team is recruiting 1,400 cardiovascular clinic patients who have
    moderate to severe sleep apnea and monitoring their sleep at home.
        One group of patients will receive extra oxygen at night. Dr.
    Redline wants to know if this simple therapy reduces the health risks
    of sleep apnea by compensating for lost breaths, or raises the risks by
    not increasing patients' breath rates. A second group of patients will
    receive another common sleep apnea treatment, continuous positive
    airway pressure (CPAP), in which a machine blows air into the throat
    each night through a mask worn over the nose and mouth. Although both
    CPAP and oxygen therapy are widely used, researchers haven't yet
    established whether using them to treat sleep apnea reduces
    cardiovascular disease risk. Dr. Redline's team will conduct
    comparative effectiveness research into the two treatments. A third
    group of patients will not undergo sleep apnea treatment.
        All three groups will have their early signs of cardiovascular
    disease treated. Together, these groups will help Dr. Redline's team
    begin to determine whether treating sleep apnea can change patients'
    risk of cardiovascular disease. The results of the study will also set
    the stage for advanced clinical trials. Her goal is to help doctors
    integrate sleep medicine into routine cardiology care and develop
    evidence-based treatment guidelines, ultimately lowering deaths from
    sleep apnea-related heart disease.
        ``A true multidisciplinary team''.--The study includes
    cardiologists and sleep medicine experts from four sites across the
    country. Some of them already collaborate through the NHLBI's Sleep
    Heart Health Study, a multi-center population study examining the
    cardiovascular effects of sleep apnea. ``My colleagues include
    engineers, informaticians, physiologists, geneticists, epidemiologists
    and clinicians,'' said Dr. Redline. ``I meet regularly with these
    diverse and talented people to review our common or overlapping
    goals.''
        Economic Impact.--Thanks to Recovery Act funds, the team was able
    to create 12 new jobs. They also bought new equipment, including
    portable devices to measure patients' blood pressure and other
    responses to sleep apnea treatments. Because the trial involves several
    sites, the team developed an advanced web-based data management
    platform. Researchers beyond the study can adapt it to their own needs
    so they can start new studies faster and manage them more efficiently.
        Broadening her Dream.--``As a child, I wanted to be a general
    physician, with a shingle on my door, and simply help people feel
    better,'' said Dr. Redline. She was accepted into an accelerated 6-year
    medical honors program when she was just 15 years old. Then her dream
    began to evolve. ``As I was exposed to academic medicine and powerful
    epidemiological methods, I realized that I wanted to work on broad
    issues that impact the health of the community, especially the
    underserved,'' she said. Learning about how the environment can impact
    people's lung health, and seeing how common but poorly understood sleep
    disorders were, Dr. Redline decided that researching sleep medicine was
    the way she could help improve public health.
        Outside the Lab.--Dr. Redline likes to spend time reading, biking,
    and kayaking.
        Aiming High.--Dr. Redline wants to find a practical treatment for
    sleep apnea that improves people's sleep quality and lowers their risk
    of heart disease; and to uncover genes that contribute to sleep apnea,
    so researchers can develop better targeted treatments.

           By Stephanie Dutchen--Last Updated: August 10, 2010.
                                     ______

       Prepared Statement of the American Association for Cancer Research
        The American Association for Cancer Research (AACR) is the world's
    oldest and largest scientific organization focused on every aspect of
    high-quality, innovative cancer research. The mission of the AACR and
    its more than 33,000 members is to prevent and cure cancer through
    research, education, communication and collaboration. We thank the
    United States Congress for its longstanding, bipartisan support for the
    National Institutes of Health (NIH) and for its commitment to funding
    cancer research.
        The AACR urges the Senate to continue this commitment to NIH in the
    coming fiscal year. To sustain the momentum generated through past
    investments in biomedical research and to improve the health of all
    Americans, the AACR recommends $35 billion for the NIH, including
    $5.795 billion for the National Cancer Institute (NCI) in fiscal year
    2012. This level of funding is needed to sustain the momentum generated
    through regular appropriations and the additional funds from the
    American Recovery and Reinvestment Act of 2009.
    Cancer research saves lives
        The Nation's historical investment in cancer research is
    unquestionably having a remarkable impact. We are in a time of
    unprecedented scientific opportunity: we are now able to accelerate
    progress against cancer by translating a wealth of scientific
    discoveries, such as the mapping of the human genome, into new
    treatments and preventive strategies for cancer. We can continue to
    make significant advances--but only if we continue to allocate the
    required resources to do so. Reversing recent cuts and providing
    stable, increased funding will greatly aid a full-scale national effort
    to lessen the burden of the more than 200 diseases we collectively call
    cancer.
        This year marks the 40th anniversary of the enactment of the
    National Cancer Act. In the four decades since President Richard M.
    Nixon signed this landmark legislation: Annual cancer death rates in
    the United States have declined steadily; the 5-year survival rate for
    all cancers combined has improved to more than 65 percent; the 5-year
    survival rate for all childhood cancers combined has increased from 30
    percent in 1976 to 80 percent today; and 12 million Americans have
    become cancer survivors, compared with only 3 million in 1971.
        These remarkable achievements are a direct result of our national
    commitment to funding cancer research, screening, and treatment
    programs at the NCI, NIH, and other agencies across the Federal
    Government. Yet this substantial progress will be slowed if the Federal
    commitment to funding for critical cancer research priorities is not
    maintained.
        In the last 40 years, innumerable advances in basic science, cancer
    prevention and detection, therapeutic development and clinical cancer
    management have been achieved. While these advances are too numerous to
    list here, the following cancer research advancements occurred in 2010
    alone, as a direct result of funding by the NIH:
      --12 new cancer drugs or cancer drug uses were approved by the FDA,
            including the first-ever therapeutic vaccine, Provenge, which
            was approved for men with metastatic prostate cancer; and
      --biological knowledge of tumor genes and the tumor microenvironment
            has led to the development of drugs that inhibit specific
            genetic targets, which may result in new treatments for
            multiple types of cancers, including melanoma and lymphoma.
        The opportunities and the science currently underway promise many
    more successes in improved treatment and prevention of cancer.
    Currently, there are: More than 800 cancer therapies from industry in
    some step of the trial process; more than 2,000 clinical trials
    accepting children and young adults in progress; and more than 200
    cancer prevention trials open.
        Right now, we are facing a precipice with cancer. The biological
    knowledge and the technological advances have positioned scientists at
    an inflection point. To pull back from Federal investment is to abandon
    science in a time when scientists will be able to make quantum leaps in
    prevention and treatment of cancer. It is imperative that sustained
    appropriations be provided to the NIH so that these opportunities and
    other promising areas such as personalized medicine and cancer
    prevention do not slip from our grasp.
    Cancer remains a significant public health challenge
        We have made significant progress against cancer in recent years,
    but as long as cancer remains the leading cause of death for Americans
    under age 85 and the second-leading cause of death overall, we cannot
    afford to slow down. In 2011, 1.5 million new cancer cases will be
    diagnosed and more than half a million American lives will be lost to
    this terrible collection of diseases.
        Moreover, the United States is facing what some have termed a
    ``cancer tsunami'' as the baby boom generation reaches age 65 this
    year. More than three-quarters of all cancers are diagnosed in
    individuals aged 55 and older, and the number of cancer cases is
    estimated to approach 2 million new cases per year by 2025. This will
    dramatically exacerbate the current problems with the healthcare system
    and it will undoubtedly hit those who can least afford it--elderly,
    medically underserved, and minority populations--the hardest.
        Beyond the enormous toll cancer takes on the lives of affected
    individuals and their loved ones, cancer places a heavy burden on the
    U.S. economy, costing an estimated $228 billion in direct medical costs
    and indirect costs associated with lost productivity due to illness and
    premature death.
    Targeted therapies as the future of cancer treatment
        The future of cancer treatment lies in the ability to treat
    patients based on the specific characteristics of a patient and his or
    her cancer--often referred to as personalized medicine. Cancer research
    is leading the way toward the realization of personalized medicine, in
    no small part thanks to Federal investment in deciphering the
    fundamental biology of cells, such as the Human Genome Project and,
    more recently, The Cancer Genome Atlas, an NCI project that is
    identifying important genetic changes involved in cancer.
        The NCI is investing in efforts that will facilitate the
    translation of this wealth of basic knowledge into new treatments,
    including validating cancer biomarkers for prognosis, metastasis,
    treatment response, and progression; accelerating the identification
    and validation of potential cancer molecular targets; minimizing the
    toxicities of cancer therapy; and integrating the clinical trial
    infrastructure for speed and efficiency.
    Accelerating progress in cancer prevention
        The AACR has long been a supporter of cancer prevention research
    aimed at identifying effective strategies to prevent cancer through
    lifestyle changes, chemoprevention, and early detection and treatment.
    Prevention is the keystone to success in the battle against cancer
    because preventing the disease is far more desirable--and cost-
    effective--than treating it. More than half of all cancers are related
    to modifiable behavioral factors, including tobacco use, diet, physical
    inactivity and sun exposure. Furthermore, many cancers can be halted in
    the early stages if individuals have access to, and take advantage of,
    screening tests. Vaccination--one of the most successful approaches for
    preventing disease--is one of the most promising areas of ongoing
    cancer prevention research.
        Research on cancer prevention at the NCI focuses on three main
    areas: Risk assessment, including understanding and modifying lifestyle
    factors that increase cancer risk; developing medical interventions
    (chemoprevention), such as drugs or vaccines, to prevent or disrupt the
    carcinogenic process; and developing early detection and screening
    strategies that result in the identification and removal of
    precancerous lesions and early-stage cancers.
        Cancer biology intersects with several areas and disciplines of
    cancer prevention, pointing to opportunities for, and the importance
    of, integrative, interdisciplinary efforts to advance clinical cancer
    prevention through hard-won science. The breadth and excitement of
    these current opportunities have never been greater.
    Addressing and conquering cancer health disparities
        Certain minority and underserved population groups continue to
    suffer disproportionately from cancer. Conquering cancer health
    disparities will contribute significantly to reducing the Nation's
    overall cancer burden, and this issue has been an important focus of
    both the NCI and the AACR. The NCI's investments in this area include:
    studying the factors that cause cancer health disparities; working with
    underserved communities to develop targeted interventions; developing
    the knowledge base for integrating cancer services to the underserved;
    collaborating to implement culturally appropriate information and
    dissemination approaches to underserved populations; and examining the
    role of health policy in eliminating cancer health disparities.
        One size does not fit all in cancer treatment and prevention--
    certain populations may require specialized approaches to achieve
    success. We must make every effort to reduce and equalize cancer rates
    across all populations. The AACR urges sustained funding for these
    programs to ensure that all people benefit from cancer research and
    that these disparities are eliminated.
    Fighting cancer in challenging fiscal times
        We are acutely aware of the difficult decisions Congress must make
    as it seeks to improve the Nation's fiscal stability. However, it is
    imperative that such efforts be grounded in the goal of securing the
    prosperity and well-being of the American people. It is not by chance
    that the United States is the world leader in cancer research and the
    development of lifesaving treatments. Our preeminence is a direct
    result of the steadfast determination of the American public and the
    U.S. Congress to reduce the burden of this devastating disease by
    supporting and investing in research through the NIH and NCI.
        Consider the following:
      --Biomedical research is essential to maintaining American global
            competitiveness. While our Nation has been the undisputed
            leader in research and innovation, other countries are catching
            up. According to the Organisation for Economic Co-operation and
            Development (OECD), national expenditures for research and
            development as a percentage of gross domestic product (GDP)
            remained static for the United States between 2001 and 2008
            while growing nearly 60 percent in China and 34 percent in
            South Korea. If this trend continues, we risk losing our global
            preeminence in biomedical research.
      --Biomedical research has a strong positive impact on State and local
            economies. NIH dollars are creating and preserving high-wage,
            high-tech jobs at a critical time for the U.S. economy. A
            recent report issued by United for Medical Research estimated
            that in fiscal year 2010, NIH awards led to the creation of
            488,000 jobs across the country, producing $68 billion in new
            economic activity. The NCI alone funds more than 6,500 research
            grants at more than 150 cancer centers and specialized research
            facilities located in 49 States. In over half the States,
            grants and contracts to institutions exceed $15 million
            annually.
      --Biomedical research is an effective and efficient use of public
            dollars. NIH funding does not stay inside the Beltway. More
            than 80 percent of the dollars appropriated to the NIH are
            distributed throughout the United States to research projects
            that have undergone rigorous review for scientific merit. NIH
            has consistently received the highest possible ranking of
            ``effective'' under the Office of Management and Budget's
            Program Assessment Rating Tool (PART), demonstrating that its
            programs set ambitious goals, achieve results, and are well-
            managed and efficient.
    Recent cuts to the NIH jeopardize scientific progress
        The $320 million in cuts to the NIH enacted in the full-year
    continuing appropriations of 2011, which included $45 million in cuts
    to the NCI, will yield harmful consequences for cancer research and
    cancer patients. This loss of funding will result in the following: a
    10 percent reduction in the number of new grants that can be awarded
    this year; a 3 percent cut to existing grants; and as much as a 5
    percent cut to funding for NCI-designated cancer centers. These cuts
    mean that success rates for grants could fall into the single digits,
    leaving numerous meritorious grant proposals, which could be the key to
    new therapies, unfunded at a time of unprecedented scientific
    opportunity. Furthermore, cancer centers and research laboratories may
    have to lay off workers as a result of reduced funding, which would
    negatively impact local economies across the Nation. Budget cuts and
    low success rates for grant proposals also discourage young scientists
    from entering the field, putting the future scientific workforce at
    risk.
    The NIH needs stable, predictable increases in funding
        Although cancer remains a costly burden in terms of its human and
    economic toll, previous investments have led to an abundance of
    promising research opportunities, and it is crucial that such
    possibilities are not lost. We thank Congress for its past support for
    the NIH and cancer research and urge Congress to continue its
    longstanding, bipartisan commitment. The American people are depending
    on Congress to ensure the Nation does not lose the health and economic
    benefits that result from our extraordinary commitment to medical
    research. The AACR looks forward to working with you to assure that our
    collective commitment to ending the pain and suffering inflicted by
    cancer is upheld and that researchers have the resources needed to
    continue to deliver hope and tangible progress.
                                     ______

       Prepared Statement of the American Association for Dental Research
    Introduction
        Mr. Chairman and Members of the Subcommittee, I am Jeff Ebersole,
    Director of the Center for Oral Health Research at the University of
    Kentucky College of Dentistry. My testimony is on behalf of the
    American Association for Dental Research, where I currently serve as
    President.
        I thank the Subcommittee for this opportunity to testify about the
    exciting advances in oral health science. With the support of this
    Committee, the research funded by the National Institute of Dental and
    Craniofacial Research (NIDCR) has not only returned dividends in terms
    of improvements in oral health across the U.S. population, but also in
    a wide array of other health issues ranging from craniofacial birth
    defects to chronic orofacial pain to oral cancer. The investments we
    make today will create an exciting tomorrow for the treatment and
    prevention of oral health diseases and disorders.
    What is the American Association for Dental Research?
        The American Association for Dental Research is headquartered in
    Alexandria, Virginia. It is a nonprofit organization with more than
    4,000 members in the United States. Its mission is to: (1) advance
    research and increase knowledge for the improvement of oral health; (2)
    support and represent the oral health research community; and (3)
    facilitate the dissemination and application of research findings. The
    AADR is the largest Division of the International Association for
    Dental Research.
    Why is Oral Health Important?
        Oral health is an essential component of health across the
    lifespan. Poor oral health and untreated oral diseases and conditions
    can have a significant impact on social development, economic
    accomplishment, and the quality of life. They can affect the most basic
    human needs including the ability to eat and drink, swallow, maintain
    proper nutrition, smile and communicate.
        Over the past 50 years, there has been a dramatic improvement in
    oral health. Still oral diseases remain a major concern. Tooth decay
    and gum disease represent the predominant infections facing the public,
    although complete tooth loss, oral cancer, trauma to the mouth, and
    congenital facial anomalies also contribute to the ongoing importance
    of oral health research and care.
        Employed adults in the United States lose more than 164 million
    hours of work each year as a result of oral health problems and
    children are estimated to lose 54 million school hours.\1\
    Approximately 25 percent of adults over the age of 60 have lost all of
    their natural teeth.\2\ Americans with the poorest oral health are
    usually those who are economically disadvantaged, lack insurance, or
    are members of racial and ethnic minorities. Moreover, as the Nation
    ages oral health issues, particularly gum disease and the oral health
    impact of medical treatments and medicines will continue to increase.
    ---------------------------------------------------------------------------
        \1\ Centers for Disease Control Publication, ``Oral Health for
    Adults,'' December 2006.
        \2\ Ibid.
    ---------------------------------------------------------------------------
    Research Accomplishments
        Salivary Diagnostics.--For many decades researchers have known that
    saliva is important for more than chewing, tasting, swallowing, and as
    the first step in digestion. A multitude of proteins and other
    molecules in saliva also play vital roles in protecting us from
    bacteria and viruses that are constantly entering through the mouth and
    can cause disease.
        Now, scientists are well on their way to understanding how saliva
    contributes to broader health functions. In 2008, an NIDCR supported
    team of biologists, chemists, engineers and computer scientists at five
    research institutions across the country mapped the salivary proteome--
    a ``catalogue and dictionary'' of proteins present in human saliva.
        This saliva database is an important first step toward being able
    to use biomarkers in saliva to diagnose or predict oral and systemic
    diseases. Saliva tests based on these biomarkers offer many advantages
    over blood tests that require a needle stick and can pose contamination
    risks from blood-borne diseases. However, much effort is still
    required. It is crucial that the research community have the resources
    necessary to refine and enrich the ``dictionary'' of proteins present
    in human saliva. Saliva tests could prove to be a potentially
    lifesaving alternative to detect diseases where early diagnosis is
    critical-- as in the case of oral cancer or heart attacks.
        Oral Cancer.--Oral cancer affects approximately 38,000 Americans
    each year. Oral cancer is any cancerous tissue growth located in the
    mouth. The death rate associated with this cancer is especially high
    due to delayed diagnosis. Only 60 percent of those with this cancer
    will survive more than 5 years.
        Researchers are developing a Point of Care diagnostic system (real-
    time) for rapid onsite detection of saliva-based tumor markers. Early
    detection of oral cancer will increase survival rates, improve the
    quality of care for patients, and it will result in a significant
    reduction in healthcare costs.
        Resources must be available to permit researchers to complete work
    on the Point of Care diagnostic systems, and to develop new therapeutic
    approaches. It should also be noted that several new drug candidates
    are now becoming available to treat oral cancer. It is believed that at
    least one of these drugs will be ready for FDA approval in the very
    near future.
        Health Disparities.--Health Disparities are the persistent gaps
    between the health status of minorities and non-minorities in the
    United States. Predicted causes of health disparities are related to
    educational, socioeconomic, and environmental characteristics of
    different ethnic and racial groups, and most recently recognized in
    historically underserved rural populations of the United States.
        The NIDCR is one of the leading institutes at NIH supporting health
    disparities research. The program at NIDCR takes a multidisciplinary
    approach to solving the complex problem of health disparities by
    addressing it from a holistic health prospective. The institute funded
    investigations engage behavioral and social scientists, health policy
    experts, economists, and basic and clinical dental and medical
    researchers. NIDCR has supported new health centers which focus on
    numerous populations at risk, including African Americans, Hispanic/
    Latinos, Native Americans and rural communities. The centers partner
    with other academic health centers, State and local health agencies,
    community and migrant health centers, and institutions that serve these
    targeted populations.
        The physical and economic burden due to health disparities is real
    and efforts must continue in order to eliminate them. I am proud to say
    that dental researchers are leading this charge.
    Conclusion
        As you can see Mr. Chairman, much has been accomplished with the
    resources provided by this committee; however, there is much yet to be
    done. Science is advancing rapidly and the next generation of
    technological innovation may greatly accelerate the next breakthroughs
    in oral, dental and craniofacial research. Researchers have already
    created prototypes for ``labs-on-a-chip,'' bioengineered tissue
    replacements, and developed powerful molecular imaging tools that
    provide a new window into complex biological systems about which we
    continue to learn. This emerging wave of knowledge and tools will
    accelerate the development of molecular-based oral healthcare. As
    importantly, the NIDCR provides the resources for training the next
    generation of biomedical scientists focusing or oral health issues as
    well as the future academics to train the next generation of dentists
    for the United States. Thus, it is vital that NIDCR have the resources
    to support a diverse portfolio of research and training. The AADR
    representing each of these constituencies respectfully requests a
    fiscal year 2012 budget of $468 million for NIDCR.
        Thank you.
                                     ______

    Prepared Statement of the American Association for Geriatric Psychiatry
        The American Association for Geriatric Psychiatry (AAGP)
    appreciates this opportunity to comment on issues related to fiscal
    year 2012 appropriations for mental health research and services. AAGP
    is a professional membership organization dedicated to promoting the
    mental health and well-being of older Americans and improving the care
    of those with late-life mental disorders. AAGP's membership consists of
    geriatric psychiatrists as well as other health professionals who focus
    on the mental health problems faced by aging adults. Although we
    generally agree with others in the mental health community about the
    importance of sustained and adequate Federal funding for mental health
    research and treatment, AAGP brings a unique perspective to these
    issues because of the elderly patient population served by our members.
    A National Health Crisis: Demographic Projections and the Mental
            Disorders of Aging
        The aging of the baby boomer generation will result in an increase
    in the proportion of persons over 65 from 12.7 percent currently to 20
    percent in 2030, with the fastest growing segment of the population
    consisting of age 85 and older. During the same period, the number of
    older adults with major psychiatric illnesses will more than double,
    from an estimated 7 million to 15 million individuals, meeting or
    exceeding the number of consumers in discrete, younger age groups.
    Center for Mental Health Services
        It is critical that there be adequate funding for the mental health
    initiatives under the jurisdiction of the Center for Mental Health
    Services (CMHS) within the Substance Abuse and Mental Health Services
    Administration (SAMHSA). While research is of critical importance to a
    better future, today's patients must also receive appropriate treatment
    for their mental health problems.
                Evidence-based Mental Health Outreach and Treatment for the
                        Elderly
        AAGP was pleased that the final budgets for the last 9 years have
    included $5 million for evidence-based mental health outreach and
    treatment to the elderly, the only federally funded services program
    dedicated specifically to the mental healthcare of older adults. AAGP
    is concerned that this program was eliminated in the President's fiscal
    year 2012 budget proposal. It is critical that SAMHSA and CMHS ensure
    that, as they design programs to promote prevention and recovery from
    mental illness, the senior citizen cohort not be ignored. AAGP asks the
    Committee to restore the funding for this critical program as well as
    ensure that all of CMHS's programs assure a life-span approach by
    specifically including the older adult population as a targeted
    population.
                Centers of Excellence for Depressive and Bipolar Disorders
        PPACA also included authorization for a new national network of
    centers of excellence for depressive and bipolar disorders, which will
    enhance the coordination and integration of physical, mental and social
    care that are critical to the identification and treatment of
    depression and other mental disorders across the lifespan. The work of
    these centers will help to disseminate and implement evidence-based
    practices in clinical settings throughout the country. AAGP strongly
    supports funding for the centers authorized by this legislation and is
    disappointed that the Administration has not recommended funding them.
    With respect to older adults, these centers would be able to focus on
    new models of care that integrate evidenced-based depression care into
    real world primary care and home care to improve the outcomes; specific
    combinations of medications and talk therapy that successfully treat
    depression and prevent relapse in older adults; specific clinical and
    biological factors that link depression and risk of Alzheimer's disease
    in some older depressed patients; and prevention of depression in older
    people at risk. AAGP recommends that these centers be funded at $10
    million for fiscal year 2012.
    Preparing a Workforce to meet the Mental Health Needs of the Aging
            Population
        In 2008, the Institute of Medicine (IOM) released a study of the
    readiness of the Nation's healthcare workforce to meet the needs of its
    aging population. The Re-tooling for an Aging America: Building the
    Health Care Workforce called for immediate investments in preparing our
    healthcare system to care for older Americans and their families. AAGP
    is deeply grateful to this subcommittee and its House counterpart for
    providing, in the appropriations bill for fiscal year 2010, funding for
    a follow-up study of the current and projected mental and behavioral
    healthcare needs for aging Americans. This study, which is now
    underway, will complement the 2008 IOM study in providing in-depth
    consideration of the mental health needs of geriatric and ethnic
    minority populations that were precluded by the broad scope of the
    earlier one.
        Virtually all healthcare providers need to be fully prepared to
    manage the common medical and mental health problems of old age. In
    addition, the number of geriatric health specialists, including mental
    health providers, needs to be increased both to provide care for those
    older adults with the most complex issues and to train the rest of the
    workforce in the common medical and mental health problems of old age.
    The small numbers of specialists in geriatric mental health, combined
    with increases in life expectancy and the growing population of the
    Nation's elderly, foretells a crisis in healthcare that will impact
    older adults and their families nationwide.
        Already, there are programs administered by the Bureau of Health
    Professions in the HHS Health Resources and Services Administration
    (HRSA) administers that are aimed to help to assure adequate numbers of
    healthcare practitioners for the Nation's geriatric population,
    especially in underserved areas. These are the only Federal programs
    that seek to increase the number of faculty with geriatrics expertise
    in a variety of disciplines, and the breadth of the programs has been
    strengthened by provisions included in the Patient Protection and
    Affordable Care Act (PPACA).
        The geriatric health professions program supports these important
    initiatives:
      --The Geriatric Education Center (GEC) program provides
            interdisciplinary training for healthcare professionals in
            assessment, chronic disease syndromes, care planning, emergency
            preparedness, and cultural competence unique to older
            Americans. PPACA authorizes $10.8 million in supplemental
            grants for the GEC Program to support training in geriatrics,
            chronic care management, and long-term care for faculty in a
            broad array of health professions schools, as well as direct
            care workers and family caregivers. GECs receiving these grants
            are required to develop and include material on depression and
            other mental disorders common among older adults, medication
            safety issues for older adults, and management of the
            psychological and behavioral aspects of dementia in all
            appropriate training courses.
      --The Geriatric Training for Physicians, Dentists, and Behavioral and
            Mental Health Professionals (GTPD Program) provides fellows
            with exposure to older adult patients in various levels of
            wellness and functioning and from a range of socioeconomic and
            racial/ethnic backgrounds.
      --The Geriatric Academic Career Awards (GACA) support the academic
            career development of geriatric specialists in junior faculty
            positions who are committed to teaching geriatrics in
            professional schools. PPACA expands the disciplines eligible
            for the awards. GACA recipients are required to provide
            training in clinical geriatrics, including the training of
            interdisciplinary teams of healthcare professionals.
      --PPACA authorized a new Geriatric Career Incentive Awards Program in
            Title VIII of the Public Health Service Act for grants to
            foster great interest among a variety of health professionals
            in entering the field of geriatrics, long-term care, and
            chronic care management. This program was authorized for $10
            million over 3 years.
      --A new program, authorized by PPACA at $10 million for 3 years, will
            provide advanced training opportunities for direct care workers
            in the field of geriatrics, long term-care or chronic care
            management.
        AAGP strongly supports increased funding for the existing programs,
    particularly as the disciplines included have been expanded, and
    funding to fully authorized levels for the new programs.
    National Institutes of Health (NIH) and National Institute of Mental
            Health (NIMH)
        With the graying of the population, mental disorders of aging
    represent a growing crisis that will require a greater investment in
    research to understand age-related brain disorders and to develop new
    approaches to prevention and treatment. Even in the years in which
    funding was increased for NIH and the NIMH, these increases did not
    always translate into comparable increases in funding that specifically
    address problems of older adults. For instance, according to figures
    provided by NIMH, NIMH total aging research amounts decreased from
    $106,090,000 in 2002 to $85,164,000 in 2006 (dollars in thousands:
    $106,090 in 2002, $100,055 in 2003, $97,418 in 2004, $91,686 in 2005,
    $85,164 in 2006).
        The critical disparity between federally funded research on mental
    health and aging and the projected mental health needs of older adults
    is continuing. If the mental health research budget for older adults is
    not substantially increased immediately, progress to reduce mental
    illness among the growing elderly population will be severely
    compromised. While many different types of mental and behavioral
    disorders occur in late life, they are not an inevitable part of the
    aging process, and continued and expanded research holds the promise of
    improving the mental health and quality of life for older Americans.
    This trend must be immediately reversed to ensure that our next
    generation of elders is able to access effective treatment for mental
    illness. Federal funding of research must be broad-based and should
    include basic, translational, clinical, and health services research on
    mental disorders in late life.
        AAGP believes that it is critical that NIH begin to invest
    increased funding in future evidence-based treatments for our Nation's
    elders. Annual increases of funds targeted for geriatric mental health
    research at NIH should be used to: (1) identify the causes of age-
    related brain and mental disorders to prevent mental disorders before
    they devastate lives; (2) speed the search for effective treatments and
    efficient methods of treatment delivery; and (3) improve the quality of
    life for older adults with mental disorders.
                Participation of Older Adults in Clinical Trials
        Federal approval for most new drugs is based on research
    demonstrating safety and efficacy in young and middle-aged adults.
    These studies typically exclude people who are old, who have more than
    one health problem, or who take multiple medications. As the population
    ages, that is the very profile of many people who seek treatment. Thus,
    there is little available scientific information on the safety of drugs
    approved by the Food and Drug Administration (FDA) in substantial
    numbers of older adults who are likely to take those drugs. Pivotal
    regulatory trials never address the special efficacy and safety
    concerns that arise specifically in the care of the Nation's mentally
    ill elderly. This is a critical public health obligation of the
    Nation's health agencies. Just as the FDA has begun to require
    inclusion of children in appropriate studies, the agency should work
    closely with the geriatric research community, healthcare consumers,
    pharmaceutical manufacturers, and other stakeholders to develop
    innovative, fair mechanisms to encourage the inclusion of older adults
    in clinical trials. Clinical research must also include elders from
    diverse ethnic and cultural groups. In addition, AAGP urges that
    Federal funds be made available each year for support of clinical
    trials involving older adults.
                Study on NIH Funding for Mental Disorders among Older
                        Adults
        As little emphasis has been placed on the development of new
    treatments for geriatric mental disorders, AAGP encourages NIH to
    promote the development of new medications specifically targeted at
    brain-based mental disorders of the elderly. AAGP urges this Committee
    to request a GAO study on spending by NIH on conditions and illnesses
    related to the mental health of older individuals. NIH is already
    working to enhance cooperative activities among NIH Institutes and
    Centers that support research on the nervous system. A GAO study of the
    work being done by these institutes in areas that predominately involve
    older adults could provide crucial insights into possible new areas of
    cooperative research, which in turn will lead to advances in prevention
    and treatment for these devastating illnesses.
    Conclusion
        AAGP recommends:
      --Increased funding for the geriatric health professions education
            programs under Title VII of the Public Health Service Act and
            full funding for new programs authorized by the PPACA;
      --Funding to support clinical trials involving older adults;
      --A GAO study on spending by NIH on conditions and illnesses related
            to the mental health of older individuals;
      --$5 million in funding to continue evidence-based geriatric mental
            health outreach and treatment programs at CMHS;
      --$10 million in funding for Centers of Excellence for Depressive and
            Bipolar Disorders.
                                     ______

     Prepared Statement of the American Association of Colleges of Nursing
        The American Association of Colleges of Nursing (AACN) respectfully
    submits this testimony highlighting funding priorities for nursing
    education and research programs in fiscal year 2012. AACN represents
    667 schools of nursing with baccalaureate and graduate nursing programs
    that educate over 337,000 students and employ more than 15,000 full-
    time faculty members. These institutions educate approximately half of
    our Nation's Registered Nurses (RNs) and all of the Advanced Practice
    Registered Nurses (APRNs), nurse faculty, and researchers.
        The programs outlined in this testimony play an integral role in
    continuing to shape, advance, and promote a professional nursing
    workforce to meet the needs of America's patients. An emphasis on two
    key components of the profession--education and research--will be
    necessary to sustain and enhance the quality of nursing care in the
    United States. The release of the landmark Institute of Medicine's
    (IOM) report, The Future of Nursing: Leading Change, Advancing Health,
    outlines specific priorities for the profession and identifies expanded
    Federal support to meet the goals of preparing a more highly educated
    nursing workforce, removing barriers so all nurses can practice to the
    full scope of their education, and enabling nurses to serve as equal
    partners in the redesign of the healthcare system.
        The ongoing reform of our healthcare system will continue to
    increase access to care, requiring a surge in the number of nurses and
    other health professionals. RNs and APRNs will be in high demand given
    the needs of an aging population, the increased complexity of care, and
    significant growth in the number of patients with chronic diseases.
    More specifically, the U.S. Bureau of Labor Statistics projects a
    demand on our delivery system that will necessitate the creation of
    581,000 new positions by 2018, a 22 percent increase in the nursing
    workforce. Without increased attention to the challenges facing nursing
    education, schools of nursing will be unable to meet this demand,
    further jeopardizing access to quality care.
        The current supply and demand of nurses demonstrates two distinct
    challenges. First, due to the present and looming need for healthcare
    by American consumers, the supply of nurses is not growing at a pace
    that will adequately meet long-term projections, including the demand
    for primary care provided by APRNs. This issue is further compounded by
    the number of nurses who will retire or leave the profession in the
    near future, ultimately reducing the nursing workforce. Currently, over
    1 million of the total 2.6 million practicing nurses are over the age
    of 50. More striking yet, over 275,000 RNs are over the age of 60
    according to the 2008 National Sample Survey of Registered Nurses.
        Second, the supply of nurses nationwide is stretched thin due, in
    large part, to capacity barriers in schools of nursing. According to
    AACN, 67,563 qualified applications were turned away from baccalaureate
    and graduate nursing programs in 2010, primarily due to budget
    constraints which impact the insufficient number of faculty, clinical
    sites, classroom space, and clinical preceptors. As the ability of most
    States to support the needs of higher education has decreased, Federal
    support for nursing education has become even more critical. National
    reform goals cannot be met without an adequate number of nurses to
    provide the cost-effective and quality care associated with the nursing
    discipline.
           nursing workforce development programs: a proven solution
        For nearly 50 years, the Title VIII Nursing Workforce Development
    Programs (42 U.S.C. 296 et seq.) have supported hundreds of thousands
    of nurses and nursing students. Between fiscal year 2006 and 2009, the
    Title VIII programs supported over 347,000 nurses and nursing students
    as well as numerous academic nursing institutions and healthcare
    facilities. As the largest source of dedicated funding for nursing, the
    Title VIII programs award grants to nursing education programs, as well
    as provide direct support through loans, scholarships, traineeships,
    and programmatic grants. The programs also favor institutions that
    educate nurses for practice in rural and medically underserved
    communities and help to develop a more diverse nursing workforce to
    meet the cultural healthcare needs of our Nation's population.
    Additionally, programs funded through Title VIII contribute to the
    promotion of academic progression, a major goal highlighted in the
    IOM's Future of Nursing report.
        Of specific interest to AACN, the Title VIII programs support
    future nurse faculty, a significant barrier to addressing the nursing
    care needs in the United States. The nurse faculty shortage has grown
    critical as the national vacancy rate is 6.9 percent for schools
    offering baccalaureate and graduate nursing programs according to an
    AACN Survey on Vacant Faculty Positions for Academic Year 2010-2011. Of
    those schools reporting vacancies, the number of positions left
    unfilled was 803. Regionally, schools of nursing are struggling to
    recruit and hire faculty. Compared to the North Atlantic (9.2 percent),
    Southern (9.5 percent), and Mid-Western (9.2 percent) regions of the
    country, the West Coast (11.7 percent) has the highest faculty vacancy
    rate.
    Title VIII Effectiveness
        The Nursing Workforce Development Programs are effective and meet
    their authorized mission. AACN's 2010-2011 Title VIII Student Recipient
    Survey included responses from 1,459 students who noted that these
    programs played a critical role in funding their nursing education,
    which will ultimately help them to achieve future career goals. The
    students responding to the Title VIII survey have career aspirations
    that meet the direct needs of the healthcare system and the profession.
    Nearly one-third (32.8 percent) of the respondents reported that their
    career goal is to become a nurse practitioner. Given the demand for
    primary care providers, the Title VIII funds are helping to support the
    next generation of these essential practitioners. Moreover, the nurse
    faculty shortage continues to inhibit the ability of nursing schools to
    increase student capacity. Of the students who responded to the survey,
    an additional 33.2 percent stated their ultimate career goal was to
    become nurse faculty. Providing support for Title VIII is the key to
    help schools expand student capacity, fill vacant nursing positions,
    and, in turn, improve healthcare quality.
    Demand for Title VIII
        While millions of Americans are struggling during this economic
    downturn and thousands of students need loans to finance their
    education, Federal support is necessary. Nursing students depend on
    Federal loans like Title VIII to pay for their education. AACN's Title
    VIII Student Recipient Survey also indicated that 73 percent of the
    undergraduate and 62.6 percent of the master's students responding to
    the question regarding funding for nursing education noted that they
    will pay for their education through Federal loans. The average loan
    amount that students reported they would take (private/Federal) to
    support their education was $19,336 for undergraduate students and
    $55,698 for master's students. These students also noted that the total
    amount they will pay for their education is $32,307 for undergraduates
    and $64,734 for master's. Given this information, it is interesting to
    note that 65.6 percent of the students reported that the amount of
    support they received from Title VIII was $3,000 or less in one fiscal
    year.
        Over the last 47 years, Congress has used the Title VIII
    authorities as a mechanism to address past nursing shortages. When the
    need for nurses was great, such as in the 1970s, appropriations were
    higher. Congress provided $160.61 million to the Title VIII programs in
    1973. Adjusting for inflation, $160.61 million in 1973 dollars would be
    equivalent to $841.371 million in 2011 dollars. The fiscal year 2011
    investment of $242.387 million represents a 70 percent reduction in
    buying power for the Title VIII programs, at a time when our Nation
    faces historic demands on our nursing workforce.
        AACN respectfully requests $313.075 million for the Nursing
    Workforce Development Programs authorized under Title VIII of the
    Public Health Service Act in fiscal year 2012 as recommended in the
    President's budget proposal.
      nursing research: supporting health promotion and disease prevention
        The National Institute of Nursing Research (NINR) is one of the 27
    Institutes and Centers at the National Institutes of Health (NIH). As
    the Nation's nucleus for nursing science, NINR funds research that
    establishes the scientific basis for health promotion, disease
    prevention, and high quality nursing care to individuals, families, and
    populations. Often working collaboratively with physicians and other
    researchers, nurse scientists are vital in setting the national
    research agenda. NINR focuses on four strategic areas which include
    promoting health and preventing disease, eliminating health
    disparities, improving quality of life, and setting directions for end-
    of-life research.
        NINR's fiscal year 2011 funding level of $144.381 million is
    approximately 0.47 percent of the overall $30 billion NIH budget.
    Spending for nursing research is a modest amount relative to the
    allocations for other health science institutes and for major disease
    category funding. For NINR to adequately continue and further its
    mission, the institute must receive additional funding. Cuts in funding
    have impeded the institute from supporting larger comprehensive studies
    needed to advance nursing science and improve the quality of patient
    care. With increased appropriations for NINR, more comprehensive,
    complex, and longitudinal studies could be funded in the critical areas
    of their mission while maintaining their portfolio of current goals,
    projects, and priorities of the institute.
        Additionally, considering that NINR presently allocates 6 percent
    of its budget to training that helps develop the pool of nurse
    researchers, increased funding would support NINR's efforts to prepare
    faculty researchers desperately needed to educate new nurses. AACN
    respectfully requests $163 million for the National Institute of
    Nursing Research in fiscal year 2012.
      nurse-led practice models: investing in nurse-managed health clinics
        The Affordable Care Act amended Sec. 330 of the Public Health
    Service Act, allowing Nurse- Managed Health Clinics (NMHCs) to apply
    for grant funds to help cover the costs of operating these unique
    community-based settings. NMHCs are nurse-practice arrangements and are
    managed by APRNs who provide primary care or wellness services to
    underserved or vulnerable populations through clinics located in places
    like public housing, churches, Native American reservations, rural
    communities, senior citizen centers, elementary schools, and
    storefronts. Each of these clinics is associated with a school,
    college, university or department of nursing, federally qualified
    health center, or independent nonprofit health or social services
    agency, and serves as safety net of providers for vulnerable
    populations. Moreover, NMHCs play a valuable role as teaching and
    practice sites for nursing students. AACN respectfully requests $20
    million for the Nurse-Managed Health Clinics authorized under Title III
    of the Public Health Service Act in fiscal year 2012 as recommended in
    the President's budget proposal.
                 capacity grants: solutions to grow enrollment
        According to AACN's latest enrollment and graduation survey, the
    major barriers to increasing student capacity in nursing schools are
    insufficient numbers of faculty, admission seats, clinical sites,
    classroom space, and clinical preceptors, as well as budget
    constraints. The Capacity for Nursing Students and Faculty Program, a
    section of the Higher Education Opportunity Act of 2008, offers
    capitation grants (formula grants based on the number of students
    enrolled/or matriculated) to nursing schools allowing them to increase
    the number of students. Schools of nursing continue to face budget cuts
    at the State level, and capacity grants are a proven method for meeting
    the needs of nursing education. AACN respectfully requests $25 million
    for this program in fiscal year 2012.
                                   conclusion
        AACN acknowledges the fiscal challenges facing this Subcommittee
    and Congress, but would be remiss in not highlighting the benefits of
    these programs. Title VIII has a long and successful record of
    providing dedicated support for the nursing workforce. The National
    Institute of Nursing Research invests in developing the scientific
    basis for quality nursing care. Nurse-Managed Health Clinics provide
    services to the underserved and training and practice settings for
    nursing students. The Capacity for Nursing Students and Faculty Program
    would allow schools to increase student capacity.
        To be effective in meeting the critical goals outlined in the IOM's
    report, The Future of Nursing: Leading Change, Advancing Health, and
    the larger health reform goals of the Nation, these programs must
    receive additional funding. AACN respectfully requests $313.075 million
    for Title VIII programs, $163 million for NINR, $20 million for Nurse-
    Managed Health Clinics, and $25 million for the Capacity for Nursing
    Students and Faculty Program in fiscal year 2012. Additional funding
    for these programs will assist schools of nursing to expand their
    educational and research programs, educate more nurse faculty, increase
    the number of practicing RNs, and ultimately improve the patient care
    provided in our healthcare system.
                                     ______

         Prepared Statement of the American Association of Colleges of
                              Osteopathic Medicine
        On behalf of the American Association of Colleges of Osteopathic
    Medicine (AACOM), I am pleased to submit this testimony in support of
    increased funding in fiscal year 2012 for programs at the Health
    Resources Services Administration (HRSA), the National Institutes of
    Health (NIH), and the Agency for Healthcare Research and Quality
    (AHRQ). AACOM represents the administrations, faculty, and students of
    the Nation's 26 colleges of osteopathic medicine at 34 locations in 26
    States. Today, more than 19,000 students are enrolled in osteopathic
    medical schools. Nearly one in five U.S. medical students is training
    to be an osteopathic physician.
    Title VII
        The health professions education programs, authorized under Title
    VII of the Public Health Service Act and administered through HRSA,
    support the training and education of health practitioners to enhance
    the supply, diversity, and distribution of the healthcare workforce,
    acting as an essential part of the healthcare safety net and filling
    the gaps in the supply of health professionals not met by traditional
    market forces. Title VII and Title VIII nurse education programs are
    the only Federal programs designed to train clinicians in
    interdisciplinary settings to meet the needs of special and underserved
    populations, as well as increase minority representation in the
    healthcare workforce.
        According to HRSA, an additional 33,000 health practitioners are
    needed to alleviate existing health professional shortages. Combined
    with faculty shortages across health professions disciplines, racial
    and ethnic disparities in healthcare, a growing, aging population and
    the anticipated demand for access to care, these needs strain an
    already fragile healthcare system. While AACOM appreciates the
    investments that have been made in these programs, we recommend
    increasing funding to $449.4 million, the same funding level requested
    by the President, in fiscal year 2012 for the Title VII programs.
    Investment in these programs, including the Primary Care Training and
    Enhancement Program, the Health Careers Opportunity Program, and the
    Centers of Excellence, is necessary to address the primary care
    workforce shortage. Strengthening the workforce has been recognized as
    a national priority, and the investment in these programs recommended
    by AACOM will help meet the demand for a well-trained, diverse
    workforce that this country will witness as a result of healthcare
    reform.
    Teaching Health Centers
        The Teaching Health Center Graduate Medical Education Program
    (THCGME) is the first of its kind to shift graduate medical education
    (GME) training to community-based care settings that emphasize primary
    care and prevention. It is uniquely positioned to provide much needed
    primary care training in underserved populations. However, because the
    program is the first of its kind, most community-based settings do not
    have existing infrastructure to provide this training. AACOM strongly
    supports the President's budget request of $10 million to fund the THC
    Development Grants. This funding would allow potential THC training
    sites to develop the infrastructure needed to administer residency
    training programs.
    National Health Service Corps
        Approximately 50 million Americans live in communities with a
    shortage of health professionals, lacking adequate access to primary
    care. Through scholarships and loan repayment, the National Health
    Service Corps (NHSC) supports the recruitment and retention of primary
    care clinicians to practice in underserved communities. At the close of
    fiscal year 2010, the NHSC provided a network of 7,500 primary
    healthcare professionals in 10,000 sites in underserved communities.
    However, this still fell approximately 20,000 practitioners short of
    fulfilling the need for primary care, dental and mental health
    practitioners in Health Professional Shortage Areas (HPSAs). Growth in
    HRSA's Community Health Center Program must be complemented with
    increases in the recruitment and retention of primary care clinicians
    to ensure adequate staffing, which the NHSC provides. AACOM supports
    the President's budget request of $418 million for this program. This
    includes $295 million from the Affordable Care Act (ACA) fund for the
    NHSC and $24.695 million in appropriated dollars for field placements
    and $98.7 million in appropriated dollars for recruitment.
    National Institutes of Health
        Research funded by the NIH leads to important medical discoveries
    regarding the causes, treatments, and cures for common and rare
    diseases, as well as disease prevention. These efforts improve our
    Nation's health and save lives. To maintain a robust research agenda,
    further investment will be needed. AACOM recommends $32 billion in
    fiscal year 2012 for the NIH. While the need is significantly greater,
    approximately $35.0 billion, anything less than the President's request
    will result in a reduction in real dollars dedicated to research.
        With today's increasingly demanding and evolving medical
    curriculum, there is a critical need for more research geared toward
    evidence-based osteopathic medicine. AACOM believes that it is vitally
    important to maintain and increase funding for biomedical and clinical
    research in a variety of areas related to osteopathic principles and
    practice, including osteopathic manipulative medicine and comparative
    effectiveness. In this regard, AACOM supports the President's budget
    request of $131.002 million for NIH's National Center for Complementary
    and Alternative Medicine to continue fulfilling this essential research
    role.
    Agency for Healthcare Research and Quality
        AHRQ supports research to improve healthcare quality, reduce costs,
    advance patient safety, decrease medical errors, and broaden access to
    essential services. AHRQ plays an important role in producing the
    evidence base needed to improve our Nation's health and healthcare. The
    incremental increases for AHRQ's Patient Centered Health Research
    Program in recent years, as well as the funding provided to AHRQ in the
    ARRA, will help AHRQ generate more of this research and expand the
    infrastructure needed to increase capacity to produce this evidence.
    More investment is needed, however, to fulfill AHRQ's mission and
    broader research agenda, especially research in patient safety and
    prevention and care management research. AACOM recommends $405 million
    in fiscal year 2012 for AHRQ. This investment will preserve AHRQ's
    current programs while helping to restore its critical healthcare
    safety, quality, and efficiency initiatives.
        AACOM is grateful for the opportunity to submit its views and looks
    forward to continuing to work with the Subcommittee on these important
    matters.
                                     ______

     Prepared Statement of the American Association of Colleges of Pharmacy
        AACP and its member colleges and schools of pharmacy appreciate the
    continued support of the U.S. House of Representatives Appropriations
    Subcommittee on Labor, Health and Human Services, and Education. Our
    Nation's 124 accredited colleges and schools of pharmacy are engaged in
    a wide-range of programs supported by grants and funding administered
    through the agencies of the Department of Health and Human Services
    (HHS) and the Department of Education. We also understand the difficult
    task you face annually in your deliberations to do the most good for
    the Nation and remain fiscally responsible to the same. AACP
    respectfully offers the following recommendations for your
    consideration as you undertake your deliberations.
      u.s. department of health and human services supported programs at
                        colleges and schools of pharmacy
    Agency for Healthcare Research and Quality (AHRQ)
        AACP supports the Friends of AHRQ recommendation of $405 million
    for AHRQ programs in fiscal year 2012.
        Pharmacy faculty are strong partners with the Agency for Healthcare
    Research and Quality (AHRQ).
      --Vincent J. Willey, Associate Professor at the University of the
            Sciences in Philadelphia, was appointed to the Comparative
            Effectiveness Research Pharmacy Workgroup.
      --AHRQ Effective Healthcare programs including the Center for
            Education and Research on Therapeutics (CERTs) and the
            Developing Evidence to Inform Decisions about Effectiveness (
            DEcIDE) support pharmacy faculty researchers focused on
            improving the effectiveness of healthcare services.
      --Researcher faculty at The University of Arizona College of
            Pharmacy's Center for Health Outcomes and PharmacoEconomic
            Research, support the Arizona CERT and its mission to improve
            therapeutic outcomes and reduce adverse events caused by drug
            interactions and drugs that prolong the QT interval, especially
            those affecting women. Researchers determined that certain drug
            combinations increased the risk of death. Published research
            from this CERT includes the 2010 Women's Health Research:
            Progress, Pitfalls and Promise, for the Institute of Medicine
            and a comparison study on the U.S. Department of Veterans
            Affairs drug-drug interactions compared to two standard
            compendia. #U18 HS17001
      --Almut G. Winterstein, University of Florida, has received a 2-year
            $482,000 award from the Agency for Healthcare Research and
            Quality for ``Comparative Safety and Effectiveness of
            Stimulants in Medicaid Youth with ADHD.'' #5R01HS018506-02
      --Sean D. Sullivan, University of Washington, received a $2.45
            million grant from AHRQ to implement the multidisciplinary
            Mentored Clinical Scientist Comparative Effectiveness Research
            Career Development (K12) Program in collaboration with research
            partners at Group Health Research Institute, the Fred
            Hutchinson Cancer Research Center, and the Veterans'
            Administration Health Services Research and Development Center
            of Excellence. #1K12HS019482-01
      --Daniel C. Malone, University of Arizona, received a 3-year grant
            from AHRQ for $1.25 million, to evaluate awareness of CER
            guides by pharmacists and physicians and identify critical
            skills needed to use these reviews to support and encourage
            safe and effective prescribing of medications. #1R18HS019220-01
    Centers for Disease Control and Prevention (CDC)
        AACP supports the CDC Coalition recommendation of $7.7 billion for
    CDC core programs in fiscal year 2012 and the Friends of NCHS
    recommendation of $162 million for the National Center for Health
    Statistics.
        The educational outcomes of a pharmacist's education include those
    related to public health. When in community-based positions,
    pharmacists are frequently providers of first contact. The opportunity
    to identify potential public health threats through regular interaction
    with patients provides public health agencies such as the CDC with on-
    the-ground epidemiologists. Pharmacy faculty are engaged in CDC-
    supported research in areas such as immunization delivery, integration
    of pharmacogenetics in the pharmacy curriculum and inclusion of
    pharmacists in emergency preparedness. Information from the National
    Center for Health Statistics (NCHS) is essential for faculty engaged in
    health services research and for the professional education of the
    pharmacist.
      --Katie J. Suda, faculty member at the University of Tennessee, was
            supported by CDC funding to conduct a national analysis of
            outpatient anti-infective prescribing patterns. She also
            prepared a continuing education program in partnership with the
            CDC entitled, ``Weighing in on Antibiotic Resistance: Community
            Pharmacists Tip the Scale,'' featured on the CDC Web site:
            http://www.cdc.gov/getsmart/specific-groups/hcp/ce-course.html.
            The program details the CDC's Get Smart program, focused on
            decreasing the amount of unnecessary antibiotics in the
            community.
      --Grace Kuo, Associate Professor of Clinical Pharmacy at the
            University of California San Diego, founded
            PharmGenEdTM, an evidence-based pharmacogenomics
            education program designed for pharmacists and physicians,
            pharmacy and medical students, and other healthcare
            professionals and is supported by funding from CDC.
            #IU38GD000070
    Health Resources and Services Administration (HRSA)
        AACP supports the Friends of HRSA recommendation of $7.65 billion
    for fiscal year 2012.
        HRSA is a Federal agency with a wide-range of policy and service
    components. Faculty at colleges and schools of pharmacy are integral to
    the success of many of these. Colleges and schools of pharmacy are the
    administrative units for interprofessional and community-based linkages
    programs including geriatric education centers and area health
    education centers. Pharmacy faculty research issues related to rural
    health delivery. Student pharmacists benefit from diversity program
    funding including Scholarships for Disadvantaged Students.
                Office of Pharmacy Affairs
        AACP recommends a program funding of $5 million for fiscal year
    2012 for the Office of Pharmacy Affairs.
        AACP member institutions are actively engaged in Office of Pharmacy
    Affairs (OPA) efforts to improve the quality of care for patients in
    federally qualified health centers and entities eligible to participate
    in the 340B drug discount program. The success of the HRSA Patient
    Safety and Clinical Pharmacy Collaborative is a direct result of past
    OPA actions linking colleges and schools of pharmacy with federally
    qualified health centers. The result of these links has been the
    establishment of medical homes that improve health outcomes for
    underserved and disadvantaged patients through the integration of
    clinical pharmacy services.
                Office of Telehealth Advancement
        Technology is an important component for improving healthcare
    quality and maintaining or increasing access to care. Colleges and
    schools of pharmacy utilize technology to increase access to care,
    improve care quality and to increase the reach of education to student
    and practicing pharmacists.
      --Keri H. Naglosky, Marcia M. Worley, Timothy P. Stratton and Randall
            D. Seifert University of Minnesota, received a $63,000 grant
            for their study, ``Pilot Study to Determine the Effectiveness
            of Pharmacist Provided MTM Using Face-to-Face and TeleMTM in
            the Treatment of Long-Haul Drivers with Hypertension Department
            of Transportation Classifications Stage 1, 2 and 3.''
      --Leigh Ann Ross and Sarah Fontenot, faculty at the University of
            Mississippi, work with The Delta Health Alliance on many
            projects including its HRSA telehealth grant and as members of
            the HRSA Patient Safety Collaborative, receiving the Clinical
            Pharmacy Services Improvement Award in 2010. Five Delta
            hospitals have telemedicine capabilities as a result of its
            funding and 86,083 individuals received medical or health
            education services during the 2009-2010 fiscal year.
            #H2AIT16626
                Poison Control Centers
        HRSA grant funding supports the management of 10 of the 57 poison
    control centers by pharmacy faculty.
      --In 2010, the Maryland Poison Center, headed by Bruce Anderson,
            faculty at the University of Maryland, answered 36,000 human
            exposure calls, 2,000 animal exposures and 25,000 requests
            for poison or drug information and over 70 percent of the human
            exposure calls were managed on site, avoiding treatment at a
            healthcare facility. This year, Paul Starr, also at the
            University of Maryland, was recognized for his 20 years as a
            certified specialist in poison information. #H4BHS15526
                Bureau of Health Professions (BHPr)
        AACP supports the Health Professions and Nursing Education
    Coalition (HPNEC) recommendation of $762.5 million for Title VII and
    VIII programs in fiscal year 2012.
        AACP member institutions are active participants in BHPr programs.
    Two colleges of pharmacy are current grantees in the Centers of
    Excellence program (Xavier University School of Pharmacy). This program
    focuses on increasing the number of underserved individuals attending
    health professions institutions. Colleges and schools of pharmacy are
    also part of Title VII interprofessional and community-based linkages
    programs including Geriatric Education Centers and Area Health
    Education Centers. These programs are essential for creating the
    educational approaches necessary for the Institute of Medicine's
    recommendations of improving quality through team-based, patient-
    centered care and serve as valuable experiential education sites for
    student pharmacists.
      --Gayle A. Hudgins, faculty at the University of Montana, was awarded
            an ARRA supplement of $132,446 from HRSA, Bureau of Health
            Professions, for equipment to enhance training for health
            professionals.
    Food and Drug Administration (FDA)
        AACP recommends a funding level of $3.7 billion for FDA programs in
    fiscal year 2012.
        The FDA sees the colleges and schools of pharmacy as essential
    partners in assuring the public has access to a healthcare professional
    well versed in the science of safety. Pharmacy faculty partner with the
    FDA to improve the drug manufacturing process through the National
    Institute for Pharmaceutical Technology and Education (NIPTE) and
    increase the science-base for decisions regarding drug and device
    safety and effectiveness.
      --Dianne M. Cappelletty, Associate Professor at The University of
            Toledo, was recently appointed to serve on the advisory
            committee to the Division of Anti-Infective and Ophthalmology
            Products.
      --James E. Polli, University of Maryland, received $1,099,990 from
            the FDA for ``Pharmacokinetic Studies of Epileptic Drugs:
            Evaluation of Brand & Generic Antiepileptic Drug Products in
            Patients.''
    National Institutes of Health (NIH)
        AACP supports the Ad Hoc Group for Medical Research recommendation
    of $35 billion for fiscal year 2012.
        Pharmacy faculty are supported in their research by nearly every
    institute at the NIH. The NIH-supported research at AACP member
    institutions spans theresearch spectrum from the creation of new
    knowledge through the translation of that new knowledge to providers
    and patients. In 2010, pharmacy faculty researchers received more than
    $358 million in grant support from the NIH. AACP member institutions
    are concerned, as are other health professions education organizations,
    of the need to increase the number of biomedical researchers.
      --At the University of California, San Francisco, Kathleen M.
            Giacomini and co-lead Deanna L. Kroetz received $15.1 million
            in funding over the next 5 years from the NIH for research into
            the genetics behind membrane transporters and a branch project
            from that research that will focus on the genetic factors that
            determine responses to the anti-diabetic drug, metformin in
            African American patients with type 2 diabetes. #2U19GM061390-
            11
      --Alice M. Clark and Ameeta K. Agarwal, University of Mississippi,
            received $388,221 from the National Institute of Allergy and
            Infectious Diseases to study New Drugs for Opportunistic
            Infections. #5R01AI027094-21
      --Eugene D. Morse, the University at Buffalo, received two grants:
            $952,000 in funding for, ``Clinical Pharmacology Quality
            Assurance and Quality Control'' funded by the National
            Institute of Allergies and Infectious Diseases/Division of AIDS
            and $2.3 Million for, ``Clinical Pharmacology Lab from NIH to
            Promote HIV Research in Africa.'' #272200800019C-4-0-1
      --Jordan K. Zjawiony and Charles L. Burandt, the University of North
            Carolina, received $71,500 from the NIH to study Chemistry and
            Pharmacology of Newly Emerging Psychoactive Plants-Year 2.
            #5R03DA023491-02
    u.s. department of education supported programs at colleges and schools
                                  of pharmacy
        AACP supports the Student Aid Alliance's recommendations for:
      --Pell Grant maximum be maintained at $5,550;
      --Gaining Early Awareness and Readiness for Undergraduate Programs
            (GEAR UP) should be funded at $333 million; and
      --Maintaining the in-school interest subsidy for graduate program
            loans.
        AACP recommends a funding level of $160 million for the Fund for
    the Improvement of Post Secondary Education (FIPSE).
        The Department of Education supports the education of healthcare
    professionals by:
      --assuring access to education through student financial aid
            programs;
      --supporting educational research allows faculty to determine
            improvements in educational approaches; and
      --maintaining the oversight of higher education through the approval
            of accrediting agencies.
        AACP actively supports increased funding for undergraduate student
    financial assistance programs. Admission to into the pharmacy
    professional degree program requires at least 2 years of undergraduate
    preparation. Student financial assistance programs are essential to
    assuring colleges and schools of pharmacy are accessible to qualified
    students. Likewise, financial assistance programs that support graduate
    education are an important component meeting our Nation's need for
    scientists and educators.
                                     ______

        Prepared Statement of the American Association of Immunologists
        The American Association of Immunologists (AAI), a not-for-profit
    professional association representing more than 7,000 of the world's
    leading experts on the immune system, appreciates having this
    opportunity to submit testimony regarding fiscal year 2012
    appropriations for the National Institutes of Health (NIH). The vast
    majority of AAI members, whose crucially important discoveries help to
    prevent, treat and cure disease, depends on NIH funding to support
    their work.\1\
    ---------------------------------------------------------------------------
        \1\ AAI members work in academia, government, and industry. Many
    members receive grants from the National Institute of Allergy and
    Infectious Diseases, the National Cancer Institute, the National
    Institute on Aging, and the National Institute of Arthritis and
    Musculoskeletal and Skin Diseases, as well as other NIH Institutes and
    Centers.
    ---------------------------------------------------------------------------
        For more than 50 years, NIH has been envy of the world and has been
    instrumental in promoting science, better health, and discovery. Unlike
    many Federal agencies, NIH distributes most of its funding to
    scientists working in all 50 States. In fact, about 80 percent of the
    $31.2 billion NIH budget is awarded to scientists working at research
    institutions throughout the United States, making NIH funding the
    foundation of our Nation's biomedical research infrastructure and a key
    factor in local and national economic growth.\2\ In addition to its
    positive economic impact on a community, NIH funding supports highly
    skilled jobs that focus on improving human health.\3\ NIH funding also
    helps train the next generation of inventors and innovators, crucial to
    the nation's future job creation and pipeline of new therapeutics.
    ---------------------------------------------------------------------------
        \2\ NIH funding supports ``almost 50,000 competitive grants to more
    than 325,000 researchers at over 3,000 universities, medical schools,
    and other research institutions in every State and around the world.''
    See http://www.nih.gov/about/budget.htm (3/9/11). According to NIH
    Director Francis Collins M.D., Ph.D., ``every dollar that NIH gives out
    in a grant returns over $2 in investments in terms of economic goods
    and services that are produced within just 1 year.'' ``Francis S.
    Collins,'' April 26, 2010, http://pubs.acs.org/cen/coverstory/88/
    8817cover.html.
        \3\ ``[E]very grant that NIH gives creates seven high-quality,
    high-paying jobs that sustain American leadership in science.''
    ``Francis S. Collins,'' April 26,2010, http://pubs.acs.org/cen/
    coverstory/88/8817cover.html.
    ---------------------------------------------------------------------------
    The role of the immune system
        The immune system's job is to protect its human or animal host from
    a wide range of infectious and chronic diseases. When the immune system
    works, the host remains healthy. But many infectious diseases,
    including influenza, HIV/AIDS, malaria, tuberculosis, salmonella, and
    the common cold, challenge and sometimes overcome the defenses mounted
    by the immune system. And many chronic diseases, including cancer,
    diabetes, multiple sclerosis, rheumatoid arthritis, asthma,
    inflammatory bowel disease, and lupus, are either caused by--or due in
    large part to--an overactive (autoimmune) or underactive immune
    response.\4\ Advances in immunological research have already yielded
    progress in preventing, diagnosing, and treating some of these
    diseases, but further progress depends on increased knowledge in the
    field of immunology.
    ---------------------------------------------------------------------------
        \4\ The immune system works by recognizing and attacking bacteria
    and viruses inside the body and by controlling the growth of tumor
    cells. A healthy immune system can protect its human or animal host
    from illness or disease either entirely--by destroying the virus,
    bacterium, or tumor cell--or partially, resulting in a less serious
    illness. It is also responsible for the rejection response following
    transplantation of organs or bone marrow. The immune system can also
    malfunction, causing the body to attack itself, resulting in an
    ``autoimmune'' disease, such as Type 1 diabetes, multiple sclerosis,
    lupus or rheumatoid arthritis.
    ---------------------------------------------------------------------------
        A young and evolving discipline,\5\ immunology has already answered
    many key questions and is now needed to explore urgent new challenges
    to community and global health, including understanding the human and
    animal immune response to: (1) pathogens that threaten to become the
    next pandemic, (2) man-made and natural infectious organisms that are
    potential agents of bioterrorism (including plague, smallpox, and
    anthrax),\6\ (3) environmental threats, and (4) cancer. While
    researchers and public health professionals must respond quickly to
    these emergent threats, AAI believes that the best preparation is to
    support consistent, ongoing research rather than to ``ramp up''
    research in times of emergency.\7\
    ---------------------------------------------------------------------------
        \5\ 5 Although the first vaccine (against smallpox) was developed
    in 1798, most of our basic understanding of the immune system has
    developed in the last 50 years, and the pace of discovery is rapidly
    increasing.
        \6\ To best protect against bioterrorism, scientists should focus
    on basic research, including working to understand the immune response,
    identifying new and potentially modified pathogens, and developing
    tools (including new and more potent vaccines) to protect against these
    pathogens.
        \7\ For example, to best protect against a pandemic, scientists
    should focus on basic research to combat seasonal flu, including
    building capacity, pursuing new production methods, and seeking
    optimized flu vaccines and delivery methods.
    ---------------------------------------------------------------------------
    Recent advances in immunological research
        Immunological research has led to unprecedented medical advances in
    recent years, including new treatments for lupus and malignant
    melanoma, and new vaccines against influenza and cervical cancer.
        The value of vaccination against disease and the importance of
    continued research and evaluation cannot be overstated. Recent
    expansion of the influenza vaccine to all U.S. children ``may induce
    herd immunity against influenza for older adults and has the potential
    to be more beneficial to older adults than the existing policy of
    preventing influenza by vaccinating older adults themselves.'' \8\ A
    recent study has shown the efficacy of vaccinating older adults,
    whether healthy or with chronic diseases, against shingles, a painful
    blistering skin rash caused by the varicella-zoster virus, the virus
    that causes chickenpox.\9\ Most recently, a new vaccine against
    rotavirus has greatly reduced hospital admissions in the United States
    in babies with infectious diarrhea and markedly decreased deaths in
    infants in the developing world.\10\ Thousands of children will not die
    due to the results of immunological and infectious disease research
    originally funded by the NIH on this killer virus.
    ---------------------------------------------------------------------------
        \8\ Cohen SA, Chui K, Naumova E, ``Influenza Vaccination in Young
    Children Reduces Influenza-associated Hospitalizations in Older Adults,
    2002-2006,'' Journal of the American Geriatrics Society, 2011;
    59(2):327-332.
        \9\ Tseng HF, Smith N, Harpaz R, Bialek SR, Sy LS, Jacobsen SJ,
    ``Herpes zoster vaccine in older adults and the risk of subsequent
    herpes zoster disease,'' Journal of the American Medical Association,
    2011 Jan 12; 305(2):160-166.
        \10\ Esposito DH, Tate JE, Kang G, Parashar UD, ``Projected impact
    and cost-effectiveness of a rotavirus vaccination program in India,
    2008,'' Clinical Infectious Diseases, 2011; 52 (2):171-177. Gagneur A,
    Nowak E, Lemaitre T, Segura JF, Delaperriere N, Abalea L, Poulhazan E,
    Jossens A, Auzanneau L, Tran A, Payan C, Jay N, de Parscau L, Oger E,
    ``Impact of rotavirus vaccination on hospitalizations for rotavirus
    diarrhea: The IVANHOE study,'' Vaccine, 2011 March 25, doi:10.1016/
    j.vaccine.2011.03.035.
    ---------------------------------------------------------------------------
        Recently, immunologists have advanced the understanding of the
    exquisitely precise regulation of the immune system and are very
    hopeful that this understanding will allow for therapeutic manipulation
    of the immune system. This important discovery about immune-system
    regulation could lead to new approaches for the prevention and
    treatment of numerous autoimmune diseases, including lupus (systemic
    lupus erythematosus),\11\ a serious chronic autoimmune disease
    affecting about 1.5 million Americans. Finally, new monoclonal
    antibodies (highly specific immune molecules) that block the immune
    response of people with autoimmune diseases (in which one's immune
    system attacks one's own body) show enormous promise in improving these
    debilitating diseases.
    ---------------------------------------------------------------------------
        \11\ Kim HJ, Verbinnen B, Tang X, Linrong L, Cantor H, ``Inhibition
    of follicular T-helper cells by CD8+ regulatory T cells is essential
    for self tolerance,'' Nature, 2010 July 22; 467: 328-322.
    ---------------------------------------------------------------------------
    Sustaining NIH Funding in a Difficult Fiscal Climate
        AAI greatly appreciates the strong historical support of this
    subcommittee for biomedical research, from doubling the NIH budget
    (fiscal year 1999 to fiscal year 2003), to passing the Appropriations
    Acts for fiscal year 2009 and 2010, to including in the American
    Recovery and Reinvestment Act of 2009 (``ARRA'') a $10.4 billion
    supplemental appropriation for NIH. As a result of this generous
    support, NIH has been able to fund many excellent, innovative projects
    with great promise for advancing human health, and to invest in the
    Nation's research infrastructure. AAI--and the entire biomedical
    research community--are deeply grateful for this support and for the
    subcommittee's strong bipartisan commitment to advancing medical
    research. And yet, AAI comes to you this year deeply concerned about
    efforts to cut, rather than invest in, the NIH budget. Imminent
    advances may not come to fruition if the fiscal year 2012
    appropriations level is unable to support NIH's current functional
    capacity ($34.4 billion), made possible in large part by this
    subcommittee's prior support. AAI remains concerned that investment in
    biomedical research continues unfettered by our global competitors,
    while our challenged budget makes it difficult for us to attract the
    best and brightest to these crucial scientific fields. The AAI funding
    recommendation for fiscal year 2012 is premised on these concerns.
    NIH Funding for Fiscal Year 2012
        AAI greatly appreciates the President's proposed increase for NIH
    for fiscal year 2012 ($31.98 billion, or 4 percent increase over the
    regular fiscal year 2011 appropriations level). More is required,
    however, for NIH to be able to support existing research projects and
    fund a reasonable number of excellent new ones. AAI therefore urges the
    subcommittee to provide NIH with a fiscal year 2012 budget of $35
    billion to enable NIH to maintain its current functional capacity and
    to provide a small funding boost for important new research. Sustained
    funding, particularly in this challenging fiscal climate, would not
    only stabilize ongoing research projects and the overall research
    enterprise, but also inspire confidence in the system among many of our
    brightest young students who are considering (but due to such limited
    grant funding, are fearful to begin) careers in biomedical research.
    NIH priorities for Fiscal Year 2012
        AAI believes strongly that the engine for biomedical innovation and
    discovery is individual investigator-initiated research. Researchers
    working in laboratories around the country, with their scientific
    collaborators around the world, are the best source of scientific
    advancement and progress. ``Top-down'' science, where Government
    directives force the research in specified directions, is less likely
    to achieve the desired goals than funding the best, most promising,
    ripest grant applications.
        AAI strongly supports the President's request for a $436 million
    increase in funding for individual research project grants (RPGs) that
    fund individual scientists. Unfortunately, this increase will only
    support approximately 43 additional RPGs. AAI notes that the
    President's budget includes $100 million to establish the Cures
    Acceleration Network (CAN). AAI recommends a significantly smaller
    appropriation for the first year of this program, with the remainder
    going to support additional RPGs.
        AAI supports the President's request for $300 million for the
    Global Fund to Fight AIDS, Tuberculosis, and Malaria--infectious
    diseases which devastate people and communities around the world.
        AAI supports the President's proposed 4 percent increase for the
    National Research Service Awards, a long-needed training stipend
    increase for young scientists who are the next generation of research
    leaders.
        AAI urges this subcommittee to do all it can to reduce the time-
    consuming, distracting, and unnecessary administrative burden that too
    often accompanies the receipt of Government funds.
        AAI recommends strongly against any legislative effort to determine
    the size and number of NIH grants. Such a decision should be a
    scientific one made by NIH.
        AAI supports the President's request for $1.538 billion for NIH
    Research, Management, and Services (RM&S) to fund the management,
    monitoring, and oversight of all research activities. Only through
    adequate funding of this account will NIH be able to supervise and
    oversee its large and complex portfolio.
    The NIH Public Access Policy
        AAI requests that the subcommittee require NIH to publicly report
    on the current and historical cost of the NIH Public Access Policy
    (``Policy''), and receive the response of private scientific publishers
    to this information. AAI continues to believe that the Policy
    duplicates publications and services which are already provided cost-
    effectively and well by the private sector, including not-for-profit
    scientific societies. AAI and other private sector publishers already
    publish--and make publicly available--thousands of scientific journals
    with millions of articles that report cutting-edge research funded by
    NIH and other entities. AAI urges that the subcommittee require NIH to
    partner with, rather than compete with, private publishers to enhance
    public access while addressing publishers' key concerns, including
    respecting copyright law and ensuring journals' continued ability to
    provide quality, independent peer review of NIH-funded research.
    Conclusion
        AAI thanks the subcommittee for its strong support for biomedical
    research, the NIH, and the biomedical researchers who devote their
    lives to scientific discovery and the prevention, treatment, and cure
    of disease.
                                     ______

      Prepared Statement of the American Association of Nurse Anesthetists

                                     FISCAL YEAR 2012 APPROPRIATIONS REQUEST SUMMARY
    ----------------------------------------------------------------------------------------------------------------
                                                                              Fiscal year--
                                                                 --------------------------------------- AANA fiscal
                                                                                                2012      year 2012
                                                                  2010 actual  2011 budget     budget      request
    ----------------------------------------------------------------------------------------------------------------
    HHS/HRSA/BHPr Title VIII Advanced Education Nursing, Nurse    \1\ $3,500,      ( \2\ )      ( \2\ )  \3\ $4,000,
     Anesthetist Education Reserve..............................          000                                    000
    Total for Advanced Education Nursing, from Title VIII.......   64,440,000   64,440,000  104,438,000  104,438,000
    Title VIII HRSA BHPr Nursing Education Programs.............  243,872,000  243,872,000  313,075,000  313,075,000
    CDC/Division of Healthcare Quality and Promotion............  ...........  ...........      ( \4\ )      ( \4\ )
    ----------------------------------------------------------------------------------------------------------------
    \1\ Awards amounted to approximately.
    \2\ Grant allocations not specified.
    \3\ For nurse anesthesia education.
    \4\ Maintain level funding.

        The American Association of Nurse Anesthetists (AANA) is the
    professional association for the 44,000 Certified Registered Nurse
    Anesthetists (CRNAs) and student nurse anesthetists practicing today,
    representing over 90 percent of the nurse anesthetists in the United
    States. Today, CRNAs deliver approximately 32 million anesthetics to
    patients each year in the United States. CRNA services include
    administering the anesthetic, monitoring the patient's vital signs,
    staying with the patient throughout the surgery, and providing acute
    and chronic pain management services. CRNAs provide anesthesia for a
    wide variety of surgical cases and in some States are the sole
    anesthesia providers in 100 percent of rural hospitals, affording these
    medical facilities obstetrical, surgical, and trauma stabilization, and
    pain management capabilities. CRNAs work in every setting in which
    anesthesia is delivered, including hospital surgical suites and
    obstetrical delivery rooms, ambulatory surgical centers (ASCs), pain
    management units and the offices of dentists, podiatrists and plastic
    surgeons. Nurse anesthetists are experienced and highly trained
    anesthesia professionals whose record of patient safety in the field of
    anesthesia was bolstered by the Institute of Medicine report in 2000,
    which found that anesthesia is 50 times safer than in the 1980s. (Kohn
    L, Corrigan J, Donaldson M, ed. To Err is Human. Institute of Medicine,
    National Academy Press, Washington DC, 2000.) Nurse anesthetists
    continue to set for themselves the most rigorous continuing education
    and re-certification requirements in the field of anesthesia. Relative
    anesthesia patient safety outcomes are comparable among nurse
    anesthetists and anesthesiologists, with a recent Health Affairs
    article, ``No Harm Found When Nurse Anesthetists Work without
    Supervision by Physicians'' finding that adverse outcomes were no more
    prevalent in States that opted out of the Medicare physician
    supervision requirement of nurse anesthetists than those States that
    didn't opt-out (Dulisse B, Cromwell J. No Harm Found When Nurse
    Anesthetists Work Without Supervision By Physicians. Health Aff.
    2010;29(8):1469-1475).
        In addition, a study published in Nursing Research indicates that
    obstetrical anesthesia, whether provided by CRNAs or anesthesiologists,
    is extremely safe, and there is no difference in safety between
    hospitals that use only CRNAs compared with those that use only
    anesthesiologists. (Simonson, Daniel C et al. Anesthesia Staffing and
    Anesthetic Complications During Cesarean Delivery: A Retrospective
    Analysis. Nursing Research, Vol. 56, No. 1, pp. 9-17. January/February
    2007). In addition, a recent AANA workforce study showed that CRNAs and
    anesthesiologists are substitutes in the production of surgeries.
    Through continual improvements in research, education, and practice,
    nurse anesthetists are vigilant in our efforts to ensure patient
    safety.
        CRNAs provide the lion's share of anesthesia care required by our
    U.S. Armed Forces through active duty and the reserves. For decades,
    CRNAs have staffed ships, remote U.S. military bases, and forward
    surgical teams without physician anesthesiologist support. In addition,
    CRNAs predominate in rural and medically underserved areas, and where
    more Medicare patients live.
    Importance of Title VIII Nurse Anesthesia Education Funding
        The nurse anesthesia profession's chief request of the Subcommittee
    is for $4 million to be reserved for nurse anesthesia education and
    $104.438 million for advanced education nursing from the Title VIII
    program. We feel that this funding request is well justified, as we
    know that more baby boomers retiring will not only reduce our nurse
    workforce from retirements but will increase the demand from an aging
    population requiring care. The Title VIII program is an effective means
    to help address the nurse anesthesia workforce demand.
        Increasing funding for advanced education nursing from $64.44
    million in fiscal year 2010 to $104.438 million is necessary to meet
    the continuing demand for nursing faculty and other advanced education
    nursing services throughout the United Staes. The program provides for
    competitive grants that help enhance advanced nursing education and
    practice and traineeships for individuals in advanced nursing education
    programs. This funding is critical to meet the nursing workforce needs
    of Americans who require healthcare, particularly as we see more
    patients enter the system with health reform. More APRNs will be needed
    to fill the gap to ensure access to care. In addition, this funding
    provides a two-fold benefit for the nurse workforce. It not only seeks
    to increase the number of providers in rural and underserved America
    but also prepares providers at the master's and doctoral levels,
    increasing the number of clinicians who are eligible to serve as
    faculty.
        There continues to be high demand for CRNA workforce in clinical
    and educational settings. The supply of clinical providers has
    increased in recent years, stimulated by increases in the number of
    CRNAs trained. Between 2000-2009, the number of nurse anesthesia
    educational program graduates doubled, with the Council on
    Certification of Nurse Anesthetists (CCNA) reporting 1,075 graduates in
    2000 and 2,375 graduates in 2010. This growth is leveling off somewhat,
    but is expected to continue. However, even though the number of
    graduates has doubled in 8 years, the demand for nurse anesthetists
    continues to rise as the population ages, the number of clinical sites
    requiring anesthesia services grows, and CRNA retirements increase.
        The problem is not that our 111 accredited programs of nurse
    anesthesia are failing to attract qualified applicants. It is that they
    have to turn them away by the hundreds. The capacity of nurse
    anesthesia educational programs to educate qualified applicants is
    limited by the number of faculty, the number and characteristics of
    clinical practice educational sites, and other factors. A qualified
    applicant to a CRNA program is a bachelor's educated registered nurse
    who has spent at least 1 year serving in an acute care healthcare
    practice environment.
        Recognizing the important role nurse anesthetists play in providing
    quality healthcare, the AANA has been working with the 111 accredited
    nurse anesthesia educational programs to increase the number of
    qualified graduates. In addition, the AANA has worked with nursing and
    allied health deans to develop new CRNA programs. To truly meet the
    nurse anesthesia workforce challenge, the capacity and number of CRNA
    schools must continue to grow. With the help of competitively awarded
    grants supported by Title VIII funding, the nurse anesthesia profession
    is making significant progress, expanding both the number of clinical
    practice sites and the number of graduates.
        The AANA is pleased to report that this progress is extremely cost-
    effective from the standpoint of Federal funding. Anesthesia can be
    provided by nurse anesthetists, physician anesthesiologists, or by
    CRNAs and anesthesiologists working together. As mentioned earlier, the
    Health Affairs study by Dulisse and Cromwell indicates the safety of
    CRNA care. Another study published recently in Nursing Economic$
    indicates that costs of educating and training a CRNA from
    undergraduate education through graduate education is roughly 15
    percent of the cost of educating and training an anesthesiologist
    (Hogan, PF, Seifert RF, Moore CS, Simonson BE, Cost Effectiveness
    Analysis of Anesthesia Providers, Nurs Econ. 2010;28(3): 150-169.) This
    study also found that among anesthesia delivery models, CRNAs acting
    independently provide anesthesia services at the lowest economic cost;
    costs for this model are 25 percent less than the second lowest cost
    model in which an anesthesiologist supervises six CRNAs. Nurse
    anesthesia education represents a significant educational cost-benefit
    for supporting CRNA educational programs with Federal dollars vs.
    supporting other, more costly, models of anesthesia education.
        To further demonstrate the effectiveness of the Title VIII
    investment in nurse anesthesia education, the AANA surveyed its CRNA
    program directors to gauge the impact of the Title VIII funding. Of the
    eleven schools that had reported receiving competitive Title VIII Nurse
    Education and Practice Grants funding from 1998 to 2003, the programs
    indicated an average increase of at least 15 CRNAs graduated per year.
    They also reported on average more than doubling their number of
    graduates. Moreover, they reported producing additional CRNAs that went
    to serve in rural or medically underserved areas.
        We believe the Subcommittee should allocate $4 million for nurse
    anesthesia education for several reasons. First, as this testimony has
    documented, the funding is cost-effective and needed. Second, this
    particular funding meets a distinct need not met elsewhere; nurse
    anesthesia for rural and medically underserved America is not affected
    by increases in the budget for the National Health Service Corps and
    community health centers, since those initiatives are for delivering
    primary and not surgical healthcare. Third, this funding meets an
    overall objective to increase access to quality healthcare in medically
    underserved America.
    Title VIII Funding for Strengthening the Nursing Workforce
        The AANA joins The Nursing Community and the Americans for Nursing
    Shortage Relief (ANSR) Alliance in support of the Subcommittee
    providing a total of $313.075 million in fiscal year 2012 for nursing
    shortage relief through Title VIII. AANA asks that of the $313.075
    million, $104.438 million go to Advanced Education Nursing and $4
    million go to nurse anesthesia education to help increase clinicians in
    underserved communities and those eligible to serve as faculty. The
    AANA appreciates the support for nurse education funding in fiscal year
    2010 and past fiscal years from this Subcommittee and from the
    Congress.
        In the interest of patients past and present, particularly those in
    rural and medically underserved parts of this country, we ask Congress
    to invest in CRNA and nursing educational funding programs and to
    provide these programs the sustained increases required to help ensure
    Americans get the healthcare that they need and deserve. Quality
    anesthesia care provided by CRNAs saves lives, promotes quality of
    life, and makes fiscal sense. This Federal support for Title VIII and
    advanced education nurses will improve patient access to quality
    services and strengthen the Nation's healthcare delivery system.
    Safe Injection Practices
        As a leader in patient safety, the AANA has been playing a vigorous
    role in the development and projects of the Safe Injection Practices
    Coalition, intended to reduce and eventually eliminate the incidence of
    healthcare facility acquired infections. Provider education and
    awareness, detection, tracking and response are all extremely important
    to preventing healthcare-associated infections. In the interest of
    promoting safe injection practice and reducing the incidence of
    healthcare facility acquired infections, we recommend the Committee
    maintain its level of funding for CDC's Division of Healthcare Quality
    and Promotion so they can address outbreaks and promote innovative ways
    to adhere to injection safety and infection control guidelines. We also
    hope the committee will support the CDC's efforts around provider
    education and patient awareness activities, as this issue transcends
    provider type and it's important to educate all types of providers and
    patients alike. In light of the recent healthcare-associated
    transmission of blood-borne pathogens in California, North Carolina,
    Florida, Colorado, and Nevada, the CDC needs resources to use the
    knowledge they have gained on detection and be able to develop new
    strategies to prevent healthcare associated transmission of blood borne
    pathogens.
                                     ______

       Prepared Statement of the American Congress of Obstetricians and
                                 Gynecologists
        The American Congress of Obstetricians and Gynecologists,
    representing 54,000 physicians and partners in women's healthcare, is
    pleased to offer this statement to the Senate Committee on
    Appropriations, Subcommittee on Labor, Health and Human Services, and
    Education. We thank Chairman Harkin, and the entire Subcommittee for
    the opportunity to provide comments on important programs to women's
    health. Today, the United States lags behind other nations in healthy
    births, yet remains high in birth costs. ACOG's Making Obstetrics and
    Maternity Safer (MOMS) Initiative seeks to improve maternal outcomes
    through more research and better data, and we urge you to make this a
    top priority in fiscal year 2012.
        Research is critically needed to understand why our maternal and
    infant mortality rate remains comparatively high. Having better data
    collection methods and comprehensive maternal mortality reviews has
    shown maternal mortality rates in some States, such as California, to
    be higher than previously thought. States without these resources are
    likely underreporting maternal and infant deaths and complications from
    childbirth. Without accurate data, the full range of causes of these
    deaths remains unknown. Effective research based on comprehensive data
    is a key MOMS element to developing and implementing evidence-based
    interventions.
        The President's budget for fiscal year 2012 takes a positive first
    step toward this goal, including a $1 billion increase for NIH, and
    ACOG requests the Subcommittee build on these increases to sustain the
    investment for women's health. Please note that given the current
    fiscal climate, our requests are more conservative this year and do not
    reflect the actual need in the health community. ACOG asks for a 1.7
    percent increase over fiscal year 2010 to the NICHD within NIH to
    $1.352 billion, a 2.3 percent increase for HRSA to $7.65 billion, a 19
    percent increase for CDC to $7.7 billion, and a 2 percent increase for
    AHRQ to $405 million.
        Funding of research and programs in the following areas are vital
    to the MOMS Initiative:
    Maternal Mortality Reviews at HHS
        National data on maternal mortality is inconsistent and incomplete
    due to the lack of standardized reporting definitions and mechanisms.
    To capture the accurate number of maternal deaths and plan effective
    interventions, maternal mortality should be addressed through multiple,
    complementary strategies. ACOG recommends that HHS fund States in
    implementing maternal mortality reviews that would allow them to
    conduct regular reviews of all deaths within the State to identify
    causes, factors in the communities, and strategies to address the
    issues. Combined with adoption of the recommended birth and death
    certificates in all States and territories, CDC could then collect
    uniform data to calculate an accurate national maternal mortality rate.
    Results of maternal mortality reviews will inform research needed to
    identify evidence based interventions addressing causes and factors of
    maternal mortality and morbidity.
        ACOG urges Congress to provide $10 million to Health and Human
    Services to assist States in setting up maternal mortality reviews.
    ACOG also urges Congress to provide $50,000 to NIH to hold a workshop
    to identify definitions for severe maternal morbidity and $100,000 to
    HHS to develop a research plan to identify and monitor severe maternal
    morbidity.
    Maternal/Child Health Research at the NIH
        The Eunice Kennedy Shriver National Institute of Child Health and
    Human Development (NICHD) conducts the majority of women's health
    research. Despite the NIH's critical advancements, reduced funding
    levels have made it difficult for research to continue.
        ACOG supports a 1.7 percent increase in funds over fiscal year 2010
    to $1.352 billion for the NICHD. A modest increase, these funds will
    assist the following research areas critical to the MOMS Initiative:
        Reducing the Prevalence of Premature Births.--There is a known link
    between pre-term birth and infant mortality, and women of color are at
    increased risk for delivering pre-term. NICHD is helping our Nation
    understand how adverse conditions and health disparities increase the
    risks of premature birth in high-risk racial groups, and how to reduce
    these risks. Prematurity rates have increased almost 35 percent since
    1981, accounting for 12.5 percent of all births, yet the causes are
    unknown in 25 percent of cases. Preterm births cost the Nation $26
    billion annually, $51,600 for every infant born prematurely. Direct
    healthcare costs to employers for a premature baby average $41,610, 15
    times higher than the $2,830 for a healthy, full-term delivery.
        Additional research is critically needed to understand how we can
    drive down our prematurity rates and NICHD conducts the majority of
    this research. For example, a 2003 NICHD study showed that progesterone
    supplementation reduces preterm birth in a select group of women,
    paving the way for its widespread clinical use. Today, around 139,000
    (3.3 percent) women are candidates for this therapy. Among these women,
    22 percent, or about 30,500, are likely to have a recurrent preterm
    birth without this treatment. With treatment, about one-third, or
    10,000, of these preterm births can be prevented. The prevention of all
    10,000 preterm births would result in direct medical cost savings of
    $334 million and total medical cost savings of $519 million. However,
    further studies are needed to determine if progesterone therapy can be
    designed to help prevent preterm delivery in other ways, including
    optimal preparation, dosage, and route of administration. The high cost
    of prematurity and past successful research at NICH highlights the need
    to sustain investments to reduce the rate of prematurity.
        ACOG supports the Surgeon General's effort to make the prevention
    of pre-term birth a national public health priority, and urges Congress
    to allocate $1 million to NICHD to create a Trans-disciplinary Research
    Center on Prematurity to help streamline efforts to reduce pre-term
    births.
        Obesity Research, Treatment and Prevention.--Obese pregnant women
    are at higher risk for poor maternal and neonatal outcomes. Additional
    research and interventions are needed to address the increased risk for
    poor outcomes in obese women receiving infertility treatment, the
    increased incidence of birth defects and stillbirths in obese pregnant
    women, ways to optimize outcomes in obese women who become pregnant
    after bariatric surgery, and the increased future risk of childhood
    obesity in their offspring.
        ACOG is grateful to the NIH for making obesity a priority and
    initiating trans-disciplinary approaches to combat obesity. The recent
    release of the Strategic Plan for NIH Obesity Research offers some
    innovative and promising directions for obesity research, and sustained
    funding is critical to implement the plan.
        Training Programs.--The average investigator is in his/her forties
    before receiving their first NIH grant, a huge dis-incentive for
    students considering bio-medical research as a career. Complicating
    matters, there is a gap between the number of women's reproductive
    health researchers being trained and the need for such research. The
    NICHD-coordinated Women's Reproductive Health Research (WRHR) Career
    Development program seeks to increase the number of ob-gyns conducting
    scientific research in women's health in order to address this gap. To
    date 170 WRHR Scholars have received faculty positions, and 7 new and
    competing WRHR sites were added in 2010.
        Additional funding to add new sites can help sustain this low-
    dollar, large impact training program while at the same time shoring up
    the women's reproductive research workforce.
    Maternal/Child Health Programs at CDC
        CDC funds programs that are critical to providing resources to
    mothers and children in need. Where NIH conducts research to identify
    causes of pre-term birth, CDC funds programs that provide resources to
    mothers to help prevent pre-term birth, and help identify factors
    contributing to pre-term birth and poor maternal outcomes.
        ACOG supports a 19 percent increase in funds over fiscal year 2010
    to $7.7 billion to increase CDC's ability to bring prevention,
    treatment and interventions to more women and children in need, and to
    help enact some of the important provisions within healthcare reform.
    This funding will help the following programs important to the MOMS
    Initiative:
        Electronic Birth Records and Death Records, National Center for
    Health Statistics (NCHS), National Vital Statistics System (NVSS).--
    NCHS is the Nation's principal health statistics agency; it collects,
    analyzes and reports on data critical to all aspects of our healthcare
    system. NCHS collects State data needed to monitor maternal and infant
    health, such as use of prenatal care, and smoking during pregnancy.
    This data allows investigators to monitor maternal and child health
    objectives, and develop efficient prevention and treatment strategies.
        Uniform consistent data from birth and death records is critical to
    conducting research and directing public programs to combat maternal
    and infant death. Only 75 percent of States and territories use the
    2003 recommended birth certificates and 65 percent have adopted the
    2003 recommended death certificate. The President recently issued a
    Memorandum to all departments and agencies encouraging expanded data
    collection on maternal mortality by using the 2003 U.S. standard birth
    certificate and updating to electronic systems, noting that until all
    States adopt the same data standards it will be difficult to formulate
    national maternal mortality ratios.
        ACOG urges Congress to allocate $11 million for States to modernize
    their birth and death records systems to the 2003 recommended
    guidelines. It is a low cost that will yield enormous gains in CDC's
    ability to collect accurate data nationally and better direct medical
    research and best practice for physicians.
        Safe Motherhood/Infant Health.--Two to three women a day die from
    delivery complications. The Safe Motherhood Program supports CDC's work
    to identify and gather information on pregnancy-related deaths; collect
    and provide information about women's health and health behaviors
    around pregnancy; and expand the use of guidelines on preconception
    care into everyday practice and healthcare policy.
        Safe Motherhood also tracks infant morbidity and mortality
    associated with pre-term birth. ACOG is concerned with recent trends
    particularly among rates of late pre-term births. Increased funding is
    needed for CDC to improve national data systems to track pre-term birth
    rates and expand epidemiological research that focuses especially on
    the causes and prevention of preterm birth and births at 37-38 weeks
    gestation.
        ACOG urges Congress to include a 23.7 percent increase in funds to
    $55.4 million for Safe Motherhood, consistent with the President's
    fiscal year 2011 budget.
    Maternal/Child Health Programs at HRSA
        HRSA delivers critical resources to communities to improve the
    health of mothers and children. ACOG urges a 2.3 percent increase in
    funds over fiscal year 2010 to $7.65 billion to increase the scope of
    HRSA programs, ultimately bringing more resources to more mothers and
    children. This funding will help expand the following programs
    important to the MOMS Initiative:
        Fetal Infant Mortality Reviews, Healthy Start Program.--The U.S.
    infant mortality rate is again on the rise and is particularly severe
    among minority and low-income women. The infant mortality rate among
    African-American women has been increasing since 2001 and reached 14.2
    deaths per 1,000 births in 2004. There also has been a startling rise
    in infant mortality in the South in the past few years.
        The Healthy Start Program through HRSA promotes community-based
    programs that focus on infant mortality and racial disparities in
    perinatal outcomes. These programs are encouraged to use the Fetal and
    Infant Mortality Review (FIMR) which brings together ob-gyn experts and
    local health departments to help solve problems related to infant
    mortality. Today more than 220 local programs in 42 States find FIMR a
    powerful tool to help solve infant mortality.
        ACOG urges Congress to include $.5 million for Healthy Start
    Programs to include FIMR.
    Maternal Child Health Block Grant (MCH)
        The MCH is the only Federal program that exclusively focuses on
    improving the health of mothers and children. State and territorial
    health agencies and their partners use MCH Block Grant funds to reduce
    infant mortality, deliver services to children and youth with special
    healthcare needs, support comprehensive prenatal and postnatal care,
    screen newborns for genetic and hereditary health conditions, deliver
    childhood immunizations, and prevent childhood injuries.
        These early healthcare services help keep women and children
    healthy, eliminating the need for later costly care. For example, every
    $1 spent on preconception care programs for women with diabetes can
    reduce health costs by up to $5.19 by preventing costly complications
    in both mothers and babies. Studies also suggest that every $1 spent on
    smoking cessation counseling for pregnant women saves $3 in neonatal
    intensive care costs.
        ACOG urges Congress to increase funding for MCH $700 million, a
    5.74 percent increase over fiscal year 2010.
    Title X Family Planning
        The Title X program provides contraceptive services, immunizations
    and other preventive healthcare, including screenings for STDs, HIV,
    breast cancer, cervical cancer, high blood pressure, and anemia to more
    than 5 million low-income men and women at more than 4,500 service
    delivery sites. These programs improve maternal and child health
    outcomes, prevent unintended pregnancies, and reduce the rate of
    abortions. Every $1 spent on family planning results in a $4 savings to
    Medicaid. Services provided at Title X clinics accounted for $3.4
    billion in healthcare savings in 2008 alone.
        ACOG supports a 3.15 percent increase in funds for Title X to $327
    million, consistent with the President's budget.
        Again, we would like to thank the Committee for its consideration
    of funding for programs to improve women's health, and we urge you to
    consider our MOMS Initiative in fiscal year 2012.
                                     ______

        Prepared Statement of the American Dental Education Association
        The American Dental Education Association (ADEA) \1\ respectfully
    submits this statement for the record and for your consideration as you
    begin to prioritize fiscal year 2012 appropriation requests. ADEA urges
    you to preserve the funding and fundamental structure of Federal
    programs that provide prevention of dental disease, access to oral
    healthcare for underserved populations, and access to careers in
    dentistry and oral health services.
    ---------------------------------------------------------------------------
        \1\ The American Dental Education Association represents all 61
    U.S. dental schools, 700 dental residency training programs, nearly 600
    allied dental programs, as well as more than 12,000 faculty who educate
    and train the nearly 50,000 students and residents attending these
    institutions. It is at these academic dental institutions that future
    practitioners and researchers gain their knowledge, where the majority
    of dental research is conducted, and where significant dental care is
    provided.
    ---------------------------------------------------------------------------
        As you know, ADEA's membership is comprised of all 61 dental
    schools in the United States. These academic dental institutions make
    substantial contributions to the oral health and well-being of the
    Nation. Services are provided through campus and offsite dental clinics
    where students and faculty provide patient care as dental homes to the
    uninsured and underserved populations. However, in order to continue to
    provide these services, there must be adequate funding. Therefore, it
    is critical that funding for oral healthcare, delivery of services, and
    research be preserved in order to ensure the level of care that is
    necessary for all segments of the population.
        ADEA's requests build upon funding from the American Economic
    Recovery and Reinvestment Act (ARRA), the Labor, Health and Human
    Services and Education fiscal year 2010 Appropriations, and the
    Continuing Resolution for fiscal year 2011. We are asking the committee
    to maintain adequate funding for the dental programs in Title VII of
    the Public Health Service Act; the National Institutes of Health and
    the National Institute of Dental and Craniofacial Research; the Dental
    Health Improvement Act; Part F of the Ryan White HIV/AIDS Treatment and
    Modernization Act: the Dental Reimbursement Program and the Community-
    Based Dental Partnerships Program; and State-Based Oral Health Programs
    at the Centers for Disease Control and Prevention. These programs
    enhance and sustain State oral health departments, fund public health
    programs proven to prevent oral disease, fund research to eradicate
    dental disease, and fund programs to develop an adequate workforce of
    dentists with advanced training to serve all segments of the population
    including children, the elderly, and those suffering from chronic and
    life-threatening diseases.
    $30 million for Primary Oral Healthcare Workforce Improvements (HHS)
        The dental programs in Title VII, Section 748 of the Public Health
    Service Act that provide training in general, pediatric, and public
    health dentistry and dental hygiene are critical. Support for these
    programs will help to ensure there will be an adequate oral healthcare
    workforce to care for the American public. The funding supports
    predoctoral oral health education and postdoctoral pediatric, general,
    and public health dentistry training. The investment that Title VII
    makes not only helps to educate dentists and dental hygienists, but
    also expands access to care for underserved communities.
        Additionally, Section 748 addresses the shortage of professors in
    dental schools with the dental faculty loan repayment program and
    faculty development courses for those who teach pediatric, general, or
    public health dentistry or dental hygiene. There are currently almost
    400 open faculty positions in dental schools. These two programs
    provide schools with assistance in recruiting and retaining faculty.
    $35 billion for the National Institutes of Health, including $468
            million for the National Institute of Dental and Craniofacial
            Research (NIDCR)
        Discoveries stemming from dental research have reduced the burden
    of oral diseases, led to better oral health for millions of Americans,
    and uncovered important associations between oral and systemic health.
    Dental researchers are poised to make breakthroughs that can result in
    dramatic progress in medicine and health, such as repairing natural
    form and function to faces destroyed by disease, accident, or war
    injuries; diagnosing systemic disease from saliva instead of blood
    samples; and deciphering the complex interactions and causes of oral
    health disparities involving social, economic, cultural, environmental,
    racial, ethnic, and biological factors. Dental research is the
    underpinning of the profession of dentistry. With grants from NIDCR,
    dental researchers in academic dental institutions have built a base of
    scientific and clinical knowledge that has been used to enhance the
    quality of the nation's oral health and overall health.
        Also, dental scientists are putting science to work for the benefit
    of the healthcare system through translational research, comparative
    effectiveness research, health information technology, health research
    economics, and further research on health disparities. NIDCR continues
    to make disparities a priority with continued funding for the Centers
    for Research to Reduce Disparities in Oral Health at Boston University,
    the University of California, San Francisco, and the University of
    Colorado at Denver, the University of Florida, and the University of
    Washington.
    $20 million for the Dental Health Improvement Act (DHIA)
        Section 340G of the Public Health Service Act created the Grants to
    States to Support Oral Health Workforce Activities as authorized by the
    Dental Health Improvement Act. This program supports the development of
    innovative dental workforce programs specific to the State's dental
    workforce needs and increases access to dental care for underserved
    populations.
        In 2010, Congress provided at total of $17.5 million to assist
    States in developing flexible dental workforce programs tailored to
    meet States' individual workforce needs. Grants are being used to
    support a variety of initiatives including, but not limited to: loan
    repayment programs to recruit culturally and linguistically competent
    dentists to work in underserved communities; rotating residents and
    students in rural areas; recruiting dental school faculty; training
    pediatricians and family medicine physicians to provide oral health
    services (screening exams, risk assessments, fluoride varnish
    application, parental counseling, and referral of high-risk patients to
    dentists); and supporting tele-dentistry. We expect fiscal year 2011
    appropriations to continue to fund the fiscal year 2010 awarded grants,
    many of which are 3-year projects.
    $19 million for Part F of the Ryan White HIV/AIDS Treatment and
            Modernization Act: Dental Reimbursement Program (DRP) and the
            Community-Based Dental Partnerships Program
        Patients with compromised immune systems are more prone to oral
    infections like periodontal disease and tooth decay. By providing
    reimbursement to dental schools and schools of dental hygiene, the
    Dental Reimbursement Program (DRP) provides access to quality dental
    care for people living with HIV/AIDS while simultaneously providing
    educational and training opportunities to dental residents, dental
    students, and dental hygiene students who deliver the care. DRP is a
    cost-effective Federal/institutional partnership that provides partial
    reimbursement to academic dental institutions for costs incurred in
    providing dental care to people living with HIV/AIDS. Congress,
    recognizing that dental care is a ``core medical service'' needed by
    HIV patients provided $13.6 million to fund Part F in 2010.
    $107 million for Diversity and Student Aid
        $24 million for Centers of Excellence (COE)
        $60 million for Scholarships for Disadvantaged Students (SDS)
        $22 million for Health Careers Opportunity Program (HCOP)
        $1.2 million for Faculty Loan Repayment Program (FLRP)
        Title VII Diversity and Student Aid programs play a critical role
    in helping to diversify the health profession's student body and
    thereby the healthcare workforce. For the last several years, these
    programs have not enjoyed adequate funding to sustain the progress that
    is necessary to meet the challenges of an increasingly diverse U.S.
    population.
    $25 million for Oral Health Programs at the Centers for Disease Control
            and Prevention (CDC)
        The CDC Oral Health Program expands the coverage of effective
    prevention programs. The program increases the basic capacity of State
    oral health programs to accurately assess the needs of the State,
    organize and evaluate prevention programs, develop coalitions, address
    oral health in state health plans, and effectively allocate resources
    to the programs. This strong public health response is needed to meet
    the challenges of oral disease affecting children, and vulnerable
    populations.
        As the oral health programs at the CDC are so important, we have
    serious concerns about the proposal to downgrade the status of the
    Division of Oral Health (DOH) at the CDC to a branch. We request that
    you do everything you can to prevent this move.
        Thank you for your consideration of this request. ADEA looks
    forward to working with you to ensure the continuation of congressional
    support for these critical programs. Please feel free to use us a
    resource on any issue affecting the oral healthcare of the nation.
        If you should have any questions regarding the aforementioned,
    please contact Deborah Darcy, ADEA Director of Congressional Affairs at
    (202) 289-7201 x 163.
                                     ______

       Prepared Statement of the American Dental Hygienists' Association
        On behalf of the American Dental Hygienists' Association (ADHA),
    thank you for the opportunity to submit testimony regarding
    appropriations for fiscal year 2012. ADHA appreciates the
    Subcommittee's past support of programs that seek to improve the oral
    health of Americans and to bolster the oral health workforce. Oral
    health is a part of total health and authorized oral healthcare
    programs require appropriations support in order to increase the
    accessibility of oral health services, particularly for the
    underserved.
        ADHA is the largest national organization representing the
    professional interests of more than 152,000 licensed dental hygienists
    across the country. Dental hygienists are primary care providers of
    oral health services and are licensed in each of the 50 States.
    Hygienists are committed to improving the Nation's oral health, a
    fundamental part of overall health and general well-being. In order to
    become licensed as a dental hygienist, an individual must graduate from
    an accredited dental hygiene education program and successfully
    complete a national written and a State or regional clinical
    examination.
        In the past decade, the link between oral health and total health
    has become more apparent and the significant disparities in access to
    oral healthcare services have been well documented. At the State and
    local level, policymakers and consumer advocates have been pioneering
    innovations to extend the reach of the oral healthcare delivery system
    and improve oral health infrastructure. At this time, when tens of
    millions of Americans struggle to obtain the oral healthcare required
    to remain healthy, Congress has a great opportunity to support oral
    health prevention, infrastructure and workforce efforts that will make
    care more accessible and cost-effective.
        ADHA urges full funding of all authorized oral health programs and
    describes some of the key oral health programs below:
    Title VII Program Grants to Expand and Educate the Dental Workforce--
            Fund at a level of $25 million in fiscal year 2012
        A number of existing grant programs offered under Title VII support
    health professions education programs, students, and faculty. ADHA is
    pleased that dental hygienists are now recognized as primary care
    providers of oral health services and are included as eligible to apply
    for several grants offered under the ``General, Pediatric, and Public
    Health Dentistry'' grants.
        With millions more Americans eligible for dental coverage in coming
    years, it is critical that the oral health workforce is bolstered.
    Dental and dental hygiene education programs currently struggle with
    significant shortages in faculty and there is a dearth of providers
    pursuing careers in public health dentistry and pediatric dentistry.
    Securing appropriations to expand the Title VII grant offerings to
    additional dental hygienists and dentists will provide much needed
    support to programs, faculty, and students in the future.
        ADHA recommends funding at a level of $25 million for fiscal year
    2012.
    Alternative Dental Health Care Provider Demonstration Project Grants--
            Fund at a level of $30 million in fiscal year 2012
        States have increasingly been pioneering new dental delivery models
    to extend access to oral healthcare services to those currently unable
    to access needed care. The Alternative Dental Health Care Provider
    Demonstration Project grants support State-level efforts to better
    utilize the existing oral health workforce as well as develop new
    provider models.
        A number of dental hygiene-based models are listed as eligible for
    the grants, including advanced practice hygienists, public health
    hygienists, and independent dental hygienists.
        Grants could also be awarded to dental therapist models, programs
    where physicians/other medical providers deliver basic dental services
    and other models deemed appropriate by the Secretary of Health and
    Human Services. Funding would also allow HRSA to fulfill its statutory
    requirement to contract with the Institute of Medicine to conduct a
    study of the demonstration projects.
        Currently, more than 30 States have statutes and rules that allow
    dental hygienists to work in community-based settings (like public
    health clinics, schools, and nursing homes) to provide oral health
    services without the presence or direct supervision of a dentist. These
    models extend the reach of dental professionals beyond the private
    dental office.
        The American Dental Education Association supports funding of this
    program. The PEW Charitable Trusts Children's Dental Campaign also
    supports funding of this program. Indeed, more than 60 organizations
    have called for funding this important program. Without the appropriate
    supply, diversity and distribution of the oral health workforce, the
    current oral health access crisis will only be exacerbated.
        ADHA recommends funding at a level of $30 million for fiscal year
    2012 to support these vital demonstration projects.
    Oral Health Prevention and Education Campaign--Fund at a level of $5
            million in fiscal year 2012
        A targeted national campaign led by the Centers for Disease Control
    to educate the public, particularly those who are underserved, about
    the benefits of oral health prevention could vastly improve oral health
    literacy in the country. While significant data has emerged over the
    past decade drawing the link between oral health and systemic diseases
    like diabetes, heart disease, and stroke, many remain unaware that
    neglected oral health can have serious ramifications to their overall
    health. Data is also emerging to highlight the role that poor oral
    health in pregnant women has on their children, including a link
    between periodontal disease and low-birth weight babies.
        ADHA advocates an allocation of $5 million in fiscal year 2012 for
    a national oral health prevention and education campaign.
    School-Based Sealant Programs--Fund at a level sufficient to ensure
            school-based sealant programs in all 50 States
        Sealants have long-proven to be low-cost and effective in
    preventing dental caries (cavities), particularly in children. While
    most dental disease is fully preventable, dental caries remains the
    most common childhood disease, five times more common than asthma, and
    more than half of all children age 5-9 have a cavity or filling.
        The CDC has noted that data collected in evaluations of school-
    based sealant programs indicates the programs are effective in stopping
    and preventing dental decay. Significant progress has been made in
    developing best practices for school-based sealant programs, yet most
    States lack well developed programs as a result of funding shortfalls.
    ADHA encourages the transfer of funding from the Public Health and
    Prevention Fund sufficient to allow CDC to meaningfully fund school-
    based sealant programs in all 50 States in fiscal year 2012.
    Oral Health Programming within the Centers for Disease Control--Fund at
            a level of $25 million in fiscal year 2012
        ADHA joins with others in the dental community in urging $25
    million for oral health programming within the Centers for Disease
    Control. This funding level will enable CDC to continue its vital work
    to control and prevent oral disease, including vital work in community
    water fluoridation. Federal grants to facilitate improved oral health
    leadership at the State level, support the collection and synthesis of
    data regarding oral health coverage and access, promote the integrated
    delivery of oral health and other medical services, enable States to
    innovate new types of oral health programs and promote a data-driven
    approach to oral health programming.
        ADHA joins with others in the oral health community to express
    concern with plans to fold the Division of Oral Health at CDC into the
    Division of Adult and Community Health, and asks the subcommittee to
    urge CDC to maintain the Division of Oral Health as a separate entity
    within the chronic disease center so that the Division of Oral Health
    can continue to improve the oral health of Americans from inception to
    old age.
        ADHA advocates for $25 million in funding for grants to improve and
    support oral health infrastructure and surveillance.
    Dental Health Improvement Grants--Fund at a level of $20 million in
            fiscal year 2012
        HRSA administered dental health improvement grants are an important
    resource for States to have available to develop and carry out State
    oral health plans and related programs. Past grantees have used funds
    to better utilize the existing oral health workforce to achieve greater
    access to care. Previously awarded grants have funded efforts to
    increase diversity among oral health providers in Wisconsin, promote
    better utilization of the existing workforce including the extended
    care permit (ECP) dental hygienist in Kansas, and in Virginia implement
    a legislatively directed pilot program to allow patients to directly
    access dental hygiene services.
        ADHA supports funding of HRSA dental health improvement grants at a
    level of $20 million for fiscal year 2012.
    National Institute of Dental and Craniofacial Research--Fund at a level
            of $468 million in fiscal year 2012
        The National Institute of Dental and Craniofacial Research (NIDCR)
    cultivates oral health research that has led to a greater understanding
    of oral diseases and their treatments and the link between oral health
    and overall health. Research breeds innovation and efficiency, both of
    which are vital to improving access to oral healthcare services and
    improved oral status of Americans in the future.
        ADHA joins with others in the oral health community to support
    NIDCR funding at a level of $468 million in fiscal year 2012.
    Conclusion
        ADHA appreciates the difficult task Appropriators face in
    prioritizing and funding the many meritorious programs and grants
    offered by the Federal Government. In addition to the items listed,
    ADHA joins other oral health organizations in support for continued
    funding of the Dental Reimbursement Program (DRP) and the Community-
    Based Dental Partnerships Program established under the Ryan White HIV/
    AIDS Treatment and Modernization Act ($19 million for fiscal year 2012)
    as well as block grants offered by HRSA's Maternal Child Health Bureau
    ($8 million for fiscal year 2012).
        ADHA remains a committed partner in advocating for meaningful oral
    health programming that makes efficient use of the existing oral health
    workforce and delivers high quality, cost-effective care.
                                     ______

            Prepared Statement of the American Diabetes Association
        Thank you for the opportunity to submit this testimony on behalf of
    the American Diabetes Association. As someone who has lived with
    diabetes for over thirty years, I am proud to be a representative of
    the nearly 105 million American adults and children living with
    diabetes or prediabetes.
        Every minute, three more people are diagnosed with diabetes. While
    nearly 26 million Americans have diabetes today, this number is
    expected to grow to 44 million in the next 25 years if present trends
    continue. Every 24 hours, 230 people with diabetes will undergo an
    amputation, 120 people will enter end-stage kidney disease programs and
    55 people will go blind from diabetes. Every single day, diabetes costs
    our country over a half a billion dollars, yet, that is but a fraction
    of the costs we face unless we immediately take action to stop the
    march of this epidemic.
        Given the toll the diabetes epidemic imposes on the Nation's health
    and economy and the promise of public diabetes research and public
    health initiatives, the American Diabetes Association (Association)
    respectfully requests programs at the National Institute of Diabetes
    and Digestive and Kidney Diseases (NIDDK) at the National Institutes of
    Health (NIH) and the Division of Diabetes Translation (DDT) at the
    Centers for Disease Control and Prevention (CDC) be top priorities in
    fiscal year 2012. As the Nation's leading non-profit health
    organization providing diabetes research, information and advocacy, the
    Association believes Federal funding for diabetes prevention and
    research is critical, not only for the 26 million American adults and
    children (8 percent of the population) who currently have diabetes, but
    for the 79 million more with prediabetes, a condition placing them at
    high risk for developing diabetes.
        The Association acknowledges the challenging fiscal climate and
    supports fiscal responsibility, but not at the expense of America's
    health and well-being. Simply put, our country cannot afford the
    consequences of failing to adequately fund diabetes research and
    programs, a cost paid in expensive complications and death. We cannot
    afford to turn our backs on the promising research which provides tools
    to prevent diabetes, better manage it and prevent complications, and
    bring us closer to a cure.
        Therefore, the Association urges the Senate LHHS Subcommittee to
    invest in research and prevention proportionate to the magnitude of the
    burden diabetes has on our country and, by doing so, to change the
    future of diabetes in America.
        Diabetes is a chronic disease that impairs the body's ability to
    use food for energy. The hormone insulin, which is made in the
    pancreas, is needed for the body to change food into energy. In people
    with diabetes, either the pancreas does not create insulin, which is
    type 1 diabetes, or the body does not create enough insulin and/or
    cells are resistant to insulin, which is type 2 diabetes. If left
    untreated, diabetes results in too much glucose in the blood stream.
    The majority of diabetes cases, 90 to 95 percent, are type 2, while
    type 1 diabetes accounts for 5 percent of diagnosed cases.
    Additionally, based on new diagnostic criteria, it is now estimated
    that 18 percent of pregnancies are affected by gestational diabetes. In
    the short term, blood glucose levels that are too high or too low (as a
    result of medication to treat diabetes) can be life threatening. The
    long-term complications of diabetes are widespread, serious--and
    deadly. In those with prediabetes, blood glucose levels are higher than
    normal and taking action to reduce their risk of developing diabetes is
    essential.
        The Centers for Disease Control and Prevention (CDC) has identified
    diabetes as a disabling, deadly epidemic, which is on the rise. Between
    1990 and 2001, the prevalence of diabetes increased by 60 percent.
    According to the CDC, one in three adults will have diabetes in 2050 if
    present trends continue. This number is even greater among minority
    populations, where nearly one in two adults will have diabetes in 2050.
        Additionally, type 2 diabetes, traditionally seen in older
    patients, is beginning to reach a younger population, due in part to
    the surge in childhood obesity. Approximately one in every 400 children
    and adolescents has diabetes, and an alarming 2 million adolescents (or
    1 in 6 overweight adolescents) aged 12-19 have prediabetes. The impact
    diabetes has on individuals and the healthcare system is enormous and
    continues to grow at a shocking rate. Diabetes is the leading cause of
    kidney failure, new cases of adult-onset blindness and non-traumatic
    lower limb amputations as well as a significant cause of heart disease
    and stroke.
        In addition to the physical toll, diabetes also attacks our
    pocketbooks. A study by the Lewin Group found when factoring in the
    additional costs of undiagnosed diabetes, prediabetes, and gestational
    diabetes, the total cost of diabetes and related conditions in the
    United States in 2007 was $218 billion ($18 billion for undiagnosed
    diabetes; $25 billion for prediabetes; $623 million for gestational
    diabetes). In 2007, medical expenditures due to diabetes totaled $116
    billion, including $27 billion for diabetes care, $58 billion for
    chronic diabetes-related complications, and $31 billion for excess
    general medical costs. Indirect costs resulting from increased
    absenteeism, reduced productivity, disease-related unemployment
    disability and loss of productive capacity due to early mortality
    totaled $58 billion. Approximately one out of every five healthcare
    dollars is spent caring for someone with diagnosed diabetes, while one
    in ten healthcare dollars is directly attributed to diabetes. Further,
    one-third of Medicare expenses are associated with treating diabetes
    and its complications.
        Despite these numbers, there is hope. A greater Federal investment
    in diabetes research at the National Institute of Diabetes and
    Digestive and Kidney Diseases (NIDDK) at the National Institutes of
    Health (NIH), and prevention, surveillance, control, and research work
    currently being done at the Division of Diabetes Translation (DDT) at
    the CDC is crucial for finding a cure and improving the lives of those
    living with, or at risk for, diabetes. Additionally, the National
    Diabetes Prevention Program is poised to dramatically cut the number of
    new diabetes cases in high-risk individuals. Accordingly, for fiscal
    year 2012, the American Diabetes Association is requesting:
      --$2.209 billion for the NIDDK, an increase of $267 million over the
            fiscal year 2011 level. This additional funding will act to
            offset years of decreased or flat funding combined with
            inflation that has lead to cutbacks in promising research. It
            will also demonstrate Congress's commitment to science and
            research in the face of this deadly epidemic.
      --$86.1 million for the DDT, which represents a total increase of
            $21.3 million over the fiscal year 2011 level for the DDT's
            critical prevention, surveillance and control programs. Even as
            proposals to consolidate the CDC's chronic disease programs
            including DDT circulate, expanded investment in the DDT will
            produce much larger savings in reduced acute, chronic, and
            emergency care spending.
      --$80 million for the implementation of the National Diabetes
            Prevention Program through the Prevention and Public Health
            Fund.
    NIH's National Institute of Diabetes and Digestive and Kidney Diseases
            (NIDDK)
        The NIDDK is poised to make major discoveries to prevent diabetes,
    better treat its complications, and--ultimately--find a cure.
    Researchers supported by the NIH are working on a variety of projects
    representing hope for the millions of individuals with both type 1 and
    type 2 diabetes. While the list of advances in treatment and prevention
    is long, much more can be achieved for people with diabetes with an
    increased investment in scientific research at the NIDDK.
        Thanks to research at the NIDDK, people with diabetes now manage
    their disease with a variety of insulin formulations and regimens far
    superior to those used in decades past. The result is the ability to
    live healthier lives with diabetes. Because of these advances, my
    hemoglobin A1C, which provides a snapshot of an individual's blood
    glucose, went from 12.9 percent, a very dangerous level, to 5.9
    percent, an accomplishment that provides me with hope of avoiding
    diabetes's devastating complications. This is a dramatic development
    for me and proof of the importance of NIDDK's work.
        Recent discoveries at the NIDDK include the ability to predict type
    1 diabetes risk, new drug therapies for type 2 diabetes, and the
    discovery of genetic markers explaining the increased burden of kidney
    disease among African Americans. The NIDDK funded the Diabetes
    Prevention Program, a multicenter clinical research trial, which found
    modest weight loss through dietary changes and increased physical
    activity could prevent or delay the onset of type 2 diabetes by 58
    percent. While great strides have been made in diabetes research, there
    are many unanswered questions about the disease meriting further study.
    Diabetes researchers across the country are poised to expand the base
    of knowledge of diabetes in order to make new discoveries transforming
    diabetes prevention and care.
        Increased fiscal year 2012 funding would allow the NIDDK to support
    additional research in order to build upon past successes, improve
    prevention and treatment, and close in on a cure. For example,
    additional funding will support a new comparative effectiveness
    clinical trial testing different medications for type 2 diabetes, a
    process that is instrumental in finding the most effective treatments
    for type 2 diabetes. fiscal year 2012 funding will also support
    researchers who are studying how insulin-producing beta cells develop
    and function, with an ultimate goal of creating therapies for replacing
    damaged or destroyed beta cells in people with diabetes. Finally,
    additional funding will support ongoing studies outlining environmental
    triggers of disease, which could identify an infectious cause of type 1
    diabetes and lead to a vaccine.
    CDC's Division of Diabetes Translation (DDT)
        The Senate Appropriations Committee's fiscal year 2011 bill
    provided increased resources to address chronic diseases through the
    creation of the Chronic Disease Initiative (CDI) at CDC. In approving
    the fiscal year 2011 LHHS bill, the full Committee acknowledged chronic
    disease programs, including the diabetes programs traditionally
    operated through the DDT, have been woefully underfunded to adequately
    address the trajectory and scope of diabetes and other diseases
    including heart disease, stroke and arthritis.
        This year, ideas continue to circulate to consolidate programs at
    CDC, including DDT. While we think coordination across chronic disease
    programs at CDC is an important endeavor, Congress must ensure the
    needs of people with, and at risk for, diabetes are adequately
    addressed. Given DDT funding has not kept pace with the magnitude of
    the growing diabetes epidemic, the Federal investment in DDT programs
    should be substantially increased--at a minimum to $86.1 million in
    fiscal year 2012--regardless of the organization of chronic disease
    programs at CDC or in any consolidation plan. As the dialogue continues
    about how best to address chronic disease prevention, DDT should be the
    centerpiece in the Federal Government's efforts in this regard and its
    State and national expertise should be maintained.
        Preserving the DDT's expertise is vital. The Division works to
    eliminate the preventable burden of diabetes through proven educational
    programs, best practice guidelines and applied research. It performs
    vital work in both primary prevention of diabetes and in preventing its
    complications. Both key missions must continue. Funds appropriated to
    DDT focus on developing and maintaining State-based Diabetes Prevention
    and Control Programs (DPCPs), supporting the National Diabetes
    Education Program (NDEP), defining the diabetes burden through the use
    of public health surveillance, and translating research findings into
    clinical and public health practice. Our request of an additional $21.3
    million will allow these programs at DDT to reach more at-risk
    Americans and help to prevent or delay this destructive disease and its
    complications.
        DDT's Diabetes Prevention and Control Programs, located in all 50
    States, the District of Columbia, and U.S. territories, work to prevent
    diabetes, to lower blood glucose and cholesterol levels and to reduce
    diabetes-related emergency room visits and hospitalizations. DDT also
    plays a leadership role in the dissemination of diabetes prevention and
    treatment information through the National Diabetes Education Program,
    a joint effort of DDT and NIDDK. Funding for the DDT also supports
    vital and groundbreaking translational research like the Search for
    Diabetes in Youth study, collaboration between DDT and NIDDK designed
    to determine the impact of type 2 diabetes in youth in order to improve
    prevention efforts aimed at young people. DDT is also engaged in
    efforts to eliminate diabetes related disparities in vulnerable
    populations that bear a disproportionate burden of the disease in urban
    and rural areas. Finally, DDT maintains vital diabetes data at the
    State and national levels through the National Diabetes Surveillance
    System, which helps determine how best to deploy resources in the most
    appropriate and cost-effective way.
        Although DDT has played an instrumental role in fighting the
    diabetes epidemic, the reach of the Division could be significantly
    broader with additional fiscal year 2012 funding. With an additional
    $21.3 million, the DDT will be able to expand the reach of DPCPs in
    every State and territory. Given the dramatic decreases in funding for
    State and local health departments, supporting the work of the DPCPs is
    more critical than ever to ensure access to diabetes care and services.
        Increased funding for DDT is needed to allow the Division to build
    upon its work in reducing health disparities through vital programs
    such as the Native Diabetes Wellness Program, furthering the
    development of effective health promotion activities and messages
    tailored to American Indian/Native Alaskan communities. Additional
    resources will enable the DDT to expand its translational research
    studies, leading to improved public health interventions.
    The National Diabetes Prevention Program
        Further studies of the Diabetes Prevention Program by the CDC have
    shown this groundbreaking intervention can be replicated in community
    settings for a cost of less than $300 per participant. With this in
    mind, the National Diabetes Prevention Program was authorized by the
    Patient Protection and Affordable Care Act of 2010. This program will
    provide funding to the CDC to expand such evidence-based programs
    across the country. We ask the Committee to direct $80 million from the
    Fund for the National Diabetes Prevention Program.
        The National Diabetes Prevention Program supports the creation of
    community-based sites where trained staff will provide those at high
    risk for diabetes with cost-effective, group-based lifestyle
    intervention programs. Local sites will be required to provide detailed
    program plans, ensure adequate training, and be rigorously evaluated
    based on the achievement of required standards and goals. The program
    also includes applied research grants, which will advance the national
    strategy for community-based programs and improve communication
    strategies for high-risk communities.
        The Fund seeks to make a national investment in prevention and
    public health programs, both to improve the health of Americans and to
    rein in healthcare costs. The National Diabetes Prevention Program is
    exactly the program the Fund should be supporting. The NIH did research
    in the clinical setting--it worked. The CDC translated this research to
    the community setting--it worked. It is an amazingly inexpensive proven
    means of combating a growing epidemic. Indeed, the Urban Institute has
    estimated a nationwide expansion of this type of diabetes prevention
    program will save a total of $190 billion over 10 years. Based on
    estimates that a large portion of burden of chronic disease falls on
    the poor and elderly, the Institute's report assumes 75 percent of this
    savings would be savings to Medicare or Medicaid.
    Conclusion
        As you consider the fiscal year 2012 appropriation for NIDDK, and
    DDT, and the National Diabetes Prevention Program, we ask you to
    consider diabetes is an epidemic growing at an astonishing rate, which
    will overwhelm the healthcare system with tragic consequences unless we
    take action. To change this future, we must increase our commitment to
    research and prevention to reflect the burden diabetes poses both for
    us and for our children. Our fight against diabetes must be
    significantly expanded. Your leadership in combating this growing
    epidemic is essential. Thank you for your commitment to the diabetes
    community and for the opportunity to submit this testimony. The
    Association is prepared to answer any questions you might have on these
    important issues.
                                     ______

      Prepared Statement of the American Foundation for Suicide Prevention
        Chairman Harkin, Ranking Member Shelby and members of the
    Committee. The American Foundation for Suicide Prevention (AFSP) thanks
    you for the opportunity to provide testimony on the funding needs of
    Federal Agencies and programs that play a critical role in suicide
    prevention efforts.
        AFSP is the leading national not-for-profit organization
    exclusively dedicated to understanding and preventing suicide through
    research, education and advocacy, and to reaching out to people with
    mental disorders and those impacted by suicide. You can find more
    information at www.asfp.org and www.spanusa.org.
        Preliminary data from the Centers for Disease Control for 2009
    shows that suicide is the 10th leading cause of death in the United
    States (36,547) and the third leading cause of death in teens and young
    adults from ages 15-24. Nearly 1.1 million Americans attempt suicide
    each year and another 8 million have suicidal thoughts. Suicide in 1
    year costs the United States $13 billion in lost earnings, 1 million
    years of lost life and suicide attempts requiring hospitalization
    amount to $3.54 billion in lost medical and work-loss costs.
        In order to more effectively combat this public health crisis, AFSP
    urges the Committee approve funding at the levels requested for the
    following programs/agencies for fiscal year 2012:
    Garrett Lee Smith Memorial Act Programs
        We respectfully request that Garrett Lee Smith Memorial Act (GLSMA)
    youth suicide prevention grant programs receive $53.2 million for
    fiscal year 2012.
        Since 2005, the Substance Abuse and Mental Health Services
    Administration (SAMHSA) has awarded GLSMA grants to 45 State programs,
    12 tribal programs, and 78 colleges and universities for programs to
    help reduce youth suicides rates. State grantees include: Alaska,
    Arizona, Colorado, Connecticut, District of Columbia, Delaware,
    Florida, Georgia, Guam, Hawaii, Iowa, Idaho, Indiana, Kentucky,
    Louisiana, Massachusetts, Maryland, Maine, Michigan, Missouri,
    Mississippi, North Carolina, North Dakota, Nebraska, New Hampshire, New
    Mexico, Nevada, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode
    Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia,
    Vermont, Washington, Wisconsin, West Virginia, and Wyoming.
        Funding for the Act is directed to three programs administered by
    SAMHSA. We request $5 million for the Suicide Prevention Technical
    Assistance Center to support its mission of providing technical
    assistance and support to grantees. We request $42 million for the
    Youth Suicide Early Intervention and Prevention Strategies grant
    program. These grants help States and tribes develop and implement
    statewide youth suicide early intervention and prevention strategies
    that will raise awareness and educate people about mental illness and
    the risk of suicide, help young people at risk of suicide take the
    first step toward seeking help, and allow States to expand access to
    treatment options. Finally, we request $6.2 million to fund the Mental
    and Behavioral Health Services on Campus matching-grant program for
    colleges and universities to help raise awareness about youth suicide,
    as well as enable those institutions to train students and faculty to
    identify and intervene when youth are in crisis, and develop a system
    to refer students for care.
    Support Federal Investment in Suicide Prevention Research at NIMH for
            Fiscal Year 2012
        Strategic investments in disease research have produced declines in
    deaths, and the same types of investments are necessary to reduce
    deaths by suicide. In fiscal year 2010 (latest data) only $41 million
    was devoted directly to suicide research. AFSP urges Congress to
    increase the investment in suicide prevention research at the National
    Institutes of Mental Health by 15 percent, or $6.15 million.
        It is illuminating to compare the number of suicide deaths with the
    number of deaths in several major disease categories against the direct
    dollars spent on research in those areas (see below). In fact, the
    Institute of Medicine, in their 2002 report ``Reducing Suicide: A
    National Imperative,'' stated the following: ``There is every reason to
    expect that a national consensus to declare war on suicide and to fund
    research and prevention at a level commensurate with the severity of
    the problem will be successful, and will lead to highly significant
    discoveries as have the wars on cancer, Alzheimer's disease, and
    AIDS.''

    Maintain Vital Funding for SAMHSA Suicide Prevention Programs and
            Mental Health Services
        As the lead Government agency charged with implementation of
    suicide prevention initiatives, AFSP urges this Committee to provide
    $3.387 billion for SAMHSA in fiscal year 2012. By this action Congress
    will recognize the important role SAMHSA plays in healthcare delivery
    and mental health services.
        As the lead Government agency charged with implementation of
    suicide prevention initiatives, SAMHSA has supported the establishment
    of a national toll-free hotline (the National Suicide Prevention
    Lifeline), a technical assistance center (the Suicide Prevention
    Resource Center), and a youth suicide prevention grant program for
    States and colleges (authorized and funded under the Garrett Lee Smith
    Memorial Act). Since its launch in January 2005, the Suicide Prevention
    Lifeline has answered more than 1 million calls and has 140 active
    crisis centers in 48 States. Beginning in 2008, SAMHSA's National
    Survey on Drug Use and Health asked respondents about suicide attempts
    and whether or not they had previously acknowledged major depression.
    This was an important first step forward in suicide surveillance,
    promoting greater attention to the interrelationship of suicide,
    substance abuse and depression. Moreover, the Agency also has been
    supporting the identification, development and promotion of best
    practices in suicide prevention, focusing on risk and protective
    factors related to suicide, with particular attention to mental health
    and substance abuse issues affecting suicide risk.
    Support Federal Investment in Data Collection in Fiscal Year 2012
        To design effective suicide prevention strategies, we must first
    have complete, accurate and timely information about deaths by suicide.
    The National Violent Death Reporting System (NVDRS) provides this
    information, which is essential to improve State and Federal suicide
    prevention activities. Current funding of $3.5 million allows only 18
    States to participate in this program. This Committee approved an
    additional $1.5 million in fiscal year 2011; however, the bill never
    got signed into law. AFSP urges this Committee to appropriate the full
    $5 million for the NVDRS in fiscal year 2012.

    Provide Funding for Depression Centers of Excellence (DCOE)
        This Committee included $10 million for the DCOE in the fiscal year
    2011 mark up as a down payment toward studying Depression, the most
    common psychiatric diagnosis associated with suicide. AFSP urges
    Congress to appropriate funds to the DCOE at the highest levels
    possible in fiscal year 2012.
        Depression Centers of Excellence would increase access to the most
    appropriate and evidence-based depression care and develop and
    disseminate evidence-based treatment standards to improve accurate and
    timely diagnosis of depression and bipolar disorders. Additionally,
    they would create a national database for large-sample effectiveness
    studies and a repository of evidence-based interventions and programs
    for depression and bipolar disorders. They would also utilize the
    network of centers as an ongoing national resource for public and
    professional education and training, with the goal of advancing
    knowledge and eradicating stigma of these mental disorders.
        Chairman Harkin, Ranking Member Shelby and Members of the
    Committee. AFSP once again thanks you for the opportunity to provide
    testimony on the funding needs of Federal Agencies and programs that
    play a critical role in suicide prevention efforts.
        Suicide robs families, communities and societies of tens of
    thousands of its citizens. In a single year, in the United States
    alone, suicide is responsible for the deaths of over 36,000 people of
    all ages and costs an estimated $13 billion in lost income. With your
    help, we can assure those tasked with leading the Federal Government's
    response to this public health crisis will have the resources necessary
    to effectively prevent suicide.
                                     ______

             Prepared Statement of the American Geriatrics Society
        Mr. Chairman and Members of the Subcommittee: We are writing on
    behalf of the American Geriatrics Society (AGS), a nonprofit
    organization of over 6,000 geriatrics healthcare professionals
    dedicated to improving the health, independence and quality of life of
    all older Americans. As the Subcommittee begins to work on its Labor-
    HHS-Education Appropriations bill, we ask that you prioritize funding
    for the geriatrics education and training programs under Title VII and
    Title VIII of the Public Health Service Act and for research funding
    within the National Institute on Aging in fiscal year 2012.
        Continued Federal investments are needed to support the training of
    the healthcare workforce and to foster groundbreaking medical research
    so that our Nation is prepared to meet the unique healthcare needs of
    the rapidly growing population of seniors. While we fully recognize the
    fiscal challenges facing our Nation, we also recognize that sustained
    and enhanced Federal investments in these initiatives are essential to
    fulfilling the promise of health reform to deliver higher quality and
    better coordinated care to our Nation's seniors.
        We ask that the subcommittee consider the following recommended
    funding levels for these programs in fiscal year 2012 $46.5 million for
    Title VII Geriatrics Health Professions Programs, $5 million for Title
    VIII Comprehensive Geriatric Education Nursing Program, and $1.4
    billion for the National Institute on Aging.
        Summarized and broken down below are the American Geriatrics
    Society's funding priorities in these areas for fiscal year 2012.
    Programs to Train Geriatrics Health Care Professionals
        This year, the first wave of baby boomers turn 65, signaling the
    start of a significant demographic shift in America's population.
    According to the Institute of Medicine's (IOM) ground-breaking 2008
    report, Retooling for an Aging America: Building the Healthcare
    Workforce, America's healthcare workforce is woefully ill-prepared to
    care for the growing and unprecedented number of seniors, especially
    those with multiple chronic and complex medical conditions.
        The increase in the older adult population is expected to be even
    greater in rural America, which are more likely to experience poor
    health and a shortage of healthcare resources. Not only are
    geriatricians few in number, but they are largely concentrated in urban
    areas. Of further concern, our Nation is facing a critical shortage of
    geriatrics faculty and healthcare professionals across disciplines. At
    the same time, the Title VII and VIII geriatrics programs under the
    Public Health Service Act have remained essentially level-funded since
    fiscal year 2007 and in each subsequent year the geriatrics programs
    have received an even smaller percentage of funding provided to Title
    VII and VIII programs.
        This trend must be reversed if we are to provide our seniors with
    the quality care they need and deserve. AGS believes it is critical
    that Congress increase the percentage of Title VII and VIII funding
    that is devoted to supporting increasing the capacity of America's
    healthcare workforce to care for older adults. Care provided by
    geriatric healthcare professionals, who understand the most complex
    cases and the most frail elderly, has shown to reduce those common and
    costly conditions that are often preventable with appropriate care,
    such as falls, polypharmacy, and delirium.
                Title VII Geriatrics Health Professions Programs ($46.5
                        million)
        Funding for Title VII Geriatrics Health Professions Programs is a
    proven investment in ensuring that older adults receive high quality
    healthcare now and in the future. These programs support three
    initiatives: the Geriatric Academic Career Awards (GACAs), the
    Geriatric Education Center (GEC) program, and geriatric faculty
    fellowships, the only programs specifically designed to address the
    evident shortage of geriatrics healthcare professionals in the United
    States. Strong and sustained investments are important to reversing the
    chronic under-funding of these essential programs at a time when our
    Nation is facing a critical shortage of geriatrics healthcare
    professionals across disciplines. We ask the subcommittee to provide a
    fiscal year 2012 appropriation of $46.5 million for Title VII
    Geriatrics Health Professions Programs.
        Our funding request of $46.5 million breaks down as follows:
      --Geriatric Academic Career Awards (GACAs) ($5.3 million).--GACAs
            support the development of newly trained geriatric physicians
            in academic medicine who are committed to teaching geriatrics
            in medical schools across the country. GACA recipients are
            required to provide training in clinical geriatrics, including
            the training of interdisciplinary teams of healthcare
            professionals. Under ACA, GACAs have been expanded to a variety
            of new disciplines beyond physicians, including those in
            nursing, social work, psychology, dentistry, and pharmacy. AGS
            has long advocated for this change. We must now ensure that
            there is adequate funding to meet the increased demand given
            the greater number of disciplines eligible for the award. A
            budget of $5.3 million would support 68 awardees at $78,000 per
            award.
          Program Accomplishments.--In Academic Year 2009-2010, there were
            84 non-competing continuation awards. GACA awardees provided
            interdisciplinary training in geriatrics training to about
            60,000 health professionals. These awardees provided culturally
            competent quality healthcare to over 525,000 underserved and
            uninsured patients in acute care services, geriatric ambulatory
            care, long-term care, and geriatric consultation services
            settings.
      --Geriatric Education Centers (GECs) ($22.7 million).--GECs provide
            grants to support collaborative arrangements involving several
            health professions, schools and healthcare facilities to
            provide multidisciplinary training in geriatrics, including
            assessment, chronic disease syndromes, care planning, emergency
            preparedness, and cultural competence unique to older
            Americans. Under ACA, Congress authorized $10.8 million over 3
            years for a supplemental grant award program that will train
            additional faculty through an intensive short-term fellowship
            program and also requires faculty to provide training to family
            caregivers and direct-care workers. Our funding request of
            $22.7 million includes continued support for the core work of
            45 GECs and for up to 24 GECs to be funded to undertake the
            work through the supplemental grant program.
          Program Accomplishments.--In Academic Year 2009-2010, the GEC
            grantees provided clinical training to 54,167 health
            professional students and to 20,791 interdisciplinary teams in
            multiple settings.
      --Geriatric Training Program for Physicians, Dentists, and Behavioral
            and Mental Health Professions ($8.5 million).--This program is
            designed to train physicians, dentists, and behavioral and
            mental health professionals who choose to teach geriatric
            medicine, dentistry or psychiatry. The program provides fellows
            with exposure to older adult patients in various levels of
            wellness and functioning, and from a range of socioeconomic and
            racial/ethnic backgrounds. Our funding request of $8.5 million
            will allow 13 institutions to continue this important faculty
            development program.
          Program Accomplishments.--In Academic Year 2009-2010, 11 non-
            competing continuation grants were supported. Forty-nine
            physicians, dentists, and psychiatric fellows provided
            geriatric care to 20,078 older adults across the care
            continuum. Geriatric physician fellows provided healthcare to
            12, 254 older adults. Geriatric dental fellows provided
            healthcare to 4,073 older adults. Geriatric psychiatry fellows
            provided healthcare to 3,751 older adults.
      --Geriatric Career Incentive Awards Program ($10 million).--This is a
            new grant award program created under ACA to foster greater
            interest among a variety of health professionals in entering
            the field of geriatrics, long-term care, and chronic care
            management. AGS supports the President's fiscal year 2012
            request of $10 million to implement this new program.
                Title VIII Comprehensive Geriatric Education Nursing
                        Program ($5 million)
        The American healthcare delivery system for older adults will be
    further strengthened by Federal investments in Title VIII Nursing
    Workforce Development Programs, specifically the comprehensive
    geriatric education grants, as nurses provide cost-effective, quality
    care. Increasing funding for the nursing comprehensive geriatric
    education program would be highly cost effective. This program supports
    additional training for nurses who care for the elderly, development
    and dissemination of curricula relating to geriatric care, and training
    of faculty in geriatrics. It also provides continuing education for
    nurses practicing in geriatrics.
        Under the new health reform law, this program is being expanded to
    include advanced practice nurses who are pursuing long-term care,
    geropsychiatric nursing or other nursing areas that specialize in the
    care of older adults. Our funding request of $5 million includes funds
    to continue the training of nurses caring for older Americans offer 200
    traineeships to nurses under this newly expanded program.
        Program Accomplishments.--In Academic Year 2009-2010, 27 CGEP
    grantees provided education and training to 3,030 Registered Nurses/
    Registered Nursing Students; 260 Advanced Practice Nurses; 221 Faculty;
    110 Home Health Aides; 483 Licensed Practical/Vocational Nurses & LPN
    students; 730 Nurse Assistants/Patient Care Associates; 810 Allied
    Health Professionals and 929 lay persons, guardians, activity
    directors. The CGEP grantees provided 459 educational course offerings
    in the care of the elderly on a variety of topics to 6,846
    participants.
    Research Funding Initiatives
                National Institute on Aging ($1.4 billion)
        The NIA leads a broad scientific effort to understand the nature of
    aging and to extend the healthy, active years of life. Robust medical
    research in aging is critical to the development of medical advances
    which will ultimately lead to higher quality and more efficient
    healthcare. Continued Federal investments in scientific research,
    including comparative effectiveness initiatives, will ensure that the
    NIA has the resources to succeed in its mission to establish research
    networks, assess clinical interventions and disseminate credible
    research findings to patients, providers and payers of healthcare.
        As a member of the Friends of the NIA, a broad-based coalition of
    more than 45 aging, disease, research, and patient groups committed to
    the advancement of medical research that affects millions of older
    Americans, AGS asks that NIA receive $1.4 billion in fiscal year 2012.
    Alternatively, in light of our Nation's immediate budget constraints,
    we request that that the NIA be funded at no less than the $1.29
    billion, as requested in the President's fiscal year 2012 budget.
        According to the Congressional Research Service, in fiscal year
    2003, NIH reached the peak of its purchasing power from regular
    appropriations when Congress completed a 5-year doubling of the NIH
    budget. In each year since then, NIH's buying power has declined
    because its annual appropriations have grown at a lower rate than the
    inflation rate for medical research.
        Essentially flat funding of NIH since 2003 has additionally led to
    declining numbers of young investigators choosing research careers,
    given the scarcity of funding to support their career development. We
    must provide the resources and tools to support the next generation of
    investigators and expand the pool of clinical researchers focused on
    advancing aging research.
        The ongoing Federal commitment to investments in science, research,
    and technology lead to cutting-edge breakthroughs in medicine and
    improved patient care. AGS urges Congress to maintain this commitment
    in fiscal year 2012 and beyond, so that we may continue to advance
    medicine to improve the quality of care of our Nation's older adults
    and the long-term goals of health reform can be fully achieved.
        In closing, geriatrics is at a critical juncture, with our Nation
    facing an unprecedented increase in the number of older patients with
    complex health needs. Strong support such as yours will help ensure
    that the promise of health reform is fulfilled and every older American
    is able to receive high-quality healthcare.
        Thank you for your consideration.
                                     ______

              Prepared Statement of the American Heart Association
        Over the past 50 years, major progress has been made in the battle
    against heart disease, stroke and other forms of cardiovascular disease
    (CVD). Improved diagnosis and treatment have been remarkable--as has
    the survival rate. According to the National Institutes of Health
    (NIH), since the 1960s, 1.6 million lives have been saved that would
    have been lost to CVD. Americans can now expect to live on average 4
    years longer due to the reduction in heart-related deaths.
        Yet, one startling fact remains. Heart disease and stroke are still
    respectively the No. 1 and No. 3 killers in the United States. Nearly
    2,200 people die of CVD each day--one death every 39 seconds. CVD is a
    major cause of disability and costs our Nation more than any disease--a
    projected $287 billion in medical expenses and lost productivity for
    2007. Today, an estimated 83 million adults suffer from CVD. Moreover,
    CVD risk factors such as obesity and high blood pressure are on the
    rise. At age 40, the lifetime risk for CVD is 2 in 3 for men and over 1
    in 2 for women.
        Moreover, a new study projects that more than 40 percent of adults
    in the United States will live with the consequences of CVD at a cost
    to exceed $1 trillion annually by the year 2030. The graying of
    Americans combined with the explosive growth in medical spending are
    the main drivers of increased costs. Our country is truly facing a
    crisis. Without prevention on a nationwide scale, managing CVD will be
    an enormous challenge. Clearly, there must be a greater emphasis on
    prevention and evidence-based approaches to healthy behaviors. This
    will require strategies to reach people where they live, work and play.
    Prevention must be an integral part of our toolkit to promote heart
    healthy and stroke-free habits and wellness at an early age.
        Yet, in the face of these statistics, heart disease and stroke
    research, treatment and prevention programs remain woefully underfunded
    and money for NIH is unpredictable for the continuity of effort needed
    for key advances to redefine disease, ramp up prevention and promote
    best care.
        Given CVD is the No. 1 killer in each State and preventable and
    treatable risk factors continue to rise, many are surprised that the
    Centers for Disease Control and Prevention (CDC) invests on average
    only 16 cents per person on heart disease and stroke prevention. Also,
    only 20 States are funded for WISEWOMAN--a proven heart disease and
    stroke prevention program that serves uninsured and under-insured low-
    income women with a high prevalence of CVD risk factors.
        Where you live could also affect if you survive a very deadly form
    of heart disease--sudden cardiac arrest (SCA). Only 21 States received
    funding in fiscal year 2010 for the Health Resources and Services
    Administration's (HRSA) Rural and Community Access to Emergency Devices
    Program designed to save lives from sudden cardiac death.
        The American Heart Association applauds the administration and
    Congress for providing hope to the 1 in 3 adults in the United States
    who live with CVD by wisely investing in the NIH and in the Prevention
    and Public Health Fund. These resources have provided a much needed
    boost to improve our Nation's physical and fiscal health. However,
    stable and sustained funding is critical for fiscal year 2012 to
    advance heart disease and stroke research, prevention and treatment.
         funding recommendations: investing in the health of our nation
        Heart disease and stroke risk factors continue to rise, yet
    promising research to stem this tide goes unfunded. Too many Americans
    die from CVD, while proven prevention efforts beg for resources for
    widespread implementation. Now is the time to boost research,
    prevention and treatment of America's No. 1 and most costly killer. If
    Congress fails to build on progress of the past half century, Americans
    will pay more in lives lost and higher healthcare costs. Our
    recommendations address these issues in a comprehensive and fiscally
    responsible manner.
    Capitalize on Investment for the National Institutes of Health (NIH)
        NIH research has revolutionized patient care and holds the key to
    finding new ways to prevent, treat and even cure CVD, resulting in
    longer, healthier lives and reduced healthcare costs. NIH invests
    resources in every State and in 90 percent of congressional districts.
    According to a 2008 study, the typical NIH grant paid the salaries of
    about 7 mainly high-tech full-time or part-time jobs in fiscal year
    2007. Further, every dollar that NIH distributes in a grant returns
    $2.21 in goods and services to the local community in 1 year.
        American Heart Association Advocates.--We advocate for a fiscal
    year 2012 appropriation of $35 billion for NIH to capitalize on the
    investment to save lives, advance better health, spur our economy and
    spark innovation. NIH research prevents and cures disease, generates
    economic growth and preserves the U.S. role as the world leader in
    pharmaceuticals and biotechnology.
    Enhance Funding for NIH Heart and Stroke Research: A Proven and Wise
            Investment
        From 1997 to 2007, death rates for coronary heart disease and
    stroke fell nearly 28 percent and 45 percent, respectively. However,
    there is still much more to be done to improve the lives of heart
    disease and stroke patients--and more importantly to prevent CVD and
    stroke in the first place. Research will help lead the way. These
    declines in mortality are directly related to NIH heart and stroke
    research, with scientists on the verge of exciting discoveries that
    could lead to new treatments and even cures. For example, the biggest
    U.S. stroke rehabilitation study showed that patients who receive home
    physical therapy improve walking skills just as effectively as those
    treated in a program and that the progress continued up to 1 year post-
    stroke. NIH research has also demonstrated that over-zealous blood
    pressure lowering and combination lipid drugs did not cut
    cardiovascular disease in adult diabetics more than standard evidence-
    based care. Moreover, studies have defined the genetic basis of risky
    responses to vital blood-thinners.
        In addition to saving lives, NIH-funded research can cut healthcare
    costs. For example, the original NIH tPA drug trial resulted in a 10-
    year net $6.47 billion reduction in stroke healthcare costs. Also, the
    Stroke Prevention in Atrial Fibrillation Trial 1 produced a 10-year net
    savings of $1.27 billion. Yet, in the face of such solid returns on
    investments and other successes, NIH still invests a meager 4 percent
    of its budget on heart research, and a mere 1 percent on stroke
    research.
    Cardiovascular Disease Research: National Heart, Lung, and Blood
            Institute (NHLBI)
        Even in the face of progress and promising research opportunities,
    there is no cure for CVD. As our population ages, demand will only
    increase to find better ways for Americans to live healthy and
    productive lives despite CVD. Stable and sustained funding is needed to
    allow NHLBI to build on investments that provided grants to use
    genetics to identify and treat those at greatest risk from heart
    disease; hasten drug development to treat high cholesterol and high
    blood pressure; and create tailored strategies to treat, slow or
    prevent heart failure. Other key studies include an analysis of whether
    maintaining a lower blood pressure than currently recommended further
    reduces risk of heart disease, stroke, and cognitive decline. This
    information is vital to manage the burden of heart disease and stroke.
    Sustained critical funding will allow for aggressive implementation of
    other initiatives in the NHLBI and cardiovascular strategic plans.
    Stroke Research: National Institute of Neurological Disorders and
            Stroke (NINDS)
        An estimated 795,000 people in this country will suffer a stroke
    this year, and more than 135,950 will die. Many of the 7 million
    survivors face severe physical and mental disabilities, emotional
    distress and huge costs--a projected $41 billion in medical expenses
    and lost productivity for 2007. A new study projects stroke prevalence
    will increase 25 percent over the next 20 years, striking more than 10
    million individuals. Over the same time period, direct medical costs
    will rise 238 percent.
        Stable and sustained funding is required for NINDS to capitalize on
    investments to prevent stroke, protect the brain from damage and
    enhance rehabilitation. This includes initiatives to: (1) determine if
    MRI brain imaging can assist in selecting stroke victims who could
    benefit from the clot busting drug tPA beyond the 3-hour treatment
    window; (2) assess chemical compounds that might shield brain cells
    during a stroke; and (3) advance stroke rehabilitation by studying if
    the brain can be helped to ``rewire'' itself after a stroke. Enhanced
    funding will also allow for proactive initiation and implementation of
    the NINDS' novel stroke planning process (a result of its Stroke
    Progress Review Group) to assess the stroke research field and develop
    priorities to advance the most promising prevention, treatment,
    recovery and rehabilitation research.
        The American Heart Association Advocates.--While AHA supports
    increased funding for the 18 Institutes and centers that conduct heart
    and stroke research, including the National Institute of Diabetes, and
    Digestive and Kidney Diseases; and the National Institute on Aging, we
    have specific funding recommendations for the NHLBI and the NINDS. AHA
    advocates for an fiscal year 2012 appropriation of $3.514 billion for
    NHLBI; and $1.857 billion for NINDS.
    Increase Funding for the Centers for Disease Control and Prevention
            (CDC)
        Prevention is the best way to protect the health of all Americans
    and reduce the economic burden of CVD. Yet, effective prevention
    strategies and programs are not being implemented due to insufficient
    resources. The President's 2012 budget proposes a Coordinated Chronic
    Disease Prevention and Health Promotion Grant Program. AHA supports
    some consolidation of chronic disease programs, but with some important
    modifications and caveats. First, CDC must preserve the Division for
    Heart Disease and Stroke Prevention. A consolidation must ensure more
    predictable and adequate funding to all 50 States, including an annual
    share of the Prevention and Public Health Fund, with resources
    allocated by formula on the basis of burden, including cost, mortality,
    morbidity, and prevalence. These programs must be evidence-based and
    targeted, with a focus on capacity, evaluation and surveillance,
    including measurable outcomes and a higher level of accountability. To
    preserve the best elements of existing programs, funding should
    preserve evidenced-based outcomes work across the full spectrum of
    prevention and clinical care, including primary and secondary
    prevention, acute treatment, rehabilitation and continuous quality
    improvement (CQI). Each State must retain staff expertise to
    effectively address heart disease and stroke. State-based advisory
    groups of stakeholders from each constituency should be formed to help
    with plan implementation. A national advisory committee of
    constituencies should be created to foster stakeholder involvement.
    Matches, including in-kind, should be required when possible to build
    support in State health departments. Plans should use some funding for
    at least one program on common risk factors to consolidated diseases
    that can show a measurable, population-based impact. The rest of the
    funds should be spent on effective, evidence-based projects aimed at
    secondary prevention, acute treatment, rehabilitation, and CQI.
        This CDC division administers WISEWOMAN that serves uninsured and
    under-insured low-income women ages 40 to 64 in 20 States. This program
    helps them avoid heart disease and stroke by providing preventive
    health services, referrals to local healthcare providers, as needed,
    and lifestyle counseling and interventions tailored to their identified
    risk factors to promote lasting, healthy behavior modifications. From
    July 2008 to June 2010, WISEWOMAN reached more than 70,000 low-income
    women. During this time period, 89 percent of them had a least one risk
    factor and 28 percent had three or more risk factors for heart disease
    and stroke. However, more than 43,000 of these women participated in at
    least one lifestyle intervention session.
        The American Heart Association Advocates.--AHA joins with the CDC
    Coalition in advocating for $7.7 billion for the CDC's ``core
    programs,'' including increases for the Division of Heart Disease and
    Stroke Prevention and WISEWOMAN. AHA recommends $37 million to expand
    WISEWOMAN to more States and serve more eligible women in already
    funded States. We join the Friends of the NCHS in asking for $162
    million for the National Center for Health Statistics.
    Restore Funding for Rural and Community Access to Emergency Devices
            (AED) Program
        About 92 percent of sudden cardiac arrest (SCA) victims die outside
    of a hospital. But, prompt CPR and defibrillation, with an automated
    external defibrillator (AED), can more than double their chances of
    survival. Communities with comprehensive AED programs have reached
    survival rates of about 40 percent. HRSA's Rural and Community AED
    Program provides grants to States, competitively, to buy AEDs, train
    lay rescuers and first responders in their use and place AEDs where SCA
    is likely to occur. From September 2007 to August 2008, 3,051 AEDs were
    bought and 10,287 people were trained. And, 795 patients were saved
    between August 1, 2009 and July 31, 2010. Due to insufficient budgets,
    only 21 states received funds for this program in fiscal year 2010.
        The American Heart Association Advocates.--For fiscal year 2012,
    AHA advocates restoring HRSA's Rural and Community AED Program to its
    fiscal year 2005 level of $8.927 million.
    Increase Funding for the Agency for Healthcare Research and Quality
            (AHRQ)
        AHRQ develops scientific evidence to improve healthcare for
    Americans. AHRQ provides patients and caregivers with valuable
    scientific evidence to make the right healthcare decisions. AHRQ's
    research also enhances quality and efficiency of healthcare, providing
    the basis for protocols that prevent medical errors and reduce
    hospital-acquired infections, and improve patient confidence,
    experiences, and outcomes.
        The American Heart Association Advocates.--AHA joins Friends of
    AHRQ in advocating for $405 million for AHRQ to preserve its vital
    initiatives, boost the research infrastructure, spur innovation,
    nurture the next generation of scientists and help reinvent health and
    healthcare.
                                   conclusion
        Cardiovascular disease continues to inflict a deadly, disabling and
    costly toll on Americans. Yet, our funding recommendations for NIH, CDC
    and HRSA outlined above will save lives and cut rising healthcare
    costs. The American Heart Association urges Congress to seriously
    consider our suggestions during the fiscal year 2012 appropriations
    process. These proposed resources represent a wise investment for our
    nation and for the health and well-being of this and future
    generations.
                                     ______

     Prepared Statement of the American Indian Higher Education Consortium
        Summary of Requests.--Summarized below are the fiscal year 2012
    recommendations of the Nation's Tribal Colleges and Universities
    (TCUs), covering three areas within the Department of Education and one
    in the Department of Health and Human Services, Administration for
    Children and Families' Head Start Program.
                        department of education programs
    Higher Education Act Programs
        Strengthening Developing Institutions.--Section 316 of HEA Title
    III-A, specifically supports TCUs' grant programs. The TCUs request
    that the Subcommittee appropriate $30 million for this critically
    important program, the same level included in the President's fiscal
    year 2012 budget request.
        TRIO Programs.--Retention and support services are vital to
    achieving the national goal of having the highest percentage of college
    graduates globally by 2020. The President's fiscal year 2012 budget
    request includes funding for TRIO programs at fiscal year 2010 levels,
    which is not enough to sustain even the current level of program
    services. The TCUs support building on the President's fiscal year 2012
    budget request for TRIO programs and technical assistance funding so
    that these essential program services can be, at a minimum, maintained
    at current levels.
        Pell Grants.--TCUs urge the Subcommittee to sustain the current
    Pell Grant maximum.
    Perkins Career and Technical Education Programs
        Section 117 of the Carl D. Perkins Career and Technical Education
    Act provides a competitively awarded grant opportunity for tribally
    chartered and controlled career and technical institutions. AIHEC
    requests $8,200,000 to fund grants under Section 117 of the Perkins
    Act. Additionally, TCUs strongly support the Native American Career and
    Technical Education Program (NACTEP) authorized under Sec tion 116 of
    the Perkins Act.
    Elementary and Secondary Education Act and Workforce Investment Act
            Programs
        American Indian Teacher and Administrator Corps.--Authorized in
    Title IX of the Elementary and Secondary Education Act (ESEA) the
    American Indian Teacher Corps and the American Indian Administrator
    Corps offer professional development grants designed to increase the
    number of American Indian teachers and administrators serving their
    reservation communities. The TCUs request that the Subcommittee
    maintain funding for these programs at the fiscal year 2010 level.
        Adult and Basic Education.--Despite the loss of Federal funding for
    tribal adult basic education (ABE) in fiscal year 1996, there remains
    an extremely high demand for ABE programs in the communities that are
    home to the TCUs. While TCUs continue to offer adult education; GED;
    remediation and literacy services for American Indians, without
    dedicated funding these efforts cannot begin to meet demand. The TCUs
    request that the Subcommittee direct that $5 million of the funds
    appropriated each year for the Adult Education State Grants be made
    available to make competitive awards to TCUs to support the vitally
    needed reservation-based adult and basic education programs.
                department of health and human services program
    Tribal Colleges and Universities Head Start Partnership Program (DHHS-
            ACF)
        Tribal Colleges and Universities are ideal partners to help achieve
    the goals of Head Start in Indian Country. The TCUs request that the
    Subcommittee direct the Head Start Bureau to make available $5 million,
    of the more than $8.1 billion for Head Start included in the
    President's fiscal year 2012 budget request or of the amount ultimately
    appropriated in fiscal year 2012, for the TCU-Head Start Partnership
    program grants. These funds will help to ensure that each of the TCUs
    has the opportunity to compete for these much-needed partnership funds,
    thereby giving a jump start to the education successes of more American
    Indian children growing up in poor and isolated tribal communities.
                 background on tribal colleges and universities
        The Nation's 36 Tribal Colleges and Universities, operating over 75
    sites, provide access to quality higher education to 80 percent of
    Indian Country. TCUs are accredited by independent, regional
    accreditation agencies and like all institutions of higher education,
    must undergo stringent performance reviews on a periodic basis to
    retain their accreditation status. In addition to college level
    programming, they provide high school completion (GED), basic
    remediation, job training, college preparatory courses, and adult
    education and literacy programs. TCUs fulfill additional roles within
    their respective reservation communities functioning as community
    centers, libraries, tribal archives, career and business centers,
    economic development centers, public meeting places, and child and
    elder care centers. Each TCU is committed to improving the lives of its
    students through higher education and to moving American Indians toward
    self-sufficiency.
        Tribal Colleges and Universities, chartered by their respective
    tribal governments, were established in response to the recognition by
    tribal leaders that local, culturally based institutions are best
    suited to help American Indians succeed in higher education. TCUs
    effectively blend traditional teachings with conventional postsecondary
    curricula. They have developed innovative ways to address the needs of
    tribal populations and are overcoming long-standing barriers to success
    in higher education for American Indians. Since the first TCU was
    established on the Navajo Nation just over 40 years ago, these vital
    institutions have come to represent the most significant development in
    the history of American Indian higher education, providing access to,
    and promoting achievement among, students who may otherwise never have
    known postsecondary education success.
      justifications for fiscal year 2012 appropriations requests for tcus
        Tribal colleges and our students are already disproportionately
    impacted by efforts to reduce the Federal budget deficit and control
    Federal spending. The final fiscal year 2011 continuing resolution
    eliminated all of the Department of Housing and Urban Development's MSI
    community-based programs, including a critical TCU-HUD facilities
    program. TCUs were able to maximize leveraging potential, often
    securing even greater non-Federal funding to construct and equip Head
    Start and early childhood centers; student and community computer
    laboratories and public libraries; and student and faculty housing in
    rural and remote communities where few or none of these facilities
    existed. Important STEM program operated by the National Science
    Foundation and NASA were cut and for the first time since the program
    was established in fiscal year 2001, no new TCU-STEM awards, our sole
    STEM education program, are scheduled to be made in fiscal year 2011.
    Additionally, TCUs and our students suffer the impact of cuts to
    programs such as GEAR-UP, TRIO, SEOG, and year-round Pell more
    profoundly than do mainstream institutions of higher education, which
    have large endowments, alternative funding sources, including the
    ability to charge higher tuition rates, enroll more financially stable
    students, and affluent alumnae. The loss of opportunity that cuts to
    DoEd, HUD, and NSF programs represent to TCUs, and to other MSIs, is
    magnified by cuts to workforce development programs within the
    Department of Labor, nursing and allied health professions tuition
    forgiveness and scholarship programs operated by the Department of
    Health and Human Services, and an important TCU-based nutrition
    education program planned by USDA. Combined, these cuts strike at the
    most economically disadvantaged and health-challenged Americans.
    Higher Education Act
        In 1998, section 316 within Title III-A of the Higher Education Act
    launched a new program specifically for the Nation's Tribal Colleges
    and Universities. Programs under Titles III and V of the Act support
    institutions that enroll large proportions of financially disadvantaged
    students and that have low per-student expenditures. TCUs, which are
    truly developing institutions, are providing access to quality higher
    education opportunities to some of the most rural, impoverished, and
    historically underserved areas of the country. Seven of the Nation's 10
    poorest counties are served by TCUs. A stated goal of the Higher
    Education Act Title III programs is ``to improve the academic quality,
    institutional management and fiscal stability of eligible institutions,
    in order to increase their self-sufficiency and strengthen their
    capacity to make a substantial contribution to the higher education
    resources of the Nation.'' The TCU Title III-A program is specifically
    designed to address the critical, unmet needs of their American Indian
    students and communities, in order to effectively prepare them to
    succeed in a global, competitive workforce. Yet, in fiscal year 2011
    this critical program was cut by 11 percent. The TCUs urge the
    Subcommittee to appropriate $30 million in fiscal year 2012 for HEA
    Title III-A section 316, which is slightly less than the fiscal year
    2010 appropriated funding level and the same as the President's fiscal
    year 2012 budget request.
        Retention and support services are vital to achieving the national
    goal of having the highest percentage of college graduates globally, by
    2020. The TRIO-Student Support Services program was created out of
    recognition that college access was not enough to ensure advancement
    and that multiple factors worked to prevent the successful completion
    of higher education for many low-income and first-generation students
    and students with disabilities. Therefore, in addition to maintaining
    the maximum Pell Grant award level, it is critical that Congress also
    sustains student assistance programs such as Student Support Services
    and Upward Bound so that low-income and minority students have the
    support necessary to allow them to persist in and complete their
    postsecondary courses of study.
        The importance of Pell Grants to TCU students cannot be overstated.
    U.S. Department of Education figures show that the majority of TCU
    students receive Pell Grants, primarily because student income levels
    are so low and our students have far less access to other sources of
    financial aid than students at State-funded and other mainstream
    institutions. Within the TCU system, Pell Grants are doing exactly what
    they were intended to do--they are serving the needs of the lowest
    income students by helping them gain access to quality higher
    education, an essential step toward becoming active, productive members
    of the workforce. The TCUs urge the Subcommittee to continue to fund
    this critical program at the highest possible level.
    Carl D. Perkins Career and Technical Education Act
        Tribally Controlled Postsecondary Career and Technical
    Institutions.--Section 117 of the Carl D. Perkins Career and Technical
    Education Act provides a competitively awarded grant opportunity for
    tribally chartered and controlled career and technical institutions.
    AIHEC requests $8,200,000 to fund grants under Section 117 of the
    Perkins Act, the same level included in the President's fiscal year
    2012 budget request.
        Native American Career and Technical Education Program.--The Native
    American Career and Technical Education Program (NACTEP) under Section
    116 of the Act reserves 1.25 percent of appropriated funding to support
    American Indian career and technical programs. The TCUs strongly urge
    the Subcommittee to continue to support NACTEP, which is vital to the
    continuation of the career and technical education programs offered at
    TCUs that provide job training and certifications to remote reservation
    communities.
    Greater Support of Indian Education Programs
        American Indian Adult and Basic Education (Office of Vocational and
    Adult Education).--This program supports adult basic education programs
    for American Indians offered by State and local education agencies,
    Indian tribes, agencies, and TCUs. Despite a lack of funding, TCUs must
    find a way to continue to provide much-in-demand basic adult education
    classes for those American Indians that the present K-12 Indian
    education system has failed. Before many individuals can even begin the
    course work needed to learn a productive skill, they first must earn a
    GED or, in some cases, even learn to read. There is an extensive need
    for basic adult educational programs and TCUs must have adequate and
    stable funding to provide these essential activities. TCUs request that
    the Subcommittee direct that $5 million of the funds appropriated
    annually for the Adult Education State Grants be made available to make
    competitive awards to TCUs to help meet the growing demand for adult
    basic education and remediation program services on their respective
    reservations.
        American Indian Teacher/Administrator Corps (Special Programs for
    Indian Children).--American Indians are greatly underrepresented in the
    teaching and school administrator ranks nationally. TCUs are community
    based institutions of higher education making them ideal catalysts for
    these two initiatives because of their current work in this area and
    the existing articulation agreements they hold with 4-year degree
    granting institutions. The TCUs request that the Subcommittee maintain
    these two programs at the fiscal year 2010 appropriated levels to
    continue to produce well-qualified American Indian teachers and school
    administrators in and for Indian Country.
    department of health and human services/administration for children and
                              families/head start
        Tribal Colleges and Universities (TCU) Head Start Partnership
    Program.--The TCU-Head Start Partnership has made a lasting investment
    in our Indian communities by creating and enhancing associate degree
    programs in Early Childhood Development and related fields. This
    program has afforded American Indian children Head Start programs of
    the highest quality. A clear barrier to the ongoing success of this
    partnership program is the lack of stable funds for the Partnership.
    The TCUs request that the Subcommittee direct the Head Start Bureau to
    designate $5 million, of the more than $8.1 billion included in the
    President's fiscal year 2012 budget request for programs under the Head
    Start Act, be made available for the TCU-Head Start Partnership
    program.
                                   conclusion
        Tribal Colleges and Universities are providing access to high
    quality higher education opportunities to many thousands of American
    Indians and essential community services and programs to many more. The
    modest Federal investment in TCUs has already paid great dividends in
    terms of employment, education, and economic development and
    continuation of this solid investment makes sound moral and fiscal
    sense. TCUs need your help if they are to sustain programs and achieve
    their missions to serve their students and communities.
        Thank you again for this opportunity to present our funding
    requests. We respectfully ask the Members of the Subcommittee for their
    continued support of the Nation's Tribal Colleges and Universities and
    full consideration of our fiscal year 2012 appropriations needs and
    recommendations.
                                     ______

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

              Prepared Statement of the American Lung Association
                              summary of programs
    Centers for Disease Control and Prevention (CDC)
        Increased overall CDC funding--$7.7 billion
      --Funding Healthy Communities--$52.8 million
      --Office on Smoking and Health--$110 million
      --National Asthma Control Program--$31 million
      --Environment and Health Outcome Tracking--$32.1 million
      --Tuberculosis programs--$231 million
      --CDC influenza preparedness--$160 million
      --NIOSH--$315.3 million
      --Prevention and Public Health Fund--$1 billion, with $330 million
            for tobacco control initiatives
    National Institutes of Health (NIH)
        Increased overall NIH funding--$35 billion
        National Heart, Lung and Blood Institute--$3.514 billion
        National Cancer Institute--$5.725 billion
        National Institute of Allergy and Infectious Diseases--$5.395
    billion
        National Institute of Environmental Health Sciences--$779.4 million
        National Institute of Nursing Research--$163 million
        National Institute on Minority Health & Health Disparities--$236.9
    million
        Fogarty International Center--$78.4 million
        For more information about this testimony, please contact Erika
    Sward at esward@lungusa.org.
        The American Lung Association is pleased to present our
    recommendations for fiscal year 2012 to the Labor, Health and Human
    Services, and Education Appropriations Subcommittee. The public health
    and research programs funded by this committee will prevent lung
    disease and improve and extend the lives of millions of Americans who
    suffer from lung disease.
        The American Lung Association is the oldest voluntary health
    organization in the United States, with national offices and local
    associations around the country. Founded in 1904 to fight tuberculosis,
    the American Lung Association is the leading organization working to
    save lives by improving lung health and preventing lung disease through
    education, advocacy and research.
    A Sustained and Sustainable Investment
        Mr. Chairman, investments in prevention and wellness can and will
    pay near term and long term dividends for the health of the American
    people and people everywhere. That is why the American Lung Association
    strongly supports the Prevention and Public Health Fund established in
    the Affordable Care Act. This fund will provide billions of dollars to
    critical public health initiatives, like community programs that help
    people quit smoking, support groups for lung cancer patients, and
    classes that teach people how to avoid asthma attacks.
        The United States must also maintain its commitment to medical
    research. A growing, sustained, predictable and reliable investment in
    the NIH provides hope for millions afflicted with lung disease. While
    our focus is on lung disease research, we strongly support increasing
    the investment in research across the entire National Institutes of
    Health.
    Lung Disease
        Each year, almost 400,000 Americans die of lung disease. It is
    America's number three killer, responsible for one in every six deaths.
    More than 37 million Americans suffer from a chronic lung disease. Each
    year lung disease costs the economy an estimated $173 billion. Lung
    diseases include: lung cancer, asthma, chronic obstructive pulmonary
    disease (COPD), tuberculosis, pneumonia, influenza, sleep disordered
    breathing, pediatric lung disorders, occupational lung disease and
    sarcoidosis.
    Improving Public Health
        The American Lung Association strongly supports investments in the
    public health infrastructure. In order for the Centers for Disease
    Control and Prevention (CDC) to carry out its prevention mission and to
    assure an adequate translation of new research into effective State and
    local programs to improve the health of all Americans, we strongly
    support increasing the overall CDC funding to $7.7 billion.
        We strongly encourage improved disease surveillance and health
    tracking to better understand diseases like asthma. We support an
    appropriations level of $32.1 million for the Environment and Health
    Outcome Tracking Network to allow Federal, State and local agencies to
    track potential relationships between hazards in the environment and
    chronic disease rates.
        We strongly support investments in communities to bring together
    key stakeholders to identify and improve policies and environmental
    factors influencing health in order to reduce the burden of chronic
    diseases. These programs lead to a wide range of improved health
    outcomes including reduced tobacco use. We strongly recommend at least
    $52.8 million in funding for the Healthy Communities program and it
    remaining a separate, stand alone program.
    Tobacco Use
        Tobacco use is the leading preventable cause of death in the United
    States, killing more than 443,000 people every year. Smoking is
    responsible for one in five U.S. deaths. The direct healthcare and lost
    productivity costs of tobacco-caused disease and disability are also
    staggering, an estimated $193 billion each year.
        Given the magnitude of the tobacco-caused disease burden and how
    much of it can be prevented; the CDC Office on Smoking and Health (OSH)
    should be much larger and better funded. Historically, Congress has
    failed to invest in tobacco control--even though public health
    interventions have been scientifically proven to reduce tobacco use.
    This neglect cannot continue if the nation wants to prevent disease and
    promote wellness.
        The American Lung Association urges that $110 million be
    appropriated to OSH for fiscal year 2012 and that OSH receive an
    additional one-third, or $330 million, of funds from the Prevention and
    Public Health Fund.
    Asthma
        The American Lung Association strongly opposes the proposal in the
    President's budget request that would merge the National Asthma Control
    Program with the Healthy Homes/Lead Poisoning Prevention Program--and
    then slash the combined programs by more than 50 percent. The Lung
    Association asks this Committee to retain the National Asthma Control
    Program as a stand-alone program and that $31 million be appropriated
    to it for fiscal year 2012.
        It is estimated that almost 25 million Americans currently have
    asthma, of whom 7.1 million are children. Asthma prevalence rates are
    over 37 percent higher among African Americans than whites. Studies
    also suggest that Puerto Ricans have higher asthma prevalence rates and
    age-adjusted death rates than all other racial and ethnic subgroups.
    Asthma is the third leading cause of hospitalization among children
    under the age of 15 and is a leading cause of school absences from
    chronic disease--accounting for over 10.5 million lost school days in
    2008. Asthma costs our healthcare system over $50.1 billion annually
    and indirect costs from lost productivity add another $5.9 billion, for
    a total of $56 billion annually.
        We recommend that the National Heart, Lung and Blood Institute
    receive $3.514 billion and the National Institute of Allergy and
    Infectious Diseases be appropriated $5.395 billion, and that both
    agencies continue their investments in asthma research in pursuit of
    treatments and cures.
    Lung Cancer
        An estimated 370,000 Americans are living with lung cancer. During
    2010, an estimated 222,520 new cases of lung cancer were diagnosed, and
    158,664 Americans died from lung cancer in 2009. Survival rates for
    lung cancer tend to be much lower than those of most other cancers.
    African Americans are the most likely to develop and die from lung
    cancer than persons of any other racial group.
        Lung cancer receives far too little attention and focus. Given the
    magnitude of lung cancer and the enormity of the death toll, the
    American Lung Association strongly recommends that the NIH and other
    Federal research programs commit additional resources to lung cancer.
    We support a funding level of $5.725 billion for the National Cancer
    Institute and urge more attention and focus on lung cancer.
    Chronic Obstructive Pulmonary Disease
        Chronic obstructive pulmonary disease, or COPD, is the third
    leading cause of death in the United States. It has been estimated that
    13.1 million patients have been diagnosed with some form of COPD and as
    many as 24 million adults may suffer from its consequences. In 2009,
    133,737 people in the United States died of COPD. The annual cost to
    the Nation for COPD in 2010 was projected to be $49.9 billion. This
    includes $29.5 billion in direct healthcare expenditures, $8.0 billion
    in indirect morbidity costs and $12.4 billion in indirect mortality
    costs. Medicare expenses for COPD beneficiaries were nearly 2.5 times
    that of the expenditures for all other patients.
        The American Lung Association strongly recommends that the NIH and
    other Federal research programs commit additional resources to COPD
    research programs. We strongly support funding the National Heart, Lung
    and Blood Institute and its lifesaving lung disease research program at
    $3.514 billion. The American Lung Association also asks the Committee
    to direct the National Heart, Lung and Blood Institute to work with the
    CDC and other appropriate agencies to prepare a national action plan to
    address COPD, which should include public awareness and surveillance
    activities.
    Influenza
        Influenza is a highly contagious viral infection and one of the
    most severe illnesses of the winter season. It is unpredictable, with
    seasonal death estimates ranging from 3,000 to 49,000 over the last 30
    years. Further, the emerging threat of a pandemic influenza is looming
    as the recently emerging strain of H1N1 reminded us. Public health
    experts warn that 209,000 Americans could die and 865,000 would be
    hospitalized if a moderate flu epidemic hits the United States. To
    prepare for a potential pandemic, the American Lung Association
    supports funding the Federal CDC Influenza efforts at $160 million.
    Tuberculosis
        Tuberculosis primarily affects the lungs but can also affect other
    parts of the body. There are an estimated 10 million to 15 million
    Americans who carry latent TB infection. Each has the potential to
    develop active TB in the future. About 10 percent of these individuals
    will develop active TB disease at some point in their lives. In 2009,
    there were 11,545 cases of active TB reported in the United States.
    While declining overall TB rates are good news, the emergence and
    spread of multi-drug resistant TB pose a significant threat to the
    public health of our Nation. Continued support is needed if the United
    States is going to continue progress toward the elimination of TB. We
    request that Congress increase funding for tuberculosis programs at CDC
    to $231 million for fiscal year 2012.
    Conclusion
        The American Lung Association also would like to indicate our
    strong support for CDC and NIH, particularly those programs that impact
    lung health. We strongly support an across the board increase for NIH
    with particular emphasis on the National Heart, Lung and Blood
    Institute, the National Cancer Institute, the National Institute of
    Allergy and Infectious Diseases, the National Institute of
    Environmental Health Sciences, the National Institute of Nursing
    Research, the National Institute on Minority Health & Health
    Disparities and the Fogarty International Center.
        Lung disease is a continuing, growing problem in the United States.
    It is America's number three killer, responsible for one in six deaths.
    Progress against lung disease is not keeping pace with other major
    causes of death and more must be done. The level of support this
    committee approves for lung disease programs should reflect the urgency
    illustrated by these numbers.
                                     ______

             Prepared Statement of the American National Red Cross
        Chairman Tom Harkin, Ranking Member Richard Shelby, and Members of
    the Subcommittee, the American Red Cross and the United Nations
    Foundation appreciate the opportunity to submit testimony in support of
    measles control activities of the U.S. Centers for Disease Control and
    Prevention (CDC). The American Red Cross and the United Nations
    Foundation recognize the leadership that Congress has shown in funding
    CDC for these essential activities. We sincerely hope that Congress
    will continue to support the CDC during this critical period in measles
    control.
        In 2001, CDC--along with the American Red Cross, the United Nations
    Foundation, the World Health Organization, and UNICEF--founded the
    Measles Initiative, a partnership committed to reducing measles deaths
    globally. The current U.N. goal is to reduce measles deaths by 95
    percent by 2015 compared to 2000 estimates. The Measles Initiative is
    committed to reaching this goal by proving technical and financial
    support to governments and communities worldwide.
        The Measles Initiative has achieved ``spectacular'' \1\ results by
    supporting the vaccination of more than 700 million children. Largely
    due to the Measles Initiative, global measles mortality dropped 78
    percent, from an estimated 733,000 deaths in 2000 to 164,000 in 2008
    (the latest year for which data is available). During this same period,
    measles deaths in Africa fell by 92 percent, from 371,000 to 28,000.
    ---------------------------------------------------------------------------
        \1\ The Lancet, Volume 8, page 13 (January 2008).

        Working closely with host governments, the Measles Initiative has
    been the main international supporter of mass measles immunization
    campaigns since 2001. The Initiative mobilized more than $700 million
    and provided technical support in more than 60 developing countries on
    vaccination campaigns, surveillance and improving routine immunization
    services. From 2000 to 2008, an estimated 4.3 million measles deaths
    were averted as a result of these accelerated measles control
    activities at a donor cost of $184/death averted, making measles
    mortality reduction one of the most cost-effective public health
    interventions.
        Nearly all the measles vaccination campaigns have been able to
    reach more than 90 percent of their target populations. Countries
    recognize the opportunity that measles vaccination campaigns provide in
    accessing mothers and young children, and ``integrating'' the campaigns
    with other life-saving health interventions has become the norm. In
    addition to measles vaccine, Vitamin A (crucial for preventing
    blindness in under nourished children), de-worming medicine (reduces
    malnutrition), and insecticide-treated bed nets (ITNs) for malaria
    prevention are distributed during vaccination campaigns. The scale of
    these distributions is immense. For example, more than 40 million ITNs
    were distributed in vaccination campaigns in the last few years. The
    delivery of multiple child health interventions during a single
    campaign is far less expensive than delivering the interventions
    separately, and this strategy increases the potential positive impact
    on children's health from a single campaign.
        The extraordinary reduction in global measles deaths contributed
    nearly 25 percent of the progress to date toward Millennium Development
    Goal #4 (reducing under-five child mortality). However, since 2009,
    Africa has experienced outbreaks affecting 28 countries, resulting in a
    four-fold increase in reported measles cases. These outbreaks highlight
    the fragility of the last decade's progress. If mass immunization
    campaigns are not continued, measles deaths will increase rapidly with
    more than half a million deaths estimated for 2013 alone.
        To achieve the 2015 goal and avoid a resurgence of measles the
    following actions are required:
      --Fully implementing activities, both campaigns and strengthening
            routine measles coverage, in India since it is the greatest
            contributor to the global burden of measles.
      --Sustaining the gains in reduced measles deaths, especially in
            Africa, by strengthening immunization programs to ensure that
            more than 90 percent of infants are vaccinated against measles
            through routine health services before their first birthday as
            well as conducting timely, high quality mass immunization
            campaigns.
      --Securing sufficient funding for measles-control activities both
            globally and nationally. The Measles Initiative faces a funding
            shortfall of an estimated $212 million for 2012-2105.
            Implementation of timely measles campaigns is increasingly
            dependent upon countries funding these activities locally. The
            decrease in donor funds available at global level to support
            measles elimination activities makes increased political
            commitment and country ownership of the activities critical for
            achieving and sustaining the goal of reducing measles mortality
            by 90 percent.
        If these challenges are not addressed, the remarkable gains made
    since 2000 will be lost and a major resurgence in measles deaths will
    occur.
        By controlling measles cases in other countries, U.S. children are
    also being protected from the disease. Measles can cause severe
    complications and death. A resurgence of measles occurred in the United
    States between 1989 and 1991, with more than 55,000 cases reported.
    This resurgence was particularly severe, accounting for more than
    11,000 hospitalizations and 123 deaths. Since then, measles control
    measures in the United States have been strengthened and endemic
    transmission of measles cases have been eliminated here since 2000.
    However, importations of measles cases into this country continue to
    occur each year. The costs of these cases and outbreaks are
    substantial, both in terms of the costs to public health departments
    and in terms of productivity losses among people with measles and
    parents of sick children. For example in 2008, 2 hospitals in Arizona
    spent an estimated $800,000 responding and containing 7 measles
    cases.\2\ The United States is currently on track to have more measles
    cases in 2011 than any year in more than a decade.
    ---------------------------------------------------------------------------
        \2\ Chen SY, Anderson S, Kutty PK, et al. J of Infect Dis 2011;
    203: 1517-1525.
    ---------------------------------------------------------------------------
    The Role of CDC in Global Measles Mortality Reduction
        Since fiscal year 2001, Congress has provided approximately $43.6
    million annually in funding to CDC for global measles control
    activities. These funds were used toward the purchase of measles
    vaccine for use in large-scale measles vaccination campaigns in more
    than 60 countries in Africa and Asia, and for the provision of
    technical support to Ministries of Health. Specifically, this technical
    support includes: Planning, monitoring, and evaluating large-scale
    measles vaccination campaigns; conducting epidemiological
    investigations and laboratory surveillance of measles outbreaks; and
    conducting operations research to guide cost-effective and high quality
    measles control programs.
        In addition, CDC epidemiologists and public health specialists have
    worked closely with WHO, UNICEF, the United Nations Foundation, and the
    American Red Cross to strengthen measles control programs at global and
    regional levels. While it is not possible to precisely quantify the
    impact of CDC's financial and technical support to the Measles
    Initiative, there is no doubt that CDC's support--made possible by the
    funding appropriated by Congress--was essential in helping achieve the
    sharp reduction in measles deaths in just 8 years.
        The American Red Cross and the United Nations Foundation would like
    to acknowledge the leadership and work provided by CDC and recognize
    that CDC brings much more to the table than just financial resources.
    The Measles Initiative is fortunate in having a partner that provides
    critical personnel and technical support for vaccination campaigns and
    in response to disease outbreaks. CDC personnel have routinely
    demonstrated their ability to work well with other organizations and
    provide solutions to complex problems that help critical work get done
    faster and more efficiently.
        In fiscal year 2011, Congress appropriated approximately $49
    million to fund CDC for global measles control activities, this
    represented at $2.6 million decrease from the previous year. The
    American Red Cross and the United Nations Foundation respectfully
    request a return to fiscal year 2010 funding levels ($52 million) for
    fiscal year 2012 for CDC's measles control activities to protect the
    investment of the last decade, and prevent a global resurgence of
    measles and a loss of progress toward Millennium Development Goal #4.
        Your commitment has brought us unprecedented victories in reducing
    measles mortality around the world. In addition, your continued support
    for this initiative helps prevent children from suffering from this
    preventable disease both abroad and in the United States.
        Thank you for the opportunity to submit testimony.
                                     ______

             Prepared Statement of the American Nurses Association
        The American Nurses Association (ANA) appreciates the opportunity
    to comment on fiscal year 2012 appropriations for the Title VIII
    Nursing Workforce Development Programs and Nurse-Managed Health
    Clinics. Founded in 1896, ANA is the only full-service professional
    association representing the interests of the Nation's 3.1 million
    registered nurses (RNs) through its State nurses associations, and
    organizational affiliates. The ANA advances the nursing profession by
    fostering high standards of nursing practice, promoting the rights of
    nurses in the workplace, and projecting a positive and realistic view
    of nursing.
        As the largest single group of clinical healthcare professionals
    within the health system, licensed registered nurses are educated and
    practice within a holistic framework that views the individual, family
    and community as an interconnected system that can keep us well and
    help us heal. Registered nurses are fundamental to the critical shift
    needed in health services delivery, with the goal of transforming the
    current ``sick care'' system into a true ``healthcare'' system. RNs are
    the backbone of hospitals, community clinics, school health programs,
    home health and long-term care programs, and serve patients in many
    other roles and settings. The ANA gratefully acknowledges this
    Subcommittee's history of support for nursing education. We also
    appreciate your continued recognition of the important role nurses play
    in the delivery of quality healthcare services, including Nurse-Managed
    Health Clinics (NMHCs).
    The Nursing Shortage
        A sufficient supply of nurses is critical in providing our Nation's
    population with quality healthcare. Registered Nurses (RNs) and
    Advanced Practice Registered Nurses (APRNs) play an integral role in
    the delivery of primary care and help to bring the focus of our
    healthcare system back where it belongs--on the patient and the
    community. The current U.S. nursing shortage is already having a
    detrimental impact on our healthcare system, and it is expected to grow
    to a 260,000 nurse shortfall by 2025. A shortage of this magnitude
    would be twice as large as any shortage experienced by this country
    since the 1960s. Cuts to Title VIII funding would be detrimental to the
    healthcare system and the patients we serve.
        As noted above, the nursing shortage is having a detrimental impact
    on the entire healthcare system. Numerous studies have shown that
    nursing shortages contribute to medical errors, poor patient outcomes,
    and increased mortality rates. A study published in the March 17, 2011
    issue of the New England Journal of Medicine shows that inadequate
    staffing is tied to higher patient mortality rate. The study supports
    findings of previous studies and finds that higher than typical rates
    of patient admissions, discharges, and transfers during a shift were
    associated with increased mortality--an indication of the important
    time and attention needed by RNs to ensure effective coordination of
    care for patients at critical transition periods.
    Nursing Workforce Development Programs
        The Nursing Workforce Development programs, authorized under Title
    VIII of the Public Health Service Act (42 U.S.C. 296 et seq.) support
    the supply and distribution of qualified nurses to meet our Nation's
    healthcare needs. Over the last 46 years, Title VIII programs have
    addressed each aspect of the nursing shortages--education, practice,
    retention, and recruitment.
      --Title VIII provides the largest source of Federal funding for
            nursing education, offering financial support for nursing
            education programs, individual students, and nurses.
      --These programs bolster nursing education at all levels, from entry-
            level preparation through graduate study.
      --Title VIII programs favor institutions that educate nurses for
            practice in rural and medically underserved communities.
      --In fiscal year 2008, these programs provided loans, scholarships,
            traineeships, and programmatic support to 77,395 nursing
            students and nurses.
        The 107th Congress recognized the detrimental impact of the
    developing nursing shortage and passed the Nurse Reinvestment Act
    (Public Law 107-205). This law improved the Title VIII Nursing
    Workforce Development programs to meet the unique characteristics of
    today's shortage. These programs were also strengthened and
    reauthorized with the adoption of the Affordable Care Act. This
    achievement holds the promise of recruiting new nurses into the
    profession, promoting career advancement within nursing and improving
    patient care delivery. However, this promise cannot be met without a
    significant investment. ANA strongly urges Congress to increase funding
    for Title VIII programs to a total of $313.075 million in fiscal year
    2012. This is also the amount requested in President Obama's fiscal
    year 2012 budget.
        Current funding levels are clearly failing to meet the need. In
    fiscal year 2008 (most recent year statistics are available), the
    Health Resources and Services Administration (HRSA) was forced to turn
    away 92.8 percent of the eligible applicants for the Nurse Education
    Loan Repayment Program (NELRP), and 53 percent of the eligible
    applicants for the Nursing Scholarship program due to a lack of
    adequate funding. These programs are used to direct RNs into areas with
    the greatest need--including departments of public health, community
    health centers, and disproportionate share hospitals.
        Title VIII includes the following program areas:
        Nursing Education Loan Repayment Program and Scholarships.--This
    line item is comprised of the Nurse Education Loan Repayment Program
    (NELRP) and the Nursing Scholarship Program (NSP). In fiscal year 2010,
    the Nurse Education Loan Repayment Program and Scholarships received
    $93.8 million.
        The NELRP repays up to 85 percent of a RN's student loans in return
    for full-time practice in a facility with a critical nursing shortage.
    The NELRP nurse is required to work for at least 2 years in a
    designated facility, during which time the NELRP repays 60 percent of
    the RN's student loan balance. If the nurse applies and is accepted for
    an optional third year an additional 25 percent of the loan is repaid.
        In fiscal year 2008, HRSA received 3,039 applications for the
    nursing scholarship. Due to lack of funding, a mere 177 scholarships
    were awarded. Therefore, 2,862 nursing students (94 percent) willing to
    work in facilities with a critical shortage were denied access to this
    program.
        Nurse Faculty Loan Program.--This program establishes a loan
    repayment fund within schools of nursing to increase the number of
    qualified nurse faculty. Nurses may use these funds to pursue a
    master's or doctoral degree. They must agree to teach at a school of
    nursing in exchange for cancellation of up to 85 percent of their
    educational loans, plus interest, over a 4-year period. In fiscal year
    2010, this program received $25 million.
        This program is vital given the critical shortage of nursing
    faculty. America's schools of nursing cannot increase their capacity
    without an influx of new teaching staff. Last year, schools of nursing
    were forced to turn away tens of thousands of qualified applicants due
    largely to the lack of faculty. In fiscal year 2008, HRSA funded 95
    faculty loans.
        Nurse Education, Practice, and Retention Grants.--This section is
    comprised of many programs designed to support entry-level nursing
    education and to enhance nursing practice. The education grants are
    designed to expand enrollments in baccalaureate nursing programs,
    develop internship and residency programs to enhance mentoring and
    specialty training, and provide new technologies in education including
    distance learning. All together, the Nurse Education, Practice, and
    Retention Grants supported 42,761 nurses and nursing students in fiscal
    year 2008. The program received $39.8 million in fiscal year 2010.
        Nursing Workforce Diversity.--This program provides funds to
    enhance diversity in nursing education and practice. It supports
    projects to increase nursing education opportunities for individuals
    from disadvantaged backgrounds--including racial and ethnic minorities,
    as well as individuals who are economically disadvantaged. In fiscal
    year 2008, 85 applications were received for workforce diversity
    grants, 51 programs were funded. In fiscal year 2010, these programs
    received $16 million.
        Advanced Nursing Education.--Advanced practice registered nurses
    (APRNs) are nurses who have attained advanced expertise in the clinical
    management of health conditions. Typically, an APRN holds a master's
    degree with advanced didactic and clinical preparation beyond that of
    the RN. Most have practice experience as RNs prior to entering graduate
    school. Practice areas include, but are not limited to: anesthesiology,
    family medicine, gerontology, pediatrics, psychiatry, midwifery,
    neonatology, and women's and adult health. Title VIII grants have
    supported the development of virtually all initial State and regional
    outreach models using distance learning methodologies to provide
    advanced study opportunities for nurses in rural and remote areas. In
    fiscal year 2009, 5,649 advanced education nurses were supported
    through these programs. In fiscal year 2010, these programs received
    $64.4 million.
        Comprehensive Geriatric Education Grants.--This authority awards
    grants to train and educate nurses in providing healthcare to the
    elderly. Funds are used to train individuals who provide direct care
    for the elderly, to develop and disseminate geriatric nursing
    curriculum, to train faculty members in geriatrics, and to provide
    continuing education to nurses who provide geriatric care. In fiscal
    year 2008, 6,514 nurses and nursing students were supported through
    these programs. In fiscal year 2010, these grants received $4.5
    million. The growing number of elderly Americans and the impending
    healthcare needs of the baby boom generation make this program
    critically important.
    Nurse-Managed Health Clinics
        A healthcare system must value primary care and prevention to
    achieve improved health status of individuals, families and the
    community. As Congress recognized through the passage of the Affordable
    Care Act (ACA) money, resources and attention must be reallocated in
    the health system to highlight importance of, and create incentives
    for, primary care and prevention.
        Nurses are strong supporters of community and home-based models of
    care. We believe that the foundation for a wellness-based healthcare
    system is built in these settings and reduces the amount of both money
    and human suffering. ANA supports the renewed focus on new and existing
    community-based programs such as Nurse Managed Health Centers (NMHCs).
        Currently, there are more than 200 Nurse Managed Health Centers
    (NMHCs) in the United States which have provided care to over 2 million
    patients annually. ANA believes that Nurse Managed Health Centers
    (NMHCs) are an efficient, sensible, cost-effective way to deliver
    primary healthcare services. These clinics are also used as clinical
    sites for nursing education. The nurse-managed care model is especially
    effective in disease prevention and early detection, management of
    chronic conditions, treatment of acute illnesses, health promotion, and
    more. Nurse Managed Health Centers (NMHCs) can also provide a medical
    home for underserved individuals as well as partnering with the Federal
    Government to reduce health disparities.
        ANA was pleased to see that the Affordable Care Act (ACA) provided
    grant eligibility to Nurse-Managed Health Clinics (NMHCs) to support
    operating costs. ACA also authorized up to $50 million a year to
    support operating costs. ANA strongly urges Congress to provide $20
    million for the Nurse-Managed Health Clinics authorized under Title
    VIII of the Public Health Service Act in fiscal year 2012 as
    recommended in President Obama's fiscal year 2012 budget.
    Conclusion
        While ANA appreciates the continued support of this Subcommittee,
    we are concerned that Title VIII funding levels have not been
    sufficient to address the growing nursing shortage. In preparation for
    the implementation of healthcare reform initiatives, which ANA
    supports, we believe there will be an even greater need for nurses and
    adequate funding for these programs is even more essential. Registered
    Nurses (RNs) and Advanced Practice Nurses (APRNs) are key providers
    whose care is linked directly to the availability, cost, and quality of
    healthcare services. ANA asks you to meet today's shortage with a
    relatively modest investment of $313.075 million in fiscal year 2012
    for the Health Resources and Services Administration Nursing Workforce
    Development programs and $20 million for Nurse-Managed Health Clinics.
    Thank you.
                                     ______

        Prepared Statement of the American Physical Therapy Association
        On behalf of more than 77,000 physical therapists, physical
    therapist assistants, and students of physical therapy, the American
    Physical Therapy Association (APTA) thanks you for the opportunity to
    submit official testimony regarding recommendations for the fiscal year
    2012 appropriations. APTA's mission is to improve the health and
    quality of life of individuals in society by advancing physical
    therapist practice, education, and research. Physical therapists across
    the country utilize a wide variety of federally funded resources to
    work collaboratively toward the advancement of these goals. APTA's
    recommendations for Federal funding, as outlined in this document,
    reflect a commitment toward these priorities for the good of society
    and the rehabilitation community.
    Department of Health and Human Services
                National Institutes of Health (NIH)
        Rehabilitation research was funded at $458 million within NIH's
    approximately $31.2 billion budget in fiscal year 2010. This represents
    roughly 1 percent of NIH funds for an area of biomedical research that
    impacts a growing percentage of our Nation's seniors, persons with
    disabilities, young persons with chronic disease or traumatic injuries,
    and children with development disabilities. The Institute of Medicine
    (IOM) estimates that 1 in 7 individuals have an impairment or
    limitation that significantly limits their ability to perform
    activities of daily living. Investment in and recognition of
    rehabilitation within NIH is a necessary step toward continuing to meet
    the needs of these individuals in our population. Through the American
    Recovery and Reinvestment Act (ARRA), rehabilitation research was able
    to take advantage of an extra infusion of approximately $75 million in
    fiscal year 2009 and $93 million in fiscal year 2010. However, APTA
    believes that rehabilitation research at NIH has been under-funded for
    many years. The funds currently utilized are well-invested for the
    impact that rehabilitation interventions will have on the quality of
    lives of individuals. Continued investment and greater recognition and
    coordination of rehabilitation research among Institutes and across
    Federal departments will enhance the returns the Federal Government
    receives when investing in this area. Taking this into consideration,
    APTA recommends $31.829 billion (a $629 million increase over fiscal
    year 2010) for NIH in fiscal year 2012 to ensure that the momentum is
    maintained that was gained under the ARRA investment to improve health,
    spur economic growth and innovation, and advance science. APTA
    recognizes the extraordinary circumstances that exist during these
    tough budgetary times, however it still remains crucial that Federal
    investments in healthcare research are preserved and at least kept on
    pace with the rate of inflation.
        Specifically, the physical therapy and rehabilitation science
    community recommends that Congress allocate crucial funding
    enhancements in the following institutes:
      --$1.356 billion (a 2 percent increase over fiscal year 2010) for the
            Eunice Kennedy Shriver National Institute of Child Health and
            Human Development (NICHD) which houses the National Center for
            Medical Rehabilitation Research (NCMRR), the only entity within
            NIH explicitly focused on the advancement of rehabilitation
            science. NCMRR fosters the development of scientific knowledge
            needed to enhance the health, productivity, independence, and
            quality-of-life of people with disabilities. A primary goal of
            the Center-supported research is to bring the health-related
            problems of people with disabilities to the attention of the
            best scientists in order to capitalize upon the myriad advances
            occurring in the biological, behavioral, and engineering
            sciences.
      --$1.66 billion (a 2 percent increase over fiscal year 2010) for the
            National Institute of Neurological Disorders and Stroke
            (NINDS). This funding level is required to enhance existing
            initiatives and invest in new and promising research to prevent
            stroke and advance rehabilitation in stroke treatment. Despite
            being a major cause of disability and the number three cause of
            death in the United States, NIH invests only 1 percent of its
            budget in stroke research. However, APTA recognizes the
            advancements that NIH-funded research has achieved in the
            specific area of stroke rehabilitation. APTA commends this area
            of leadership at NIH and encourages a continued focus on
            rehabilitation interventions and physical therapy to maximize
            an individual's function and quality of life after a stroke.
      --$550 million for the National Institute of Arthritis and
            Musculoskeletal and Skin Diseases (NIAMS) for arthritis and
            musculoskeletal research.
                Centers for Disease Control and Prevention (CDC)
        APTA was disappointed to see the cuts that have been implemented
    within CDC for fiscal year 2011. The contributions of CDC to the lives
    of countless individuals are limited only by the resources available
    for carrying out its vital mission. Our Nation and the world will
    continue to benefit from further improvement in public health and
    investment in scientific advancement and prevention. APTA recommends
    Congress provide at least $7.7 billion for CDC's fiscal year 2012
    ``core programs'' in the fiscal year 2012 Labor-HHS-Education
    Appropriations bill. This request reflects the support CDC will need to
    fulfill its core missions for fiscal year 2012. APTA strongly believes
    that the activities and programs supported by CDC are essential in
    protecting the health of the American people. APTA supports the
    Prevention and Public Health Fund (PPHF) and its underlying purpose of
    providing supplemental funding as an investment to expand
    infrastructure for prevention initiatives. We are not supportive of
    efforts to use the PPHF to supplant current programmatic funding within
    the budgets of agencies, such as CDC.
        Physical therapists play an integral role in the prevention,
    education, and assessment of the risk for falls. The CDC is currently
    only allocating $2 million per year to address the increasing
    prevalence of falls, a problem costing more than $19.2 billion a year.
    Among older adults, falls are the leading cause of injury deaths. This
    is why APTA respectfully requests that $21.7 million be provided in
    funding for the ``Unintentional Injury Prevention'' account to allow
    CDC's National Center for Injury Prevention and Control (NCIPC) to
    comprehensively address the large-scale growth of older adult falls.
    CDC has made great strides in developing and laying the groundwork for
    evidence-based falls prevention programs that link clinical
    intervention with community-based programs to make an impactful benefit
    for American society in addressing this expensive and burdensome
    healthcare problem. Without an increase in resources, CDC is unable to
    effectively scale-up and expand infrastructure beyond the few cities in
    which the programs have currently been developed to begin reaching all
    communities across the United States.
        Traumatic Brain Injury (TBI) is a leading cause of death and
    disability among young Americans and continues to be the signature
    injury of the conflicts in Iraq and Afghanistan. CDC estimates that at
    least 5.3 million Americans, approximately 2 percent of the U.S.
    population, currently require lifelong assistance to perform activities
    of daily living as a result of TBI. High quality, evidence-based
    rehabilitation for TBI is typically a long and intensive process. From
    the battlefield to the football field, American adults and youth
    continue to sustain TBIs at an alarming rate and funding is desperately
    needed for better diagnostics and evaluation, treatment guidelines,
    improved quality of care, education and awareness, referral services,
    State program services, and protection and advocacy for those less able
    to advocate for themselves. APTA recommends at least $10 million in
    fiscal year 2012 for CDC's TBI Registries and Surveillance, Brain
    Injury Acute Care Guidelines, Prevention, and National Public
    Education/Awareness programs, specifically with the great work that has
    been produced through the ``Heads Up'' concussions initiative.
        CDC's Well-Integrated Screening and Evaluation for Women Across the
    Nation (WISEWOMAN) programs screens uninsured and under-insured low-
    income women ages 40 to 64 for heart disease and stroke risk and those
    with abnormal results receive counseling, education, referral and
    follow up. WISEWOMAN reached over 70,000 women in only 20 States from
    July 2008 to June 2010. Of these women, nearly 90 percent were found to
    have one or more heart disease or stroke risk factors and about 30
    percent had at least three. More than 60 percent of the women
    participated in a minimum of one behavioral modification session, and
    among those WISEWOMAN participants who were re-screened one year later,
    average blood pressure and cholesterol levels had decreased
    considerably. APTA recommends $37 million ($16.3 million increase over
    fiscal year 2010) for CDC's WISEWOMAN Program in fiscal year 2012.
                Health Resources and Services Administration (HRSA)
        With the passage of healthcare reform legislation, it becomes more
    important now than ever that America is able to supply an adequate and
    well-trained healthcare workforce to meet the demands of an expanded
    market of U.S. citizens that have health insurance coverage. APTA urges
    you to provide at least $7.65 billion for HRSA in fiscal year 2012.
    While we recognize the reality of the current fiscal climate, this
    amount reflects the minimum amount necessary for the agency to
    adequately meet the needs of the populations it serves. The relatively
    level funding HRSA has received over the past several years has
    undermined the ability of its successful programs to grow and be
    expanded to represent professions that shape the entire healthcare
    team, such as physical therapy. Any shortage areas of physical
    therapists and rehabilitation professionals may become more accentuated
    as the percentage of the U.S. population that has health coverage
    increases and demand rises. It is crucial that efforts are undertaken
    to strengthen the healthcare workforce and delivery across the whole
    spectrum of an individual's care--from onset through rehabilitation.
    More resources are needed for HRSA to achieve its ultimate mission of
    ensuring access to culturally competent, quality health services;
    eliminating health disparities; and rebuilding the public health and
    healthcare infrastructure.
        In conjunction with the importance of funding TBI efforts within
    CDC, APTA also recommends $8 million for the HRSA Federal TBI State
    Grant Program and $4 million for the HRSA Federal TBI Protection &
    Advocacy (P&A) Systems Grant Program.
    Department of Education
        In 2008, as part of the reauthorization of the Higher Education Act
    (Public Law 110-315), the Loan Forgiveness for Service in Areas of
    National Need (LFSANN) program was created. This program would provide
    a modest amount of loan forgiveness for a variety of education and
    healthcare professional groups, including physical therapists, upon a
    commitment to serve in targeted populations that were identified as
    areas of crucial importance and national need. However, the program has
    not been implemented because it has not received any funding. APTA
    commends the recent efforts of Congress to reform the higher education
    loan industry. The lowering of the limit on the income-based repayment
    plan for consolidated Federal Direct Loans will assist the burdensome
    payments for all higher education loan borrowers. However, this program
    still fails to meet the most important impact of LFSANN--channeling
    providers and professionals into areas where there are demonstrated
    shortages and high need, such as physical therapy care for veterans and
    children and adolescents. APTA strongly urges Congress to take action
    and provide $10 million in initial funding for this vital LFSANN
    program that will impact the healthcare and education services of those
    most in need.
                National Institute for Disability and Rehabilitation
                        Research (NIDRR)
        NIDRR has been one of the longest standing agencies to focus on
    federally funded medical rehabilitation research. Rehabilitation
    research makes a difference in the lives of individuals with
    impairments, functional limitations, and disability. Advancements in
    rehabilitation research have led to greater quality of life for
    individuals who have spinal cord injuries, loss of limb, stroke and
    other orthopedic, neurological, and cardiopulmonary disorders.
    Investment in NIDRR is a necessary step toward continuing to meet the
    needs of individuals in our population who have chronic disease,
    developmental disabilities or traumatic injuries. Therefore, APTA
    recommends at least $20 million per year for NIDRR to support research
    and development, capacity building, and knowledge translation in
    health, rehabilitation, and function.
        APTA also requests $11 million for NIDRR's TBI Model Systems
    administered by the Department of Education. The TBI Model Systems of
    Care program represents an already existing vital national network of
    expertise and research in the field of TBI, and weakening this program
    would have resounding effects on both military and civilian
    populations. The TBI Model Systems are the only source of non-
    proprietary longitudinal data on what happens to people with brain
    injury. They are a key source of evidence-based medicine and
    rehabilitation care for this crucial and growing population.
    Conclusion
        As previously stated, APTA recognizes the extraordinarily tough
    budgetary pressures that are facing the U.S. Federal Government.
    However, there are certain programs and agencies that are essential and
    vital to the health of Americans. APTA looks forward to working with
    the Subcommittee and the various agencies outlined above to advance the
    capability of meeting the rehabilitation needs of society. If the
    Subcommittee has questions or needs additional resources, please
    contact Nate Thomas, Associate Director of Federal Government Affairs
    at APTA, at natethomas@apta.org or 703-706-8527. APTA's mailing address
    is provided on the letterhead of the first page of this document.
                                     ______

          Prepared Statement of the American Psychological Association
        This statement is the testimony of the American Psychological
    Association (APA), the largest scientific and professional organization
    representing psychology in the United States and the world's largest
    association of psychologists. APA's membership includes more than
    154,000 researchers, educators, clinicians, consultants and students.
    Through its divisions in 54 subfields of psychology and affiliations
    with 60 State, territorial and Canadian provincial associations, APA
    works to advance psychology as a science, as a profession and as a
    means of promoting health, education and human welfare. APA welcomes
    the opportunity to bring to your attention some priority requests and
    concerns for the fiscal year 2012 appropriations bill.
    Health Resources and Services Administration
                Bureau of Health Professions
        The APA requests that the Subcommittee include $5 million for the
    Graduate Psychology Education Program (GPE) within the Health Resources
    and Services Administration. This nationally competitive grant program
    provides integrated healthcare services to underserved rural and urban
    communities and individuals with the least access to much needed mental
    and behavioral health services and support (e.g., children, older
    adults, and chronically ill persons, victims of abuse or trauma,
    including veterans). To date there have been over 100 grants in 32
    States to universities and hospitals throughout the Nation. All
    psychology graduate students who benefited from GPE funds are expected
    to work with underserved populations and over 80 percent will work in
    underserved areas immediately after completing the training.
        Currently GPE is authorized under the Public Health Service Act
    [Public Law 105-392 Section 755(b)(1)(J)] and funded under the ``Allied
    Health and Other Disciplines'' account in the Labor-HHS Appropriations
    Bill. An authorization of Appropriations of $10 million was included in
    the Patient Protection and Affordable Care Act. It was also included in
    the fiscal year 2011 Omnibus bill, which did not pass, for $7 million;
    and it has been included in H.R. 1 for fiscal year 2011 and the Senate
    2011 continuing resolutions, as well as the President's budget (for a
    number of years). Established in 2002, GPE grants have supported the
    interdisciplinary training of over 3,000 graduate students of
    psychology and other health professions to provide integrated
    healthcare services to underserved populations. The fiscal year 2012
    GPE funding request will focus especially on providing services to
    returning military personnel and their families, unemployed persons and
    older adults in underserved communities. Also the GPE funding request
    will also be used to create training opportunities at our Nation's
    federally Qualified Health Centers, which play a critical role in
    meeting the healthcare needs of our Nation's underserved persons.
    National Institutes of Health (NIH)
        As a member of the Ad hoc Group for Medical Research Funding and
    the Coalition for Health Funding, APA encourages the Subcommittee to
    provide a minimum of $31.8 billion for the NIH. Sustained growth for
    NIH will build on the Nation's longstanding, bipartisan commitment to
    better health, which has established the United States as the world
    leader in medical research and innovation. NIH research means hope for
    patients. Potentially revolutionary new avenues of research hold
    promise for new early screenings and new treatments for disease. Recent
    funding has created dramatic new research opportunities in areas
    ranging from genetics to the behavioral research conducted by APA
    members. In addition, NIH research is boosting the economies of
    communities nationwide, at over 3,000 universities, medical schools,
    teaching hospitals and other research institutions. This committee
    should take justifiable pride in the progress and promise that NIH
    research is engendering.
        There are several issues at NIH to which APA would draw the
    Subcommittee's attention:
      --Addictions Research Institute.--NIH research on alcohol and
            substance abuse has shed important light on critical policy
            issues ranging from the rehabilitation of drug-addicted felons
            to treatment of children exposed to substances in utero. APA is
            closely monitoring NIH's proposal to create a new combined
            institute that would fund research on both alcohol and
            substance abuse. In our view this research is significantly
            underfunded when weighed against the public health and public
            safety impacts of alcohol, tobacco and illicit substance use,
            and we are concerned that research funding be maintained and
            increased as the new institute is created. We urge the
            Subcommittee to insist that NIH establish rigorous and
            transparent baselines of current funding levels and the
            allocation of those funds across the existing NIH Institutes
            and Centers to better assess and understand the proposed
            organizational change. The continued active involvement of
            extramural scientists at every stage of this process, as well
            as that of the Office of Behavioral and Social Sciences
            Research, will help ensure that the new institute has the right
            infrastructure to truly optimize the conduct of addiction
            research.
      --Funding for OppNet.--For fiscal year 2012, APA supports a budget of
            $38.2 million for OBSSR. This sum reflects the Administration's
            request of $28 million for OBSSR and includes $10 million
            needed to support the NIH-wide commitment to carry out OppNet,
            an initiative strongly supported by the Subcommittee. The
            OppNet initiative has made significant progress since its
            start. Thus far, OppNet has awarded 35 competitive revisions to
            add basic science projects to existing research project grants.
            Eight competitive revisions to Small Business Innovation
            Research/Small Business Technology and Transfer projects have
            been awarded. OppNet has also provided much-needed training in
            basic social and behavioral sciences research.
      --National Center to Advance Translational Sciences.--APA believes
            firmly that the proposed new National Center to Advance
            Translational Sciences should include sufficient staff
            expertise and resources to manage research on the translation
            of behavioral interventions into communities. Just as it is
            critical for NIH to speed the translation of research into drug
            or technology development, it is critical for behavioral
            interventions on diet, exercise, and psychotherapy to be
            translated and disseminated to communities in need of them.
    Centers for Disease Control and Prevention
        As a member of the Centers for Disease Control and Prevention (CDC)
    Coalition, APA supports an appropriation of $7.7 billion for CDC's
    ``core programs'' for fiscal year 2012. In addition to playing a key
    role in maintaining a strong public health infrastructure and
    protecting Americans from public health threats and emergencies, CDC
    programs play a crucial role in reducing healthcare costs and
    strengthening the Nation's health system. This request reflects the
    minimum amount CDC will need to fulfill its core missions for fiscal
    year 2012.
        National Center for Health Statistics.--APA endorses the
    President's fiscal year 2012 request of $162 million in funding for
    NCHS. NCHS is the Nation's principal health statistics agency, and the
    health data collected by NCHS are an essential part of the Nation's
    statistical and public health infrastructure. The Subcommittee's
    support is helping NCHS rebuild after years of underinvestment and
    restore the collection of essential health data. With your continued
    support, NCHS will modernize its data collection efforts to produce
    higher quality, more timely data.
        Prevention Research Centers.--APA recognizes the importance of a
    focus on prevention in improving health in America and the significant
    contributions of the Prevention Research Centers network of community,
    academic, and public health partners to research on evidenced based
    approaches in health promotion. APA urges Congress to allocate the
    resources necessary to support the Prevention Research Centers so that
    this network of academic institutions and organizations can continue to
    contribute as widely and effectively to prevention science. APA opposes
    any program consolidation that would lead to disproportionate funding
    cuts for the Prevention Research Centers. Insofar as consolidation of
    programs as proposed in the fiscal year 2012 President's budget occurs,
    APA requests that Congress designate specific funding for Prevention
    Research Centers.
    Substance Abuse and Mental Health Services Administration (SAMHSA)
        APA is highlighting three requests for the Committee's support at
    SAMHSA's Center for Mental Health Services:
      --First, APA strongly recommends that Congress allocate the fully
            authorized amount ($50 million) for SAMHSA's National Child
            Traumatic Stress Network (NCTSN) program which works to aid the
            recovery of children, families, and communities impacted by a
            wide range of trauma, including physical and sexual abuse,
            natural disasters, sudden death of a loved one, the impact of
            war on military families, and much more. Specifically, APA
            recommends that SAMHSA increase the number of NCTSN grantees
            and maintain the collaborative model envisioned in the original
            authorization.
      --Second, APA urges the Committee to increase its support for the
            Minority Fellowship Program. Racial and ethnic minorities are
            projected to represent 40 percent of our Nation's population in
            upcoming years. Therefore, APA urges Congress to increase
            funding for the Minority Fellowship Program by $2.6 million.
            This unique workforce development initiative trains ethnic
            minority healthcare professionals to bring mental and
            behavioral healthcare services to rural and underserved
            minority communities.
      --Third, APA encourages Congress to provide at least level support
            for the three programs authorized under the Garrett Lee Smith
            Memorial Act, especially the Campus Suicide Prevention Program.
            These programs make suicide prevention initiatives and mental
            health support available to populations in need and merit
            continued appropriations.
    Administration on Aging
        Mental health.--Older adults are one of the fastest growing
    segments of the U.S. population and approximately 25 percent of older
    Americans have a mental or behavioral health problem. In particular,
    older white males (age 85 and over) currently have the highest rates of
    suicide of any group in the United States. Accordingly, APA urges an
    expanded effort to address the mental and behavioral health needs of
    older adults including implementation of the mental and behavioral
    health provisions in the Older Americans Act Amendments of 2006, to
    provide grants to States for the delivery of mental health screening,
    and treatment services for older individuals and programs to increase
    public awareness and reduce the stigma associated with mental disorders
    in older individuals. APA also recommends that AoA designate an officer
    to administer mental health services for older Americans.
        Caregivers.--Family caregivers play an essential role in providing
    long-term services and supports for the chronically ill and aging. For
    this reason APA supports the Lifespan Respite Care Program and urges
    Congress to appropriate $50 million for this initiative in fiscal year
    2012. In addition, the Secretary of HHS should ensure that State
    agencies and Aging and Disability Resource Centers (ADRCs) use the
    funds to serve all age groups, chronic conditions and disability
    categories equitably and without preference.
        The agencies under this Subcommittee's jurisdiction provide
    critical support to APA's members, their home institutions, and their
    students and patients. The APA commends the Committee for accepting
    written testimony from public witnesses.
                                     ______

          Prepared Statement of the American Public Health Association
        The American Public Health Association (APHA) is the oldest and
    most diverse organization of public health professionals and advocates
    in the world dedicated to promoting and protecting the health of the
    public and our communities. We are pleased to submit our views on
    Federal funding for public health activities in fiscal year 2012.
    Recommendations for Funding the Public Health Service
        APHA's budget recommendations for the Public Health Service
    includes funding for the Centers for Disease Control and Prevention
    (CDC), the Health Resources and Services Administration (HRSA), the
    Substance Abuse and Mental Health Services Administration (SAMHSA), the
    Agency for Healthcare Research and Quality (AHRQ), and the National
    Institutes of Health (NIH). Together all of these agencies play a
    critical role in keeping Americans healthy.
    CDC
        APHA believes that Congress should support CDC as an agency--not
    just the individual programs that it funds. In the best judgment of the
    CDC Coalition--given the challenges and burdens of chronic disease, a
    potential influenza pandemic, terrorism, disaster preparedness, new and
    reemerging infectious diseases and our many unmet public health needs
    and missed prevention opportunities--we believe the agency will require
    funding of at least $7.7 billion for CDC's ``core programs'' in fiscal
    year 2012. This request represents a 36 percent increase over fiscal
    year 2011 and a 31 percent increase over the President's fiscal year
    2012 request. We are deeply disappointed with the more than $740
    million in cuts to CDC's budget authority included in the proposed
    fiscal year 2011 continuing resolution (CR). While CDC programs will
    receive significant new funding from the Prevention and Public Health
    Fund in fiscal year 2011, we are concerned that this funding would
    essentially supplant cuts made to CDC's budget authority. As you know
    the Prevention and Public Health Fund was intended to supplement and
    not supplant the base funding of our public health agencies and
    programs.
        The President's fiscal year 2012 budget proposes to consolidate a
    number of chronic disease programs within CDC. APHA and other advocates
    are currently engaged in conversations with CDC and members of Congress
    to better understand what this consolidation will mean for the funding
    that is passed on to our State and local health agencies and the
    various programs our members have supported in the past. We look
    forward to working with Congress, the Administration and CDC to ensure
    that any effort to consolidate the programs leads to best health
    outcomes for the American people. We must ensure that CDC's National
    Center for Chronic Disease Prevention and Health Promotion has the
    resources it needs to assist our States and communities in their
    efforts to reduce the burden of chronic disease.
        By translating research findings into effective intervention
    efforts, CDC has been a key source of funding for many of our State and
    local programs that aim to improve the health of communities. Perhaps
    more importantly, Federal funding through CDC provides the foundation
    for our State and local public health departments, supporting a trained
    workforce, laboratory capacity and public health education
    communications systems.
        CDC also serves as the command center for our Nation's public
    health defense system against emerging and reemerging infectious
    diseases. With the potential onset of a worldwide influenza pandemic,
    in addition to the many other natural and man-made threats that exist
    in the modern world, the CDC has become the Nation's--and the world's--
    expert resource and response center, coordinating communications and
    action and serving as the laboratory reference center. States and
    communities rely on CDC for accurate information and direction in a
    crisis or outbreak. This has been demonstrated most recently by CDC's
    quick response and ongoing investigation into human infections with
    H1N1 flu (swine flu) in the United States and internationally.
        CDC's National Center for Injury Prevention and Control works to
    prevent unintentional and violence-related injuries to minimize the
    consequences of injuries when they occur by researching the problem;
    identifying the risk and protective factors; developing and testing
    interventions; and ensuring widespread adoption of proven strategies.
    We urge you to ensure the agency has the resources it needs to address
    these leading causes of death and disability.
        We must address the growing disparity in the health of racial and
    ethnic minorities. CDC is helping States address serious disparities in
    infant mortality, breast and cervical cancer, cardiovascular disease,
    diabetes, HIV/AIDS and immunizations. APHA is committed to ending
    health disparities and we encourage the Subcommittee to provide
    adequate funds for these efforts.
        We also encourage the Subcommittee to provide adequate funding for
    CDC's National Center for Environmental Health. We ask that the
    Subcommittee to continue its recent efforts to expand and enhance CDC's
    capacity to help the Nation prepare for and adapt to the potential
    health effects of climate change by providing CDC with $15 million for
    climate change and health activities. Expanded funding would allow CDC
    to provide technical assistance, training and tools to help State and
    local health officials and improve coordination and integration of
    climate change across CDC. We also urge the Committee to closely
    evaluate the significant cut made to CDC's Healthy Homes/Lead Poisoning
    Prevention and the National Asthma Control programs in the President's
    budget to ensure these programs have adequate funding to provide States
    and localities with the funding they need to protect public health.
    HRSA
        We request an overall funding level of $7.65 billion for HRSA in
    fiscal year 2012. This recommendation represents a 22 percent increase
    over fiscal year 2011 and a 12 percent increase over the President's
    fiscal year 2012 request. We believe this level of funding is the
    minimum amount necessary for HRSA to continue to meet the healthcare
    needs of the American public. Over the past several years, HRSA has
    received mostly level funding, undermining the ability of its
    successful programs to grow. Additionally we are deeply disappointed
    with the more than $1.2 billion in cuts made to the agency in the final
    fiscal year 2011 continuing resolution and the potential negative
    consequences for public health. Our fiscal year 2012 requested minimum
    level of funding will better allow the agency to carry out critical
    public health programs and services that reach millions of Americans,
    including training for public health and healthcare professionals,
    providing primary care services through community health centers,
    improving access to care for rural communities, supporting maternal and
    child healthcare programs, providing healthcare to people living with
    HIV/AIDS, and many more. However, much more is needed for the agency to
    achieve its ultimate mission of ensuring access to culturally
    competent, quality health services; eliminating health disparities; and
    rebuilding the public health and healthcare infrastructure.
        HRSA operates programs in every State and thousands of communities
    across the country and is a national leader in providing health
    services for individuals and families. The agency serves as a health
    safety net for the medically underserved, including the 50 million
    Americans who were uninsured in 2009 and 50 million Americans who live
    in neighborhoods where primary healthcare services are scarce.
        The $7.65 billion fiscal year 2012 HRSA funding request is based
    upon recommendations provided by public health professionals to support
    HRSA programs including:
      --Health Professions programs support the education and training of
            primary care physicians, nurses, dentists, optometrists,
            physician assistants, nurse practitioners, public health
            personnel, mental and behavioral health professionals,
            pharmacists, and other allied health providers; improve the
            distribution and diversity of health professionals in medically
            underserved communities; and ensure a sufficient and capable
            health workforce able to provide care for all Americans and
            respond to the growing demands of our aging and increasingly
            diverse population. In addition, the Patient Navigator Program
            helps individuals in underserved communities, who suffer
            disproportionately from chronic diseases, navigate the health
            system.
      --Primary Care programs support more than 7,000 community health
            centers in every State and territory, improving access to
            preventive and primary care in geographically isolated and
            economically distressed communities. In addition, the health
            centers program targets populations with special needs,
            including migrant and seasonal farm workers, homeless
            individuals and families, and those living in public housing.
      --Maternal and Child Health Flexible Maternal and Child Health Block
            Grants, Healthy Start and other programs provide services,
            including prenatal and postnatal care, newborn screening tests,
            immunizations, school-based health services, mental health
            services, and well-child care for more than 34 million
            uninsured and underserved women and children not covered by
            Medicaid or the Children's Health Insurance Program, including
            children with special needs.
      --HIV/AIDS programs provide assistance to metropolitan and other
            areas most severely affected by the HIV/AIDS epidemic; support
            comprehensive care, drug assistance and support services for
            people living with HIV/AIDS; provide education and training for
            health professionals treating people with HIV/AIDS; and address
            the disproportionate impact of HIV/AIDS on women and
            minorities.
      --Family Planning Title X programs provide reproductive healthcare
            and other preventive services for more than 5 million low-
            income women at over 4,500 clinics nationwide. These programs
            improve maternal and child health outcomes, prevent unintended
            pregnancies, and reduce the rate of abortions.
      --Rural Health programs improve access to care for the 60 million
            Americans who live in rural areas. Rural Health Outreach and
            Network Development Grants, Rural Health Research Centers,
            Rural and Community Access to Emergency Devices Program, and
            other programs are designed to support community-based disease
            prevention and health promotion projects, help rural hospitals
            and clinics implement new technologies and strategies, and
            build health system capacity in rural and frontier areas.
      --Special Programs include the Organ Procurement and Transplantation
            Network, the National Marrow Donor Program the C.W. Bill Young
            Cell Transplantation Program, and National Cord Blood
            Inventory. Strong funding would facilitate an increase in
            organ, marrow and cord blood transplantation.
        Greater investment is necessary to sufficiently fund HRSA services
    and programs that continue to face increasing demands. We urge you to
    consider HRSA's role in building the foundation for health service
    delivery and ensuring that vulnerable populations receive quality
    health services, while continuing to strengthen our Nation's health
    safety net programs. By supporting, planning for and adapting to change
    within our healthcare system, we can build on the successes of the past
    and address new gaps that may emerge in the future.
    AHRQ
        We request a funding level of at least $405 million for AHRQ for
    fiscal year 2012. This level of funding is needed for the agency to
    fully carry out its Congressional mandate to conduct, support, and
    disseminate research and translate research into knowledge and
    information that can be used to improve the health of all Americans.
    AHRQ focuses on improving healthcare quality, eliminating racial and
    ethnic disparities in health, reducing medical errors, and improving
    access and quality of care for children and persons with disabilities.
    SAMHSA
        APHA supports a funding level of $3.671 billion for SAMHSA for
    fiscal year 2012. This funding level would provide support for
    substance abuse prevention and treatment programs, as well as continued
    efforts to address emerging substance abuse problems in adolescents,
    the nexus of substance abuse and mental health, and other serious
    threats to the mental health of Americans.
    NIH
        APHA supports a funding level of $35 billion for the NIH for fiscal
    year 2012. The translation of fundamental research conducted at NIH
    provides some of the basis for community based public health programs
    that help to prevent and treat disease.
    Conclusion
        In closing, we emphasize that the public health system requires
    stronger financial investments at every stage. Successes in biomedical
    research must be translated into tangible prevention opportunities,
    screening programs, lifestyle and behavior changes, and other
    interventions that are effective and available for everyone. Without a
    robust and sustained investment in our Nation's public health agencies,
    we will fail to meet the mounting health challenges facing our Nation.
                                     ______

          Prepared Statement of the American Public Power Association
        The American Public Power Association (APPA) appreciates the
    opportunity to submit this statement supporting funding for the Low-
    Income Home Energy Production Assistance Program (LIHEAP) for fiscal
    year 2012.
        APPA has consistently supported an increase in the authorization
    level for LIHEAP. The Administration's fiscal year 2012 budget requests
    $2.57 billion for LIHEAP. APPA supports extending the current level of
    $5.1 billion for the program.
        APPA is the national service organization representing the
    interests of over 2,000 municipal and other State and locally owned
    utilities throughout the United States (all but Hawaii). Collectively,
    public power utilities deliver electricity to 1 of every 7 electricity
    consumers (approximately 46 million people), serving some of the
    Nation's largest cities. However, the vast majority of APPA's members
    serve communities with populations of 10,000 people or less.
        APPA is proud of the commitment that its members have made to their
    low-income customers. Many public power systems have low-income energy
    assistance programs based on community resources and needs. Our members
    realize the importance of having in place a well-designed low-income
    customer assistance program combined with energy efficiency and
    weatherization programs in order to help consumers minimize their
    energy bills and lower their requirements for assistance. While highly
    successful, these local initiatives must be coupled with a strong
    LIHEAP program to meet the growing needs of low-income customers. In
    the last several years, volatile home-heating oil and natural gas
    prices, severe winters, high utility bills as a result of dysfunctional
    wholesale electricity markets and the effects of the economic downturn
    have all contributed to an increased reliance on LIHEAP funds. Even at
    $5.1 billion, LIHEAP cannot provide assistance to all who qualify for
    the program. Cutting this program by $2.5 billion would have very
    serious consequences for those who rely on the program.
        Also when considering LIHEAP appropriations this year, we encourage
    the subcommittee to provide advanced funding for the program so that
    shortfalls do not occur in the winter months during the transition from
    one fiscal year to another. LIHEAP is one of the outstanding examples
    of a State-operated program with minimal requirements imposed by the
    Federal Government. Advanced funding for LIHEAP is critical to enabling
    States to optimally administer the program.
        Thank you again for this opportunity to relay our support for
    increased LIHEAP funding for fiscal year 2012.
                                     ______

          Prepared Statement of the American Society for Microbiology
        The American Society for Microbiology (ASM) is pleased to submit
    the following testimony on the fiscal year 2012 appropriation for the
    Centers for Disease Control and Prevention (CDC). The ASM is the
    largest single life science organization in the world with over 38,000
    members. The ASM mission is to enhance the science of microbiology, to
    gain a better understanding of life processes and to promote the
    application of this knowledge for improved health and environmental
    well being.
        The ASM supports the proposed fiscal year 2012 budget of $11.3
    billion for the CDC, a 3.4 percent increase over the fiscal year 2010
    funding level. The budget recognizes the importance of maintaining a
    strong infrastructure to address infectious disease prevention and
    control. The CDC's role, in partnership with State and local health
    departments and international partners, is to monitor for known and
    emerging infectious disease threats through surveillance and laboratory
    diagnosis, and to develop control and prevention strategies for these
    diseases. Examples include vaccine preventable diseases, foodborne
    diseases, pandemic influenza, vectorborne and zoonotic diseases,
    healthcare acquired infections (HAIs) and antimicrobial resistance. The
    proposed fiscal year 2012 budget addresses these threats and provides
    targeted resources for them.
        The fiscal year 2012 proposed budget includes an increase in
    funding for HIV/AIDS, sexually transmitted diseases (STD), tuberculosis
    (TB), and hepatitis, and gives the States added flexibility to shift
    funding among these programs based on local priorities. The ASM
    supports this approach. The ASM also supports the $68 million increase
    in funding for emerging and zoonotic diseases, including $40 million in
    funding from the Prevention and Public Health Fund to enhance
    epidemiology and laboratory capacity in State health departments.
        However, caution must be taken regarding any reductions in effort
    for ``low impact, disease specific programs'' as proposed in the fiscal
    year 2012 budget. Experience indicates that an emerging public health
    threat can occur with almost any pathogen, and capacity must be
    sustained with this possibility in mind. Examples of such complacency
    include the reemergence of drug resistant tuberculosis in the 1990s and
    West Nile virus in 1999. The proposed elimination of prion activities
    at CDC could have such an impact, as these diseases are related to
    human variant Creutzfeld Jakob Disease (vCJD) and to chronic wasting
    disease, which is an emerging animal health problem in several areas of
    the United States.
        The ASM supports investments to address healthcare associated
    infections. CDC provided resources through the American Recovery and
    Reinvestment Act (ARRA) to develop programs for surveillance and
    prevention of HAIs, which have resulted in substantial HAI reductions
    in these infections with significant cost savings to the healthcare
    system. These investments must be sustained after ARRA funding ends,
    and the proposed $47 million for HAIs would accomplish this goal.
        The ASM supports the $8.7 million increase in funding for food
    safety. The CDC recently released new estimates of foodborne diseases,
    concluding that 1 in 6 people in the United States get sick each year
    (about 48 million people). The delayed recognition of the widespread
    outbreaks of salmonellosis associated with eggs during 2010
    demonstrates the need to sustain and enhance vigilance for foodborne
    outbreaks. In that outbreak, over 1,900 confirmed illnesses were
    reported (likely a small percentage of actual cases) and 500 million
    eggs were recalled. CDC's surveillance systems will also play a pivotal
    role in assessing the success of programs developed as a result of the
    recently passed Food Safety Modernization Act.
        The ASM is concerned about the following proposed reductions in the
    fiscal year 2012 CDC budget:
      --There is a substantial decline in preparedness funding, including a
            $72 million cut in funds for State and local preparedness
            grants. Such declines will have a significant impact on the
            ability of frontline public health workers to be able to
            respond to all hazard emergencies at a time of restrained
            budgets at the State and local level. The ASM recommends such
            grants be maintained at fiscal year 2010 funding levels.
      --The proposed elimination of funding for the CDC genomics program
            should be restored. Public health genomics is an area of
            growing importance, including the ability to identify risk
            factors for enhanced susceptibility or resistance to infectious
            diseases. Such genetic factors have important implications for
            disease prevention and treatment, and must be tied to
            epidemiologic investigations and disease surveillance efforts.
      --The ASM does not endorse the elimination of targeted funding for
            CDC's antimicrobial resistance (AR) activities and the transfer
            of these funds into the overall budget for emerging infections.
            While ASM appreciates the need for funding flexibility,
            antimicrobial resistance is a substantial public health problem
            that leads to significant morbidity and death and markedly
            increases healthcare costs. To address this threat, sustained
            dedicated funding is necessary.
    CDC Infectious Disease Programs Protect Public Health
        Infectious diseases cause about one-fourth of all deaths globally,
    more than 11 million people, over half of them children. In the United
    States, influenza and pneumonia account for more than 56,000 deaths
    each year. Of the 1.1 million people living in the United States living
    with HIV/AIDS, about 21 percent do not know that they are HIV positive;
    there are more than 56,000 new HIV infections annually. Last year, the
    CDC responded to multiple disease outbreaks and incidents that included
    surveillance of cholera in post earthquake Haiti and activation of
    CDC's Emergency Operations Center as part of the Federal response to
    the gulf oil spill.
        In the United States, the economic and societal costs of infectious
    diseases are significant, exacerbated by previously unknown microbial
    pathogens, rising drug resistance among pathogens and increasing travel
    and commerce between geographic areas. The CDC Office of Infectious
    Diseases leads United States efforts to stop or minimize the onslaught
    of infectious diseases, with highly qualified personnel at three
    national centers that specialize in (1) Emerging and Zoonotic
    Infectious Diseases; (2) HIV/AIDS, Viral Hepatitis, STD, and TB
    Prevention; or (3) Immunization and Respiratory Diseases.
        The ASM endorses the proposed fiscal year 2012 budget for key
    programs at CDC, including the following:
        Emerging Infectious Diseases/Antimicrobial Resistance.--CDC is a
    world leader in detecting and preventing emerging and reemerging
    infectious diseases, a role which depends on strong science
    capabilities and readiness to confront the unexpected. CDC's
    infrastructure and partnerships have dealt quickly with the more than
    three dozen new human pathogens of medical significance identified in
    the past 30 years. Recent CDC advances include developing one of the
    first candidate vaccines against all four species of dengue virus, now
    in human trials, and a plan to screen U.S. blood donations for West
    Nile virus. fiscal year 2012 funding will support planned EID
    activities like the development and deployment of improved diagnostic
    tests for plague, dengue and chikungunya. About 75 percent of recently
    emerging human infectious diseases originated in animals, making
    zoonotic diseases another high priority at CDC, along with vectorborne
    diseases spread by mosquitoes, ticks, fleas and other vectors. Two
    reports last year illustrate the critical nature of CDC's EID
    activities: In Florida, an estimated 5 percent of Key West's population
    showed recent exposure to the dengue fever virus; and the new
    antimicrobial resistance gene called New Delhi metallo b lactamase
    (NDM-1), first detected in 2008, is spreading to additional countries.
        Increased fiscal year 2012 funding will support CDC efforts against
    the alarming (and rising) number of pathogens now resistant to
    antimicrobial drugs. As part of the U.S. Interagency Task Force on
    Antimicrobial Resistance, CDC distributes both intramural and
    extramural AR funding for surveillance, prevention, and research
    activities. Agency surveillance networks routinely collect data on
    cases of resistant pathogens. CDC provides epidemiology and laboratory
    support for outbreaks of AR organisms, and distributes educational
    materials to promote appropriate use of antimicrobials. Investments in
    AR programs are cost effective; one study estimated that the additional
    medical cost per U.S. patient infected with an AR pathogen ranges from
    about $19,000 to nearly $30,000. Another estimate concluded that
    preventing a single case of multidrug resistant (MDR) tuberculosis can
    save up to $700,000. In fiscal year 2010, CDC diagnosed and treated
    about 1,000 cases of tuberculosis (including 40 MDR) among overseas
    immigrant applicants and U.S. bound refugees, saving States an
    estimated $45 million.
        HIV/AIDS.--Scientific advances announced last year have added new
    tools to CDC's numerous HIV prevention activities; using a vaginal
    microbicide or daily doses of an oral antiretroviral drug (PrEP) both
    lowered risk of infection in clinical trials. In July 2010, the
    Administration released its National HIV/AIDS Strategy for the United
    States (NHAS). Proposed fiscal year 2012 budget increases would invest
    substantially in the NHAS 5 year goals to reduce new infections: (1)
    lower the annual number of new infections by 25 percent, from 56,300 to
    42,225; (2) reduce the HIV transmission rate by 30 percent, from 5
    persons infected per 100 people with HIV to 3.5 persons infected; and
    (3) increase from 79 to 90 the percentage of people living with HIV who
    know their serostatus.
        Viral Hepatitis.--Proposed fiscal year 2012 increases for viral
    hepatitis prevention would boost CDC surveillance in 10 high burden
    State and local health departments. Prevention of viral hepatitis has
    been successful in recent years, in large part due to vaccines against
    hepatitis A and B viruses. HAV incidence has decreased approximately 92
    percent nationwide since 1995; rates of HBV have been reduced far below
    the original Healthy People 2010 goal of 4.5 cases per 100,000. In the
    first half of fiscal year 2010, CDC funded health departments
    administered over 130,000 doses of HBV vaccine to at risk adults and
    ensured that 87 percent of infants born to HBsAg+ women were
    vaccinated. Incidence of hepatitis C infections has dropped from more
    than 45,000 cases annually to an estimated 20,000, primarily as a
    result of screening the U.S. blood supply and falling case numbers
    among intravenous drug users. However, 2.7-3.9 million Americans have
    HCV, most unaware of their infection. The fiscal year 2012 budget would
    address last year's Institute of Medicine report, which concluded that
    public health programs have insufficient hepatitis related resources
    and that efforts to prevent and control viral hepatitis are not
    adequate.
        Sexually Transmitted Diseases.--Fiscal year 2012 increases would
    strengthen CDC's STD infrastructure, which supports 65 State and local
    prevention programs, and sustain the CDC's surveillance of drug
    resistant STD pathogens like that causing gonorrhea. Reducing STD
    infections is highly cost effective; for example, CDC estimates that
    reductions in gonorrhea and syphilis from 1990 to 2003 saved the U.S.
    economy $5 billion. Cost savings with chlamydia screening in sexually
    active young women are an estimated $2,500-$37,000 per year. Aggressive
    public health efforts to prevent STDs have had positive results; for
    instance, from 1999 to 2009, rates of primary and secondary syphilis
    among females declined by 30 percent, while congenital syphilis dropped
    32 percent. Yet, in general, STDs in the United States persist at
    unacceptable levels: CDC estimates that there are approximately 19
    million new STD infections each year, which cost the U.S. healthcare
    system $16.4 billion annually (2009 figures).
    CDC Campaigns Prevent Disease in the United States, Worldwide
        Healthcare Associated Infections.--In the United States, 1 in 20
    hospital patients get an infection during medical treatment. Of the
    nearly 2 million infections acquired in some type of healthcare setting
    annually, almost 100,000 are fatal. A 2009 CDC report estimates that
    each year U.S. hospitals spend between $28 billion and $35.7 billion to
    treat often preventable HAIs. Depending on the effectiveness of
    infection control interventions used, the CDC expects that prevention
    measures could save from $5.7 billion-$31.5 billion of these costs. To
    illustrate, intensive care units have reduced bloodstream infections in
    patients with central lines by 58 percent since 2001, using CDC
    recommended infection control procedures and saving up to 27,000 lives
    and $1.8 billion. The proposed fiscal year 2012 budget would
    significantly increase support for the CDC's HAI activities and its
    National Health Care Safety Network (NHSN) that had provided monitoring
    capacity to more than 3,900 health facilities by the end of 2010. With
    the increased funding, routine NHSN participation will expand from
    2,500 to 6,500 healthcare settings (5,500 hospitals; the rest include
    hemodialysis and long-term care facilities). In March this year, the
    CDC awarded $10 million for HAI research at five academic medical
    centers, as part of its Prevention Epicenter program.
        Immunization.--The Administration's fiscal year 2012 CDC budget
    invests substantial resources into vaccine preventable diseases,
    continuing national immunization campaigns against diseases like
    seasonal and pandemic influenza. The number of lives saved and medical
    costs reduced can be considerable. According to the CDC, ``for every
    birth cohort who receives seven [routine childhood] vaccines . . .
    society saves $9.9 billion in direct medical costs; over 33,500 lives
    are saved; and 14 million cases of disease are prevented.'' Other
    examples of returns on CDC investment include vaccination against
    Haemophilus influenzae type b (Hib), responsible for a 99 percent
    decline in this leading cause of bacterial meningitis in children under
    age 5, for an estimated medical cost savings of $950 million per year
    plus another $1.14 billion of retained earnings by unpaid caregivers.
    In the past year, CDC reported that 3 years of rotavirus vaccinations
    had reduced severe rotavirus disease by 85 percent, and helped develop
    the guidelines for deploying the new pneumococcal vaccine expected to
    greatly reduce pneumonia and ear infections among children. In
    December, CDC launched its Vaccine Tracking System to follow vaccine
    orders from manufacturer to distributor to health providers.
        Global Health.--Lower respiratory tract infections, diarrheal
    diseases, HIV/AIDS, TB and malaria together account for nearly one-
    fifth of deaths globally. CDC is a lead partner in the Administration's
    Global Health Initiative, underscoring the importance of infectious
    diseases no matter where outbreaks occur. The fiscal year 2012 budget
    includes increase of funds for global polio eradication, an
    international campaign begun in 1988 that is nearing victory with only
    four countries still harboring endemic disease. Last year, there were
    about 900 cases reported, declining from more than 350,000 in 1988.
    fiscal year 2012 funds will purchase 254 million doses of oral polio
    vaccine for use in mass immunization campaigns in Southeast Asia,
    Africa and Europe, to achieve CDC's target of zero polio endemic
    countries by the end of 2012. Funding will support the CDC vaccination
    campaign toward a 90 percent reduction in global measles related
    mortality; by 2008, CDC and its partners had helped reduce measles
    deaths by 78 percent, from an estimated 733,000 in 2000 to about
    164,000.
        Quarantine and migration related activities also are part of the
    agency's multi level strategies in global health; CDC operates 20 U.S.
    quarantine stations and responds to outbreaks in refugee camps
    overseas. Travel and trade allow pathogens to move quickly. The 2009
    ``swine flu'' spread to 30 countries within 6 weeks. About 1.8 million
    airline passengers cross international borders daily, and about half of
    international travelers worldwide have some kind of health problem
    while traveling. An estimated 50,000-70,000 refugees and 1.2 million
    immigrants resettle in the United States each year, while more than 2
    million people travel to or through this country by air, sea, or land
    daily.
                                     ______

          Prepared Statement of the American Society for Microbiology
        The American Society for Microbiology (ASM) wishes to submit the
    following written testimony on the fiscal year 2012 appropriation for
    the National Institutes of Health (NIH). The ASM is the largest single
    life science organization with over 38,000 members. Its mission is to
    enhance the science of microbiology, to gain a better understanding of
    life processes and to promote the application of this knowledge for
    improved health and environmental well being.
        The ASM urges Congress to support strong Federal funding for
    biomedical research and to provide $35 billion in funding for the NIH
    in fiscal year 2012. Continued investments in science and public health
    programs are critical to the Nation's health, economic growth, national
    security and global leadership. Acquiring knowledge at the frontiers of
    science is the basis for new technologies, medical discoveries, new
    industries and high value jobs. Investments in biomedical research lead
    to more effective treatments, preventions and cures for chronic and
    infectious diseases, improving the quality of life for people
    everywhere. Reducing funding for research project grants will slow
    medical progress on a myriad of diseases, adversely affecting human
    life. Attracting and retaining scientists and maintaining the vitality
    of the research enterprise will become more difficult if the Nation
    does not remain committed to sustained and predictable funding for
    research and training. We, therefore, urge Congress to make increased
    appropriations for biomedical research a national priority as the
    Federal budget is considered for the coming fiscal year.
       national institutes of health: a crucial investment for the future
        The NIH is a primary contributor to growing the Nation's economy
    and ensuring U.S. leadership in science. The NIH expends 97 percent of
    its annual budget on R&D activities through its 27 centers and
    institutes. NIH funding helps foster innovation among more than 300,000
    research personnel at over 3,000 universities and research
    institutions, with about 6,000 scientists working in NIH's own
    laboratories.
        Life saving successes in biomedical research depend on NIH support:
    for example, the development last year of a new 2 hour diagnostic test
    for tuberculosis and drug resistant TB bacteria; a potential drug
    against malaria parasites, evidence that an anti-HIV treatment could
    also prevent infection, research suggesting a role for intestinal
    bacteria in obesity, and the 2010 Nobel Prize winning methods to
    synthesize compounds that have already proven effective against HIV and
    herpes virus. NIH funded research improves the health of our
    communities, represents investment in local and national economic
    growth and advances U.S. science and medicine.
    Investing in Scientific Innovation, Advancing Medical Knowledge
        NIH funded research has repeatedly reshaped medicine and continues
    to enhance public health. NIH routinely identifies new research
    initiatives and pursues transformative research. NIH recently
    delineated five priority areas with particular promise for safeguarding
    our future, including:
      --High throughput technologies.--DNA sequencing, nanotechnology and
            other computer supported technologies can generate massive data
            sets that enable comprehensive approaches to disease, like the
            NIH microbiome project to understand how interactions with the
            microbes that live on and in the human body influence health
            and disease.
      --Translational medicine.--NIH programs will increasingly focus on
            translating basic scientific discoveries into new clinical
            diagnostics and treatments (bench to bedside).
      --Informing healthcare reform.--With U.S. expenditures on healthcare
            approaching 20 percent of our gross domestic product, NIH
            research areas like personalized medicine and pharmacogenomics
            seek cost effective solutions through disease treatment and
            prevention tailored to individual patients.
      --Global health.--In addition to NIH's ongoing efforts against AIDS,
            tuberculosis and malaria, more resources will go toward
            combating neglected tropical diseases that devastate low income
            countries.
      --Reinvigorating the biomedical research community.--NIH is
            reevaluating the Nation's future scientific workforce needs in
            terms of its own training programs, as well as optimizing NIH's
            extramural research investments to more effectively discover
            innovative medical solutions.
               the importance of investigator initiated research
        The majority of NIH funds are distributed across the country to
    extramural researchers through grants, contracts and fellowships.
    Investigator initiated, competitively awarded Research Project Grants
    (RPGs) are the single most effective mechanism for ensuring research
    innovation. Early in the decade, an average of 1 out of 3 grant
    applications were funded. In recent years, the success rate has fallen
    to roughly 1 in 5, with only a 15 percent success rate estimated for
    fiscal year 2011, despite an abundance of research opportunities.
        Scientific advances require investigator inspiration and
    persistence often over years of research. For example, a large share of
    the research awarded the 2010 Nobel Prize in Chemistry occurred in a
    laboratory supported since 1979 by the National Institute of General
    Medical Sciences (NIGMS). Success developing the DNA based TB rapid
    diagnostic test announced last year followed more than 8 years of
    National Institute of Allergy and Infectious Diseases (NIAID) support.
    NIH funding also enables transformative research that has a higher
    degree of risk for failure, but potential for huge scientific rewards,
    like recipients of the relatively new EUREKA program (Exceptional,
    Unconventional Research Enabling Knowledge Acceleration) managed by
    NIGMS. Among this year's new NIGMS grants are projects designed to
    decipher the genetic code in yeast and to use bacterial components to
    induce patient specific stem cells that facilitate gene therapy.
        At NIH, long range strategies for research success include
    workforce development and mentoring young researchers. NIAID, for
    example, met its own target of supporting ``new investigators'' in
    fiscal year 2009 by funding about 20 percent of those who applied for
    R01 grants as first time principal investigator. NIGMS, which
    distributes 70 percent of its budget to research project grants,
    contributes an additional 10 percent to underwrite institutional
    training grants and fellowships that specifically fulfill its mission
    to train the next generation of medical scientists. In addition, NIGMS
    funds approximately 50 percent of Ph.D. research training positions at
    NIH, including the Medical Scientist Training (M.D.-Ph.D.) program.
    Additional NIH grant programs focus on K-12 education in science,
    technology, engineering and mathematics (STEM), to foster a future
    technical workforce.
        The NIH regularly identifies research intended to ultimately
    produce public health benefits. In fiscal year 2009, NIAID released 33
    new funding opportunity announcements that are already producing
    results in selected areas, including innovative approaches to vaccine
    development against HIV, malaria and hepatitis C, and clinical trials
    specifically designed to counter the threat of antimicrobial resistance
    among pathogens. Research concepts reviewed periodically by NIAID
    advisory councils may anticipate potential research initiatives for
    upcoming funding cycles. For example, concepts approved in September
    2010 included research to prevent the spread of drug resistant
    pathogens; support for Functional Genomics Research Centers that will
    generate massive genetic data sets readily available to the broad
    scientific community; improved diagnostics for Lyme disease; and a
    ``pluripotent approach'' for sexual and reproductive health that might
    combine contraceptive methods with microbicides, vaccine or other
    disease preventives.
    NIH Research to Address Threats of Infectious Diseases and
            Antimicrobial Resistance
        Infectious diseases cause approximately 26 percent of all deaths
    worldwide, more than 11 million people annually. Each year infectious
    diseases kill approximately 6.5 million children, most in developing
    countries. These preventable diseases also greatly impact public health
    systems in the United States. For example, influenza and pneumonia
    account for more than 56,000 deaths annually, while each year there are
    more than a million new cases of sexually transmitted diseases. Despite
    ground breaking triumphs against infectious diseases over decades of
    research, both predictable and unexpected infectious agents continue to
    challenge medical science. In recent years of flat funding, NIAID has
    had to respond to additional public health threats like bioterrorism
    and unforeseen infectious diseases, by steadily expanding its research
    portfolio and its capabilities to recognize and quickly counter newly
    emerging and reemerging diseases in the United States and elsewhere.
    The scope and significance of NIAID sponsored research cannot be
    overstated.
        The emergence of drug resistant microbial pathogens seriously
    complicates efforts to stop or minimize infectious diseases. The
    magnitude of the problem elevates the public health significance of
    antimicrobial resistance. Examples of clinically important microbes
    that are rapidly developing resistance to available drugs include
    bacteria that cause pneumonia, ear infections and meningitis, skin,
    bone, lung and bloodstream infections, urinary tract infections,
    foodborne infections and infections in healthcare settings. In recent
    years there have been dramatic examples like chloroquine resistant
    malaria, methicillin resistant Staphylococcus aureus (MRSA) infection
    and multidrug resistant and extensively drug resistant tuberculosis.
    Ten percent of all hospitalized patients in this country have or
    develop resistant infections, adding $55 billion in annual healthcare
    costs. The public health burden of MRSA is enormous with over 90,000
    MRSA infections per year in the United States. As a result, more NIH
    funding must be allotted to relevant research. In 2010 NIAID announced
    four new contracts for large scale clinical trials (making a total of
    eight trials) focused on treatment alternatives for diseases for which
    antibiotics are prescribed most often (e.g., middle ear infections).
    Also in 2010, NIAID reported a newly identified MRSA toxin, the only
    MRSA toxin currently known to destroy specific human immune cells and a
    possible target of future drugs.
        HIV/AIDS.--Since 1981, when the U.S. epidemic began, HIV/AIDS has
    killed more than 565,000 people in the United States. Each year there
    are about 2 million AIDS related deaths worldwide and an additional 2.7
    million become newly infected, including about 56,000 new infections
    annually in the United States. An estimated 33 million are living with
    HIV/AIDS, over 1 million of those in this country. In large part due to
    NIH support, medical science now offers rising hope amidst these grim
    statistics, as those with HIV/AIDS live longer and better. In 2010,
    NIAID funded researchers reported several studies that have been called
    landmarks in the fight against this difficult disease:
      --Preexposure prophylaxis (PrEP) with a daily dose of an approved
            anti-HIV drug reduces the risk of infection among men who have
            sex with men; studies of other at risk populations continue.
      --After nearly 15 years of research, scientists discovered the first
            vaginal microbicide gel that gives women some protection
            against HIV infection.
      --Various research groups have discovered at least eight antibodies
            that can stop HIV from infecting human cells in the laboratory,
            which could help scientists design effective vaccines.
      --A study in Cambodia demonstrated that people coinfected with HIV
            and tuberculosis can benefit from starting antiretroviral
            therapy earlier than originally believed (antiretroviral
            treatment can worsen the symptoms of coinfections, so timing is
            critical).
        Emerging Infectious Diseases.--Since 2003, NIAID has had principal
    responsibility for NIH's research and development of medical
    countermeasures against radiological, nuclear, chemical and biological
    terrorist threats. NIAID's programs on biodefense and emerging/
    reemerging infectious diseases are inevitably intertwined. Researchers
    study hemorrhagic fevers caused by Ebola and other viruses, West Nile
    virus, prion diseases, influenza viruses, anthrax, and dozens of other
    infectious diseases, seeking vaccines, therapeutics, and diagnostics to
    prevent or curb disease outbreaks. Last year, for instance, NIAID
    scientists announced a new, quick method called real time quaking
    induced conversion assay (RT QuIC) to detect prions, which cause fatal
    brain diseases like mad cow disease in cattle, Creutzfeldt Jakob
    disease in humans, and scrapie in sheep. Other researchers discovered a
    new form of murine prion disease that resembles a form of human
    Alzheimer's disease.
        Last August, after more than a decade of work by NIAID scientists,
    a dengue vaccine began human clinical testing; the virus infects about
    50 million to 100 million people annually. NIAID also awarded new
    contracts to private industry to develop delivery systems for new
    vaccines against anthrax and dengue fever; clinical trials of the three
    vaccines should begin within 3 years. Two other experimental vaccines
    showed promise against Marburg virus (cause of hemorrhagic fever with a
    fatality rate up to 80 percent) and Ebola virus (up to 90 percent
    fatality).
        National Security and Research.--Beginning in the late 1990s and
    especially following 2001, funding for research in the Department of
    Defense related to global diseases that impact U.S. military on foreign
    soil as well as protection against biothreats on U.S. soil decreased.
    This research is now primarily entrusted to NIAID and other NIH
    institutes, FDA and CDC. Research related to defense is interdependent
    on advances in other areas of research, especially those related to
    emerging infections. Reports issues recently by the Institute of
    Medicine and the National Biodefense Science Board emphasize the need
    to properly fund these agencies for medical countermeasure development.
        Genomics.--NIAID and NIGMS sponsor genomic research for improving
    human health. At NIGMS, investigators are using human genetic
    information to explain and identify individuals' reactions to certain
    drugs--research called pharmacogenetics, which is focused on the NIH
    goal of cost effective ``predictive, personalized, and preemptive
    medicine.'' NIAID supported genomic research programs include genome
    sequencing centers and bioinformatics resource centers. By the end of
    2010, the Institute's two Structural Genomics Centers for Infectious
    Diseases had determined 500 3-D protein structures from microorganisms
    on the NIAID Category A-C priority lists or otherwise considered major
    human pathogens.
        Global Health.--Infectious diseases travel easily across
    international borders, and the economic stability of nations can be
    shaken by high rates of morbidity and mortality from such diseases.
    Fiscal year 2009 marked the 30th anniversary of the Institute's
    International Collaborations in Infectious Disease Research (ICIDR)
    program. That year NIAID supported 643 international projects in 97
    countries, with 72 percent of the funds invested in HIV/AIDS research.
    In mid 2010, NIAID announced funding to establish 10 new malaria
    research centers around the world. NIAID supported researchers recently
    developed a chemical that may prove to be a new malaria drug; it has
    more than a decade since the last new class of antimalarials became
    available against a disease that kills nearly 1 million people every
    year. Preliminary data suggest that the new compound might be effective
    as a single dose, rather than the current standard treatment of
    multiple doses over several days. Also last year, other NIAID grantees
    described a previously unknown metabolic pathway used by malaria
    parasites to survive inside human blood cells.
                                   conclusion
        For over a century, NIH funded discoveries have saved lives,
    stimulated private industry and fostered the next generation of
    scientists and physicians. More than 130 Nobel Prize winners have
    received support from NIH, but more importantly, the health of millions
    worldwide has been improved through NIH programs. NIH investments have
    also yielded remarkable financial rewards, from basic research that
    helped launch the biotech industry to the recent development of a
    highly effective meningitis vaccine that each year saves an estimated
    $950 million in medical costs and another $1.14 billion in patient/
    caregiver earnings. The ASM strongly recommends that Congress support
    innovation in the medical sciences and increase funding for the
    National Institutes of Health in fiscal year 2012.
                                     ______

            Prepared Statement of the American Society for Nutrition
        The American Society for Nutrition (ASN) appreciates the
    opportunity to submit testimony regarding fiscal year 2012
    appropriations for the National Institutes of Health (NIH) and the
    National Center for Health Statistics (NCHS). ASN is the professional
    scientific society dedicated to bringing together the world's top
    researchers, clinical nutritionists and industry to advance our
    knowledge and application of nutrition to promote human and animal
    health. Our focus ranges from the most critical details of nutrition
    research to broad societal applications. ASN respectfully requests $35
    billion for NIH, and we urge you to adopt the President's request of
    $162 million for NCHS in fiscal year 2012.
        Basic and applied research on nutrition, nutrient composition, the
    relationship between nutrition and chronic disease, and nutrition
    monitoring are critical to the health of all Americans and the U.S.
    economy. Awareness of the growing epidemic of obesity and the
    contribution of chronic illness to burgeoning healthcare costs has
    highlighted the need for improved information on dietary components,
    dietary intake, strategies for dietary change and nutritional
    therapies. The health costs of obesity alone are estimated at $147
    billion each year. This enormous health and economic burden is largely
    preventable, along with the many other chronic diseases that plague the
    United States. It is for this reason that we urge you to consider these
    recommended funding levels for two agencies under the Department of
    Health and Human Services that have profound effects on nutrition
    research, nutrition monitoring, and the health of all Americans--the
    National Institutes of Health and the National Center for Health
    Statistics.
    National Institutes of Health
        The National Institutes of Health (NIH) is responsible for
    conducting and supporting 90 percent (approximately $1 billion) of
    federally funded basic and clinical nutrition research. Nutrition
    research, which makes up about 4 percent of the NIH budget, is truly a
    trans-NIH endeavor, being conducted and funded across multiple
    Institutes and Centers. In order to fulfill the full potential of
    biomedical research, including nutrition research, ASN recommends an
    fiscal year 2012 funding level of $35 billion for the agency, a modest
    increase over the current funding level of $34 billion (including
    supplemental appropriations). This increase is necessary to maintain
    both the existing and future scientific infrastructure. Although the
    discovery process produces tremendous value, it often takes a lengthy
    and unpredictable path. Economic stagnation is disruptive to training,
    careers, long range projects and ultimately to progress. NIH needs
    sustainable and predictable budget growth to achieve the full promise
    of medical research to improve the health and longevity of all
    Americans and continue our Nation's dominance in this area.
        NIH and its grantees have played a major role in the growth of
    knowledge that has led to an unprecedented number of scientific
    breakthroughs that have transformed our understanding of human health,
    helping Americans to live longer, healthier and more productive lives.
    Many of these discoveries are nutrition-related and have impacted the
    way clinicians prevent and treat heart disease, cancer, diabetes and
    other chronic diseases. By 2030 the number of Americans age 65 and
    older is expected to grow to 72 million, and the incidence of chronic
    disease will also grow. Sustained support for nutrition research is
    required if we are to successfully confront the healthcare challenges
    associated with an older population.
    CDC National Center for Health Statistics
        The National Center for Health Statistics (NCHS), housed within the
    Centers for Disease Control and Prevention (CDC), is the Nation's
    principal health statistics agency. The NCHS provides critical data on
    all aspects of our healthcare system, and it is responsible for
    monitoring the Nation's health and nutrition status through surveys
    such as the National Health and Nutrition Examination Survey (NHANES).
    Nutrition and health data are essential for tracking the nutrition,
    health and well being of the American public, especially for observing
    nutritional and health trends in our Nation's children. Through
    learning both what Americans eat and how their diets directly affect
    their health, the NCHS is able to monitor the prevalence of obesity and
    other chronic diseases in the United States and track the performance
    of preventive interventions, as well as assess consumption of
    ``nutrients of concern'' such as Vitamin D and calcium. Data such as
    these are critical to guide policy development in the area of health
    and nutrition.
        To continue support for the agency and its important mission, ASN
    recommends an fiscal year 2012 funding level of $162 million for the
    agency. Flat and decreased funding levels threaten the collection of
    this important information, most notably vital statistics and the
    NHANES. Moreover, nearly 30 percent of the funding for NHANES comes
    from other Federal agencies such as the NIH and the USDA Agricultural
    Research Service. When these agencies face flat budgets or worse,
    budget cuts, they withdraw much-needed support for NHANES, placing this
    valuable resource in peril. Sustained funding for NCHS can help to
    ensure uninterrupted collection of vital health and nutrition
    statistics.
        Thank you for your support of the National Institutes of Health
    (NIH) and the National Center for Health Statistics (NCHS), and thank
    you for the opportunity to submit testimony regarding fiscal year 2012
    appropriations. Please contact Sarah Ohlhorst, MS, RD, Director of
    Government Relations, if ASN may provide further assistance. She can be
    reached at address: 9650 Rockville Pike, Bethesda MD 20814; telephone
    number: 301.634.7281 or email address: sohlhorst@nutrition.org.
                                     ______

         Prepared Statement of the American Society for Pharmacology &
                           Experimental Therapeutics
        The American Society for Pharmacology and Experimental Therapeutics
    (ASPET) is pleased to submit written testimony in support of the
    National Institutes of Health (NIH) fiscal year 2012 budget. ASPET is a
    5,100 member scientific society whose members conduct basic and
    clinical pharmacological research within the academic, industrial and
    government sectors. Our members discover and develop new medicines and
    therapeutic agents that fight existing and emerging diseases, as well
    as increase our knowledge regarding how therapeutics affects humans.
        For fiscal year 2012, ASPET supports a $35 billion budget for the
    NIH. Research funded by the NIH improves public health, helps stimulate
    our economy and improves global competitiveness. Sustained growth for
    the NIH should be an urgent national priority. Flat funding or cuts to
    the NIH budget will delay cures, eliminate jobs, and jeopardize
    American leadership and innovation in biomedical research.
        A $35 billion budget for the NIH in fiscal year 2012 will help
    restore some of the lost opportunities and purchasing power since 2003,
    when Congress finished a bipartisan effort of doubling the NIH budget.
    Currently, the NIH cannot begin to fund all the high quality research
    that needs to be done. At the moment only one-in-five research projects
    can be supported. The situation has now reached a critical point:
      --Over the past 6 years, the number of research project grants funded
            by NIH has declined almost every year.
      --NIH funds 2,000 fewer grants in total than in fiscal year 2004.
      --NIH made 1,000 fewer competing (new and renewed) awards in 2010
            than it did in 2003.
      --Success rates for new applications have fallen for three straight
            years.
        If flat funding continues, or if additional cuts are made to the
    NIH budget for fiscal year 2012, important research that improves the
    quality of life, offers life-saving new therapeutics, and ultimately
    reduces healthcare costs will be delayed or stopped. International
    competitors will continue to gain on this highly innovative U.S.
    enterprise, and we will lose a generation of young scientists who see
    no prospects for careers in biomedical research. Flat or reduced
    funding for NIH will mean that the agency would have to dramatically
    reduce new awards and many research projects in progress would not
    receive sufficient funding to complete the work, thus representing a
    waste of valuable research resources.
        An fiscal year 2012 NIH budget of $35 billion would help to restore
    momentum to NIH funding. Scientific discovery takes time. As recent
    experience has shown from the post-doubling experience and more recent
    stimulus funding in 2009 and 2010, ``boom and bust'' cycles of rapid
    funding followed by significant periods of stagnation or retraction in
    the NIH budget diminish scientific progress. A $35 billion fiscal year
    20121 NIH budget will help the agency manage its research portfolio
    effectively without too much disruption of existing grants to
    researchers throughout the country. The NIH, and the entire scientific
    enterprise, cannot rationally manage boom or bust funding cycles. Only
    through steady, sustainable and predictable funding increases can NIH
    continue to fund the highest quality biomedical research to help
    improve the health of all Americans and continue to make significant
    economic impact in many communities across the country. An fiscal year
    2012 NIH budget of $35 billion will help the NIH move to more fully
    exploit promising areas of biomedical research and translate the
    resulting findings into improved healthcare.
    Investing in NIH Improves Human Health
        Diminished funding for NIH will mean a loss of scientific
    opportunities to discover new therapeutic targets and will create
    disincentives to young scientists to commit to careers in biomedical
    science. A $35 billion fiscal year 2012 NIH budget would provide the
    various institutes that make up the NIH with an opportunity to fund
    more high quality and innovative research in many disease areas.
    Earlier and significant investments in NIH research have been
    instrumental in improving human health:
      --Parkinson's disease is estimated to afflict over 1 million
            Americans at an annual cost of $26 billion. The discovery of
            Levodopa was a breakthrough in treating the disease and allows
            patients to lead relatively normal, productive lives. It is
            estimated that treatments slowing the progress of disease by 10
            percent could save the United States $327 million a year.
            Current treatments slow progression of disease, but more
            research is needed to identify the causes of the disease and
            develop better therapies.
      --More than 38 million Americans are blind or visually impaired, and
            that number will grow with an aging population. Eye disease and
            vision loss cost the United States $68 billion annually. NIH
            funded research has developed new treatments that delay or
            prevent diabetic retinopathy, saving $1.6 billion a year.
            Discovery of gene variations in age related macular
            degeneration could result in new screening tests and preventive
            therapies.
      --Almost 5 million Americans suffer from Alzheimer's disease at
            annual costs of more than $100 billion. It is estimated that by
            2050 more than 14 million Americans will live with the disease.
            There are over 28 new drugs for Alzheimer's disease in
            development, but more basic research is needed to keep the
            pipeline for new drugs robust. Inadequate funding could delay,
            prevent, and improve the treatment of the disease.
      --Heart disease and stroke are the number one and three killers of
            Americans, respectively. Cardiovascular disease costs the
            United States more than $350 billion annually. Since 1970,
            death rates from cardiovascular disease have fallen by 50
            percent, but still remain the leading cause of death. Statin
            drugs that reduce cholesterol help to prevent heart disease and
            stroke, decrease recurrence of heart attacks and improve
            survival rates for heart transplant patients.
      --Cancer is the second leading cause of death in the United States.
            The NIH estimates that the annual cost of the disease is over
            $228 billion. NIH research has shown that human papillomavirus
            (HPV) vaccines protect against persistent infection by the two
            types of HPV that cause approximately 70 percent of cervical
            cancers. NIH funded researchers are using nanotechnology to
            develop probes that could pinpoint the location of tumors and
            deliver drugs directly to cancer cells.
        NIH-funded studies have also indicated that adopting intensive
    lifestyle changes delayed onset of type-2 diabetes by 58 percent, and
    that progesterone therapy can reduce premature births by 30 percent in
    at-risk women. Historically, our past investment in basic biological
    research has led to many innovative medicines. The National Research
    Council reported that of the 21 drugs with the highest therapeutic
    impact, only five were developed without input from the public sector.
    The significant past investment in the NIH has provided major gains in
    our knowledge of the human genome, resulting in the promise of
    pharmacogenomics and a reduction in adverse drug reactions that
    currently represent a major worldwide health concern. Already, there
    are several examples where complete human genome sequence analysis has
    pinpointed disease-causing variants that have led to improved therapy
    and cures. Although the costs for such analyses have been reduced
    dramatically by technology improvements, widespread use of this
    approach will require further improvements in technology that will be
    delayed or obstructed with inadequate NIH funding.
        Unless NIH can maintain an adequate funding stream, scientific
    opportunities will be delayed, lost, or forfeited to other countries.
    This investment in NIH also will directly support jobs for U.S.
    citizens and residents and help to stimulate the economy.
    Investing in NIH Helps America Compete Economically
        A $35 billion budget in fiscal year 2012 will also help the NIH
    train the next generation of scientists. This investment will help to
    create jobs and promote economic growth.
        Worldwide, other nations continue to invest aggressively in
    science. China has grown its science portfolio with annual increases to
    the research and development budget averaging over 23 percent annually
    since 2000. And while Great Britain has imposed strict austerity
    measures to address that Nation's debt problems, the British
    conservative party had the foresight to keep its strategic investments
    in science at current levels. Investment in research and development as
    a percentage of gross domestic product has remained static for the
    United States in the first decade of the 21st century, while growing by
    nearly 60 percent in China and 34 percent in South Korea.
        NIH research funding helps to catalyze private sector growth. More
    than 83 percent of NIH funding is awarded to over 3,000 universities,
    medical schools, teaching hospitals and other research institutions in
    every State. NIH also helps form the key scientific foundations for the
    pharmaceutical and biotechnology industries.
        Inadequate funding for NIH means more than a loss of scientific
    potential and discovery. Failing to help meet the NIH's scientific
    potential will mean a significant reduction in research grants, the
    resulting phasing-out of high quality research programs and jobs lost.
    Conclusion
        ASPET has full awareness for the many competing and important
    priorities facing the subcommittee. However, NIH and the biomedical
    research enterprise face a critical moment and the agency's
    contribution to the economic and physical well being of American's
    health should make it one of the Nation's top priorities. With enhanced
    and sustained funding, NIH has the potential to address many of the
    more promising scientific opportunities that currently challenge
    medicine. A $35 billion fiscal year 2012 NIH budget will allow the
    agency to begin moving forward again to prevent, diagnose and treat
    disease, restoring the NIH to its role as a national treasure that
    attracts and retains the best and brightest to biomedical research, and
    providing hope to millions of individuals afflicted with illness and
    disease.
                                     ______

            Prepared Statement of the American Society of Nephrology
    Introduction
        The American Society of Nephrology (ASN) thank you for the
    opportunity to submit a statement for the record to the Senate
    Appropriations Subcommittee on Labor, Health and Human Services,
    Education, and Related Agencies (LHHS Subcommittee). ASN urges the LHHS
    subcommittee to support robust funding for medical research in the
    fiscal year 2012 Federal budget.
        ASN is a not-for-profit professional society of more than 11,000
    scientists and physicians dedicated to cutting-edge medical research
    and delivering the highest quality therapies to patients. Foremost
    among ASN's concerns is the continued support of basic, translational,
    and clinical nephrology research.
        The society's statement focuses on those issues and programs that
    most immediately fall under the committee's jurisdiction and assist our
    members in finding breakthrough treatments and cures for patients with
    kidney disease. We want to express our strong support for advancing
    programs supported by the National Institutes of Health (NIH) and the
    Agency for Healthcare Research and Quality (AHRQ). The ASN thanks the
    Subcommittee for its steadfast support of these programs and requests
    continued support of medical research in fiscal year 2012.
    The Face of Kidney Disease
        Chronic kidney disease now is a major public health problem in the
    United States, with as many as one in nine Americans or 26 million
    people suffering from kidney disease of some degree. This number is
    projected to rise, underscoring that support of medical research into
    the causes and treatments of kidney disease is essential to protecting
    public health. A growing population, a significant and growing cohort
    of Americans above age 65, the combined epidemics of cardiovascular
    disease, diabetes, and hypertension all lead to an increasing number of
    Americans with chronic kidney disease.
        Chronic kidney disease affects people regardless of age, race, sex,
    socio economic background, or geographic location. It is estimated that
    at least 15 million people suffer from CKD, meaning that they have lost
    at least 50 percent of their kidney function. Most don't know it.
    Another 20 million more Americans are at increased risk of developing
    kidney disease. Again, most are unaware. Hypertension and diabetes are
    leading causes of kidney disease, with diabetes accounting for 44
    percent of new cases of complete kidney failure. With both diabetes and
    hypertension on the rise, the need for additional kidney disease
    research takes on greater importance.
        Kidney disease is also a major risk factor for cardiovascular
    disease, with half of patients with kidney failure dying from
    cardiovascular disease. Research at NIH continues to disentangle the
    relationship between kidney disease, cardiovascular disease, diabetes
    and hypertension.
        Without treatment chronic kidney disease often progresses to
    complete kidney failure also known as end stage renal disease (ESRD),
    or permanent kidney failure. Patients with ESRD require dialysis or
    transplantation to survive for which Medicare covers the cost for
    almost all patients. Nearly 500,000 Americans have ESRD, and that
    continues to grow. Additionally, African-Americans, Native Americans,
    and Hispanics are at greater risk of developing ESRD than Caucasians.
    NIH research is helping to unlock the reasons behind these health
    disparities.
    Economics Costs
        Although no dollar amount can be affixed to human suffering or the
    loss of human life, economic data can help to identify and quantify the
    current and projected future financial costs associated with ESRD. The
    annual average cost per ESRD patient on dialysis is approximately
    $71,000. This major cost to Medicare highlights the need to investigate
    new, and better apply, recently proven strategies for preventing and
    slowing the progress of kidney disease.
        In short, we can treat and maintain patients who are at risk for
    losing their kidney function but the critical need is to prevent the
    loss of kidney function and its complications in the first place.
    Meeting this vital goal can only be accomplished through more concerted
    research and education.
    Kidney Disease Research
                National Institutes of Health (NIH)
        NIH research is vital to the public and economic health of the
    United States. As such, ASN supports the Administration's program level
    request of $31.987 billion for NIH in fiscal year 2012. Recognizing the
    economic challenges of the country's current fiscal situation, ASN
    nonetheless submits that maintaining level funding for NIH is
    imperative to the future health and well-being of the Nation. Research
    supported by NIH helps discover new cures and treatments for the
    millions of Americans with kidney disease and improves the lives of
    patients across the country. Medical research funded through NIH means
    hope for patients with kidney disease.
        NIH research also serves as a vital economic engine. More than 80
    percent of NIH funding flows back to States, maintaining jobs and
    promoting economic vitality. Support for NIH research helps ensure that
    the United States remains the world leader in cutting edge treatments
    for chronic disease. NIH grants and research fund the cures of
    tomorrow, and also fund researchers who form the backbone of our global
    competitiveness in the medical field. A drop in funding, even one that
    is short lived could have drastic consequences for the future research
    workforce.
        In fiscal year 2012 an NIH budget of $31.987 billion will allow
    research funding to keep pace with inflation, sustain the invaluable
    research projects currently underway, and allow the research workforce
    to remain adequately supported and protect a valuable investment in
    human talent.
                Agency for Health Care Research and Quality (AHRQ)
        Complementing the medical research conducted at NIH, AHRQ sponsors
    health services research designed to improve the quality of healthcare,
    decrease healthcare costs, and provide access to essential healthcare
    services by translating research into measurable improvements in the
    healthcare system. AHRQ supports emerging critical issues in healthcare
    delivery and addresses the particular needs of at risk populations. ASN
    firmly believes in the value of AHRQ's research and quality agenda,
    which continues to provide healthcare providers, policymakers, and
    patients with critical information needed to improve healthcare and
    treatment of chronic conditions such as kidney disease. AS such ASN
    supports the Administration's budget request of $366 million for AHRQ
    in fiscal year 2012.
    Conclusion
        The progression of chronic kidney disease to kidney failure can be
    slowed, with further research, treatments for stopping progression or
    even reversing it can be envisioned. Meanwhile, millions of Americans
    face a gradual decline in their quality of life because of kidney
    disease. Treatments of kidney failure including transplantation
    increase the ability of patients to be productive citizens. In many
    cases, abnormalities associated with early stage chronic renal disease
    remain undetected and are not diagnosed until the late stages. Chronic
    kidney disease requires our serious and immediate attention.
        Medical research undertaken at NIH and AHRQ is essential to the
    health of patients with kidney disease, both present and future. As
    such, ASN urges the Subcommittee to adopt level funding for these
    programs in fiscal year 2012.
        Thank you for your continued support for medical research and
    kidney disease. The society appreciates the opportunity to submit
    written testimony in support of NIH and AHRQ. To discuss this written
    testimony, ASN, medical research or kidney disease, please contact ASN
    Director of Policy and Public Affairs Paul Smedberg.
                                     ______

         Prepared Statement of the American Society of Plant Biologists
        On behalf of the American Society of Plant Biologists (ASPB) we
    would like to thank the Subcommittee for its support of the National
    Institutes of Health (NIH).
        ASPB and its members recognize the difficult fiscal environment our
    Nation faces, but believe investments in scientific research will be a
    critical step toward economic recovery. ASPB asks that the Subcommittee
    Members encourage increased support for plant biology research within
    NIH, which has contributed in innumerable ways to improving the lives
    of people throughout the world.
        The American Society of Plant Biologists is an organization of
    approximately 5,000 professional plant biology researchers, educators,
    graduate students, and postdoctoral scientists with members in all 50
    States and throughout the world. A strong voice for the global plant
    science community, our mission--achieved through work in the realms of
    research, education, and public policy--is to promote the growth and
    development of plant biology, to encourage and communicate research in
    plant biology, and to promote the interests and growth of plant
    scientists in general.
    Plant Biology Research and America's Future
        Plants are vital to our very existence. They harvest sunlight,
    converting it to chemical energy for food and feed; they take up carbon
    dioxide and produce oxygen; and they are the primary producers on which
    all life depends. Indeed, plant biology research is making many
    fundamental contributions in the areas of domestic fuel security and
    environmental stewardship; the continued and sustainable development of
    better foods, fabrics, pharmaceuticals, and building materials; and in
    the understanding of basic biological principles that underpin
    improvements in the health and nutrition of all Americans. In fact, the
    2009 National Research Council (NRC) report A New Biology for the 21st
    Century placed plant biology at the center of urgent priorities in
    energy, food, health, and the environment.
        For example, because plants are the ultimate source of both human
    nutrition and nutrition for domestic animals, plant biology has the
    potential to contribute greatly to reducing healthcare costs as well as
    playing an integral role in discovery of new drugs and therapies.
    Although the National Institutes of Health does offer some funding
    support to plant biology research, additional support would enable
    plant biologists to offer much more to advance the missions of the
    National Institutes of Health.
        The importance of disciplinary and agency integration is a central
    theme of several recent NRC reports including A New Biology for the
    21st Century, Research at the Intersection of the Physical and Life
    Sciences, and Inspired by Biology: From Molecules to Materials to
    Machines. ASPB encourages NIH to continue and expand its partnerships
    with other Federal science agencies--including the National Science
    Foundation, Department of Agriculture and Department of Energy--in
    advancing understanding about living systems that has application to a
    range of areas including human health.
    Plant Biology and the National Institutes of Health
        The mission of the NIH is to pursue ``fundamental knowledge about
    the nature and behavior of living systems and the application of that
    knowledge to extend healthy life and reduce the burdens of illness and
    disability.'' Plant biology research is highly relevant to this
    mission.
        Plants are often the ideal model systems to advance our
    ``fundamental knowledge about the nature and behavior of living
    systems,'' as they provide the context of multi-cellularity while
    affording ease of genetic manipulation, a lesser regulatory burden, and
    inexpensive maintenance requirements than the use of animal systems.
    Many basic biological components and mechanisms are shared by both
    plants and animals. For example, a molecule named cryptochrome that
    senses light was identified first in plants and subsequently found to
    also function in humans, where it plays a central role in regulating
    our biological clock. Several human genetic disorders are linked to the
    malfunctioning of this clock--not to mention the effect of jet lag. As
    another example, some fungal pathogens can infect both humans and
    plants, and the molecular mechanisms employed by both the pathogen and
    its targeted host can be very similar.
        More recently, a property known as RNA interface was first noted in
    plants; plant biologists trying to increase the color intensity of
    petunias by introducing a gene inducing pigment production instead
    observed a loss of color. RNA interface, which has potential
    application in the treatment of human disease, was further elucidated
    in other plants and animals and earned two American scientists--Andrew
    Fire and Craig Mello--the 2006 Nobel Prize in Physiology or Medicine.
    Health and Nutrition
        Plant biology research is also central to the application of basic
    knowledge to ``extend healthy life and reduce the burdens of illness
    and disability.'' This connection is most obvious in the inter-related
    areas of nutrition and clinical medicine. Without good nutrition, there
    cannot be good health. Indeed, one World Health Organization study on
    childhood nutrition in developing countries concluded that over 50
    percent of the deaths of children less than 5 years of age could be
    attributed to malnutrition's effects in exacerbating common illnesses
    such as respiratory infections and diarrhea. Strikingly, most of these
    deaths were not linked to severe malnutrition but only to mild or
    moderate nutritional deficiencies. Plant biology researchers are
    working today to improve the nutritional content of crop plants by, for
    example, increasing the availability of nutrients and vitamins such as
    iron, vitamin E, and vitamin A. (Up to 500,000 children in the
    developing world go blind every year as a result of vitamin A
    deficiency).
        By contrast, obesity, cardiac disease, and cancer take a striking
    toll in the developed world. Among many plant biology initiatives
    relevant to these concerns are research to improve the lipid
    composition of plant fats and efforts to optimize concentrations of
    plant compounds that are known to have anti-carcinogenic properties,
    such as the glucosinolates found in broccoli and cabbage, and the
    lycopenes found in tomato. Beta-glucans from certain cereals reduce
    serum cholesterol and insulin demand in diabetics. And scientists are
    able to use the fundamental knowledge of protein structures to reduce
    non-nutritious compounds, increasing the density and quality of
    proteins in some grains. Ongoing development of crop varieties with
    tailored nutraceutical content is an important contribution that plant
    biologists are making toward realizing the goal of personalized
    medicine, especially personalized preventative medicine.
    Drug Discovery
        Plants are also fundamentally important as sources of both extant
    drugs and drug discovery leads. In fact, over 10 percent of the drugs
    considered by the World Health Organization to be ``basic and
    essential'' are still exclusively obtained from flowering plants. Some
    historical examples are quinine, which is derived from the bark of the
    cinchona tree and was the first highly effective anti-malarial drug;
    and the plant alkaloid morphine, which revolutionized the treatment of
    pain. These pharmaceuticals are still in use today.
        A more recent example of the importance of plant-based
    pharmaceuticals is the anti-cancer drug taxol. The discovery of taxol
    came about through collaborative work involving scientists at the
    National Cancer Institute within NIH and plant biologists at the U.S.
    Department of Agriculture. The plant biologists collected a wide
    diversity of plant materials, which were then evaluated for anti-
    carcinogenic properties. It was found that the bark of the Pacific yew
    tree yielded one such compound, which was isolated and named taxol
    after the tree's Latin name, Taxus brevifolia. Originally, taxol could
    only be obtained from the tree bark itself, but additional research led
    to the elucidation of its molecular structure and eventually to its
    chemical synthesis in the laboratory.
        On the basis of a growing understanding of metabolic networks,
    plants will continue to be sources for the development of new medicines
    to help treat cancer and other ailments. Taxol is just one example of a
    plant secondary compound. Since plants produce an estimated 200,000
    such compounds, they will continue to provide a fruitful source of new
    drug leads, particularly if collaborations such as the one described
    above can be fostered and funded. With additional research support,
    plant biologists can lead the way to developing new medicines and
    biomedical applications to enhance the treatment of devastating
    diseases.
    Conclusion
        Despite the fact that plant biology research underlies so many
    vital practical considerations for our country, the amount invested in
    understanding the basic function and mechanisms of plants is small when
    compared with broader impacts.
        The NIH does recognize that plants are a vital component of its
    mission. However, because the boundaries of plant biology research are
    permeable and because information about plants integrates with many
    different disciplines that are highly relevant to NIH, ASPB hopes that
    the Subcommittee will provide direction to NIH to support additional
    plant biology research in order to help pioneer new discoveries and new
    methods in biomedical research.
        Thank you for your consideration of our testimony on behalf of the
    American Society of Plant Biologists. Please do not hesitate to contact
    ASPB if we can be of any assistance in the future; ASPB Public Affairs
    Director Dr. Adam P. Fagen can be reached at 301-296-0898 (phone), 301-
    296-0899 (fax), or afagen@aspb.org.
                                     ______

      Prepared Statement of the American Society of Tropical Medicine and
                                    Hygiene
        The American Society of Tropical Medicine and Hygiene--the
    principal professional membership organization representing, educating,
    and supporting scientists, physicians, clinicians, researchers,
    epidemiologists, and other health professionals dedicated to the
    prevention and control of tropical diseases--appreciates the
    opportunity to submit testimony to the Senate Labor, Health and Human
    Services, and Education Appropriations Subcommittee.
        We understand the fiscal constraints we as a country are in and are
    sensitive to the job Congress must do. The benefits of U.S. investment
    in tropical diseases are not only humanitarian, they are diplomatic as
    well. With this in mind, we respectfully request that the Subcommittee
    fund the following agencies in the fiscal year 2012 LHHS Appropriations
    bill to allow them to maintain their current programs and research
    priorities while ensuring a continued U.S. Government investment in
    global health and tropical medicine research and development:
        National Institutes of Health, specifically:
      --Malaria and neglected tropical disease treatment, control, and
            research and development efforts within the National Institute
            of Allergy and Infectious Diseases;
      --An expanded focus on the treatment, control, and research and
            development for new tools for diarrheal disease within the NIH;
            specifically the inclusion of enteric infections on the
            Research, Condition, and Disease Categorization (RCDC) process
            on the Research Portfolio Online Reporting Tools (RePORT)
            website; and,
      --Research capacity development in countries where populations are at
            heightened risk for malaria, NTDs, and diarrheal diseases
            through the Fogarty International Center.
        The Centers for Disease Control and Prevention, including:
      --CDC global health programs such as the CDC malaria program and
            providing direct funding to the CDC for NTD and diarrheal
            disease work; and
      --Preserving and funding the activities of the CDC Vector Borne
            Disease Program as they merge with the Emerging and Infectious
            Disease Program to protect the United States from new and
            emerging infections.
                  return on investment of u.s.-funded research
        CDC and NIH play essential roles in research and development for
    tropical medicine and global health. Both agencies are at the forefront
    of the new science that leads to tools to combat malaria and NTDs. This
    research provides jobs for American researchers and an opportunity for
    the United States to be a leader in the fight against global disease,
    in addition to lifesaving new drugs and diagnostics to some of the
    poorest, most at-risk people in the world.
        For example, in Illinois, where ASTMH is based, 57,000 people are
    employed in bioscience research, which includes global health research.
    Illinois receives over $700 million in funding from NIH and over $200
    million from CDC.\1\ New Jersey also has a high level of investment in
    health-related research and development, with over 211,000 jobs
    supported by global health, and an economic impact of more than $60
    billion on the State in 2009.\2\ Small investments in global health and
    tropical medicine research and development can yield big returns for
    State economies and research institutions.
    ---------------------------------------------------------------------------
        \1\ Research America, ``Global Health R&D, A Smart Investment for
    Illinois,'' http://www.researchamerica.org/uploads/
    ILGHeconomicsheet.pdf.
        \2\ Research America, ``Global Health R&D, A Smart Investment for
    New Jersey,'' http://www.researchamerica.org/uploads/
    NewJerseyFactSheet.pdf.
    ---------------------------------------------------------------------------
                                tropical disease
        Most tropical diseases are prevalent in either sub-Saharan Africa,
    parts of Asia (including the Indian subcontinent), or Central and South
    America. Many of the world's developing nations are located in these
    areas; thus, tropical medicine tends to focus on diseases that impact
    the world's most impoverished individuals.
        Malaria.--Malaria remains a global emergency affecting mostly poor
    women and children; it is an acute, sometimes fatal disease. Despite
    being treatable and preventable, malaria is one of the leading causes
    of death and disease worldwide. Approximately every 30 seconds, a child
    dies of malaria--a total of about 800,000 under the age of 5 every
    year. The World Health Organization estimates that one half of the
    world's people are at risk for malaria and that there are 108 malaria-
    endemic countries. Additionally, WHO has estimated that malaria reduces
    sub-Saharan Africa's economic growth by up to 1.3 percent per year.
        Neglected Tropical Diseases, also known as Diseases of Poverty.--
    NTDs are a group of chronic parasitic diseases, such as hookworm,
    elephantiasis, schistosomiasis, and river blindness, which represent
    the most common infections of the world's poorest people. These
    infections have been revealed as the stealth reason why the ``bottom
    billion''--the 1.4 billion poorest people living below the poverty
    line--cannot escape poverty, because of the effects of these diseases
    on reducing child growth, cognition and intellect, and worker
    productivity.
        Diarrheal disease.--The child death toll due to diarrheal illnesses
    exceeds that of AIDS, tuberculosis, and malaria combined. In poor
    countries, diarrheal disease is second only to pneumonia as the cause
    of death among children under 5 years old. Every week, 31,000 children
    in low-income countries die from diarrheal diseases.
        The United States has a long history of leading the fight against
    tropical diseases that cause human suffering and pose financial burden
    that can negatively impact a country's economic and political
    stability. Tropical diseases, many of them neglected for decades,
    impact U.S. citizens working or traveling overseas, as well as our
    military personnel. Furthermore, some of the agents responsible for
    these diseases can be introduced and become established in the United
    States (like West Nile virus), or might even be weaponized.
                         national institutes of health
        National Institute of Allergy and Infectious Diseases.--A long-term
    investment is critical to achieve the drugs, diagnostics, and research
    capacity needed to control malaria and NTDs. NIAID, the lead institute
    for malaria research, plays an important role in developing the drugs
    and vaccines needed to fight malaria. The NIH, through NIAID, also
    conducts research to better understand NTDs, through its own basic and
    clinical studies as well as extramural research.
        ASTMH encourages the subcommittee to:
      --Increase funding for NIH to expand the agency's investment in
            malaria, NTD, diarrheal disease research and to coordinate that
            work with other government agencies to maximize resources and
            ensure development of basic discoveries into usable solutions;
      --Specifically invest in NIAID to support its role at the forefront
            of these efforts to developing the next generation of drugs,
            vaccines, and other interventions; and,
      --Urge NIH to include enteric infections and neglected diseases in
            its RCDC process on the RePORT website to outline the work that
            is being done in these important research areas.
        Fogarty International Center (FIC).--Biomedical research has
    provided major advances in the treatment and prevention of malaria,
    NTDs, and other infectious diseases. These benefits, however, are often
    slow to reach the people who need them most. FIC plays a critical role
    in strengthening science and public health research institutions in
    low-income countries. FIC works to strengthen research capacity in
    countries where populations are particularly vulnerable to threats
    posed by malaria, NTDs, and other infectious disease. This maximizes
    the impact of U.S. investments and is critical to fighting malaria and
    other tropical diseases.
        ASTMH encourages the subcommittee to:
      --Allocate sufficient resources to FIC in fiscal year 2012 to
            increase these efforts, particularly as they address the
            control and treatment of malaria, NTDs and diarrheal disease.
                 the centers for disease control and prevention
        Malaria Efforts.--Malaria has been eliminated as an endemic threat
    in the United States for over fifty years and CDC remains on the
    cutting edge of global efforts to reduce the toll of this deadly
    disease. CDC efforts on malaria fall into three broad categories:
    prevention, treatment, and monitoring/evaluation of efforts. The agency
    performs a wide range of basic research within these categories, such
    as:
      --Conducting research on antimalarial drug resistance to inform new
            strategies and prevention approaches;
      --Assessing new monitoring, evaluation, and surveillance strategies;
      --Conducting additional research on malaria vaccines, including field
            evaluations; and
      --Developing innovative public health strategies for improving access
            to antimalarial treatment and delaying the appearance of
            antimalarial drug resistance.
        ASTMH encourages the subcommittee to:
      --Fund a comprehensive approach to effective and efficient malaria
            control, including adequately funding the important
            contributions of CDC.
        NTD Programs.--CDC currently receives zero dollars directly for NTD
    work; however this should be changed to allow for more comprehensive
    work to be done on NTDs at the CDC. CDC has a long history of working
    on NTDs and has provided much of the science that underlies the global
    policies and programs in existence today. This work is important to any
    global health initiative, as individuals are often infected with
    multiple NTDs simultaneously.
        ASTMH encourages the subcommittee to:
      --Provide direct funding to CDC to continue its work on NTDs; and
      --Urge CDC to continue its monitoring, evaluation, and technical
            assistance in these areas as an underpinning of efforts to
            control and eliminate these diseases.
        Vector-borne Disease Program (VBDP).--The President's fiscal year
    2012 budget folds the CDC Vector Borne Disease Program into the newly
    configured Emerging and Zoonotic Infectious Diseases program at CDC.
    Through the VBDP, researchers are able to practice essential
    surveillance and monitoring activities that protect the United States
    from deadly infections before they reach our borders. The world is
    becoming increasingly smaller as international travel increases and new
    pathogens are introduced quickly into new environments. We have seen
    this with SARS, avian influenza, and now, dengue fever, in the United
    States. Arboviruses like dengue, and others, such as chikungunya, are a
    constant threat to travelers, and to Americans generally.
        Dengue fever, a disease with increased risk for Americans as the
    weather warms and dengue cases increase, is an example of why it is
    imperative that CDC be able to continue its disease monitoring and
    surveillance activities to protect the country from new and emerging
    threats like dengue and other arboviruses. Dengue fever, a viral
    disease transmitted by the Aedes mosquito, recently reemerged as a
    threat to Americans, with documented cases in the Florida Keys. Dengue
    usually results in fever, headache, and chills, but hemorrhagic dengue
    fever can cause severe internal bleeding, loss of blood, and even
    death. Because the Aedes mosquito is urban dwelling and often breeds in
    areas of poor sanitation, dengue is a serious concern for poor
    residents of costal, urban areas in Texas, Louisiana, Mississippi,
    Alabama, and Florida.
        ASTMH encourages the subcommittee to:
      --Ensure that CDC maintain these important activities by continuing
            CDC funding for VBDP activities and require the program receive
            at least their fiscal year 2010 level of funding.
                                   conclusion
        Thank you for your attention to these important U.S. and global
    health matters. We know Congress and the American people face many
    challenges in choosing funding priorities, and we hope you will provide
    the requested fiscal year 2012 resources to those programs identified
    above that meet critical needs for Americans and people around the
    world. ASTMH appreciates the opportunity to share its expertise, and we
    thank you for your consideration of these requests that will help
    improve the lives of Americans and the global poor.
                                     ______

              Prepared Statement of the American Thoracic Society

                        SUMMARY: FUNDING RECOMMENDATIONS
                            [In millions of dollars]
    ------------------------------------------------------------------------
                                                                   Amount
    ------------------------------------------------------------------------
    National Institutes of Health.............................      35,000
        National Heart, Lung and Blood Institute..............       3,514
        National Institute of Allergy and Infectious Disease..       5,395
        National Institute of Environmental Health Sciences...         779.4
        Fogarty International Center..........................          78.4
        National Institute of Nursing Research................         163
    Centers for Disease Control and Prevention................       7,700
        National Institute for Occupational Safety & Health...         332.4
        Asthma Programs.......................................          31
        Div. of Tuberculosis Elimination......................         231
        Office on Smoking and Health..........................         330
        National Sleep Awareness Roundtable (NSART)...........           1
    ------------------------------------------------------------------------

        The American Thoracic Society (ATS) is pleased to submit our
    recommendations for programs in the Labor Health and Human Services and
    Education Appropriations Subcommittee purview. Founded in 1905, the ATS
    is an international education and scientific society of 15,000
    specialists focused on respiratory, critical care and sleep medicine.
    Lung Disease in America
        Diseases of breathing constitute the third leading cause of death
    in the United States, responsible for one of every seven deaths.
    Diseases affecting the respiratory (breathing) system include chronic
    obstructive pulmonary disease (COPD), lung cancer, tuberculosis,
    influenza, sleep disordered breathing, pediatric lung disorders,
    occupational lung disease, sarcoidosis, asthma, and critical illness.
    COPD is now the third leading cause of disease death. The number of
    people with asthma in the United States has surged over 150 percent
    since 1980 and the root causes of the disease are still not fully
    known.
        Despite the rising lung disease burden, lung disease research is
    underfunded. In fiscal year 2010, lung disease research represented
    just 22.6 percent of the National Heart Lung and Blood Institute's
    (NHLBI) budget. Although COPD is the third leading cause of death in
    the United States, research funding for the disease is a small fraction
    of the money invested for the other three leading causes of death. In
    order to stem the devastating effects of lung disease, research funding
    must continue to grow.
    National Institutes of Health
        The NIH is the world's leader in groundbreaking biomedical health
    research into the prevention, treatment and cure of diseases such as
    lung cancer, COPD and tuberculosis. Eighty-five percent of the NIH
    budget is invested in U.S. communities through universities, medical
    schools, hospitals and innovative small businesses, creating jobs and
    economic productivity. The American Reinvestment Recovery Act (ARRA)
    has generated remarkable scientific innovation that is paving the way
    for medical advances to improve patient outcomes. Without a funding
    increase in fiscal year 2012 to sustain the research pipeline, the NIH
    will be forced to reduce the number of research grants funded, which
    will result in the halting of vital research into diseases affecting
    millions around the world. We ask the subcommittee to provide $35
    billion in funding for the NIH in fiscal year 2012.
    Centers for Disease Control and Prevention
        In order to ensure that health promotion and chronic disease
    prevention are given top priority in Federal funding, the ATS supports
    a funding level for the Centers for Disease Control and Prevention
    (CDC) that enables it to carry out its prevention mission, and ensure a
    translation of new research into effective State and local public
    health programs. We ask that the CDC budget be adjusted to reflect
    increased needs in chronic disease prevention, infectious disease
    control, including TB control to prevent the spread of drug-resistant
    TB, and occupational safety and health research and training. The ATS
    recommends a funding level of $7.7 billion for the CDC in fiscal year
    2012.
    COPD
        COPD is the third leading cause of death in the United States and
    the third leading cause of death worldwide, yet the disease remains
    relatively unknown to most Americans. COPD is the term used to describe
    the limitation in breathing due mainly to emphysema and chronic
    bronchitis. CDC estimates that 12 million patients have COPD; an
    additional 12 million Americans are unaware that they have this life
    threatening disease. In 2010, the estimated economic cost of lung
    disease in the United States was $186 billion, including $117 billion
    in direct health expenditures and $69 billion in indirect morbidity and
    mortality costs.
        Despite the growing burden of COPD, the United States does not
    currently have a comprehensive public health action plan on the
    disease. The ATS urges Congress to direct the NHLBI to develop a
    national action plan on COPD, in coordination with the Centers for
    Disease Control and Prevention (CDC) to expand COPD surveillance,
    development of public health interventions and research on the disease
    and increase public awareness of the disease. The NHLBI has shown
    successful leadership in educating the public about COPD through the
    COPD Education and Prevention Program.
        CDC has an additional role to play in this work. We urge CDC to
    include COPD-based questions to future CDC health surveys, including
    the National Health and Nutrition Evaluation Survey (NHANES), the
    National Health Information Survey (NHIS) and the Behavioral Risk
    Factor Surveillance Survey (BRFSS).
    Tobacco Control
        Cigarette smoking is the leading preventable cause of death in the
    United States, responsible for one in five deaths annually. The ATS is
    pleased that the Department of Health and Human Services has made
    tobacco use prevention a key priority. The CDC's Office of Smoking and
    Health coordinates public health efforts to reduce tobacco use. In
    order to significantly reduce tobacco use within 5 years, as
    recommended by the subcommittee in fiscal year 2010, the ATS recommends
    a total funding level of $330 million for the Office of Smoking and
    Health in fiscal year 2012, which includes an allocation of $220
    million from the Prevention and Public Health Fund.
    Pediatric Lung Disease
        The ATS is pleased to report that infant death rates for various
    lung diseases have declined for the past 10 years. In 2007, of the 10
    leading causes of infant mortality, 4 were lung diseases or had a lung
    disease component. Many of the precursors of adult respiratory disease
    start in childhood. It is estimated that close to 22 million people
    suffer from asthma, including an estimated 7.1 million children. The
    ATS encourages the NHLBI to continue with its research efforts to study
    lung development and pediatric lung diseases.
    Asthma
        Asthma is a significant public health problem in the United States.
    Approximately 23 million Americans currently have asthma, including 7.1
    million children. In 2009, 3,445 Americans in 2009 died as a result of
    asthma exacerbations. Asthma is the third leading cause of
    hospitalization among children under the age of 15 and is a leading
    cause of school absences from chronic disease. The disease costs our
    healthcare system over $50.1 billion per year. African Americans have
    the highest asthma prevalence of any racial/ethnic group.
        The President's fiscal year 2012 budget request proposes to merge
    the CDC's National Asthma Control Program with the Healthy Homes/Lead
    Poisoning Prevention Program and recommends funding cuts to the
    combined programs of over 50 percent. The ATS is deeply concerned that
    this proposal would drastically reduce States' capacity to implement a
    proven public health response to this disease. Asthma public health
    interventions are cost-effective. A study published in the American
    Journal of Respiratory Critical Care recently found that for every
    dollar invested in asthma interventions, there was a $36 benefit. We
    urge the subcommittee to ensure that CDC's National Asthma Control
    Program remains a stand-alone program and receives an appropriation of
    $31 million for fiscal year 2012.
    Sleep
        Several research studies demonstrate that sleep-disordered
    breathing and sleep-related illnesses affect an estimated 50-70 million
    Americans. The public health impact of sleep illnesses and sleep
    disordered breathing is still being determined, but is known to include
    increased mortality, traffic accidents, lost work and school
    productivity, cardiovascular disease, obesity, mental health disorders,
    and other sleep-related comorbidities. Despite the increased need for
    study in this area, research on sleep and sleep-related disorders has
    been underfunded. The ATS recommends a funding level of $1 million in
    fiscal year 2012 to support activities related to sleep and sleep
    disorders at the CDC, including for the National Sleep Awareness
    Roundtable (NSART), surveillance activities, and public educational
    activities. The ATS also recommends an increase of funding for research
    on sleep disorders at the Nation Center for Sleep Disordered Research
    (NCSDR) at the NHLBI.
    Tuberculosis
        Tuberculosis (TB) is the second leading global infectious disease
    killer, claiming 1.7 million lives each year. It is estimated that 9-12
    million Americans have latent tuberculosis. Drug-resistant TB poses a
    particular challenge to domestic TB control due to the high costs of
    treatment and intensive healthcare resources required. The global TB
    pandemic and spread of drug resistant TB presents a persistent public
    health threat to the United States.
        Despite declining rates, persistent challenges to TB control in the
    United States remain. Specifically: (1) racial and ethnic minorities
    continue to suffer from TB more than majority populations; (2) foreign-
    born persons are adversely impacted; (3) sporadic outbreaks occur,
    outstripping local capacity; (4) continued emergence of drug
    resistance; and (5) there are critical needs for new diagnostics,
    treatment and prevention tools.
        The Comprehensive Tuberculosis Elimination Act (CTEA, Public Law
    110-392), enacted in 2008, reauthorized programs at CDC with the goal
    of putting the United States back on the path to eliminating TB. The
    ATS, recommends a funding level of $231 million in fiscal year 2012 for
    CDC's Division of TB Elimination, as authorized under the CTEA, and
    encourages the NIH to expand efforts, as requested under the CTEA, to
    develop new tools to reduce the rising global TB burden.
    Critical Illness
        The burden associated with the provision of care to critically ill
    patients is anticipated to increase significantly as the population
    ages. Approximately 200,000 people in the United States require
    hospitalization in an intensive care unit because they develop a form
    of pulmonary disease called Acute Lung Injury. Despite the best
    available treatments, 75,000 of these individuals die each year from
    this disease. Investigation into diagnosis, treatment and outcomes in
    critically ill patients should be a high priority, and the NIH should
    be encouraged and funded to coordinate investigation related to
    critical illness in order to meet this growing national imperative.
    Fogarty International Center
        The Fogarty International Center (FIC) at NIH provides training
    grants to U.S. universities to teach AIDS treatment and research
    techniques to international physicians and researchers. Because of the
    link between AIDS and TB infection, FIC has created supplemental TB
    training grants for these institutions to train international health
    professionals in TB treatment and research. The ATS recommends Congress
    provide $78.4 million for FIC in fiscal year 2012, to allow expansion
    of the TB training grant program from a supplemental grant to an open
    competition grant.
    Researching and Preventing Occupational Lung Disease
        The National Institute of Occupational Safety and Health (NIOSH) is
    the sole Federal agency responsible for conducting research and making
    recommendations for the prevention of work-related diseases and injury.
    The ATS recommends that Congress provide $364.3 million in fiscal year
    2012 for NIOSH to expand or establish the following activities: the
    National Occupational Research Agenda (NORA); tracking systems for
    identifying and responding to hazardous exposures and risks in the
    workplace; emergency preparedness and response activities; and training
    medical professionals in the diagnosis and treatment of occupational
    illness and injury.
    Conclusion
        Lung disease is a growing problem in the United States. The level
    of support this subcommittee approves for lung disease programs should
    reflect the urgency illustrated by these numbers. The ATS appreciates
    the opportunity to submit this statement to the subcommittee.
                                     ______

        Prepared Statement of the Americans for Nursing Shortage Relief
        The undersigned organizations of the ANSR Alliance greatly
    appreciate the opportunity to submit written testimony regarding fiscal
    year 2012 appropriations for the Title VIII Nursing Workforce
    Development Programs at the Health Resources and Services
    Administration (HRSA) and the Nurse Managed Health Clinics as
    authorized under Title III of the Public Health Service Act. We
    represent a diverse cross-section of healthcare and other related
    organizations, healthcare providers, and supporters of nursing issues
    that have united to address the national nursing shortage. ANSR stands
    ready to work with Congress to advance programs and policy that will
    ensure our Nation has a sufficient and adequately prepared nursing
    workforce to provide quality care to all well into the 21st century.
    The Alliance, therefore, urges Congress to:
      --Appropriate $313 million in funding for Nursing Workforce
            Development Programs under Title VIII of the Public Health
            Service Act at the Health Resources and Services Administration
            (HRSA) in fiscal year 2012.
      --Appropriate $20 million in fiscal year 2012 for the Nurse Managed
            Health Clinics as authorized under Title III of the Public
            Health Service Act.
    The Nursing Shortage
        Nursing is the largest healthcare profession in the United States.
    According to the National Council of State Boards of Nursing, there
    were nearly 3.780 million licensed RNs in 2009. Nurses and advanced
    practice nurses (nurse practitioners, nurse midwives, clinical nurse
    specialists, and certified registered nurse anesthetists) work in a
    variety of settings, including primary care, public health, long-term
    care, surgical care facilities, and hospitals. The March 2008 study,
    The Future of the Nursing Workforce in the United States: Data, Trends,
    and Implications, calculates a projected demand of 500,000 full-time
    equivalent registered nurses by 2025. According to the U.S. Bureau of
    Labor Statistics, employment of registered nurses is expected to grow
    by 22 percent from 2008 to 2018, much faster than the average for all
    occupations and, because the occupation is very large, 581,500 new jobs
    will result. Based on these scenarios, the shortage presents an
    extremely serious challenge in the delivery of high quality, cost-
    effective services, as the Nation looks to reform the current
    healthcare system. Even considering only the smaller projection of
    vacancies, this shortage still results in a critical gap in nursing
    service, essentially three times the 2001 nursing shortage.
    The Desperate Need for Nurse Faculty
        Nursing vacancies exist throughout the entire healthcare system,
    including long-term care, home care and public health. Even the
    Department of Veterans Affairs, the largest sole employer of RNs in the
    United States, has a nursing vacancy rate of 10 percent. In 2006, the
    American Hospital Association reported that hospitals needed 116,000
    more RNs to fill immediate vacancies, and that this 8.1 percent vacancy
    rate affects hospitals' ability to provide patient care. Government
    estimates indicate that this situation only promises to worsen due to
    an insufficient supply of individuals matriculating in nursing schools,
    an aging existing workforce, and the inadequate availability of nursing
    faculty to educate and train the next generation of nurses. At the
    exact same time that the nursing shortage is expected to worsen, the
    baby boom generation is aging and the number of individuals with
    serious, life-threatening, and chronic conditions requiring nursing
    care will increase. Consequently, more must be done today by the
    government to help ensure an adequate nursing workforce for the
    patients/clients of today and tomorrow.
        A particular focus on securing and retaining adequate numbers of
    faculty is essential to ensure that all individuals interested in--and
    qualified for--nursing school can matriculate in the year that they are
    accepted. The National League for Nursing found that in the 2009-2010
    academic year,
      --42 percent of qualified applications to prelicensure RN programs
            were turned away.
      --One in four (25.1 percent) of prelicensure RN programs turned away
            qualified applicants.
      --Four out of five (60 percent) of prelicensure RN programs were
            considered ``highly selective'' by national college admissions
            standards, accepting less than 50 percent of applications for
            admission.
        Aside from having a limited number of faculty, nursing programs
    struggle to provide space for clinical laboratories and to secure a
    sufficient number of clinical training sites at healthcare facilities.
        ANSR supports the need for sustained attention on the efficacy and
    performance of existing and proposed programs to improve nursing
    practices and strengthen the nursing workforce. The support of research
    and evaluation studies that test models of nursing practice and
    workforce development is integral to advancing healthcare for all in
    America. Investments in research and evaluation studies have a direct
    effect on the caliber of nursing care. Our collective goal of improving
    the quality of patient care, reducing costs, and efficiently delivering
    appropriate healthcare to those in need is served best by aggressive
    nursing research and performance and impact evaluation at the program
    level.
    The Nursing Supply Impacts the Nation's Health and Economic Safety
        Nurses make a difference in the lives of patients from disease
    prevention and management to education to responding to emergencies.
    Chronic diseases, such as heart disease, stroke, cancer, and diabetes,
    are the most preventable of all health problems as well as the most
    costly. Nearly half of Americans suffer from one or more chronic
    conditions and chronic disease accounts for 70 percent of all deaths.
    In addition, increased rates of obesity and chronic disease are the
    primary cause of disability and diminished quality of life.
        Even though America spends more than $2 trillion annually on
    healthcare--more than any other nation in the world--tens of millions
    of Americans suffer every day from preventable diseases like type 2
    diabetes, heart disease, and some forms of cancer that rob them of
    their health and quality of life. In addition, major vulnerabilities
    remain in our emergency preparedness to respond to natural,
    technological and manmade hazards. An October 2008 report issued by
    Trust for America's Health, entitled ``Blueprint for a Healthier
    America,'' found that the health and safety of Americans depend on the
    next generation of professionals in public health. Further, existing
    efforts to recruit and retain the public health workforce are
    insufficient. New policies and incentives must be created to make
    public service careers in public health an attractive professional
    path, especially for the emerging workforce and those changing careers.
        The Institute of Medicine report, Hospital-Based Emergency Care: At
    the Breaking Point, notes that nursing shortages in U.S. hospitals
    continue to disrupt hospitals operations and are detrimental to patient
    care and safety. Hospitals and other healthcare facilities across the
    country are vulnerable to mass casualty incidents themselves and/or in
    emergency and disaster preparedness situations. As in the public health
    sector, a mass casualty incident occurs as a result of an event where
    sudden and high patient volume exceeds the facilities resources. Such
    events may include the more commonly realized multi-car pile-ups, train
    crashes, hazardous material exposure in a building or within a
    community, high occupancy catastrophic fires, or the extraordinary
    events such as pandemics, weather-related disasters, and intentional
    catastrophic acts of violence.
        Since 80 percent of disaster victims present at the emergency
    department, nurses as first receivers are an important aspect of the
    public health system as well as the healthcare system in general. The
    nursing shortage has a significant adverse impact on the ability of
    communities to respond to health emergencies, including natural,
    technological and manmade hazards.
    Summary
        The link between healthcare and our Nation's economic security and
    global competitiveness is undeniable. Having a sufficient nursing
    workforce to meet the demands of a highly diverse and aging population
    is an essential component to reforming the healthcare system as well as
    improving the health status of the Nation and reducing healthcare
    costs. To mitigate the immediate effect of the nursing shortage and to
    address all of these policy areas, ANSR requests $313 million in
    funding for Nursing Workforce Development Programs under Title VIII of
    the Public Health Service Act at HRSA and $20 million for the Nurse
    Managed Health Clinics under Title III of the Public Health Service Act
    in fiscal year 2012.
                       list of ansr member organizations
    Academy of Medical-Surgical Nurses
    American Academy of Ambulatory Care Nursing
    American Association of Critical-Care Nurses
    American Association of Nurse Assessment Coordinators
    American Organization of Nurse Executives
    American Society for Pain Management Nursing
    American Society of PeriAnesthesia Nurses
    Association for Radiologic & Imaging Nursing
    Association of Community Health Nursing Educators
    Association of Pediatric Hematology/Oncology Nurses
    Emergency Nurses Association
    Infusion Nurses Society
    International Nurses Society on Addictions
    National Association of Clinical Nurse Specialists
    National Association of Hispanic Nurses
    National Association of Nurse Practitioners in Women's Health
    National Council of State Boards of Nursing
    National Council of Women's Organizations
    National League for Nursing
    National Nursing Centers Consortium
    National Student Nurses' Association, Inc.
    Nurses Organization of Veterans Affairs
    Society of Trauma Nurses
                                     ______

                 Prepared Statement of the Arthritis Foundation
        The Arthritis Foundation greatly appreciates the opportunity to
    submit testimony in support of increased investment for arthritis
    research, prevention and programs at the Centers for Disease Control
    and Prevention (CDC); National Institutes of Health (NIH); Agency for
    Healthcare Research and Quality (AHRQ); and for the Health Resources
    and Services Administration (HRSA).
        Arthritis is a complex family of musculoskeletal disorders with
    many causes, not yet fully understood, and so far there are no cures.
    It consists of more than 100 different diseases or conditions that
    destroy joints, bones, muscles, cartilage and other connective tissue
    which hampers or halts physical movement. Arthritis is one of the most
    prevalent chronic health problems and the most common cause of
    disability in the United States. 50 million people (1 in 5 adults) and
    almost 300,000 children live with the pain of arthritis every day.
    Arthritis limits the daily activities of 21 million Americans and
    accounts for $128 billion annually in economic costs, including $81
    billion in direct costs for physician visits and surgical interventions
    and $47 billion in indirect costs for missed work days. Counter to
    public perception, two-thirds of the people with doctor-diagnosed
    arthritis are under the age of 65. The pain, cost and disability
    associated with arthritis is simply unacceptable.
        By the year 2030, an estimated 67 million or 25 percent of the
    projected adult population will have arthritis. Furthermore, arthritis
    limits the ability of people to effectively manage other chronic
    diseases. More than 57 percent of adults with heart disease and more
    than 52 percent of adults with diabetes also have arthritis. The
    Arthritis Foundation strongly believes that in order to prevent or
    delay arthritis from disabling people and diminishing their quality of
    life that a significant investment in proven prevention and
    intervention strategies is essential.
        The following items summarize the Arthritis Foundation fiscal year
    2012 funding recommendations for health agencies under the
    Subcommittee's jurisdiction.
    Centers for Disease Control and Prevention
        The Arthritis Foundation recommends a level of $7.7 billion for
    CDC's core programs in fiscal year 2012. This amount is representative
    of what CDC needs to fulfill its core public health mission in fiscal
    year 2012; activities and programs that are essential to protect the
    health of the American people. CDC continues to be faced with
    unprecedented challenges and responsibilities, ranging from chronic
    disease prevention, eliminating health disparities, bioterrorism
    preparedness, to combating the obesity epidemic. More than 70 percent
    of CDC's budget actually flows out to States and local health
    organizations and academic institutions, many of which are currently
    struggling to meet growing needs with fewer resources.
        The President's fiscal year 2012 budget request proposed to
    collapse existing programs for the top five leading chronic disease
    causes of death and disability--arthritis, cancer, diabetes, and heart
    disease and stroke--into a single State Block Grant program along with
    State funding for public health activities related to nutrition,
    physical activity, obesity and school health. These Administration
    proposals also rely on funding from the Prevention and Public Health
    Fund to support these activities.
        In light of the fiscal challenges facing the Nation and the need to
    reduce inefficiencies from Federal program overlap and lack of
    coordination, the Arthritis Foundation recognizes that the CDC must
    combat chronic disease through careful coordination and collaboration
    across strategic programs. However, at the same time, agency leadership
    must ensure that the vital public health infrastructure that has been
    developed over the past two decades for combating arthritis should not
    be dismantled.
        The clear need to ensure that the burgeoning number of Americans
    with arthritis are served by effective efforts, lead the Arthritis
    Foundation to conclude that, as proposed, the Administration's
    consolidated chronic disease prevention program is not in the best
    interest of those with arthritis. To sustain and build on the
    achievements and progress made to date in combating arthritis, it is
    critical that arthritis-specific activities are preserved and
    strengthened in any approach to combating chronic disease.
        As the fiscal year 2012 funding process continues, the Arthritis
    Foundation appreciates the opportunity to evaluate any consolidated
    chronic disease program proposal to ensure that the following
    priorities are addressed:
      --Programs should be designed around similar target populations,
            including people with or at risk of arthritis, the Nation's
            most common cause of disability and a major barrier to physical
            activity.
      --Any consolidation must be limited to programs with clear
            programmatic and operational overlap.
      --CDC and states must retain staff expertise in disease areas and the
            infrastructure to support them;
      --Programs must be supported by State-based advisory groups made up
            of stakeholders from the impacted disease areas;
      --A national advisory committee at CDC should be created to foster
            stakeholder involvement from arthritis and other chronic
            disease communities.
        The CDC's arthritis program received $13.1 million in fiscal year
    2011 funding and about half of that amount will be distributed via
    competitive grant to 12 States. Research shows that the pain and
    disability of arthritis can be decreased through early diagnosis and
    appropriate management, including evidence-based self-management
    activities that enable weight control and physical activity. The
    Arthritis Foundation's Self-Help Program, a group education program,
    has been proven to reduce arthritis pain by 20 percent and physician
    visits by 40 percent. These evidence-based interventions are recognized
    by the CDC to reduce the pain of arthritis and importantly reduce
    healthcare expenditures through a reduction in physician visits. For
    arthritis prevention to grow to include another 12-15 States an
    investment of an additional $10 million is required.
    National Institutes of Health/National Institute of Arthritis and
            Musculoskeletal and Skin Diseases
        The Arthritis Foundation supports $35 billion in fiscal year 2012
    for NIH to invest in improving the health and quality of life for all
    Americans. NIH-funded research drives scientific innovation and
    develops new and better diagnostics, improved prevention strategies,
    and more effective treatments. Approximately 83 percent of appropriated
    funds for NIH research are sent to every State in the Nation in the
    form of merit based peer review grants. These investigator initiated
    grants enable the highest quality of research to be conducted at
    research facilities and hospitals all across the Nation employing
    hundreds of thousand of individuals and representing an integral part
    of hundreds of local communities. Congress should recognize the unique
    role NIH plays as the economic engine in the biomedical industry.
        NIH-funded research has led to new treatments, which have greatly
    improved the quality of life for people living with arthritis; however,
    the ultimate goal is to find a cure. The Arthritis Foundation firmly
    believes research holds the key to tomorrow's advances and provides
    hope for a future free from arthritis pain. As one of the largest non-
    profit contributors to arthritis research, the Arthritis Foundation
    fills a vital role in the big picture of arthritis research. Our
    research program complements government and industry-based arthritis
    research by focusing on training new investigators and pursuing
    innovative strategies for preventing, controlling and curing arthritis.
        The mission of the NIH/National Institute of Arthritis and
    Musculoskeletal and Skin Diseases (NIAMS) is to support research into
    the causes, treatment, and prevention of arthritis and musculoskeletal
    and skin diseases and the training of basic and clinical scientists to
    carry out this research. Research opportunities at NIAMS are being
    curtailed due to the stagnating and in some cases declining numbers of
    new grants being awarded. The training of new investigators has
    unnecessarily slowed down and contributed to a crisis in the research
    community where new investigators have begun to leave biomedical
    research careers. The Arthritis Foundation urges Congress to prioritize
    NIAMS funding to address the Nations most chronic, disabling and costly
    diseases.
        Last year, scientists supported by the National Institutes of
    Health developed a technique that lead to the successful re-growth of
    damaged leg joints in animals. The accomplishment shows that it's
    possible to lure the body's own cells to injured regions and generate
    new tissues, such as cartilage and bone. The finding could point the
    way toward joint renewal in humans, which could be a dramatic and less
    costly alternative to the 1 million joint replacement surgeries each
    year.
        Juvenile arthritis afflicts 300,000 children in the United States
    and when left untreated, it can cause permanent damage to joints and
    tissues throughout the body. Juvenile arthritis has serious
    consequences that can limit a young person's ability to grow properly,
    learn, and become a productive citizen in the workforce. With a dire
    critical shortage of pediatric rheumatologists to treat these children,
    it is vital that the NIH and NIAMS continue supporting a national
    network of cooperating clinical centers for the care and study of
    children with arthritis through the Childhood Arthritis and
    Rheumatology Research Alliance (CARRA). This NIH funded project is in
    the beginning stages of collecting data from the largest group of
    children with juvenile rheumatic diseases nationwide. The data will be
    available to pediatric rheumatologists throughout the United States.
    The collection and distribution of such disease data are crucial to the
    understanding of the progression of juvenile arthritis and specific
    outcomes related to treatment. NIH must continue to fund this
    invaluable resource to improve the outcomes and lives of children with
    juvenile arthritis as is currently done for children with cancer. The
    Arthritis Foundation has also invested our research dollars in this
    CARRA initiative.
        Public investment in biomedical research holds the real promise of
    improving the lives of millions of Americans with arthritis. An
    investment in NIH funded research is an investment in our Nation's
    future.
    Health Resources and Services Administration
        The Arthritis Foundation strongly recommends funding a loan
    repayment program for pediatric specialist at the $30 million level
    within HRSA for fiscal year 2012. A pediatric loan repayment program
    was authorized by Congress in 2010 (in the Affordable Care Act) and
    requires funding to commence. HRSA is essential to developing the
    healthcare workforce that is so critical in primary care as well as
    shortages in specialty care, like pediatric rheumatology.
        Juvenile arthritis is the leading cause of acquired disability in
    children and is the sixth most common childhood disease. Sustaining the
    field of pediatric rheumatology is essential to the care of the almost
    300,000 children under the age of 18 living with a form of juvenile
    arthritis. Children who are diagnosed with juvenile arthritis will live
    with this chronic and potentially disabling disease for their entire
    life. Therefore, it is imperative that children are diagnosed quickly
    and start treatment before significant irreversible joint damage is
    done. However, it is a challenge to first find a pediatric
    rheumatologist, as nine States do not have a single one, and then to
    have a timely appointment as many States have only one or two to see
    thousands of patients. Pediatric rheumatology is one of the smallest
    pediatric subspecialties with less than 200 pediatric rheumatologists
    actively practicing in the United States. A report to Congress in 2007
    stated there was a 75 percent shortage of pediatric rheumatologists and
    recommended loan repayment program to help address this critical
    workforce shortage issue. The Affordable Care Act included authorizing
    HRSA $30 million to establish a loan repayment program for pediatric
    specialists including pediatric rheumatologists. The Arthritis
    Foundation strongly recommends the Subcommittee provide an initial
    appropriation to begin this critical program.
    Agency for Healthcare Research and Quality (AHRQ)
        The Arthritis Foundation recommends an overall funding level of
    $405 million for AHRQ in fiscal year 2012. AHRQ funds research and
    programs at local universities, hospitals, and health departments that
    improve healthcare quality, enhance consumer choice, advance patient
    safety, improve efficiency, reduce medical errors, and broaden access
    to essential services. Specifically, the science funded by AHRQ
    provides consumers and their healthcare professionals with valuable
    evidence to make the right healthcare decisions for themselves and
    their families.
        The Arthritis Foundation appreciates the opportunity to submit our
    recommendations for fiscal year 2012 to Congress on behalf of the 50
    million adults and 300,000 children with arthritis and looks forward to
    working with the Subcommittee in the coming months.
                                     ______

                    Prepared Statement of ASME International
        The NIH Task Force (``Task Force'') of the ASME Bioengineering
    Division is pleased to provide comments on the bioengineering-related
    programs contained within the National Institutes of Health (NIH)
    fiscal year 2012 budget request. The Task Force is focused on the
    application of mechanical engineering knowledge, skills, and principles
    for the conception, design, development, analysis and operation of
    biomechanical systems.
    The Importance of Bioengineering
        Bioengineering is an interdisciplinary field that applies physical,
    chemical, and mathematical sciences, and engineering principles to the
    study of biology, medicine, behavior, and health. It advances knowledge
    from the molecular to the organ levels, and develops new and novel
    biologics, materials processes, implants, devices, and informatics
    approaches for the prevention, diagnosis, and treatment of disease, for
    patient rehabilitation, and for improving health. Bioengineers have
    employed mechanical engineering principles in the development of many
    life-saving and life-improving technologies, such as the artificial
    heart, prosthetic joints, diagnostics, and numerous rehabilitation
    technologies.
    Background
        The NIH is the world's largest organization dedicated to improving
    health through medical science. During the last 50 years, NIH has
    played a leading role in the major breakthroughs that have increased
    average life expectancy by 15 to 20 years.
        The NIH is comprised of different Institutes and Centers that
    support a wide spectrum of research activities including basic
    research, disease and treatment-related studies, and epidemiological
    analyses. The mission of individual Institutes and Centers varies from
    either study of a particular organ (e.g. heart, kidney, eye), a given
    disease (e.g. cancer, infectious diseases, mental illness), a stage of
    life (e.g. childhood, old age), or finally it may encompass
    crosscutting needs (e.g., sequencing of the human genome). The National
    Institute of Biomedical Imaging and Bioengineering (NIBIB) focuses on
    the development, application, and acceleration of biomedical
    technologies to improve outcomes for a broad range of healthcare
    challenges.
    Fiscal Year 2012 NIH Budget Request
        The total fiscal year 2012 NIH budget request is $31.98 billion, or
    2.4 percent above the $31.08 billion fiscal year 2010 appropriated
    amount and 4.1 percent above the $30.7 billion provided for fiscal year
    2011. The Task Force recognizes that this proposed increase is
    significant given the Administration's commitment to reducing the
    Federal deficit. However, the Task Force notes that the
    Administration's 2.4 percent increase to the overall NIH budget from
    fiscal year 2010 to fiscal year 2012 is less than the up to 3 percent
    projected increase in medical research costs due to inflation for
    fiscal year 2012 alone--as predicted by the Biomedical Research and
    Development Price Index (BRDPI). This inflationary pressure is
    compounded with the $30.7 billion appropriation for fiscal year 2011, a
    $260 million or 0.8 percent reduction in funding from the previous
    fiscal year, and a BRDPI of 2.9 percent for fiscal year 2011, resulting
    in a significant decrease in funding for the NIH over fiscal year 2010
    to fiscal year 2012.
        NIH is enacting policies to guide investments while limiting the
    impact of these inflationary cost increases, including a 1 percent
    increase in the average cost of competing and non-competing Research
    Project Grants (RPGs); a 1 percent increase in Research Centers and
    Other Research; and a 1 percent increase for Intramural Research and
    Research Management and Support; and constraints on staffing levels.
    However, these policies alone are not sufficient to offset the need for
    additional support for critical areas of health research, especially
    given reduction in funding and high inflation rate for fiscal year
    2011. We therefore fully support the President's proposed fiscal year
    2012 budget level for the NIH given current budget constraints, but
    further recommend out-year budget increases well beyond BRDPI inflation
    rates.
        The Task Force further notes that NIH received $10.4 billion as
    part of the American Recovery and Reinvestment Act (ARRA) of 2009
    (Public Law 111-5), an important influx for several key divisions of
    NIH over the fiscal year 2009 and fiscal year 2010 funding cycles,
    particularly the NIBIB, which received $78 million--less than 1 percent
    of the $10.4 billion ARRA budget assigned to the NIH for the fiscal
    year 2009 and fiscal year 2010 funding cycles. NIBIB has already
    exhausted this budget, leaving no additional ARRA funding to leverage
    through the fiscal year 2011 budget cycle and underscoring the need for
    more robust investment in bioengineering at NIBIB. While this one-time
    influx of funding for health research and infrastructure was justified,
    the Task Force notes that the unstable nature of such funding inhibits
    the potential impact on the economy and should not be viewed as a
    viable substitute for steady and consistent support from Congress for
    these critical national research priorities.
        The Administration estimates 9,158 Research Project Grants (RPG)
    will be supported under the fiscal year 2012 budget for NIH-wide RPGs.
    From fiscal year 2010 to fiscal year 2011, inflationary pressures and
    budget factors combined to result in a decrease of 652 in the number of
    competing RPGs. The Task Force commends the Administration for again
    focusing on funding RPGs in fiscal year 2012, resulting in an increase
    of 424 supported grants over the fiscal year 2011 level of competing
    RPGs. We reiterate again however, that the number of RPGs supported
    from fiscal year 2010 to fiscal year 2012 will still decline by 228
    under this austere fiscal year 2012 budget scenario.
    NIBIB Research Funding
        The Administration's fiscal year 2012 budget request supports $322
    million for the NIBIB, an increase of $5.6 million or 1.8 percent from
    the fiscal year 2010 appropriated amount. The mission of the NIBIB is
    to seek to improve human health by leading the development and
    application of emerging and breakthrough technologies based on a
    merging of the biological, physical, and engineering sciences. As noted
    above, this increase is well under the 3 percent projected increase in
    research costs due to inflation (predicted by the BRDPI index) and, as
    a consequence, actually results in an effective decrease in funding for
    NIBIB compared to fiscal year 2010.
        The budget for NIBIB Research Grants would remain flat at $262.7
    million. Funding for intramural research would increase 7.3 percent to
    $11.8 million from $11 million in fiscal year 2010. NIBIB's Research
    Management and Support request is $17.3 million, a 3 percent increase
    over fiscal year 2010.
        NIBIB funds the Applied Science and Technology (AST) program, which
    supports the development and application of innovative technologies,
    methods, products, and devices for research and clinical application
    that transform the practice of medicine. The fiscal year 2012 request
    for AST is $170.6 million, a $2.2 million increase or 1.3 percent
    increase from fiscal year 2010.
        Additionally, NIBIB funds the Discover Science and Technology (DST)
    program, which is focused on the discovery of innovative biomedical
    engineering and imaging principles for the benefit of public health.
    The fiscal year 2011 request for DST is $95.3 million, a $1.2 million
    or 1.3 percent increase from fiscal year 2010.
        The Technological Competitiveness-Bridging the Sciences program,
    which funds interdisciplinary approaches to research, would receive
    $25.9 million in fiscal year 2012, a $0.9 million increase or 3.6
    percent over the fiscal year 2010 enacted level.
    Task Force Recommendations
        The Task Force is concerned that the United States faces rapidly
    growing challenges from our counterparts in the European Union and Asia
    with regards to bioengineering advancements. While total health-related
    U.S. research and development investments have expanded significantly
    over the last decade, investment in bioengineering at NIBIB have
    remained relatively flat over the last several years. In fact, the
    fiscal year 2012 budget actually represents a small reduction in
    funding when the fiscal year 2003 NIBIB appropriation of $280 million
    is adjusted for inflation--$329 million in 2010 dollars--leaving NIBIB
    with an effective reduction in funding of $7 million since 2003.
        The Task Force wishes to emphasize that, in many instances,
    bioengineering-based solutions to healthcare problems can result in
    improved health outcomes and reductions in healthcare costs. For
    example, coronary stent implantation procedures cost approximately
    $20,000, compared to bypass graft surgery at double the cost. Stenting
    involves materials science (metals and polymers), mechanical design,
    computational mechanical modeling, imaging technologies, etc. that
    bioengineers work to develop. Not only is the procedure less costly,
    but the patient can return to normal function within a few days rather
    than months to recover from bypass surgery, greatly reducing other
    costs to the economy. Therefore, we strongly urge Congress to consider
    increased funding for bioengineering within the NIBIB and across NIH,
    and work to strengthen these investments in the long run to reduce U.S.
    healthcare costs and support continued U.S. leadership in
    bioengineering.
        Even during these challenging fiscal times, the NIBIB must obtain
    sustained funding increases, both to accelerate medical advancements as
    our Nation's population ages, and to mirror the growth taking place in
    the bioengineering field. The Task Force believes that the
    Administration's budget request for fiscal year 2012 is not aligned
    with the long-term challenges posed by this objective; a 1.8 percent
    budget increase will not keep up with current inflationary increases
    for biomedical research, eroding the United States' ability to lay the
    groundwork for the medical advancements of tomorrow.
        While the Task Force supports Federal proposals that seek to double
    Federal research and development in the physical sciences over the next
    decade, we believe that strong Federal support for bioengineering and
    the life sciences is essential to the health and competitiveness of the
    United States. The supplemental funding that NIH received as part of
    ARRA and the budget request by the Administration does not erase the
    past several years of disappointing budgets. Congress and the
    Administration should work to develop a specific plan, beyond President
    Obama's call for ``innovations in healthcare technology'' to focus on
    specific and attainable medical and biomedical research priorities
    which will reduce the costs of healthcare and improve healthcare
    outcomes. Further, Congress and the Administration should include in
    this strategy new mechanisms for partnerships between NSF and the NIH
    to promote bioengineering research and education. The Task Force feels
    these initiatives are necessary to build capacity in the U.S.
    bioengineering workforce and improve the competitiveness of the U.S.
    bioengineering research community.
                                     ______

     Prepared Statement of the Association for Professionals in Infection
        Control and Epidemiology (APIC) and the Society for Healthcare
                         Epidemiology of America (SHEA)
        The Association for Professionals in Infection Control and
    Epidemiology (APIC) and The Society for Healthcare Epidemiology of
    America (SHEA) thank you for this opportunity to submit testimony on
    Federal efforts to eliminate healthcare-associated infections (HAIs).
        APIC's mission is to improve health and patient safety by reducing
    the risk of HAIs and related adverse outcomes. The organization's more
    than 14,000 members, known as infection preventionists, direct
    infection prevention and control programs that save lives and improve
    the bottom line for hospitals and other healthcare facilities
    throughout the United States and around the globe. Our association
    strives to promote a culture within healthcare institutions where all
    members of the healthcare team fully embrace the elimination of HAIs.
    We advance these efforts through education, research, collaboration,
    practice guidance, public policy, and support for credentialing.
        SHEA was founded in 1980 to advance the application of the science
    of healthcare epidemiology. The Society works to achieve the highest
    quality of patient care and healthcare personnel safety in all
    healthcare settings by applying epidemiologic principles and prevention
    strategies to a wide range of quality-of-care issues. SHEA is a growing
    organization, strengthened by its membership in all branches of
    medicine, public health, and healthcare epidemiology. SHEA and its
    members are committed to implementing evidence-based strategies to
    prevent HAIs. SHEA members have scientific expertise in evaluating
    potential strategies for eliminating preventable HAIs.
        APIC and SHEA collaborate with a wide range of infection prevention
    and infectious diseases societies, specialty medical societies in other
    fields, quality improvement organizations, and patient safety
    organizations in order to identify and disseminate evidence-based
    practices. The Centers for Disease Control and Prevention (CDC), its
    Division of Healthcare Quality Promotion (DHQP) and the Federal
    Healthcare Infection Control Practices Advisory Committee (HICPAC), and
    the Council of State and Territorial Epidemiologists (CSTE) have been
    invaluable Federal partners in the development of guidelines for the
    prevention and control of HAIs and in their support of translational
    research designed to bring evidence-based practices to patient care.
    Further, collaboration between experts in the field (epidemiologists
    and infection preventionists), the CDC and the Agency for Healthcare
    Research and Quality (AHRQ) plays a critical role in defining and
    prioritizing the research agenda. In 2008, APIC and SHEA aligned with
    The Joint Commission and the American Hospital Association to produce
    and promote the implementation of evidence-based recommendations in the
    Compendium of Strategies to Prevent Healthcare-Associated Infections in
    Acute Care Hospitals (http://www.shea-online.org/about/compendium.cfm).
    APIC and SHEA also contribute expert scientific advice to quality
    improvement organizations such as the Institute for Healthcare
    Improvement (IHI), the National Quality Forum (NQF), and State-based
    task forces focused on infection prevention and public reporting
    issues.
        HAIs are among the leading causes of preventable death in the
    United States, accounting for an estimated 1.7 million infections and
    99,000 associated deaths in 2002. In addition to the substantial human
    suffering caused by HAIs, these infections contribute $28 billion to
    $33 billion in excess healthcare costs each year.
        The good news is that some of these infections are on the decline.
    In particular, bloodstream infections associated with indwelling
    central venous catheters, or ``central lines,'' are largely preventable
    when healthcare providers use the CDC infection prevention
    recommendations in the context of a performance improvement
    collaborative. Healthcare professionals have reduced these infections
    in hospital intensive care unit (ICU) patients by 58 percent since
    2001, which represents up to 27,000 lives saved. In spite of this
    notable progress, there is a great deal of work to be done to achieve
    the goal of HAI elimination. These additional opportunities to save
    lives and improve patient safety involve settings outside ICUs and
    those patients who need hemodialysis.
        To build and then sustain these winnable battles against HAIs, we
    urge you, in fiscal year 2012, to support the CDC Coalition's request
    for $7.7 billion for the CDC's ``core programs.'' Within that broader
    area, the CDC is currently involved in a number of projects that have
    allowed for significant progress to be made in reducing HAIs. In light
    of this important work, we ask that you provide the CDC with its
    requested amount of $47.4 million for HAI prevention activities.
        Included among these activities is support for State-based programs
    to expand facility enrollment in the CDC's National Healthcare Safety
    Network (NHSN), an important reporting and monitoring tool that enables
    officials to track where HAIs are occurring and identify where
    improvements need to be made. NHSN's data analysis function helps our
    members analyze facility-specific data and compare rates to national
    metrics. Importantly, the patients we serve throughout the United
    States have established expectations that reported reductions in the
    frequency of HAIs are accurate. APIC and SHEA have, through their
    respective networks of members, identified limitations in other
    measures of performance. These studies have consistently identified
    that data from the CDC's NHSN provides a more precise picture of
    performance relative to reduction of HAIs. Many States consider NHSN to
    be the best option for implementing standardized reporting of HAI data.
    The CDC has also been supporting research networks to address important
    scientific gaps in HAI prevention, improvement in HAI tracking and
    monitoring methodologies, as well as responding to requests for
    assistance from health departments and healthcare facilities. It is
    vital to ensure that the NHSN meets these expectations from patients
    and that our successes are real and tangible improvements in the care
    provided.
        In addition, we request that the Subcommittee provide $50 million
    for antimicrobial resistance activities. As the CDC states in its
    request, ``repeated and improper uses of antibiotics are important
    factors in the increase in drug-resistant bacteria, viruses, and
    parasites,'' and ``preventing infections and decreasing inappropriate
    antibiotic use are the best strategies to control resistance.''
    Ensuring the effectiveness of antibiotics well into the future is vital
    for the nation's public health. It is essential, therefore, that the
    CDC maintains the ability to monitor organism resistance in healthcare
    and promote appropriate antibiotic use. This has become even more
    critical due to two recent developments. First, pharmaceutical
    manufacturers have largely abandoned development of newer antibiotics
    because there are several market-based disincentives to investing in
    this research and development. Second, there is an epidemic of
    infections caused by Clostridium difficile, a bacterium that is
    triggered by use of antibiotics. These infections are widespread,
    disproportionately affect older adults, and can be fatal. There are
    several examples in the scientific literature that demonstrate the rate
    of C. difficile infections drops in facilities with active, effective
    antimicrobial stewardship programs.
        We also support the Administration's $5 million request for HAI
    activities. This funding will allow HHS, under the HHS Action Plan to
    Prevent Healthcare-Associated Infections (HAI Action Plan), to
    prioritize recommended clinical practices, strengthen data systems, and
    develop and launch a nationwide HAI prevention campaign. APIC and SHEA
    members have been engaged in this partnership for HAI prevention under
    the leadership of HHS Assistant Secretary for Health, Dr. Howard Koh
    and Deputy Assistant Secretary for Healthcare Quality, Dr. Don Wright.
        We believe the development of the HAI Action Plan and the funding
    to support these activities has been critical to the effort to build
    support for a coordinated Federal plan and message on preventing
    infections. Additionally, we strongly believe that the CDC has the
    necessary expertise to define appropriate metrics through which the HAI
    Action Plan can best measure its efforts.
        APIC and SHEA also request that the Subcommittee approve $10.7
    million for the Centers for Medicare and Medicaid Services (CMS)
    surveys of ambulatory surgical centers (ASCs) as part of the budget
    request addressing direct survey costs. CMS's survey process, jointly
    developed with the CDC in this case, consists of targeting infection
    control deficiencies in ASCs with a frequency of every 4 years. Due to
    the increasing number of surgeries performed in outpatient settings,
    and the need to ensure that basic infection prevention practices are
    followed, APIC believes continuation of this survey tool is essential.
    This support will also protect patients' lives as there have been
    several outbreaks in ASCs involving transmission of bloodborne
    pathogens, such as hepatitis C, due to unsafe practices.
        Also within the direct survey costs portion of CMS's request, the
    agency indicates plans to launch an HAI pilot program as part of the
    HHS HAI strategic plan. This promises to produce a significant amount
    of feedback on HAI prevention as CMS intends to survey critical access
    hospitals and smaller hospitals across 10 to 25 States. This will allow
    officials to gather information from facilities whose practices and
    data have not traditionally been monitored or widely shared.
        APIC and SHEA are pleased with the Administration's continued
    support of biomedical research by providing an increase of almost $32
    billion for the National Institutes of Health (NIH) in fiscal year
    2012, a 2.4 percent increase over fiscal year 2010 levels. The NIH is
    the single largest funding source for infectious diseases research in
    the United States and the life-source for many academic research
    centers. The NIH-funded work conducted at these centers lays the ground
    work for advancements in treatments, cures, and medical technologies.
    It is critical that we maintain this momentum for medical research
    capacity.
        Unfortunately, support for basic, translational, and
    epidemiological HAI research has not been a priority of the NIH.
    Despite the fact that HAIs are among the top ten annual causes of death
    in the United States, scientists studying these infections have
    received relatively less funding than colleagues in many other
    disciplines. In 2008, NIH estimated that it spent more than $2.9
    billion on funding for HIV/AIDS research, approximately $2 billion on
    cardiovascular disease research, and about $664 million on obesity
    research. By comparison, the National Institute of Allergy and
    Infectious Diseases (NIAID) provided $18 million for MRSA research.
    APIC and SHEA believe that as the magnitude of the HAI problem becomes
    an increasing part of our public health dialogue, it is imperative that
    the Congress and funding organizations put significant resources behind
    this momentum.
        The limited availability of Federal funding to study HAIs has the
    effect of steering young investigators interested in pursuing research
    on HAIs toward other, better-funded fields. While industry funding is
    available, the potential conflicts of interest, particularly in the
    area of infection prevention technologies, make this option seriously
    problematic. These challenges are limiting professional interest in the
    field and hampering the clinical research enterprise at a time when it
    should be expanding.
        Our field is faced with the need to bundle, implement and adhere to
    interventions we believe to be successful while simultaneously
    conducting basic, epidemiological, pathogenetic and translational
    studies that are needed to move our discipline to the next level of
    evidence-based patient safety. The current convergence of scientific,
    public and legislative interest in reducing rates of HAIs can provide
    the necessary momentum to address and answer important questions in HAI
    research. APIC and SHEA strongly urge you to enhance NIH funding for
    fiscal year 2012 to ensure adequate support for the research foundation
    that holds the key to addressing the multifaceted challenges presented
    by HAIs.
        Finally, we support the $34 million in the Administration's fiscal
    year 2012 budget that would continue, and allow expansion of, funding
    for AHRQ grants related to HAI prevention in multiple healthcare
    settings, including surgical and dialysis centers. Infections are one
    of the leading causes of hospitalization and death for patients on
    hemodialysis. According to the CDC, approximately 37,000 bloodstream
    infections occurred in hemodialysis outpatients with central lines
    (2008). AHRQ's plans to broaden research support in ambulatory and
    long-term care settings to align with the HHS HAI Action Plan represent
    another positive step in addressing HAIs in a comprehensive fashion.
        We thank you for the opportunity to submit testimony and greatly
    appreciate this Subcommittee's assistance in providing the necessary
    funding for the Federal Government to have a leadership role in the
    effort to eliminate HAIs.
                                     ______

       Prepared Statement of the Association for Research in Vision and
                                 Ophthalmology
    Congressional and Presidential support for biomedical research
        In 2009, Congress spoke volumes in passing S. Res. 209 and H. Res.
    366, which designated the years 2010 to 2020 as The Decade of Vision,
    in which the majority of 78 million Baby Boomers will face the greatest
    risk for aging eye disease. This decade is not the time for a less-
    than-inflationary increase for a community that lost 20.1 percent
    purchasing power over the course of the last 10 years.\1\
    ---------------------------------------------------------------------------
        \1\ Calculations were based solely upon annual biomedical research
    and development price index (BRDPI) and annual appropriated amounts.
    Fiscal year 2011 funding levels and fiscal year 2011 BRDPI were not
    part of the calculation.
    ---------------------------------------------------------------------------
        As President Obama has stated repeatedly, most recently during the
    2011 State of the Union Address, biomedical research reduces healthcare
    costs, increases productivity, and it ensures global competitiveness of
    the United States.
        ARVO has two major requests for Senate:
      --For Senate to budget NIH in fiscal year 2012 at $35 billion.
          This amount: Is a $3 billion increase over the President's
            proposed budget; maintains NIH net funding levels from fiscal
            year 2009 and fiscal year 2010; and ensures that NIH can
            maintain funding for existing grants and award the same number
            of new grants.
      --For Senate to make vision health a priority and fund NEI in fiscal
            year 2012 above the 1.8 percent increase over last year that
            was proposed by the President.
        --We request this even if Congress does not fund NIH at $35
                billion.
        --Why? Investing in research is a short term investment, with a
                2.2-fold economic return from innovation. It has a long
                term pay-off that can reduce healthcare spending on eye
                diseases that are increasing in aging populations and
                growing minority populations that have vision health
                disparities (e.g. glaucoma and diabetic retinopathy). The
                majority of research grant budgets pay for good paying
                positions. Very little of the budget goes towards supplies
                and equipment. It addresses one of American's greatest
                fears: fear of losing eye sight.
    Grant review eliminates budget excess
        ARVO stands behind member John Ash, Ph.D., who stated the following
    during January 2011 ARVO Advocacy Day visits to Capitol Hill: ``We
    understand the need for budget cuts, but we should be cutting budgets
    similar to how U.S. citizens trim their household budgets, not across
    the board, but rather where there is waste and inefficiency. We
    challenge you to find another government agency that uses money more
    efficiently than the National Institutes of Health.''
        The strategic plan for NIH grant programs (for example, the NEI
    strategic plan) represents the collective vision of hundreds of
    scientists throughout the United States. Funding decisions for
    individual grant applications are awarded based on scientific merit and
    past progress. Specifically, experts review grant applications and
    assign scores based on the quality and impact of the proposed research.
    Scientific merit and funding decisions are based on applicant
    competitiveness among peers. An additional level of scrutiny and
    guidance is provided by an NEI program panel of experts, the National
    Advisory Eye Council. Progress on funded projects is monitored annually
    by NIH, and excess budgets are trimmed taking into consideration
    ongoing development of other projects. Thus, the process is highly
    competitive from conception of a project through completion.
    Cost of vision impairment
        Vision disorders are the fourth most prevalent disability in the
    United States and the most frequent cause of disability in children.
    NEI estimates that vision impairment and eye disease cost the United
    States $68 billion annually. However, this number does not factor in
    the impact of indirect healthcare costs, lost productivity, reduced
    independence, diminished quality of life, increased depression, and
    accelerated mortality.
        NEI's fiscal year 2010 baseline funding of $707 million reflects
    just a little more than 1 percent of the annual costs of eye disease.
    The continuum of vision loss presents a major public health problem, as
    well as a significant financial challenge to the public and private
    sectors.
    Prevention saves money long term
        Seventy-seven percent of Americans agree that research is part of
    the solution to rising healthcare costs, and 84 percent understand that
    prevention and wellness reduce healthcare costs (Your Candidates-Your
    Health Poll, August 2010). Less-than-inflationary budget increases
    represent short term cost-cutting that will cost taxpayers more money
    in the long term. Prevention can save Medicare/Medicaid payments for
    vision care in the aging population and in minority populations with
    disproportionate incidence of eye disease (e.g. glaucoma and diabetic
    retinopathy). NEI funding is a vital investment in overall health and
    vision health of our Nation that prevents health expenditures.
    Maintaining vision allows people to remain independent and employed,
    reduces family burdens, and ultimately, improves the safety of
    individuals and the entire community (driving safety being a prime
    example).
    Research is an economic investment
        Merely 2 percent of Americans think research is not important to
    the U.S. economy (National Poll, May 2010). The largest portion of NIH
    grant budgets is for salaries distributed across the country, and many
    of the positions funded are for good paying jobs. The lower paying jobs
    are an investment in training the future biomedical research work
    force. To learn about the economic impact of research by state, visit
    http://www.researchamerica.org/economic_impact.
    Vision research improves eye care
        Below are three of the top vision success stories since 2003, as
    reported by nearly 400 U.S.-based ARVO members, who work at NEI-funded
    institutions. Examples come from responses to an ARVO survey about the
    NEI strategic plan. There were too many vision achievements to list
    them all.
        Drug therapies for macular degeneration (AMD).--Vision researchers
    developed a therapy to treat the most aggressive form of AMD (``wet''
    AMD) that works much better than even hoped for. Not only is vision
    loss stopped, in many cases sight is partially regained. The therapy is
    so successful that it is now being used for other eye complications
    (e.g., eye infections, injuries and diabetes). Furthermore, a National
    Eye Institute-funded clinical trial (Comparison of AMD Treatments
    Trial), comparing safety and effectiveness of two drugs to treat
    advanced AMD, shows that a $50 drug (Avastin) is as effective as a
    $2,000 drug (Lucentis). Since 250,000 patients are treated each year
    for AMD, this will reduce Medicare and other government health
    spending. http://1.usa.gov/jZpZyv
        Gene therapies for eye disease.--Vision researchers developed gene
    therapies for three retinal diseases: Leber congenital amaurosis, color
    blindness and retinitis pigmentosa. They also identified important
    genetic risk factors for age-related eye diseases, including age-
    related macular degeneration and glaucoma. Critically, these
    discoveries are the first ``pay-off'' of any kind from the Human Genome
    Project for patients and taxpayers.
        Cellular and molecular therapies.--Using regenerative medical
    approaches, vision researchers made important progress in repairing
    damaged eye tissues (e.g., cornea and retina). By repairing damaged
    tissues vision function is rescued.
    Continued vision research needs
        ARVO members expressed continued need for research support for the
    following areas (and many additional areas not covered here).
      --Aging eye disease.--Accelerate our efforts in basic and
            translational research to discover the causes of and new
            treatments for macular degeneration, diabetic retinopathy and
            other vision-robbing diseases whose risks of occurrence and
            severity increase with age.
      --Children's vision.--Find noninvasive ways to detect vision problems
            in children early enough to start treatment before vision is
            lost or their education is affected.
      --Brain and eye injury.--Develop ways to rapidly seal wounds and
            trauma encountered by civilians and the military, so ocular and
            brain function can be maintained.
      --Eye pain.--Understand the basis of eye pain and develop therapies
            to treat it.
      --Eye infections.--Identify better ways to identify and treat drug-
            resistant eye-infections with antibiotics and anti-viral
            medications. Certain infections can destroy eye tissues in just
            24 hours.
      --Invest in shared therapeutic targets.--Identify common, shared
            causes for common eye diseases and common systemic diseases.
            Establish meaningful collaborations between researchers, so
            shared therapeutic strategies may be developed that can treat
            multiple diseases.
      --Identify at-risk groups and raise awareness.--Support development
            of educational tools to raise awareness and treatment
            compliance in people in age groups or ethnic groups, who are
            more susceptible to certain eye diseases.
          Understand environmental factors that make it more likely to
            develop eye disease and educate people on how to prevent eye
            disease.
      --Eye surgery.--Identify circumstances when the risk of performing
            eye surgery is greater than the benefit. Develop ways to treat
            sight problems without surgery, including facilitating natural
            wound healing.
    Resources
        Facts about State vision health: http://apps.nccd.cdc.gov/DDT_VHI/
    VHIHome.aspx.
        Fact sheet about vision and blindness: http://
    www.researchamerica.org/uploads/factsheet16vision.pdf.
        The Silver Book: Vision Loss. http://www.eyeresearch.org/pdf/
    VisionLossSilverbook.pdf.
    About ARVO
        ARVO is the world's largest international association of vision
    scientists (scientists who study diseases and disorders of the eye).
    About 80 percent of members from the United States (>7,000 total) are
    supported by NIH grant funding. Vision science is a multi-disciplinary
    field, but the National Eye Institute is the only freestanding NIH
    institute with a mission statement that specifically addresses vision
    research. ARVO supports increased fiscal year 2011 and fiscal year 2012
    NIH funding.
        ARVO is also a member of the National Alliance for Eye and Vision
    Research, and supports their testimony. www.eyeresearch.org
                                     ______

      Prepared Statement of the Association of American Cancer Institutes
        The Association of American Cancer Institutes (AACI), representing
    94 of the Nation's premier academic and free-standing cancer centers,
    appreciates the opportunity to submit this statement for consideration
    by the United States Senate Subcommittee on Labor, Health and Human
    Services, Education and Related Agencies, Committee on Appropriations.
        AACI thanks the administration, Congress and the Subcommittee for
    their long-standing commitment to ensuring quality care for cancer
    patients, as well as for providing researchers with the tools that they
    need to develop better cancer treatments and, ultimately, to cure this
    disease.
        President Obama's fiscal year 2012 budget calls for $31.829 billion
    for NIH. This is an increase of $1.045 billion (3.4 percent) over the
    fiscal year 2010 comparable level of $30.784 billion. The President's
    proposed budget for the National Cancer Institute would be increased by
    $95 million, to $5.2 billion.
        Sustaining progress against cancer requires a Federal commitment to
    funding research through the NIH and NCI at a level that at least keeps
    pace with medical inflation. With that in mind, AACI is joining with
    its colleagues in the biomedical research community in supporting the
    proposed increases for NIH and NCI and in calling on Congress to
    further strengthen the impact of the President's request by increasing
    funding to $35 billion for NIH and to $5.9 billion for NCI. The
    requested increases account for lost funding due to discontinuation of
    the American Recovery and Reinvestment Act of 2009, and the ongoing
    shortfall in NIH and NCI funding in relation to annual changes in the
    Biomedical Research and Development Price Index (BRDPI), which
    indicates how much the NIH budget must change to maintain purchasing
    power.
        Taking a closer look at the President's proposed fiscal year 2012
    budget, as with so many complicated and vitally important matters, the
    devil is in the details. While the President's budget includes a
    proposed increase of $95.31 million over fiscal year 2010 for NCI, the
    line item funding for Cooperative Clinical Research remains the same as
    fiscal year 2010--$254.487 million. Other NCI line items show funding
    decreases, including Comprehensive/Specialized Cancer Centers ($46.001
    million decrease) and Research and Development Contracts ($39.409
    million decrease).
        AACI and its members are acutely aware of the difficult fiscal
    environment that the country is facing. The vast majority of our cancer
    centers exist within universities that are undergoing drastic budget
    reductions and as a consequence, directors at our member cancer centers
    are already facing extreme budgetary challenges. Furthermore, many of
    our senior and most promising young investigators are now without NCI
    funding and are requiring significant bridge funding from private
    sources. In recent years, however, it has become more challenging to
    raise philanthropic and other external funds. As a result, we continue
    to be highly dependent on Federal cancer center grants.
        Recent developments at one member center, the Nevada Cancer
    Institute (NVCI), illustrate that need. Serving 15,000 patients since
    it opened in 2005, NVCI has recently lain off half of its 300
    employees. In a local news report, NVCI officials cited a number of
    reasons for the layoffs, including a miserable economy that has hurt
    fundraising, a worsening reimbursement environment that provides less
    money from government and private insurance entities for services
    rendered, and fewer Federal grant dollars in the recession. (``Debt
    puts Nevada Cancer Institute on heels'', Las Vegas Review-Journal,
    April 8, 2011.)
        Cancer centers are already challenged to provide the infrastructure
    necessary to support funded researchers, and cuts in Federal grants
    will limit our ability to provide well functioning shared resources to
    investigators who depend on them to complete their research. For most
    matrix cancer centers, the majority of NCI grant funds are used to
    sustain the shared resources so essential to basic, translational,
    clinical and population cancer research, or to provide matching dollars
    which allow departments to recruit new cancer researchers to a
    university and support them until they receive their first grants.
        As highlighted by NCI Director Harold Varmus in a January ``town
    hall'' meeting with NCI staff, independent investigator research is a
    particularly valuable resource, particularly in the area of genomics
    and molecular epidemiology. Such research is highly dependent on state-
    of-the-art shared resources like tissue processing and banking, DNA
    sequencing, microRNA platforms, proteomics, biostatistics and
    biomedical informatics. This infrastructure is expensive, and it is not
    clear where cancer centers would turn for alternative funding if NCI
    grant contributions to these efforts were reduced.
        An investigator and medicinal chemist at a large AACI member center
    spent 7 years developing two new targeted drugs that are now in
    clinical trial testing. One agent shows promise in cancers of the
    blood; the other against breast, colon, lung and prostate tumors.
    Research on these agents required advanced technologies provided by the
    center's shared resources, including analytical cell-sorting,
    microarray assays, and toxicopathological evaluations of mouse models,
    which are an essential part of drug discovery. If budget cuts had
    forced the closure of one or more of these shared resources, these new
    targeted therapies might never have made it to the patients who are now
    benefiting from them. The researcher has 8 to 10 more compounds in the
    pipeline, the fate of which hinges largely on the 2012 budget.
    Unfortunately, hundreds of other promising cancer researchers across
    the U.S. share this troubling uncertainty.
    Cancer Research: Benefiting Americans' Health and Economic Well-being
        Cancer's financial and personal impact on America is substantial
    and growing--one in two men and one in three women will face cancer in
    their lifetimes, and cancer cost our Nation more than $228 billion in
    2008 (Centers for Disease Control and Preventions, Addressing The
    Cancer Burden: At A Glance 2010).
        The U.S. Centers for Disease Control & Prevention's latest report
    on cancer survivorship, ``Cancer Survivors-United States, 2007'', shows
    that the number of cancer survivors in the United States increased from
    3 million in 1971 to 9.8 million in 2001 and 11.7 million in 2007--an
    increase from 1.5 percent to 4 percent of the U.S. population. Cancer
    survivors largely consist of people who are 65 years of age or older
    and women. More than a million people were alive in 2007 after being
    diagnosed with cancer 25 years or more earlier. Of the 11.7 million
    people living with cancer in 2007, 7 million were 65 years of age or
    older, 6.3 million were women, and 4.7 million were diagnosed 10 years
    earlier or more
        Investing in cancer research is a prudent step--both for the health
    of our Nation and for its economic well-being. Cancer research,
    conducted in academic laboratories across the country, saves money by
    reducing healthcare costs associated with the disease, enhances the
    United States' global competitiveness, and has a positive economic
    impact on localities that house a major research center.
        In May 2011, AACI engaged Tripp Umbach, a research firm
    specializing in economic impact studies, to conduct an analysis of
    potential effects on statewide and national economic activity and
    employment resulting from NCI funding cuts to AACI cancer centers. Two
    reduced funding levels were considered: (1) a ``conservative'' 0.8
    percent reduction, as implemented in the 2011 continuing resolution for
    the Federal budget, passed by Congress in March, and, (2) an
    ``aggressive'' 5.3 percent cut, reflecting an overall fiscal year 2012
    budget reduction proposed by some members of Congress. This reduction
    would rollback NCI funding to 2008 levels. The impact of the 0.8
    percent cut is already being felt: NCI announced on May 5 that it would
    need to cut funding for the NCI cancer centers program by 5 percent.
        The report estimates that the total economic decline resulting from
    a 0.8 percent cut in NCI funding would result in a loss of at least
    $84.5 million to the U.S. economy, with a 5.3 percent funding drop
    causing a $564.7 million economic loss nationwide. The economic impact
    is even greater when overall NIH funding is considered. A 0.8 percent
    reduction in NIH funding would mean a $530.8 million loss to the U.S.
    economy, with a 5.3 percent reduction leading to a $3.5 billion loss.
        Employment declines from the 0.8 percent NCI funding reduction
    would total at least 629 jobs while 4,200 jobs would be lost with a 5.3
    percent funding cut. Applying the same calculations to total NIH
    appropriations would eliminate nearly 4,000 jobs based on the
    conservative reduction, increasing to 26,300 jobs lost with a 5.3
    percent cut. It is important to note that research and health sciences
    jobs are generally high-paying and the loss of even a handful of such
    jobs can have a measurable effect on local economic activity.
        While the economic aspects of cancer research are important, what
    cannot be overstated is the impact cancer research has had on
    individuals' lives--lives that have been lengthened and even saved by
    virtue of discoveries made in cancer research laboratories at cancer
    centers across the United States.
        Biomedical research has provided Americans with better cancer
    treatments, as well as enhanced cancer screening and prevention
    efforts. Some of the most exciting breakthroughs in current cancer
    research are those in the field of personalized medicine. In
    personalized medicine for cancer, not only is the disease itself
    considered when determining treatments, but so is the individual's
    unique genetic code. This combination allows physicians to better
    identify those at risk for cancer, detect the disease, and treat the
    cancer in a targeted fashion that minimizes side effects and refines
    treatment in a way to provide the maximum benefit to the patient.
        In the laboratory setting, multi-disciplinary teams of scientists
    are working together to understand the significance of the human genome
    in cancer. For instance, the Cancer Genetic Markers of Susceptibility
    initiative is comparing the DNA of men and women with breast or
    prostate cancer with that of men and women without the diseases to
    better understand the diseases. The Cancer Genome Atlas is in
    development as a comprehensive catalog of genetic changes that occur in
    cancer.
        Illustrating the successes realized by cancer research, NCI's most
    recent Annual Report to the Nation on the Status of Cancer reported
    that rates of death in the United States from all cancers for men and
    women continued to decline between 2003 and 2007, the most recent
    reporting period available. The report also finds that the overall rate
    of new cancer diagnoses for men and women combined decreased an average
    of slightly less than 1 percent per year for the same period.
        Despite those improvements, ``cancer disparities'' abound, with
    different groups of cancer sufferers and cancer types showing little
    improvement or higher rates of incidence. For example, childhood cancer
    incidence rates (rates of new diagnoses) continued to increase while
    death rates in this age group decreased. Childhood cancer is classified
    as cancers occurring in those 19 years of age or younger. And there are
    several other forms of cancer (e.g. pancreatic, lung) and patient
    populations (racial and ethnic minorities, the poor, those with
    psychosocial issues) with high rates of cancer mortality and morbidity.
    Furthermore, with the increased incidence and survival comes higher
    morbidity because two-thirds of this surviving patient population
    experience late effects that are classified as serious to life-
    threatening.
    The Nation's Cancer Centers
        The nexus of cancer research in the United States is the Nation's
    network of cancer centers represented by AACI. These cancer centers
    conduct the highest-quality cancer research anywhere in the world and
    provide exceptional patient care. The Nation's research institutions,
    which house AACI's member cancer centers, receive an estimated $3.71
    billion from the National Cancer Institute (NCI) to conduct cancer
    research in fiscal year 2010; more than two-thirds of NCI's total
    budget (U.S. Department of Health and Human Services, National
    Institutes of Health, National Cancer Institute 2010 Fact Book). In
    fact, approximately 84 percent of NCI's budget supports research at
    nearly 650 universities, hospitals, cancer centers, and other
    institutions in all 50 States. Because these centers are networked
    nationally, opportunities for collaborations are many--assuring wise
    and non-duplicative investment of scarce Federal dollars.
        In addition to conducting basic, clinical, and population research,
    the cancer centers are largely responsible for training the cancer
    workforce that will practice in the United States in the years to come.
    Much of this training depends on Federal dollars, via training grants
    and other funding from NCI. Sustained Federal support will
    significantly enhance the centers' ability to continue to train the
    next generation of cancer specialists--both researchers and providers
    of cancer care.
        By providing access to a wide array of expertise and programs
    specializing in prevention, diagnosis, and treatment of cancer, cancer
    centers play an important role in reducing the burden of cancer in
    their communities. The majority of the clinical trials of new
    interventions for cancer are carried out at the nation's network of
    cancer centers.
    Conclusion
        These are exciting times in science and, particularly, in cancer
    research. The AACI cancer center network is unrivaled in its pursuit of
    excellence, and places the highest priority on affording all Americans
    access to superior cancer care, including novel treatments and clinical
    trials. It is through the power of collaborative innovation that we
    will accelerate progress toward a future without cancer, and research
    funding through the NIH and NCI is essential to achieving our goals.
                                     ______

       Prepared Statement of the Association of American Medical Colleges
        The Association of American Medical Colleges (AAMC) is a not-for-
    profit association representing all 134 accredited U.S. and 17
    accredited Canadian medical schools; nearly 400 major teaching
    hospitals and health systems; and nearly 90 academic and scientific
    societies. Through these institutions and organizations, the AAMC
    represents 128,000 faculty members, 75,000 medical students, and
    110,000 resident physicians. The association appreciates the
    opportunity to address four programs that play critical roles in
    assisting medical schools and teaching hospitals to fulfill their
    missions of education, research, and patient care: the National
    Institutes of Health (NIH); the Agency for Healthcare Research and
    Quality (AHRQ); health professions education funding through the Health
    Resources and Services Administration (HRSA)'s Bureau of Health
    Professions; and the National Health Service Corps. The AAMC
    appreciates the Subcommittee's longstanding, bipartisan efforts to
    strengthen these programs.
        National Institutes of Health.--The NIH is one of the Nation's
    greatest achievements. The Federal Government's unwavering support for
    medical research through the NIH has created a scientific enterprise
    that is the envy of the world and has contributed greatly to improving
    the health and well-being of all Americans--indeed of all humankind.
        The AAMC is grateful to the Subcommittee for its efforts to
    prioritize NIH funding in fiscal year 2011 and supports the budget
    request of $31.748 billion for NIH in fiscal year 2012. More than 83
    percent of NIH research funding is awarded to more than 3,000 research
    institutions in every State; at least half of this funding supports
    life-saving research at America's medical schools and teaching
    hospitals. This successful partnership not only lays the foundation for
    improved health and quality of life, but also strengthens the Nation's
    long-term economy.
        The foundation of scientific knowledge built through NIH-funded
    research drives medical innovation that improves health and quality of
    life through new and better diagnostics, improved prevention
    strategies, and more effective treatments. NIH research has contributed
    to dramatically increased and improved life expectancy over the past
    century. A baby born today can look forward to an average life span of
    nearly 78 years--almost three decades longer than a baby born in 1900,
    and life expectancy continues to increase. People are staying active
    longer, too: the proportion of older people with chronic disabilities
    dropped by nearly a third between 1982 and 2005. Thanks to insights
    from NIH-funded studies, the death rate for coronary heart disease is
    more than 60 percent lower--and the death rate for stroke, 70 percent
    lower--than in the World War II era.
        For example, a new ability to comprehend the genetic mechanisms
    responsible for disease is already providing insights into diagnostics
    and identifying a new array of drug targets. We are entering an era of
    personalized medicine, where prevention, diagnosis, and treatment of
    disease can be individualized, instead of using the standardized
    approach that all too often wastes healthcare resources and potentially
    subjects patients to unnecessary and ineffective medical treatments and
    diagnostic procedures.
        Peer-reviewed, investigator-initiated basic research is the heart
    of NIH research. These inquiries into the fundamental cellular,
    molecular, and genetic events of life are essential if we are to make
    real progress toward understanding and conquering disease. Additional
    funding is needed to sustain and enhance basic research activities,
    including increasing support for current researchers and promoting
    opportunities for new investigators and in those areas of biomedical
    science that historically have been underfunded.
        The application of the results of basic research to the detection,
    diagnosis, treatment, and prevention of disease is the ultimate goal of
    medical research. Clinical research not only is the pathway for
    applying basic research findings, but it often provides important
    insights and leads to further basic research opportunities. The AAMC
    supports additional funding for the continued expansion of clinical
    research and clinical research training opportunities, including
    rigorous, targeted post-doctoral training; developmental support for
    new and junior investigators; and career support for established
    clinical investigators, especially to enable them to mentor new
    investigators.
        Anecdotal evidence suggests that changes in healthcare delivery
    systems and other financial factors pose a serious threat to the
    research infrastructure of America's medical schools and teaching
    hospitals, particularly for clinical research. The AAMC supports
    efforts to enhance the research infrastructure, including resources for
    clinical and translational research; instrumentation and emerging
    technologies; and animal and other research models.
        Among the areas NIH has identified as ripe for investment and
    integral to the health of the American people is enhancing the evidence
    base for healthcare decisions. NIH's long-standing investment in
    Comparative Effectiveness Research (CER) has informed the clinical
    guidelines that assist physicians and their patients in making better
    decisions about the most effective care. Knowledge from NIH-supported
    CER has changed the way diabetes, atrial fibrillation, hypertension,
    HIV/AIDS, schizophrenia, and many other conditions are treated. In
    addition to diagnostic and treatment trials, knowing more about the
    performance of disease prevention initiatives and medical care delivery
    will improve health.
        The AAMC supports efforts to reinvigorate research training,
    including developing expanded medical research opportunities for
    minority and disadvantaged students. For example, the volume of data
    being generated by genomics research, as well as the increasing power
    and sophistication of computing assets on the researcher's lab bench,
    have created an urgent need, both in academic and industrial settings,
    for talented individuals well-trained in biology, computational
    technologies, bioinformatics, and mathematics to realize the promise
    offered by modern interdisciplinary research.
        The AAMC is heartened by the Administration's proposals to provide
    a four percent stipend increase for predoctoral and postdoctoral
    research trainees supported by NIH's Ruth L. Kirschstein National
    Research Service Awards program. These stipend increases are necessary
    if medical research is to remain an attractive career option for the
    brightest U.S. students. Attracting the most talented students and
    postdoctoral fellows is essential if the United States is to retain its
    position of world leadership in biomedical and behavioral research.
        As Raymond Orbach, former Under Secretary for Science at the
    Department of Energy for President George W. Bush, noted in a recent
    editorial in Science, ``Other countries, such as China and India, are
    increasing their funding of scientific research because they understand
    its critical role in spurring technological advances and other
    innovations. If the United States is to compete in the global economy,
    it too must continue to invest in research programs.''
        Agency for Healthcare Research and Quality.--Complementing the
    medical research supported by NIH, AHRQ sponsors health services
    research designed to improve the quality of healthcare, decrease
    healthcare costs, and provide access to essential healthcare services
    by translating research into measurable improvements in the healthcare
    system. The AAMC firmly believes in the value of health services
    research as the Nation continues to strive to provide high-quality,
    efficient, and cost-effective healthcare to all of its citizens. The
    AAMC joins the Friends of AHRQ in recommending $405 million for the
    agency in fiscal year 2012.
        As the lead Federal agency to improve healthcare quality, AHRQ's
    overall mission is to support research and disseminate information that
    improves the delivery of healthcare by identifying evidence-based
    medical practices and procedures. The Friends of AHRQ funding
    recommendation will allow AHRQ to continue to support patient-centered
    health research and other valuable research initiatives including
    strategies for translating the knowledge gained from patient-centered
    research into clinical practice, healthcare delivery, and provider and
    patient behaviors. These research findings will better guide and
    enhance consumer and clinical decisionmaking, provide improved
    healthcare services, and promote efficiency in the organization of
    public and private systems of healthcare delivery.
        Health Professions Funding.--The Title VII and VIII health
    professions and nursing education programs are the only Federal
    programs designed to improve the supply, distribution, and diversity of
    the Nation's healthcare workforce. For almost 50 years, Title VII and
    Title VIII have provided education and training opportunities to a wide
    variety of aspiring healthcare professionals, both preparing them for
    careers in the health professions and helping bring healthcare services
    to our rural and underserved communities. Through loans, loan
    guarantees, and scholarships to students, and grants and contracts to
    academic institutions and non-profit organizations, the Title VII and
    Title VIII programs fill the gaps in the supply of health professionals
    not met by traditional market forces. The AAMC supports the fiscal year
    2012 request of $762.5 million for these important workforce programs
    in the upcoming fiscal year.
        Since 1963, the Title VII and Title VIII education and training
    programs have helped the workforce adapt to the evolving healthcare
    needs of the ever-changing American population. In an effort to renew
    and update Titles VII and VIII to meet current workforce challenges,
    the programs were reauthorized in 2010--the first reauthorization in
    the past decade. Reauthorization not only improved the efficiency of
    the Title VII and Title VIII programs, but also laid the groundwork for
    innovative programs with an increased focus on recruiting and retaining
    professionals in underserved communities.
        The AAMC appreciates the Subcommittee's longstanding support of the
    Title VII and Title VIII programs, as well as bipartisan recognition
    that a strong healthcare workforce is essential to the continued health
    and prosperity of the American people, particularly in the face of
    unprecedented existing and looming provider shortages. However,
    recognition alone will not solve the significant disparities between
    the needs of the American people and the number of providers willing
    and able to care for them. To ensure that the Nation's already fragile
    healthcare system is able to care for the expanding elderly population;
    meet the unique needs of the country's sick and ailing children and
    minority populations; and provide essential primary care services to
    the neediest amongst us, it is essential that Congress prioritize the
    healthcare workforce with a strong commitment to the Title VII and
    Title VIII health professions programs in fiscal year 2012.
        In addition to funding for Title VII and Title VIII, HRSA's Bureau
    of Health Professions also supports the Children's Hospitals Graduate
    Medical Education program. This program provides critical Federal
    graduate medical education support for children's hospitals to prepare
    the future primary care workforce for our Nation's children and for
    pediatric specialty care--the greatest workforce shortage in children's
    healthcare. The AAMC has serious concerns about the President's plan to
    eliminate support for this essential program in fiscal year 2012, as
    well as the $48.5 million (15 percent) cut imposed on the program in
    fiscal year 2011. At a time when the Nation faces a critical doctor
    shortage and more Americans are about to enter the health insurance
    system, any cuts to funding that supports physician training will have
    serious repercussions for Americans' health. We strongly urge
    restoration to $317.5 million in fiscal year 2012.
        National Health Service Corps.--The AAMC lauds the commitment of
    the Affordable Care Act to address health professional workforce
    shortages by authorizing up to $535.1 million for the NHSC in fiscal
    year 2012. The NHSC is widely recognized--both in Washington and in the
    underserved areas it helps--as a success on many fronts. It improves
    access to healthcare for the growing numbers of underserved Americans,
    provides incentives for practitioners to enter primary care, reduces
    the financial burden that the cost of health professions education
    places on new practitioners, and helps ensure access to health
    professions education for students from all backgrounds. Over its 39-
    year history, the NHSC has offered recruitment incentives, in the form
    of scholarship and loan repayment support, to more than 37,000 health
    professionals committed to serving the underserved.
        In spite of the NHSC's success, demand for health professionals
    across the country remains high. At a field strength of 7,530 in fiscal
    year 2010, the NHSC fell over 24,000 practitioners short of fulfilling
    the need for primary care, dental, and mental health practitioners in
    Health Professions Shortage Areas (HPSAs), as estimate by HRSA. While
    the ``American Recovery and Reinvestment Act of 2009'' (Public Law 111-
    5) provided a temporary boost in annual awards, this increase must be
    sustained to help address the health professionals workforce shortage
    and growing maldistribution.
        The AAMC supports the president's fiscal year 2012 budget request
    of $124 million, which returns the NHSC to fiscal year 2008
    discretionary levels. The president's budget also assumes that the NHSC
    has access to $295 million in additional dedicated funding through the
    HHS Secretary's CHC Fund. This additional funding is necessary to
    sustain the increased NHSC field strength and help address current
    health professional workforce shortages. The AAMC further recommends
    that the Subcommittee include report language directing the Secretary
    to provide this enhanced funding for the NHSC over the fiscal year 2008
    level, as directed under healthcare reform.
                                     ______

     Prepared Statement of the Association of American Veterinary Medical
                                    Colleges
        The Association of American Veterinary Medical Colleges (AAVMC) is
    pleased to submit this statement for the record in support of the
    fiscal year 2012 budget request of $449.5 million for the health
    professions education programs authorized under Title VII of the Public
    Health Service Act and administered through the Health Resources and
    Services Administration (HRSA). AAVMC is also pleased to provide
    comments on the pending transfer of authorities of the National Center
    for Research Resources (NCRR) within the National Institutes of Health
    (NIH).
        AAVMC provides leadership for and promotes excellence in academic
    veterinary medicine to prepare the veterinary workforce with the
    scientific knowledge and skills required to meet societal needs through
    the protection of animal health, the relief of animal suffering, the
    conservation of animal resources, the promotion of public health, and
    the advancement of medical knowledge. AAVMC provides leadership for the
    academic veterinary medical community, including in the United States
    all 28 colleges of veterinary medicine, nine departments of veterinary
    science, eight departments of comparative medicine, two other
    veterinary medical educational institutions; and internationally, all
    five veterinary medical colleges in Canada, eleven international
    colleges of veterinary medicine, and three international affiliate
    colleges of veterinary medicine.
        The Title VII and VIII health professions and nursing programs
    provide education and training opportunities to a wide variety of
    aspiring healthcare professionals, including veterinarians. An
    essential component of the healthcare safety net, the Title VII and
    Title VIII programs are the only Federal programs designed to train
    healthcare providers in interdisciplinary settings to meet the needs of
    the country's special and underserved populations, as well as to
    increase minority representation in the healthcare workforce.
        While we are keenly aware that the Subcommittee continues to face
    difficult decisions as it seeks to improve the Nation's fiscal health,
    a continued Congressional commitment to programs supporting healthcare
    workforce development is essential to the physical health and
    prosperity of the American people.
        The two areas within HRSA of greatest importance to AAVMC members
    are the Public Health Workforce Development programs and Student
    Financial Assistance.
        The Public Health Workforce Development programs are designed to
    increase the number of individuals trained in public health, to
    identify the causes of health problems, and to respond to such issues
    as managed care, new disease strains, food supply, and bioterrorism.
    The Public Health Traineeships and Public Health Training Centers seek
    to alleviate the critical shortage of public health professionals by
    providing up-to-date training for current and future public health
    workers, particularly in underserved areas. The Title VII
    reauthorization reorganized this cluster to include a focus on loan
    repayment as an incentive for public health professionals to practice
    in disciplines and settings experiencing shortages. The Public Health
    Workforce Loan Repayment Program provides loan repayment for public
    health professionals accepting employment with Federal, State, local,
    and tribal public health agencies.
        AAVMC is also working to amend these authorizations so that
    veterinarians engaged in public health are explicitly included and
    prioritized for funding as their counterparts in human medicine and
    dentistry are. On March 8, 2011 the United States House of
    Representatives passed H.R. 525, the Veterinary Public Health
    Amendments Act. AAVMC is eager to see this legislation pass the Senate
    and become law so that the urgent workforce needs of veterinarians
    engaged in public health are fully recognized and supported, as the
    needs of their counterparts in human medicine are.
        The loan programs under Student Financial Assistance support
    financially needy and disadvantaged medical and nursing school students
    in covering the costs of their education The Health Professional
    Student Loan (HPSL) program provides loans covering the cost of
    attendance for financially needy health professions students based on
    institutional determination. The HPSL program is funded out of each
    institution's revolving fund and does not receive Federal
    appropriations. The Loans for Disadvantaged Students program provides
    grants to health professions institutions to make loans to health
    professions students from disadvantaged backgrounds.
        AAVMC would also like to express concern over the pending
    reorganization and possible elimination of NCRR programs over the
    coming fiscal year. We recognize the importance of the NIH's initiative
    to create the National Center for Advancing Translational Sciences
    (NCATS) and welcome the potential benefits to our Nation's health of an
    invigorated focus on translational medicine and therapeutics. AAVMC's
    faculty members are proud of their significant contributions toward
    improving human health through transdisciplinary involvement and
    collaboration in translational research and comparative medicine. The
    support offered by NCRR programs and resources to our institutions and
    faculty have made possible their important contributions to our
    Nation's health.
        To successfully fulfill its mission of accelerating the development
    and delivery of new, more effective therapeutics, NCATS will rely on a
    diverse team of appropriately trained laboratory scientists and
    clinical researchers capitalizing on the development of tools and
    technologies and making discoveries at molecular and cellular levels
    that can be tested and proven in animal-based studies. Although a
    logical and rational argument can be made for including NCRR's Clinical
    and Translational Science Award (CTSA) program, which is designed to
    develop teams of investigators from various fields of research who can
    transform scientific discoveries made in the laboratory into treatments
    and strategies for patients in the clinic, into the new NCATS, the same
    cannot be said for excluding and dismembering other components of NCRR,
    such as animal resources, training programs, and high-end
    instrumentation and technologies which are so critical to NCATS
    mission.
        Further, as indicated in the NCRR Task Force Straw Model, proposing
    to subdivide these other NCRR components disrupts the extant scientific
    synergies that have been demonstrated meritorious to date, and forfeits
    the strategic relationships that have been built between programs over
    the last 20 years. For example, splitting the animal resources into
    different administrative structures erects a bureaucratic obstacle that
    needlessly hinders the flow of basic scientific discoveries made in
    induced genetic mutations in mice to clinically applicable mechanisms-
    of-action studied and tested in non-human primates.
        Although it is expected that following this restructuring NCRR will
    no longer exist as a center, a rational consideration would be to
    maintain a large component of NCRR programs together after reassignment
    of the CTSA program within the new NCATS. Those charged with making
    these decisions should be mindful that NCRR's unique, cross-cutting
    programs are and have been successful through careful planning,
    thoughtful leadership, and effective management by its administrative
    and scientific staff, program officers, and officials who understand
    these programs and are most qualified to ensure continued success of
    their respective programs and initiatives.
        We urge members of this committee to examine the issues raised
    above and seek answers from the Administration as you conduct the
    constitutionally mandated responsibility of overseeing Federal agencies
    and their actions, such as the proposed reorganization within NIH.
        Thank you for the opportunity to provide comments on the fiscal
    year 2012 budget for the Department of Health and Human Services. AAVMC
    is please to serve as a resource to Congress as you debate these
    important issues. Please feel free to contact me directly at 202-371-
    9195 x. 117 or by writing to bsmith@aavmc.org.
                                     ______

         Prepared Statement of the Association of Independent Research
                                   Institutes
        The Association of Independent Research Institutes (AIRI)
    respectfully submits this written testimony for the record to the
    Senate Appropriations Subcommittee on Labor, Health and Human Services,
    Education and Related Agencies. AIRI appreciates the commitment that
    the members of this Subcommittee have made to biomedical research
    through your strong support for the National Institutes of Health
    (NIH), and recommends that you maintain this support for NIH in fiscal
    year 2012 by providing $31.987 billion for NIH in fiscal year 2012,
    which represents a 3.4 percent increase above the fiscal year 2011
    level.
        AIRI is a national organization of more than 80 independent, non-
    profit research institutes that perform basic and clinical research in
    the biological and behavioral sciences. AIRI institutes vary in size,
    with budgets ranging from a few million to hundreds of millions of
    dollars. In addition, each AIRI member institution is governed by its
    own independent board of directors, which allows our members to focus
    on discovery-based research while remaining structurally nimble and
    capable of adjusting their research programs to emerging areas of
    inquiry. Researchers at independent research institutes consistently
    exceed the success rates of the overall NIH grantee pool, and receive
    about 10 percent of NIH's peer-reviewed, competitively awarded
    extramural grants.
        In recent years, Congress has taken important steps to jump start
    the Nation's economy through investments in science. Simultaneously,
    the NIH community is advancing and accelerating the biomedical research
    agenda in this country by focusing on scientific opportunities to
    address public health challenges. However, flat NIH budgets since 2003
    have affected the agency's ability to pursue new, cutting-edge
    opportunities. This funding uncertainty is disruptive to training,
    careers, long-range projects, and ultimately, to research progress. The
    research engine needs a predictable, sustained investment in science to
    maximize the Nation's return.
        Not only is NIH research essential to advancing health, it also
    plays a key economic role in communities nationwide. More than 83
    percent of NIH funding is spent in communities across the Nation,
    creating jobs at more than 3,000 independent research institutions,
    universities, teaching hospitals, and other institutions in every
    State. NIH research also supports long-term competitiveness for
    American workers. NIH funding forms one of the key foundations for
    sustained U.S. global competitiveness in industries like biotechnology,
    medical device and pharmaceutical development, and more.
        Highlighted below are examples of how independent research
    institutes uniquely contribute to the NIH mission and activities.
        Translating Research into Treatments and Therapeutics.--To further
    its primary goal of improving health, NIH is engaged in a significant
    reorganization process focused on advancing translational science. AIRI
    looks forward to collaborating with NIH in this area as independent
    research institutes are particularly adept at translating basic
    discoveries into therapeutics, often partnering with industry. As a
    network of efficient, nimble independent research institutes that have
    been conducting translational research for years, AIRI is well-
    positioned to be a strong partner in bringing research from the bench
    to the bedside.
        Currently, over 15 AIRI member institutions are affiliated and
    collaborate with the Clinical and Translational Science Awards (CTSA)
    program. Many AIRI institutes also support research on human embryonic
    stem cells (hESC) with the hope of discovering new and innovative
    disease interventions. However, uncertainty surrounding NIH funding and
    hESC research will hinder the agency's efforts to advance the
    introduction of new, life-saving cures and treatments into the
    marketplace.
        Fostering the Next Generation Scientific Workforce.--The biomedical
    research community is dependent upon a knowledgeable, skilled, and
    diverse workforce to address current and future critical health
    research questions. While the primary function of AIRI member
    institutions is research, most are highly involved in training the next
    generation of biomedical researchers and ensuring that a pipeline of
    promising scientists are prepared to make significant and potentially
    transformative discoveries in a variety of areas.
        AIRI supports policies that promote the United States' ability to
    maintain a competitive edge in biomedical science. Initiatives focusing
    on career development and recruitment of a diverse scientific workforce
    are important to innovation in biomedical research and the public
    health of the Nation. The cultivation and preservation of this
    workforce is dependent upon several factors:
      --The ability to recruit scientists and students globally is
            essential to maintaining a strong workforce.
      --Training programs both in basic and clinical biomedical research,
            initiatives focusing on career development, and recruiting a
            diverse scientific workforce are important to innovation in
            biomedical research for the benefit of public health.
      --The continued national emphasis on promoting education in the
            fields of science, technology, engineering, and mathematics
            (STEM) is key to bolstering the pipeline.
        Pursuing New Knowledge.--The NIH model for conducting biomedical
    research, which involves supporting scientists at universities, medical
    centers, and independent research institutes, provides an effective
    approach to making fundamental discoveries in the laboratory that can
    be translated into medical advances that save lives. Moreover, efforts
    to expand the knowledge base in medical and associated sciences bolster
    the Nation's economic well-being and ensure a continued high return on
    the public investment in research.
        AIRI member institutions are private, stand-alone research centers
    that set their sights on the vast frontiers of medical science,
    specifically focused on pursuing knowledge about the biology and
    behavior of living systems and the application of that knowledge to
    improve human life and reduce the burdens of illness and disability.
    Additionally, AIRI member institutes have embraced technologies and
    research centers to collaborate on biological research for all
    diseases. Using advanced technology platforms or ``cores,'' AIRI
    researchers use genomics, imaging, and other broad-based technologies
    to advance therapeutics development and drug discovery.
        Providing Efficiency and Flexibility.--AIRI member institutes'
    small size and flexibility provide an environment that is particularly
    conducive to creativity and innovation. Independent research institutes
    possess a unique versatility and culture that encourages them to share
    expertise, information, and equipment across all research institutions
    and elsewhere. These collaborative activities help minimize bureaucracy
    and increase efficiency, allowing for fruitful partnerships with
    entities in a variety of disciplines and industries. Also, unlike
    institutes of higher education, independent research institutes are
    able to focus solely on scientific inquiry and discoveries, allowing
    them to respond quickly to the research needs of the country.
        Supporting Local Economies.--AIRI is unique from other biomedical
    research organizations in that our membership consists of institutions
    located in regions not traditionally associated with cutting-edge
    research. AIRI members are located in 25 States, including many smaller
    or less-populated States that do not have major academic research
    institutions. In many of these regions, independent research institutes
    are major employers and economic engines, and exemplify the positive
    impact of investing in research and science.
        AIRI thanks the Subcommittee for its important work dedicated to
    ensuring the health of the Nation, and we appreciate this opportunity
    to urge the Subcommittee to provide $31.987 billion for NIH in the
    fiscal year 2012 appropriations bill. AIRI looks forward to working
    with Congress to support research that improves the health and quality
    of life for all Americans.
                                     ______

       Prepared Statement of the Association of Maternal & Child Health
                                    Programs
        Chairman Harkin and distinguished subcommittee members: On behalf
    of the Association of Maternal & Child Health Programs (AMCHP), I am
    pleased to submit testimony describing AMCHP's request for $700 million
    in funding for fiscal year 2012 for the Title V Maternal and Child
    Health Services block grant, a 5 percent increase over fiscal year
    2010. The Maternal and Child Health (MCH) Services Block Grant supports
    a wide range of programs that meet State and locally determined needs.
    In 2008, over 40 million individuals were served by maternal and child
    health programs supported through the MCH Services Block Grant.
        AMCHP did not develop this request lightly and our members are very
    cognizant of the many important and urgent discussions about reducing
    the Federal deficit and Government spending. However, we strongly
    contend that with the recent economic downturn and increased need to
    provide services to vulnerable populations a $700 million request is
    worthy of serious consideration by the Committee.
        The MCH Services Block Grant provides support and services to
    millions of American women, infants and children, including children
    with special healthcare needs. It has been proven a cost effective,
    value-based, and flexible funding source used to address the most
    pressing and unique needs of each State. States and jurisdictions use
    the MCH Services Block Grant to design and implement a wide range of
    maternal and child health programs that meet national and State needs.
    Although specific initiatives may vary among the 59 States and
    jurisdictions, all of them work to accomplish the following:
      --Reduce infant mortality and incidence of disabling conditions among
            children;
      --Increase the number of children appropriately immunized against
            disease;
      --Increase the number of children in low-income households who
            receive assessments and follow-up diagnostic and treatment
            services;
      --Provide and ensure access to comprehensive perinatal care for
            women; preventative and child care services; comprehensive
            care, including long-term care services, for children with
            special healthcare needs; and rehabilitation services for blind
            and disabled children; and
      --Facilitate the development of comprehensive, family centered,
            community-based, culturally competent, coordinated systems of
            care for children with special healthcare needs.
        The MCH Services Block Grant improves the health of America's women
    and children by:
      --Supporting programs that work. The MCH Services Block Grant earned
            the highest program rating by the Office of Management and
            Budget's (OMB) Program Assessment Rating Tool (PART). OMB found
            that MCH Services Block Grant funded programs helped to
            decrease the infant mortality rate, prevent disabling
            conditions, increase the number of children immunized, increase
            access to care for uninsured children, and improve the overall
            health of mothers and children. Reduced MCH Services Block
            Grant funding threatens the ability of these programs to carry
            on this work. Our results are available to the public through a
            national website known as the Title V Information System. Such
            a transparent system is remarkably rare for a Federal program
            and we are proud of the progress we have made in demonstrating
            results.
      --Addressing the growing health needs of women, children and
            families. As States face economic hardships and face limits on
            their Medicaid and CHIP programs, more women and children seek
            care and preventive services through MCH Services Block Grant
            funded programs. Resources are needed to reduce infant
            mortality, provide a range of preventive health and early
            intervention services to those in need, improve oral
            healthcare, reach more children and youth with special
            healthcare needs, and reduce racial disparities in healthcare.
      --Supporting and integrating other federally funded programs such as
            Community Health Centers, Healthy Start, WIC, CHIP and
            Medicaid. The MCH Services Block Grant helps identify areas of
            need in a State and works with all State and Federal programs
            to complement healthcare services and promote disease
            prevention for women, children, and families.
        To help illustrate the importance of MCH Services Block Grant
    funding I would like to share Michelle's story. Michelle is a young
    girl from Iowa who was helped by Iowa's MCH Services Block Grant
    supported programs.
        Katrina is the mother of Michelle, an energetic, 10 year old girl
    from Spencer, Iowa who loves listening to music, riding and playing
    with horses. While enrolling her daughter into school, Katrina got a
    ``mother's feeling'' that something just wasn't quite right with her
    daughter and despite the family pediatrician telling her that there was
    nothing wrong, she reached out to the Child Health Specialty Clinic
    (CHSC) in Sioux City for help. It was at that Title V funded clinic
    that it was discovered by a professional geneticist that her child was
    suffering from Phelan-McDermid Syndrome (PMS). PMS is caused by damage
    to, or deletion of, specific genes and impacts normal childhood
    development. Frequently, individuals with PMS have intellectual
    disabilities along with little or no expressive language and often
    there can be a large variety of moderate and even some severe physical
    disabilities.
        Because of the proper diagnosis from the geneticist at the
    specialty clinic, Katrina is able to get her daughter proper physical
    rehabilitation treatments twice a week from her local hospital back
    home in Spencer. A diagnosis of this kind could not have been found
    without the aid of CHSC staff and the clinic in Sioux City, which along
    with all Iowan CHSC clinics, are funded by the Title V Maternal & Child
    Health Block Grant. Title V is so valuable because CHSC clinics provide
    direct clinical services to children when services are not readily
    available in the community. CHSC clinics also provide care
    coordination, family support and infrastructure building, all in an
    effort to continue to improve healthcare for children and families
    across the entire state.
        Thanks to Child Health Specialty Clinics, Iowan families are able
    to receive testing and diagnosis that they can find nowhere else. Not
    only are the people at these clinics determined to help children
    medically, they also make a point to get to know the children on a
    personal level. Katrina describes the people at the clinic by stating:
    ``They know each and every child when they arrive, and they truly love
    the kids they see.'' If you were to ask Katrina how she felt about
    Iowa's Title V funded specialty clinics she wouldn't shy away from
    telling you that, ``They help so much. The people there really do
    care.''
        The MCH Services Block Grant supports a similar network in every
    State and none of this could happen without the MCH Services Block
    Grant. We hope that all our Nation's citizens are as proud as Katrina
    because of the work of MCH Services Block Grant supported programs and
    professionals.
        America has made huge strides in advancing the health of women and
    children but our country faces huge challenges in improving maternal
    and child health outcomes and addressing the needs of vulnerable
    children. On the sentinel measures of how well our society is doing to
    protect women and children we compare badly to other industrialized
    countries. Today, the United States ranks 30th in infant mortality
    rates and 41st in maternal mortality. Sadly, every 18 minutes a baby in
    America dies before his or her first birthday and each day in America
    we lose 12 babies due to a Sudden Unexpected Infant Death. There are
    places in this country where the African-American infant mortality rate
    is double, and in some places even triple, the rate for whites.
    Preventable injuries remain the leading cause of death for all
    children. Nationwide we still fail to adequately screen all young
    children for developmental concerns, and childhood obesity has reached
    epidemic proportions threatening to reverse a century of progress in
    extending life expectancy to our Nation's very future.
        Without adequate funding MCH Services Block Grant programs will be
    overwhelmed by the mismatch between State needs and available
    resources. AMCHP members ask for your leadership in making the
    important decision to fund the MCH Services Block Grant at $700 million
    for fiscal year 2012. State maternal and child health programs have a
    long track record of demonstrating our positive impact on MCH outcomes
    and are fully accountable for the funds that we receive. Maintaining
    vital funding for the MCH Services Block Grant is an effective and
    efficient way to support our Nation's women, children, and families.
        In closing Mr. Chairman and distinguished members, I ask you to
    imagine with me an America in which every child has the opportunity to
    live until his or her first birthday; a Nation where our Federal and
    State partnership has effectively moved the needle on our most pressing
    maternal and child health issues such as infant mortality. Imagine all
    American parents being as proud as Katrina. Imagine a day when we are
    celebrating significant reductions or even the total elimination of
    health disparities by creatively solving our most urgent maternal and
    child health challenges.
        The MCH Services Block Grant aims to do just that using resources
    effectively to improve the health of all of America's women and
    children. Supporting the MCH Services Block Grant is a cost-effective
    investment in our Nation's future. We appreciate you support and
    leadership in funding it at $700 million for Federal fiscal year 2012.
        Thank you.
                                     ______

     Prepared Statement of the Association of Minority Health Professions
                                    Schools
        Mr. Chairman and members of the subcommittee, thank you for the
    opportunity to present my views before you today. I am Dr. Wayne J.
    Riley, Chairman of the Board of Directors of the Association of
    Minority Health Professions Schools (AMHPS) and the President and Chief
    Executive Officer of Meharry Medical College. AMHPS, established in
    1976, is a consortium of our Nation's 12 historically black medical,
    dental, pharmacy, and veterinary schools. The members are two dental
    schools at Howard University and Meharry Medical College; four schools
    of medicine at The Charles Drew University, Howard University, Meharry
    Medical College, and Morehouse School of Medicine; five schools of
    pharmacy at Florida A&M University, Hampton University, Howard
    University, Texas Southern University, and Xavier University; and one
    school of veterinary medicine at Tuskegee University. In all of these
    roles, I have seen firsthand the importance of minority health
    professions institutions and the Title VII Health Professions Training
    programs.
        Mr. Chairman, I want to welcome you to this new role of leading the
    L-HHS Subcommittee. I speak for our institutions, when I say that the
    minority health professions institutions and the Title VII Health
    Professionals Training programs address a critical national need.
    Persistent and severe staffing shortages exist in a number of the
    health professions, and chronic shortages exist for all of the health
    professions in our Nation's most medically underserved communities.
    Furthermore, even after the landmark passage of health reform, it is
    important to note that our Nation's health professions workforce does
    not accurately reflect the racial composition of our population. For
    example while blacks represent approximately 15 percent of the U.S.
    population, only 2-3 percent of the Nation's health professions
    workforce is black. Mr. Chairman, I would like to share with you how
    your committee can help AMHPS continue our efforts to help provide
    quality health professionals and close our Nation's health disparity
    gap.
        There is a well established link between health disparities and a
    lack of access to competent healthcare in medically underserved areas.
    As a result, it is imperative that the Federal Government continue its
    commitment to minority health profession institutions and minority
    health professional training programs to continue to produce healthcare
    professionals committed to addressing this unmet need--even in austere
    financial times.
        An October 2006 study by the Health Resources and Services
    Administration (HRSA), entitled ``The Rationale for Diversity in the
    Health Professions: A Review of the Evidence'' found that minority
    health professionals serve minority and other medically underserved
    populations at higher rates than non-minority professionals. The report
    also showed that; minority populations tend to receive better care from
    practitioners who represent their own race or ethnicity, and non-
    English speaking patients experience better care, greater
    comprehension, and greater likelihood of keeping follow-up appointments
    when they see a practitioner who speaks their language. Studies have
    also demonstrated that when minorities are trained in minority health
    profession institutions, they are significantly more likely to: (1)
    serve in rural and urban medically underserved areas, (2) provide care
    for minorities and (3) treat low-income patients.
        As you are aware, Title VII Health Professions Training programs
    are focused on improving the quality, geographic distribution and
    diversity of the healthcare workforce in order to continue eliminating
    disparities in our Nation's healthcare system. These programs provide
    training for students to practice in underserved areas, cultivate
    interactions with faculty role models who serve in underserved areas,
    and provide placement and recruitment services to encourage students to
    work in these areas. Health professionals who spend part of their
    training providing care for the underserved are up to 10 times more
    likely to practice in underserved areas after graduation or program
    completion.
        In fiscal year 2012, funding for the Title VII Health Professions
    Training programs must at the very least be maintained, especially the
    funding for the Minority Centers of Excellence (COEs) and Health
    Careers Opportunity Program (HCOPs). In addition, the funding for the
    National Institutes of Health (NIH)'s National Institute on Minority
    Health and Health Disparities (NIMHD), as well as the Department of
    Health and Human Services (HHS)'s Office of Minority Health (OMH),
    should be preserved.
        Minority Centers of Excellence.--COEs focus on improving student
    recruitment and performance, improving curricula in cultural
    competence, facilitating research on minority health issues and
    training students to provide health services to minority individuals.
    COEs were first established in recognition of the contribution made by
    four historically black health professions institutions to the training
    of minorities in the health professions. Congress later went on to
    authorize the establishment of ``Hispanic'', ``Native American'' and
    ``Other'' Historically black COEs. For fiscal year 2012, I recommend a
    funding level of $24.602 million for COEs.
        Health Careers Opportunity Program (HCOP).--HCOPs provide grants
    for minority and non-minority health profession institutions to support
    pipeline, preparatory and recruiting activities that encourage minority
    and economically disadvantaged students to pursue careers in the health
    professions. Many HCOPs partner with colleges, high schools, and even
    elementary schools in order to identify and nurture promising students
    who demonstrate that they have the talent and potential to become a
    health professional. For fiscal year 2012, I recommend a funding level
    of $22.133 million for HCOPs.
    National Insitutes of Health
        Research Centers at Minority Institutions.--The Research Centers at
    Minority Institutions program (RCMI), currently administered by the
    National Center for Research Resources, has a long and distinguished
    record of helping our institutions develop the research infrastructure
    necessary to be leaders in the area of health disparities research.
    Although NIH has received unprecedented budget increases in recent
    years, funding for the RCMI program has not increased by the same rate.
    Therefore, the funding for this important program grow at the same rate
    as NIH overall in fiscal year 2012.
        National Institute on Minority Health and Health Disparities.--The
    National Institute on Minority Health and Health Disparities (NIMHD) is
    charged with addressing the longstanding health status gap between
    minority and nonminority populations. The NIMHD helps health
    professions institutions to narrow the health status gap by improving
    research capabilities through the continued development of faculty,
    labs, and other learning resources. The NIMHD also supports biomedical
    research focused on eliminating health disparities and develops a
    comprehensive plan for research on minority health at the NIH.
    Furthermore, the NIMHD provides financial support to health professions
    institutions that have a history and mission of serving minority and
    medically underserved communities through the Centers of Excellence
    program. For fiscal year 2012, I recommend funded increases
    proportional with the funding of the over NIH.
    Department of Health and Human Services
        Office of Minority Health.--Specific programs at OMH include:
    assisting medically underserved communities with the greatest need in
    solving health disparities and attracting and retaining health
    professionals; assisting minority institutions in acquiring real
    property to expand their campuses and increase their capacity to train
    minorities for medical careers; supporting conferences for high school
    and undergraduate students to interest them in healthcareers, and
    supporting cooperative agreements with minority institutions for the
    purpose of strengthening their capacity to train more minorities in the
    health professions.
        The OMH has the potential to play a critical role in addressing
    health disparities. For fiscal year 2012, I recommend a funding level
    of $65 million for the OMH.
    Department of Education
        Strengthening Historically Black Graduate Institutions.--The
    Department of Education's Strengthening Historically Black Graduate
    Institutions (HBGI) program (Title III, Part B, Section 326) is
    extremely important to AMHPS. The funding from this program is used to
    enhance educational capabilities, establish and strengthen program
    development offices, initiate endowment campaigns, and support numerous
    other institutional development activities. In fiscal year 2012, an
    appropriation of $65 million is suggested to continue the vital support
    that this program provides to historically black graduate institutions.
        Mr. Chairman, please allow me to express my appreciation to you and
    the members of this subcommittee. With your continued help and support,
    AMHPS' member institutions and the Title VII Health Professions
    Training programs and the historically black health professions schools
    can help this country to overcome health disparities. Congress must be
    careful not to eliminate, paralyze or stifle the institutions and
    programs that have been proven to work. The Association seeks to close
    the ever widening health disparity gap. If this subcommittee will give
    us the tools, we will continue to work towards the goal of eliminating
    that disparity everyday.
        Thank you, Mr. Chairman, and I welcome every opportunity to answer
    questions for your records.
                                     ______

      Prepared Statement of the Association of Public Television Stations
        On behalf of America's 361 public television stations, we
    appreciate the opportunity to submit testimony for the record on the
    importance of Federal funding for local public television stations.
    Corporation for Public Broadcasting--Fiscal Year 2014 Request: $495
            million, 2-year advance funded
        More than 40 years after the inception of public television, local
    stations continue to serve as the treasured cultural institutions
    envisioned by their founders, reaching America's local communities with
    unsurpassed programming and services.
        Public broadcasting serves the public good--in education, public
    affairs, public safety, cultural affairs and many other areas--and
    richly deserves public support. The overwhelming majority of Americans
    agree. In a recent bi-partisan poll conducted by Hart Research
    Associates/American Viewpoint, nearly 70 percent of American voters,
    including majorities of self-identifying Democrats, Independents, and
    Republicans, support continued Federal funding for public broadcasting.
    In addition, the same poll shows that Americans consider PBS to be the
    second most appropriate expenditure of public funds, behind only
    national defense. Federal support for CPB and local public television
    stations has resulted in a nationwide system of locally owned and
    controlled, trusted, community-driven and community responsive media
    entities.
        Furthermore, the power of digital technology has enabled stations
    to greatly expand their delivery platforms to reach Americans where
    they are increasingly consuming media--online and on-demand--in
    addition to on-air. At the same time that stations are expanding their
    services and the impact they have in their communities, stations are
    also facing unprecedented funding challenges--presenting them with the
    greatest financial hurdles in their 40 year history. Every revenue
    source upon which our operations depend is under tremendous pressure.
    State funding support is in a wholesale free-fall. Despite serving as a
    long-time example of the incredible work that can be accomplished by a
    public-private partnership, this model is in peril as the current
    economic climate has put immense pressure on private funding sources.
    Continued Federal support for public broadcasting is more important now
    than ever before.
        More than 70 percent of funding appropriated to CPB reaches local
    stations in the form of Community Service Grants (CSGs). On average,
    Federal spending makes up approximately 15 percent of local television
    station's budgets. However, for many smaller and rural stations,
    Federal funding represents more than 30-50 percent (and in a handful of
    instances, an even larger percentage) of their total budget. For all
    stations, this Federal funding is the ``lifeblood'' of public
    broadcasting, providing critical seed money to local stations which
    leverage each $1 of the Federal investment to raise over $6 from state
    legislatures, private foundations and their viewers.
        Funding through CPB is absolutely essential to public television
    stations. Stations rely on the Federal investment to develop local
    programming, operate their facilities, pay their employees and provide
    community resources on-air, on-line and on-the-ground. This funding is
    particularly important to rural stations who struggle to raise local
    funds from individual donors due to the smaller and often economically
    strained population base. At the same time it is often more costly to
    serve rural areas due to the topography and distances between
    communities.
        A 2007 GAO report concluded that Federal funding, such as CSGs, is
    an irreplaceable source of revenue, and that ``substantial growth of
    nonFederal funding appears unlikely.'' It also found that ``cuts in
    Federal funding could lead to a reduction in staff, local programming
    or services.''
        At an annual cost of about $1.39 per year for each American, public
    broadcasting is a smart investment. This successful public-private
    partnership creates important economic activity while providing an
    essential educational and cultural service. Public broadcasting
    directly supports over 21,000 jobs, and of the vast majority of them
    are in local public television and radio stations in hundreds of
    communities across America.
        In addition, the advent of digital technology has created enormous
    potential for stations, allowing them to bring content to Americans in
    new, innovative ways while retaining our public service mission. Public
    television stations are now utilizing a wide array of digital tools to
    expand their current roles as educators, local conveners and vital
    sources of trusted information at a time when their communities need
    them most.
        For example, in an effort to confront the dropout crisis in
    America's high schools, CPB has just announced a significant investment
    and partnership with local stations and their communities to address
    this daunting problem that could have disastrous effects on America's
    future if it is not soon addressed. Together with schools and
    organizations that are already addressing the dropout crisis, the
    stations will provide their resources and services to raise awareness,
    coordinate action with community partners, and work directly with
    students, parents, teachers, mentors, volunteers and leaders to lower
    the drop-out rate in their respective communities.
        In order for our stations to continue playing this vital role in
    their communities, APTS and PBS respectfully request $495 million for
    CPB, two-year advance funded for fiscal year 2014.
        Advance funding is essential to the mission of public broadcasting.
    This longstanding practice, which was enacted by President Ford in
    1976, allows stations the ability to maximize fundraising efforts to
    leverage the promise of Federal dollars for local impact--ensuring the
    continuation of this strong public-private partnership. The 2-year
    advance funding mechanism also gives stations critical lead time needed
    to plan and produce high-quality programs. Additionally, the 2-year
    advance funding mechanism insulates programming decisions from
    political influence, as President Ford and the Congress intended in
    their initial proposal for advance funding.
    Ready To Learn--Fiscal Year 2012 Request: $27.3 million (Department of
            Education)
        The Ready to Learn Television program's success in improving
    children's literacy and preparing them for school is proven and
    unquestioned.
        Ready To Learn combines the power of public media's on-air and
    online educational content with on-the-ground local station community
    engagement to build the reading skills of children between the ages of
    two and eight, especially those from low-income families or those most
    lacking reading skills.
        Over the last 5 years, 60 independent studies have proven the
    effectiveness of the Ready To Learn approach. For example, in one study
    pre-schoolers who were exposed to a curriculum composed of programming
    and interactive games from top Ready To Learn programs, including SUPER
    WHY!, Between the Lions and Sesame Street, outscored children who
    received a comparison (science) curriculum in all five measures of
    early literacy.
        In addition to being research-based and teacher tested, the Ready
    To Learn Television program also provides excellent value for our
    Federal dollars. In the last five-year grant round, public broadcasting
    leveraged an additional $50 million in funding to augment the $73
    million investment by the Department of Education for content
    production. Without the investment of the Federal Government, this
    supplemental investment would likely end.
        The President's budget proposes consolidating public broadcasting's
    signature early education initiative, the Ready To Learn Television
    program, into a larger grant program. APTS and PBS are concerned that
    the consolidation of this program could lead to, at worst, the
    elimination of this critical program that has been the driving force
    behind the creation of public television's unparalleled children's
    educational programming. At best, the proposed budget would remove the
    mechanisms that have provided for the tremendously efficient and
    effective nature in which the Ready To Learn Television program has
    successfully operated.
        Consolidation or elimination of the Ready To Learn Television
    program would severely affect the ability of local stations to respond
    to their communities' educational needs, removing the needed resources
    provided by this program for children, parents and teachers.
        Ready To Learn is public television. This program is a shining
    example of a public-private partnership as Federal funds are leveraged
    to create the most popular and impactful children's educational content
    that is supplemented by on-line and on-the-ground resources. Without
    the Ready To Learn Television program, millions of families would lose
    access to this incredible high-quality education content, especially
    low-income and underserved households for whom this program is
    targeted.
        We urge the Committee to maintain the Ready To Learn Television
    program as a stable line-item in the fiscal year 2012 budget and resist
    the calls for consolidation. APTS and PBS respectfully request level
    funding of $27.3 million for the Ready To Learn Television program in
    fiscal year 2012.
    CPB Digital Funding--Fiscal Year 2012 Request: $36 million
        Public television stations have been at the forefront of the
    digital transition, embracing the technology early and recognizing its
    benefits to their viewers. Fortunately, Congress wisely recognized that
    the federally mandated transition to digital broadcast would place a
    hardship on public television's limited resources. Since 2001, Congress
    has provided public television stations with funds to ensure that they
    have the ability to continue to meet their public service mission and
    deliver the highest quality educational, cultural and public affairs
    programming post-transition.
        Although the federally mandated portion of the transition is
    complete, what remains to be finished is the ability of stations to
    fully replicate their analog services in digital. As stations have
    completed the transition of their main transmitters, they will continue
    to convert their master controls, digital storage equipment and other
    studio equipment--necessary to produce and distribute local educational
    programming. The CPB Digital program is also critical to providing
    funds that can be invested in interactive public media that maximizes
    investments in digital infrastructure--including such content
    investments as the American Archive.
        Public television has used this new public digital spectrum to
    maximize programming choices by offering an array of new channel
    options, including the national offerings of Vme (the first 24-hour,
    Spanish-language, educational channel), World, and Create.
        More importantly, stations have also used these multicast
    capabilities to expand their local offerings with digital channels
    dedicated to community or State-focused programming. Some stations have
    even utilized this technology to provide gavel-to-gavel coverage of
    their State legislatures. In addition, digital broadcasting has enabled
    stations to double the amount of noncommercial, children's educational
    programming offered to the American public.
        APTS and PBS respectfully request $36 million in CPB Digital
    funding for fiscal year 2012 to enable stations to fully leverage this
    groundbreaking technology.
                                     ______

         Prepared Statement of the Association of Rehabilitation Nurses
    Introduction
        On behalf of the Association of Rehabilitation Nurses (ARN), I
    appreciate having the opportunity to submit written testimony to the
    Senate L-HHS Appropriations Subcommittee regarding funding for nursing
    and rehabilitation related programs in fiscal year 2012. ARN represents
    more than 5,700 Registered Nurses (RNs) who work to enhance the quality
    of life for those affected by physical disability and/or chronic
    illness. ARN understands that Congress has many concerns and limited
    resources, but believes that chronic illnesses and physical
    disabilities are heavy burdens on our society that must be addressed.
    Rehabilitation Nurses and Rehabilitation Nursing
        Rehabilitation nurses help individuals affected by chronic illness
    and/or physical disability adapt to their condition, achieve their
    greatest potential, and work toward productive, independent lives. They
    take a holistic approach to meeting patients' nursing and medical,
    vocational, educational, environmental, and spiritual needs.
    Rehabilitation nurses begin to work with individuals and their families
    soon after the onset of a disabling injury or chronic illness. They
    continue to provide support and care, including patient and family
    education, which empowers these individuals when they return home, or
    to work, or school. The rehabilitation nurse often teaches patients and
    their caregivers how to access systems and resources.
        Rehabilitation nursing is a philosophy of care, not a work setting
    or a phase of treatment. These nurses base their practice on
    rehabilitative and restorative principles by: (1) managing complex
    medical issues; (2) collaborating with other specialists; (3) providing
    ongoing patient/caregiver education; (4) setting goals for maximum
    independence; and (5) establishing plans of care to maintain optimal
    wellness. Rehabilitation nurses practice in all settings, including
    freestanding rehabilitation facilities, hospitals, long-term subacute
    care facilities/skilled nursing facilities, long-term acute care
    facilities, comprehensive outpatient rehabilitation facilities, home
    health, and private practices, just to name a few.
        With the Affordable Care Act's focus on creating a system that will
    increase access to quality care, emphasize prevention, and decrease
    cost, it is critical that a substantial investment be made in the
    nursing workforce programs and in the scientific research that provides
    the basis for nursing practice. To ensure that patients receive the
    best quality care possible, ARN supports Federal programs and research
    institutions that address the national nursing shortage and conduct
    research focused on nursing and medical rehabilitation, e.g., traumatic
    brain injury. Therefore, ARN respectfully requests that the
    Subcommittee provide increased funding for the following programs:
                Nursing Workforce and Development Programs at the Health
                        Resources and Services Administration (HRSA)
        ARN supports efforts to resolve the national nursing shortage,
    including appropriate funding to address the shortage of qualified
    nursing faculty. Rehabilitation nursing requires a high-level of
    education and technical expertise, and ARN is committed to assuring and
    protecting access to professional nursing care delivered by highly-
    educated, well-trained, and experienced Registered Nurses (RNs) for
    individuals affected by chronic illness and/or physical disability.
        According to the Health Resources and Services Administration
    (HRSA), in 2010, our healthcare workforce experienced a shortage of
    more than 400,000 nurses.\1\ The demand for nurses will continue to
    grow as the baby-boomer population ages, nurses retire, and the need
    for healthcare intensifies. Implementation of the new health reform law
    will also increase the need for a well-trained and highly skilled
    nursing workforce. The Institute of Medicine has released
    recommendations on how to help the nursing workforce to meet these new
    demands, but we are destined to fall short of these lofty goals if
    there are not enough nurses to facilitate change.
    ---------------------------------------------------------------------------
        \1\ http://bhpr.hrsa.gov/healthworkforce/reports/nursing/
    rnbehindprojections/4.htm.
    ---------------------------------------------------------------------------
        According to the U.S. Bureau of Labor Statistics, nursing is the
    Nation's top profession in terms of projected job growth, with more
    than 581,500 new nursing positions being created through 2018.\2\ These
    positions are in addition to the existing jobs that healthcare
    employers have not been able to fill. Educating new nurses to fill
    these gaping vacancies is a great way to put Americans back to work and
    simultaneously enhance an ailing healthcare system.
    ---------------------------------------------------------------------------
        \2\ http://www.bls.gov/oco/ocos083.htm#outlook.
    ---------------------------------------------------------------------------
        ARN strongly supports the national nursing community's request of
    $313.075 million in fiscal year 2012 funding for Federal Nursing
    Workforce Development programs at HRSA.
                National Institute on Disability and Rehabilitation
                        Research (NIDRR)
        The National Institute on Disability and Rehabilitation Research
    (NIDRR) provides leadership and support for a comprehensive program of
    research related to the rehabilitation of individuals with
    disabilities. As one of the components of the Office of Special
    Education and Rehabilitative Services at the U.S. Department of
    Education, NIDRR operates along with the Rehabilitation Services
    Administration and the Office of Special Education Programs.
        The mission of NIDRR is to generate new knowledge and promote its
    effective use to improve the abilities of people with disabilities to
    perform activities of their choice in the community, and also to expand
    society's capacity to provide full opportunities and accommodations for
    its citizens with disabilities. NIDRR conducts comprehensive and
    coordinated programs of research and related activities to maximize the
    full inclusion, social integration, employment and independent living
    of individuals of all ages with disabilities. NIDRR's focus includes
    research in areas such as: employment, health and function, technology
    for access and function, independent living and community integration,
    and other associated disability research areas.
        ARN strongly supports the work of NIDRR and encourages Congress to
    provide the maximum possible fiscal year 2012 funding level.
                National Institute of Nursing Research (NINR)
        ARN understands that research is essential for the advancement of
    nursing science, and believes new concepts must be developed and tested
    to sustain the continued growth and maturation of the rehabilitation
    nursing specialty. The National Institute of Nursing Research (NINR)
    works to create cost-effective and high-quality healthcare by testing
    new nursing science concepts and investigating how to best integrate
    them into daily practice. Through grants, research training, and
    interdisciplinary collaborations, NINR addresses care management of
    patients during illness and recovery, reduction of risks for disease
    and disability, promotion of healthy lifestyles, enhancement of quality
    of life for those with chronic illness, and care for individuals at the
    end of life. NINR's broad mandate includes seeking to prevent and delay
    disease and to ease the symptoms associated with both chronic and acute
    illnesses. NINR's recent areas of research focus include the following:
    End of life and palliative care in rural areas; research in multi-
    cultural societies; bio-behavioral methods to improve outcomes
    research; and increasing health promotion through comprehensive
    studies.
        ARN respectfully requests $163 million in fiscal year 2012 funding
    for NINR to continue its efforts to address issues related to chronic
    and acute illnesses.
                Traumatic Brian Injury (TBI)
        According to the Brain Injury Association of America, 1.7 million
    people sustain a traumatic brain injury (TBI) each year.\3\ This figure
    does not include the 150,000 cases of TBI suffered by soldiers
    returning from wars in Afghanistan and conflicts around the world.
    ---------------------------------------------------------------------------
        \3\ http://www.biausa.org/living-with-brain-injury.htm.
    ---------------------------------------------------------------------------
        The annual national cost of providing treatment and services for
    these patients is estimated to be nearly $60 million in direct care and
    lost workplace productivity. Continued fiscal support of the Traumatic
    Brain Injury Act will provide critical funding needed to further
    develop research and improve the lives of individuals who suffer from
    traumatic brain injury.
        Continued funding of the TBI Act will promote sound public health
    policy in brain injury prevention, research, education, treatment, and
    community-based services, while informing the public of needed support
    for individuals living with TBI and their families.
        ARN strongly supports the current work being done by the Centers
    for Disease Control and Prevention (CDC) and HRSA on TBI programs.
    These programs contribute to the overall body of knowledge in
    rehabilitation medicine.
        ARN urges Congress to support the following fiscal year 2012
    funding requests for programs within the TBI Act: $10 million for CDC's
    TBI registries and surveillance, prevention and national public
    education and awareness efforts; $8 million for the HRSA Federal TBI
    State Grant Program; and $4 million for the HRSA Federal TBI Protection
    and Advocacy Systems Grant Program.
    Conclusion
        ARN appreciates the opportunity to share our priorities for fiscal
    year 2012 funding levels for nursing and rehabilitation programs. ARN
    maintains a strong commitment to working with Members of Congress,
    other nursing and rehabilitation organizations, and other stakeholders
    to ensure that the rehabilitation nurses of today continue to practice
    tomorrow. By providing the fiscal year 2012 funding levels detailed
    above, we believe the Subcommittee will be taking the steps necessary
    to ensure that our Nation has a sufficient nursing workforce to care
    for patients requiring rehabilitation from chronic illness and/or
    physical disability.
                                     ______

         Prepared Statement of the Brain Injury Association of America
        Thank you for the opportunity to submit this written testimony with
    regard to the fiscal year 2012 Labor-HHS-Education appropriations bill.
    My testimony is on behalf of the Brain Injury Association of America
    (BIAA), our national network of State affiliates, and hundreds of local
    chapters and support groups from across the country.
        In the civilian population alone every year, more than 1.7 million
    people sustain brain injuries from falls, car crashes, assaults and
    contact sports. Males are more likely than females to sustain brain
    injuries. Children, teens and seniors are at greatest risk.
        Recently, we are seeing an increasing number of service members
    returning from the conflicts in Iraq and Afghanistan with TBI, which
    has been termed one of the signature injuries of the war. Many of these
    returning service members are undiagnosed or misdiagnosed and
    subsequently they and their families will look to community and local
    resources for information to better understand TBI and to obtain vital
    support services to facilitate successful reintegration into the
    community.
        For the past 13 years Congress has provided minimal funding through
    the HRSA Federal TBI Program to assist States in developing services
    and systems to help individuals with a range of service and family
    support needs following their loved one's brain injury. Similarly, the
    grants to State Protection and Advocacy Systems to assist individuals
    with traumatic brain injuries in accessing services through education,
    legal and advocacy remedies are woefully underfunded. Rehabilitation,
    community support and long-term care systems are still developing in
    many States, while stretched to capacity in others. Additional numbers
    of individuals with TBI as the result of war-related injuries only adds
    more stress to these inadequately funded systems.
        BIAA respectfully urges you to provide States with the resources
    they need to address both the civilian and military populations who
    look to them for much needed support in order to live and work in their
    communities.
        With broader regard to all of the programs authorized through the
    TBI Act, BIAA specifically requests:
      --$10 million (+$4 million) for the Centers for Disease Control and
            Prevention TBI Registries and Surveillance, Brain Injury Acute
            Care Guidelines, Prevention and National Public Education/
            Awareness
      --$8 million (+$1 million) for the Health Resources and Services
            Administration (HRSA) Federal TBI State Grant Program
      --$4 million (+$1 million) for the HRSA Federal TBI Protection &
            Advocacy (P&A) Systems Grant Program
        CDC--National Injury Center.--The Centers for Disease Control and
    Prevention's National Injury Center is responsible for assessing the
    incidence and prevalence of TBI in the United States. The CDC estimates
    that 1.7 million TBIs occur each year and 3.4 million Americans live
    with a life-long disability as a result of TBI. In addition, the TBI
    Act as amended in 2008 requires the CDC to coordinate with the
    Departments of Defense and Veterans Affairs to include the number of
    TBIs occurring in the military. This coordination will likely increase
    CDC's estimate of the number of Americans sustaining TBI and living
    with the consequences.
        CDC also funds States for TBI registries, creates and disseminates
    public and professional educational materials, for families, caregivers
    and medical personnel, and has recently collaborated with the National
    Football League and National Hockey League to improve awareness of the
    incidence of concussion in sports. CDC plays a leading role in helping
    standardize evidence based guidelines for the management of TBI and $1
    million of this request would go to fund CDC's work in this area.
        HRSA TBI State Grant Program.--The TBI Act authorizes the HHS,
    Health Resources and Service Administration (HRSA) to award grants to
    (1) States, American Indian Consortia and territories to improve access
    to service delivery and to (2) State Protection and Advocacy (P&A)
    Systems to expand advocacy services to include individuals with
    traumatic brain injury. For the past 13 years the HRSA Federal TBI
    State Grant Program has supported State efforts to address the needs of
    persons with brain injury and their families and to expand and improve
    services to underserved and unserved populations including children and
    youth; veterans and returning troops; and individuals with co-occurring
    conditions
        In fiscal year 2009, HRSA reduced the number of State grant awards
    to 15, in order to increase each monetary award from $118,000 to
    $250,000. This means that many States that had participated in the
    program in past years have now been forced to close down their
    operations, leaving many unable to access brain injury care.
        Increasing the program to $8 million will provide funding necessary
    to sustain the grants for the 15 States currently receiving funding
    along with the 3 additional States added this year and to ensure
    funding for 4 additional States. Steady increases over 5 years for this
    program will provide for each State including the District of Columbia
    and the American Indian Consortium and territories to sustain and
    expand State service delivery; and to expand the use of the grant funds
    to pay for such services as Information & Referral (I&R), systems
    coordination and other necessary services and supports identified by
    the State.
        HRSA TBI P&A Program.--Similarly, the HRSA TBI P&A Program
    currently provides funding to all State P&A systems for purposes of
    protecting the legal and human rights of individuals with TBI. State
    P&As provide a wide range of activities including training in self-
    advocacy, outreach, information and referral and legal assistance to
    people residing in nursing homes, to returning military seeking
    veterans benefits, and students who need educational services.
        Effective Protection and Advocacy services for people with
    traumatic brain injury is needed to help reduce Government expenditures
    and increase productivity, independence and community integration.
    However, advocates must possess specialized skills, and their work is
    often time-intensive. A $4 million appropriation would ensure that each
    P&A can move toward providing a significant PATBI program with
    appropriate staff time and expertise.
        NIDRR TBI Model Systems of Care.--Funding for the TBI Model Systems
    in the Department of Education is urgently needed to ensure that the
    Nation's valuable TBI research capacity is not diminished, and to
    maintain and build upon the 16 TBI Model Systems research centers
    around the country.
        The TBI Model Systems of Care program represents an already
    existing vital national network of expertise and research in the field
    of TBI, and weakening this program would have resounding effects on
    both military and civilian populations. The TBI Model Systems are the
    only source of non-proprietary longitudinal data on what happens to
    people with brain injury. They are a key source of evidence-based
    medicine, and serve as a ``proving ground'' for future researchers.
        In order to make this program more comprehensive, Congress should
    provide $11 million (+$1.5 million) in fiscal year 2011 for NIDRR's TBI
    Model Systems of Care program, in order to add one new Collaborative
    Research Project. In addition, given the national importance of this
    research program, the TBI Model Systems of Care should receive ``line-
    item'' status within the broader NIDRR budget.
        We ask that you consider favorably these requests for the CDC, the
    HRSA Federal TBI Program, and the NIDRR TBI Model Systems Program to
    further data collection, increase public awareness, improve medical
    care, assist States in coordinating services, protect the rights of
    persons with TBI, and bolster vital research.
                                     ______

                   Prepared Statement of the CAEAR Coalition
        On behalf of the tens of thousands of individuals living with HIV/
    AIDS to whom members of the Communities Advocating Emergency AIDS
    Relief (CAEAR) Coalition provide care, I thank Chairman Harkin and
    Ranking Member Shelby for affording us the opportunity to submit
    testimony regarding increased funding for the Ryan White HIV/AIDS
    Program.
        The Communities Advocating Emergency AIDS Relief (CAEAR) Coalition
    is a national membership organization which advocates for sound Federal
    policy, program regulations, and sufficient appropriations to meet the
    care, treatment, support service and prevention/wellness needs of
    people living with HIV/AIDS and the organizations that serve them,
    focusing on ensuring access to high quality healthcare and the evolving
    role of the Ryan White Program.
    A Wise Investment in a Program That Works
        The Ryan White Program works. In its Program Assessment Rating Tool
    (PART), the White House Office of Management and Budget (OMB) gave the
    Ryan White Program its highest possible rating of ``effective''--a
    distinction shared by only 18 percent of all programs rated. According
    to OMB, effective programs ``set ambitious goals, achieve results, are
    well-managed and improve efficiency.'' Even more impressively, OMB's
    assessment of the Ryan White Program found it to be in the top 1
    percent of all Federal programs in the area of ``Program Results and
    Accountability.'' Out of the 1,016 Federal programs rated--98 percent
    of all Federal programs--the Ryan White Program was one of seven that
    received a score of 100 percent in ``Program Results and
    Accountability.''
        The Ryan White Program serves as the indispensable safety net for
    thousands of low-income, uninsured or underinsured people living with
    HIV/AIDS.
      --Part A provides much-needed funding to the 52 major metropolitan
            areas hardest hit by the HIV/AIDS epidemic with severe needs
            for additional resources to serve those living with HIV disease
            in their communities.
      --Part B assists States and territories in improving the quality,
            availability, and organization of healthcare and support
            services for individuals and families with HIV.
      --The AIDS Drug Assistance Program (ADAP) in Part B provides life-
            saving, urgently needed medications to people living with HIV/
            AIDS in all 50 States and the territories.
      --Part C provides grants to 349 faith- and community-based primary
            care health clinics and public health providers in 49 States,
            Puerto Rico and the District of Columbia. These clinics play a
            central role in the delivery of HIV-related medical services to
            underserved communities, people of color, and rural areas where
            Part C funded clinics provide the only HIV specific medical
            services available in the region.
      --Part F AETC supports training for healthcare providers to identify,
            counsel, diagnose, treat, and manage individuals with HIV
            infection and to help prevent high-risk behaviors that lead to
            infection. It has 130 program sites with coverage in all 50
            States.
        CAEAR Coalition's fiscal year 2012 funding requests for Part A,
    Part B base and ADAP, and Part C reflect the amounts authorized by
    Congress in the most recent authorization of the program.
        There continues to be an increasing gap between the number of
    people living with HIV/AIDS in the United States in need of care and
    the Federal resources available to serve them. Between 2001 and 2008
    the number of people living with AIDS grew 35 percent and yet funding
    for medical care and support services in communities with the greatest
    burden of HIV disease grew less than 12 percent between 2001 and 2011.
    Similarly, funding for Part C-funded, faith and community-based primary
    care clinics, which provide medical care for people living with HIV/
    AIDS in remote, rural and geographically isolated, urban communities
    nationwide, grew by only 11 percent between 2001 and 2011 as the number
    of people they care for grew by 52 percent. The authorized amounts we
    request would not fully address these funding deficiencies, but would
    begin to reduce the still growing gaps in funding.
        We thank you in advance for your consideration of our comments and
    our request for:
      --$751.9 million for Part A to support grants to the cities where
            most people with HIV/AIDS live and receive their care and
            treatment.
      --$495 million for Part B base to provide additional needed resources
            to the States to bolster the public health response statewide
            regardless of location.
      --$991 million in funding for the ADAP line item in Part B so
            uninsured and underinsured people with HIV/AIDS can access the
            anti-HIV and other prescribed medications they need to survive.
      --$272.2 million for Part C to support grants to faith- and
            community-based organizations, healthcare agencies, and
            clinics.
      --$50 million to fund the 11 regional centers funded under by Part F
            AETC to offer specialized clinical education and consultation
            to frontline providers.
    Sufficient Funding for Ryan White Programs Saves Money and Saves Lives
        Increased funding for Ryan White Programs will reap a significant
    health return for minimal investment. Data show that Part A and Part C
    programs have reduced HIV-related hospital admissions by 30 percent
    nationally and by up to 75 percent in some locations. The programs
    supported by the Ryan White HIV/AIDS Program also have been critical in
    reducing AIDS mortality by 70 percent. The Ryan White Program works,
    resulting in both economic stimulus and social savings by helping keep
    people, stable, healthy and productive.
    Growing Needs as More Tested and Entering Care
        The Centers for Disease Control and Prevention (CDC) estimates that
    as of 2006 there were 1,106,400 persons living with HIV/AIDS in the
    United States. Approximately one-half were not in care and receiving
    treatment. New CDC recommendations for routine HIV testing have
    increased the influx of newly diagnosed individuals into care, but with
    56,000 newly diagnosed individuals per year, the Federal resources have
    not kept pace with the burgeoning need.
        The fiscal year 2012 appropriation presents a crucial opportunity
    to provide the Ryan White Program with the levels of funding needed to
    address a growing epidemic in young men, as the CDC continues to
    increase efforts to expand HIV testing so people living with HIV know
    their status, control their health, and protect others.
        CAEAR Coalition supports efforts to help individuals infected with
    HIV learn their status at the earliest possible time. However, CAEAR
    Coalition is concerned about the unmet demand for services created by
    insufficient resources at the Federal level. Researchers estimate that
    CDC's expanded HIV testing guidelines will bring an additional 46,000
    people into care over 5 years and significantly reduce the 21 percent
    of people living with HIV who do not know they are infected and
    therefore are not in care. Bringing these individuals into care will
    save large sums of money in the long run, but requires an initial
    investment now. Research clearly shows that averting a single HIV
    infection saves $221,365 in lifetime healthcare costs \1\, and getting
    people on anti-HIV treatment early lowers levels of HIV circulating in
    the body and reduces potential transmissions \2\--saving lives and
    money in the long term--but we must invest now in care and treatment to
    reap those rewards. Caring for individuals early in their disease will
    increase the cost of care by $2.7 billion over 5 years and the majority
    of those costs will fall to Federal discretionary programs like the
    Ryan White Program and will not be offset by entitlement programs.\3\
    ---------------------------------------------------------------------------
        \1\ Holtgrave DR, Briddell K, Little E, Bendixen AV, Hooper M,
    Kidder DP, et al. Cost and threshold analysis of housing as an HIV
    prevention intervention. AIDS & Behavior.(2007)11(Suppl 2), S162-S166.
        \2\ Montaner J, Lima VD, Barrios R, et al. Association of highly
    active antiretroviral therapy coverage, population viral load, and
    yearly new HIV diagnoses in British Columbia, Canada: a population-
    based study. The Lancet (2010) 376(9740): 532-539.
        \3\ Martin EG, Paltiel AD, Walensky, RP, Schackman BR, Expanded HIV
    Screening in the United States: What Will It Cost Government
    Discretionary and Entitlement Programs? A Budget Impact Analysis. Value
    in Health (2010) 13: 893--902.
    ---------------------------------------------------------------------------
        Community-based providers are stretched to provide high-quality
    care with the scarce resources available. CAEAR Coalition is concerned
    that many HIV expert medical staff are scheduled to retire and the
    persistent financial pressures may accelerate the loss of trained
    professionals in the field. This additional pressure on an already
    overburdened system will leave many of the more than 200,000 HIV-
    infected individuals who do not know their HIV status without access to
    the care they need.
        State budget cuts have created a continuing and growing ADAP
    funding crisis as a record number of people are in need of ADAP
    services due to the economic downturn. As of May 2011, there are 8,100
    people on ADAP waiting lists in 13 States. Additionally, ADAP waiting
    lists and other cost-containment measures, including limited
    formularies, reducing eligibility, or removing already enrolled people
    from the program, are clear evidence that the need for HIV-related
    medications continues to outstrip availability. ADAPs are forced to
    make difficult trade-offs between serving a greater number of people
    living with HIV/AIDS with fewer services or serving fewer people with
    more services. Additional resources are needed to reduce and prevent
    further use of cost-containment measures to limit access to ADAPs and
    to allow all State ADAPs to provide a full range of HIV antiretrovirals
    and treatment for opportunistic infections.
        The number of clients entering the 349 Part C community health
    centers and outpatient clinics has consistently increased over the last
    5 years. Over 247,000 unduplicated persons living with HIV/AIDS receive
    medical care in Part C-funded community health centers and clinics each
    year. These faith- and community-based HIV/AIDS providers are
    staggering under the burden of treatment and care after years of
    funding cuts prior to the modest increase in recent years. The success
    of the CDC's routine HIV testing recommendations has generated new
    clients for Part C-funded health centers and clinics too, but
    unfortunately with no increase in funding to provide the high quality
    healthcare services and treatment access people with HIV/AIDS require.
    Ryan White-Funded Programs are Economic Engines in their Communities
        Ryan White--funded programs, including many community health
    centers, are small businesses providing jobs, vendor contracts and
    other types of economic development to low-income, urban and rural
    communities, frequently serving as anchors for existing and new
    businesses and investments. These organizations employ people in their
    communities, providing critical entry-level jobs, community-based
    training and career building.
        For example, a large, urban community health center brings an
    estimated economic impact of $21.6 million, employing 281 people, and a
    small, rural health center has an estimated economic impact of $3.9
    million, employing 52 people. Investing in AIDS care and treatment is
    an investment in jobs and community development in communities that
    need it most.
    Ryan White Program Key to Meeting the Goals of the National HIV/AIDS
            Strategy
        CAEAR Coalition is eager to work with Congress to meet the
    challenges posed by the HIV/AIDS epidemic. In 2012, we have the
    collective chance to implement the community-embraced healthcare goals
    and policies in the National HIV/AIDS Strategy (NHAS). The National
    Strategy is an opportunity to reinvigorate the Nation's response to the
    HIV/AIDS epidemic and stop its relentless movement into our
    communities. The Ryan White HIV/AIDS Program is key to reaching the
    NHAS goals of reducing new HIV infections, increasing access to care
    and improving health outcomes for people living with HIV/AIDS, and
    reducing HIV-related health disparities. Ryan White provides HIV/AIDS
    care and treatment services to a significantly higher proportion of
    racial/ethnic minorities and women than their representation among
    reported AIDS cases--suggesting the programs and resources are targeted
    to underserved and marginalized populations. Early care and treatment
    are more critical than ever because we can help those infected learn
    their status and get into care and treatment in order to improve their
    own health and the health of their communities.
        The Ryan White Program's history of accomplishments for public
    health and people living with HIV/AIDS is a wonderful legacy for the
    U.S. Congress. There continues to be a vast need for additional
    resources to address the healthcare and treatment needs of people
    living with HIV across the country. In recognition of its high level of
    effectiveness and validation over time from credible Federal Government
    institutions, CAEAR urges the committee to provide the Ryan White HIV/
    AIDS Program with the funding levels authorized by Congress for fiscal
    year 2012.
                                     ______

     Prepared Statement of the Centers for Disease Control and Prevention
                                (CDC) Coalition
        The CDC Coalition is a nonpartisan coalition of more than 140
    organizations committed to strengthening our Nation's prevention
    programs. Our mission is to ensure that health promotion and disease
    prevention are given top priority in Federal funding, to support a
    funding level for the Centers for Disease Control and Prevention (CDC)
    that enables it to carry out its prevention mission, and to assure an
    adequate translation of new research into effective State and local
    programs. Coalition member groups represent millions of public health
    workers, clinicians, researchers, educators, and citizens served by CDC
    programs.
        The CDC Coalition believes that Congress should support CDC as an
    agency--not just the individual programs that it funds. In the best
    judgment of the CDC Coalition--given the challenges and burdens of
    chronic disease, a potential influenza pandemic, terrorism, disaster
    preparedness, new and reemerging infectious diseases and our many unmet
    public health needs and missed prevention opportunities--we believe the
    agency will require funding of at least $7.7 billion for CDC's ``core
    programs'' in fiscal year 2012. This request represents a 36 percent
    increase over fiscal year 2011 and a 31 percent increase over the
    President's fiscal year 2012 request. We are deeply disappointed with
    the more than $740 million in cuts to CDC's budget authority included
    in the proposed fiscal year 2011 continuing resolution (CR). While CDC
    programs will receive significant new funding from the Prevention and
    Public Health Fund in fiscal year 2011, we are concerned that this
    funding would essentially supplant cuts made to CDC's budget authority.
    As you know the Prevention and Public Health Fund was intended to
    supplement and not supplant the base funding of our public health
    agencies and programs.
        By translating research findings into effective intervention
    efforts, CDC has been a key source of funding for many of our State and
    local programs that aim to improve the health of communities. Perhaps
    more importantly, Federal funding through CDC provides the foundation
    for our State and local public health departments, supporting a trained
    workforce, laboratory capacity and public health education
    communications systems.
        CDC also serves as the command center for our Nation's public
    health defense system against emerging and reemerging infectious
    diseases. With the potential onset of a worldwide influenza pandemic,
    in addition to the many other natural and man-made threats that exist
    in the modern world, the CDC has become the Nation's--and the world's--
    expert resource and response center, coordinating communications and
    action and serving as the laboratory reference center. States and
    communities rely on CDC for accurate information and direction in a
    crisis or outbreak.
    The Multiple Roles of CDC
        CDC serves as the lead agency for bioterrorism and other public
    health emergency preparedness and must receive sustained support for
    its preparedness programs in order for our Nation to meet future
    challenges. Given the challenges of terrorism and disaster
    preparedness, and our many unmet public health needs and missed
    prevention opportunities we urge you to provide adequate funding for
    State and local capacity grants. We ask the Subcommittee to ensure that
    our States and local communities are prepared in the event of an act of
    terrorism or other public health threat this year and in future years.
    Unfortunately, this is not a threat that is going away.
    Addressing the Leading Causes of Death and Disability
        The President's fiscal year 2012 budget proposes to consolidate a
    number of chronic disease programs within CDC. Members of the CDC
    Coalition are currently engaged in conversations with CDC and members
    of Congress to better understand what this consolidation will mean for
    the funding that is passed on to our State and local health and
    education agencies and the various programs our members have supported
    in the past. We look forward to working with Congress, the
    administration and CDC to ensure that any effort to consolidate
    programs leads to the best health outcomes for the American people. We
    must ensure that CDC's National Center for Chronic Disease Prevention
    and Health Promotion has the resources it needs to assist our States
    and communities in their efforts to reduce the burden of chronic
    disease.
        Heart disease remains the Nation's No. 1 killer. In 2007, over
    616,000 people in the United States died from heart disease, accounting
    for nearly 25 percent of all U.S. deaths. More women than men die of
    heart disease each year, and in 2007, females had higher rates of
    inpatient heart attack mortality than males. Stroke is the third
    leading cause of death and is a leading cause of disability. In 2007,
    stroke killed more than 135,000 people (61 percent of them women),
    accounting for about 1 of every 18 deaths.
        Cancer is the second most common cause of death in the United
    States. There were an estimated 1,529,560 new cancer cases and 569,490
    deaths from cancer in 2010. The financial cost of cancer is also
    significant. According to the National Institutes of Health (NIH), in
    2008 the overall cost for cancer in the United States was more than
    $228.1 billion: $93.2 billion for direct medical costs, $18.8 billion
    for lost worker productivity due to illness, and $116.1 billion for
    lost worker productivity due to premature death.
        Among the ways CDC is fighting cancer, is through funding the
    National Breast and Cervical Cancer Early Detection Program that helps
    low-income, uninsured and medically underserved women gain access to
    lifesaving breast and cervical cancer screenings and provides a gateway
    to treatment upon diagnosis. CDC also funds grants to States to develop
    Comprehensive Cancer Control (CCC) plans, bringing together a broad
    partnership of public and private stakeholders to set joint priorities
    and implement specific cancer prevention and control activities
    customized to address each State's particular needs.
        Although more than 25.8 million Americans have diabetes, nearly 7
    million cases are undiagnosed. In 2010, about 1.9 million people aged
    20 years or older were newly diagnosed with diabetes. Diabetes is the
    leading cause of kidney failure, nontraumatic lower-limb amputations,
    and new cases of blindness among adults in the United States. The total
    direct and indirect costs associated with diabetes were $178 billion in
    2007. Preventive care such as routine eye and foot examinations, self-
    monitoring of blood glucose, and glycemic control could reduce these
    numbers.
        Over the last 25 years, obesity rates have doubled among adults and
    children, and tripled in teens. Obesity, diet and inactivity are cross-
    cutting risk factors that contribute significantly to heart disease,
    cancer, stroke and diabetes. CDC funds programs to encourage the
    consumption of fruits and vegetables, encourage sufficient exercise,
    and to develop other habits of healthy nutrition and activity.
        An estimated 443,000 people die prematurely every year due to
    tobacco use. CDC's tobacco control efforts seek to prevent tobacco
    addition in the first place, as well as help those who want to quit. We
    must continue to support these vital programs and reduce tobacco use in
    the United States.
        Each day more than 3,900 young people initiate cigarette smoking.
    At the same time, according to CDC, only 3.8 percent of elementary
    schools, 7.9 percent of middle schools and 2.1 percent of high schools
    provide daily physical education or its equivalent for the entire
    school year. Almost 90 percent of young people do not eat the
    recommended number of servings of fruits and vegetables, while nearly
    30 percent of young people are overweight or at risk of becoming
    overweight. And every year, almost 800,000 adolescents become pregnant
    and nearly 4 million teens are infected with a sexually transmitted
    disease. CDC plays a critical role in ensuring good public health and
    health promotion in our schools.
        CDC provides national leadership in helping control the HIV
    epidemic by working with community, State, national, and international
    partners in surveillance, research, prevention and evaluation
    activities. CDC estimates that about 1.1 million Americans are living
    with HIV, 21 percent of who are undiagnosed. Also, the number of people
    living with HIV is increasing, as new drug therapies are keeping HIV-
    infected persons healthy longer and dramatically reducing the death
    rate. Prevention of HIV transmission is the best defense against the
    AIDS epidemic that has already killed more than 617,000 in the United
    States and dependant areas and is devastating populations around the
    globe.
        The United States has the highest rates of sexually transmitted
    diseases (STDs) in the industrialized world. More than 19 million new
    infections occur each year, almost half of them among young people. CDC
    estimates that STDs, including HIV, cost the U.S. healthcare system as
    much as $15.3 billion annually. Over the past several years,
    significant ground has been lost in the fight against STDs. While
    syphilis was on the verge of elimination in the United States at the
    start of the decade, rates have increased by 114 percent since 2000. An
    adequate investment in STD prevention could save millions in annual
    healthcare costs in the future.
        CDC and its National Center for Health Statistics collect data on
    chronic disease prevalence, health disparities, emergency room use,
    teen pregnancy, infant mortality and causes of death. The health data
    collected through the Behavioral Risk Factor Surveillance System, Youth
    Risk Behavior Survey, Youth Tobacco Survey, National Vital Statistics
    System, and National Health and Nutrition Examination Survey are an
    essential part of the Nation's statistical and public health
    infrastructure. Adequate funding for these activities is essential for
    tracking America's health as a nation and developing targeted and
    appropriate public health policies and prevention interventions.
        We must address the growing disparity in the health of racial and
    ethnic minorities. CDC is helping States address serious disparities in
    infant mortality, breast and cervical cancer, cardiovascular disease,
    diabetes, HIV/AIDS and immunizations. Our members are committed to
    ending the disparities and we encourage the Subcommittee to provide
    adequate funds for these efforts.
        CDC oversees immunization programs for children, adolescents and
    adults, and is a global partner in the ongoing effort to eradicate
    polio worldwide. The value of adult immunization programs to improve
    length and quality of life, and to save healthcare costs, is realized
    through a number of CDC programs, but there is much work to be done and
    a need for sound funding to achieve our goals. Influenza vaccination
    levels remain low for adults. Levels are substantially lower for
    pneumococcal vaccination and significant racial and ethnic disparities
    in vaccination levels persist among the elderly. In addition,
    developing functional immunization registries in all States will be
    less costly in the long run than maintaining the incomplete systems
    currently in place.
        Childhood immunizations provide one of the best returns on
    investment of any public health program. For every dollar spent on
    seven vaccines recommended in the childhood series, $16.50 is saved in
    direct and indirect costs. An estimated 14 million cases of childhood
    disease and 33,000 deaths are prevented each year through timely
    immunization. Despite the incredible success of the program, it faces
    serious financial challenges.
        Injuries are the leading causes of death for persons aged 1-44
    years. Unintentional injuries and violence such as older adult falls,
    unintentional drug poisonings, child maltreatment and sexual violence
    accounts for over 35 percent of emergency department visits annually.
    Annually, injury and violence cost the United States approximately $406
    billion in direct and indirect medical costs including lost
    productivity. Unintentional injury consistently remains the leading
    cause of death among young Americans ages 1-34 with 37.1 percent of
    unintentional fatal injuries caused by motor vehicle traffic
    fatalities. Conversely, violence related injuries are also substantial
    with homicide being the second leading cause of death for persons 15-24
    years, while suicide is the 11th leading cause of death across all age
    groups. The consequences of these injuries can be far reaching from
    physical, emotional, financial turmoil to long term disability. CDC's
    Injury Center works to prevent unintentional and violence-related
    injuries to minimize the consequences of injuries when they occur by
    researching the problem; identifying the risk and protective factors;
    developing and testing interventions; ensuring widespread adoption of
    proven strategies and gathering data to assist States and communities
    to develop prevention programs and practices through the use of
    surveillance systems like the National Violent Death Reporting System.
        One in every 33 babies born each year in the United States is born
    with one or more birth defects. Birth defects are the leading cause of
    infant mortality. Children with birth defects who survive often
    experience lifelong physical and mental disabilities. More than 50
    million people in the United States currently live with a disability,
    and 17 percent of children under the age of 18 have a developmental
    disability. The National Center on Birth Defects and Developmental
    Disabilities at CDC conducts programs to protect and improve the health
    of children and adults by preventing birth defects and developmental
    disabilities; promoting optimal child development and health and
    wellness among children and adults with disabilities.
        We also encourage the Subcommittee to provide adequate funding for
    CDC's Center for Environmental Health to revitalize environmental
    public health services at the national, State and local level and
    sustain current programs. These services are essential to protecting
    and ensuring the health and well being of the American public from
    threats associated with West Nile virus, climate change, terrorism, E.
    coli, lead-based paint and other hazards.
        We appreciate the Subcommittee's past support for CDC programs in a
    climate of competing priorities. We thank you for considering our
    fiscal year 2012 request for $7.7 billion for CDC's ``core programs.''
                                     ______

     Prepared Statement of the Charles R. Drew University of Medicine and
                                    Science
        Mr. Chairman and members of the Subcommittee, thank you for the
    opportunity to present you with testimony. The Charles Drew University
    is distinctive in being the only dually designated Historically Black
    Graduate Institution and Hispanic Serving Institution in the Nation. We
    would like to thank you, Mr. Chairman, for the support that this
    subcommittee has given to our University to produce minority health
    professionals to eliminate health disparities as well as do
    groundbreaking research to save lives.
        The Charles Drew University is located in the Watts-Willowbrook
    area of South Los Angeles. Its mission is to prepare predominantly
    minority doctors and other health professionals to care for underserved
    communities with compassion and excellence through education, clinical
    care, outreach, pipeline programs and advanced research that makes a
    rapid difference in clinical practice. The Charles Drew University has
    established a national reputation for translational research that
    addresses the health disparities and social issues that strike hardest
    and deepest among urban and minority populations.
    Health Resources and Services Administration
        Title VII Health Professions Training Programs.--The health
    professions training programs administered by the Health Resources and
    Services Administration (HRSA) are the only Federal initiatives
    designed to address the longstanding under representation of minorities
    in healthcareers. HRSA's own report, ``The Rationale for Diversity in
    the Health Professions: A Review of the Evidence,'' found that minority
    health professionals disproportionately serve minority and other
    medically underserved populations, minority populations tend to receive
    better care from practitioners of their own race or ethnicity, and non-
    English speaking patients experience better care, greater comprehension
    and greater likelihood of keeping follow-up appointments when they see
    a practitioner who speaks their language. Studies have also
    demonstrated that when minorities are trained in minority health
    professions institutions, they are significantly more likely to: (1)
    serve in medically underserved areas, (2) provide care for minorities
    and (3) treat low-income patients.
        Minority Centers of Excellence.--The purpose of the COE program is
    to assist schools, like Charles Drew University, that train minority
    health professionals, by supporting programs of excellence. The COE
    program focuses on improving student recruitment and performance;
    improving curricula and cultural competence of graduates; facilitating
    faculty and student research on minority health issues; and training
    students to provide health services to minority individuals by
    providing clinical teaching at community-based health facilities. For
    fiscal year 2012, the funding level for COE should be $24.602 million.
        Health Careers Opportunity Program.--Grants made to health
    professions schools and educational entities under HCOP enhance the
    ability of individuals from disadvantaged backgrounds to improve their
    competitiveness to enter and graduate from health professions schools.
    HCOP funds activities that are designed to develop a more competitive
    applicant pool through partnerships with institutions of higher
    education, school districts, and other community based entities. HCOP
    also provides for mentoring, counseling, primary care exposure
    activities, and information regarding careers in a primary care
    discipline. Sources of financial aid are provided to students as well
    as assistance in entering into health professions schools. For fiscal
    year 2012, the HCOP funding level of $22.133 million is recommended.
    National Institutes of Health
        National Institute on Minority Health and Health Disparities.--The
    NIMHD is charged with addressing the longstanding health status gap
    between under-represented minority and non minority populations. The
    NIMHD helps health professional institutions to narrow the health
    status gap by improving research capabilities through the continued
    development of faculty, labs, telemedicine technology and other
    learning resources. The NIMHD also supports biomedical research focused
    on eliminating health disparities and developed a comprehensive plan
    for research on minority health at NIH. Furthermore, the NIMHD provides
    financial support to health professions institutions that have a
    history and mission of serving minority and medically underserved
    communities through the COE program and HCOP. For fiscal year 2012, an
    increase proportional to NIH's increase is recommended for NIMHD to
    support these critical activities.
        Research Centers At Minority Institutions.--RCMI at the National
    Center for Research Resources (NCRR) has a long and distinguished
    record of helping institutions like The Charles Drew University develop
    the research infrastructure necessary to be leaders in the area of
    translational research focused on reducing health disparities research.
    Although NIH has received some budget increases over the last 5 years,
    funding for the RCMI program has not increased by the same rate.
    Therefore, the funding for this important program grow at the same rate
    as NIH overall in fiscal year 2012.
    Department of Health and Human Services
        Office of Minority Health.--Specific programs at OMH include:
    assisting medically underserved communities, supporting conferences for
    high school and undergraduate students to interest them in
    healthcareers, and supporting cooperative agreements with minority
    institutions for the purpose of strengthening their capacity to train
    more minorities in the health professions. For fiscal year 2012, I
    recommend a funding level of $65 million for OMH to support these
    critical activities.
    Department of Education
        Strengthening Historically Black Graduate Institutions.--The
    Department of Education's Strengthening Historically Black Graduate
    Institutions program (Title III, Part B, Section 326) is extremely
    important to MMC and other minority serving health professions
    institutions. The funding from this program is used to enhance
    educational capabilities, establish and strengthen program development
    offices, initiate endowment campaigns, and support numerous other
    institutional development activities. In fiscal year 2012, an
    appropriation of $65 million is suggested to continue the vital support
    that this program provides to historically black graduate institutions.
    Conclusion
        Despite all the knowledge that exists about racial/ethnic, socio-
    cultural and gender-based disparities in health outcomes, the gap
    continues to widen. Not only are minority and underserved communities
    burdened by higher disease rates, they are less likely to have access
    to quality care upon diagnosis. As you are aware, in many minority and
    underserved communities preventative care and research are inaccessible
    either due to distance or lack of facilities and expertise. As noted
    earlier, in just one underserved area, South Los Angeles, the number
    and distribution of beds, doctors, nurses and other health
    professionals are as parlous as they were at the time of the Watts
    Rebellion, after which the McCone Commission attributed the so-named
    ``Los Angeles Riots'' to poor services--particularly access to
    affordable, quality healthcare. The Charles Drew University has proven
    that it can produce excellent health professionals who 'get' the
    mission--years after graduation they remain committed to serving people
    in the most need. But, the university needs investment and committed
    increased support from Federal, State and local governments and is
    actively seeking foundation, philanthropic and corporate support.
        Even though institutions like The Charles Drew University are
    ideally situated (by location, population, community linkages and
    mission) to study conditions in which health disparities have been well
    documented, research is limited by the paucity of appropriate research
    facilities. With your help, the Life Sciences Research Facility will
    translate insight gained through research into greater understanding of
    disparities and improved clinical outcomes. Additionally, programs like
    Title VII Health Professions Training programs will help strengthen and
    staff facilities like our Life Sciences Research Facility.
        We look forward to working with you to lessen the huge negative
    impact of health disparities on our Nation's increasingly diverse
    populations, the economy and the whole American community.
        Mr. Chairman, thank you again for the opportunity to present
    testimony on behalf of The Charles Drew University. It is indeed an
    honor.
                                     ______

       Prepared Statement of the Children's Environmental Health Network
        On behalf of the Children's Environmental Health Network (CEHN), a
    national multi-disciplinary organization whose mission is to protect
    the fetus and the child from environmental health hazards and promote a
    healthy environment, I thank you for the opportunity to submit
    testimony in support of fiscal year 2012 appropriations for U.S.
    Department of Health and Human Services (HHS) for activities that
    protect children from environmental hazards.
        CEHN appreciates the wide range of needs that you must consider for
    funding. We urge you to give priority to those programs that directly
    protect and promote children's environmental health. In so doing, you
    will improve not only our children's health and development, but also
    their educational outcomes and their future.
        The world in which today's children live has changed tremendously
    from that of previous generations, including a phenomenal increase in
    the substances to which children are exposed. Every day, children are
    exposed to a mix of chemicals, most of them untested for their effects
    on developing systems. In general, children have unique vulnerabilities
    and susceptibilities to toxic chemicals. In some cases, an exposure
    which may cause little or no harm to an adult may lead to irreparable
    damage to a child. Exposure to neurotoxicants in utero or early
    childhood can result in life-long learning and developmental delays.
        Investments in programs that protect and promote children's health
    will be repaid by healthier children with brighter futures. Protecting
    our children--those born as well as those yet to be born--from
    environmental hazards is truly a national security issue. Cutting or
    weakening programs that protect children from harmful chemicals in
    their environment is not only very costly to our Nation (for example,
    the Clean Air Act Amendments of 1990 have saved $1 trillion in
    healthcare costs\1\), such cuts will reduce the number of exceptionally
    bright children in future generations. Our Nation's future will depend
    upon its future leaders. As our experience with removing lead from
    gasoline illustrates (removing lead in gasoline has saved the United
    States an estimated $200 billion each year since 1980 in the form of
    higher IQs for that year's newborns) \2\, when we protect children from
    harmful chemicals in their environment, we help to assure that they
    will reach their full potential. We have a responsibility to our
    Nation's children, and to the Nation that they will someday lead, to
    provide them with a healthy environment.
    ---------------------------------------------------------------------------
        \1\ Health and Welfare Benefits Analyses to Support the Second
    Section 812 Benefit-Cost Analysis of the Clean Air Act, Final Report,
    prepared by Industrial Economics for the U.S. EPA, February 2011.
        \2\ ``Economic Gains Resulting from the Reduction in Children's
    Exposure to Lead in the United States,'' Grosse SD, Matte TD, Schwartz
    J, Jackson RJ, Environ Health Perspectives 2002, 110(6): doi:10.1289/
    ehp.02110563
    ---------------------------------------------------------------------------
        Additionally, American competiveness depends on having healthy
    educated children who grow up to be healthy productive adults. Yet,
    growing numbers of our children are diagnosed with chronic and
    developmental illnesses and disabilities. The National Academy of
    Sciences estimates that toxic environmental exposures play a role in 28
    percent of neurobehavioral disorders in children and this does not
    include other conditions such as asthma or cancers. Thus it is vital
    that the Federal programs and activities that protect children from
    environmental hazards receive adequate resources. Key programs in your
    jurisdiction which CEHN urges you to support include:
    Centers for Disease Control and Prevention (CDC)
        The CDC is the Nation's leader in public health promotion and
    disease prevention, and should receive top priority in Federal funding.
    CDC continues to be faced with unprecedented challenges and
    responsibilities. CEHN applauds your support for CDC in past years and
    urges you to support a funding level of $7.7 billion for CDC's core
    programs in fiscal year 2012.
        Within CDC, the National Center for Environmental Health (NCEH) is
    particularly important to protecting the environmental health of young
    children. NCEH programs, such as its efforts to continue and expand
    biomonitoring and its national report card on exposure information, are
    key national assets. CEHN is thus deeply concerned about the proposed
    severe cuts to CDC's environmental public health programs in the
    President's fiscal year 2012 budget. We join with many others in
    strongly opposing the proposal to consolidate CDC's Healthy Homes/Lead
    Poisoning Prevention and the National Asthma Control Programs and
    reducing funding for these programs by more than half.
        The CDC's National Environmental Public Health Tracking Program
    helps to track environmental hazards and the diseases they may cause
    and to coordinate and integrate local, State and Federal health
    agencies' collection of critical health and environmental data. Public
    health officials need integrated health and environmental data so that
    they can protect the public's health. We urge you to reverse the CDC
    operating plan for fiscal year 2011, which eliminates all budget
    authority for this vital program. We urge you to support additional
    funding for the program in fiscal year 2012.
        The Built Environment and Health Program (also known as the Healthy
    Community Design Initiative) would be abolished. Other cuts to the
    center's core environmental work include its radiation activities and
    building capacity in local health departments. We urge you to oppose
    these cuts.
        CEHN also strongly supports CDC's Environmental Health Laboratory
    and its biomonitoring activities, which allow us to measure with great
    precision the actual levels of more than 450 chemicals and nutritional
    indicators in people's bodies. This information helps public health
    officials to determine which population groups are at high risk for
    exposure and adverse health effects, assess public health
    interventions, and monitor exposure trends over time.
    National Institutes of Health (NIH)
        CEHN joins others in the health field in requesting that the
    Committee provide $35 billion for the National Institutes of Health
    (NIH) in fiscal year 2012, including $779.4 million for the National
    Institute of Environmental Health Sciences (NIEHS).
        NIEHS is the leading institute conducting research to understand
    how the environment influences the development and progression of human
    disease. Children are uniquely vulnerable to harmful substances in
    their environment, and the NIEHS plays a critical role in uncovering
    the connections between environmental exposures and children's health.
    Thus it plays a vital role in our efforts to understand how to protect
    children, whether it is identifying and understanding the impact of
    substances that are endocrine disruptors or understanding childhood
    exposures that may not affect health until decades later.
        CEHN therefore urges you to provide $779.4 million for NIEHS in
    fiscal year 2012.
    Children's Environmental Health Research Centers of Excellence
        The Children's Environmental Health Research Centers, jointly
    funded by the NIEHS and the EPA, play a key role in providing the
    scientific basis for protecting children from environmental hazards.
    With their modest budgets, which have been unchanged for more than 10
    years, these centers generate valuable research. A unique aspect of
    these Centers is the requirement that each Center actively involves its
    local community in a collaborative partnership, leading both to
    community-based participatory research projects and to the translation
    of research findings into child-protective programs and policies. The
    scientific output of these centers has been outstanding. For example,
    findings from four Centers clearly showed that prenatal exposure to a
    widely used pesticide affected developmental outcomes at birth and
    early childhood. This was important information to EPA's decision
    makers in their regulation of this pesticide.
        Several Centers have established longitudinal cohorts which have
    resulted in valuable research results. The Network is concerned that as
    a Center's multi-year grant ends and the Center is shuttered, these
    cohorts and the invaluable information they can provide are being lost.
    The Network urges the Committee to assure that NIEHS has the funding
    and the direction to support Centers in continuing these cohorts.
        The work of these Centers has also shown us that, in addition to
    research regarding a specific pollutant or health outcome, research is
    desperately needed in understanding the totality of the child's
    environment--for example, all of the exposures the child experiences in
    the home, school, and child care environment--and how to evaluate those
    multiple factors. CEHN urges you to support these Centers, to assure
    they receive full funding and are extended and expanded as described
    above.
    National Children's Study
        CEHN urges the Committee to assure stable support for the National
    Children's Study (NCS) for all Institutes involved in this landmark,
    evidence-based longitudinal study examining the effects of
    environmental influences on the health and development of more than
    100,000 children across the United States. This study may be the only
    means that we will have to understand the links between exposures and
    the health and development of children and to identify the antecedents
    for a healthy adulthood. 2012 will be a critical year for the NCS. It
    is vital that the funding is in place to launch the main study
    involving all of the centers. Already approximately 700 babies have
    been born into the study.
        We urge the Committee to assure that the NCS retains on its
    original focus on environmental chemicals. While the NCS is housed at
    NIH, it must be a multi-agency study and it must be responsive to its
    mission and to the lead agencies, in and out of NIH
        CEHN also asks the Committee to direct NIH to ensure that protocols
    are in place within NCS for measuring exposures in child care and
    school settings; it is critically important to understand how school
    and child care exposures differ from home exposures very early in the
    study process.
    Pediatric Environmental Health Specialty Units
        Funded jointly by the Agency for Toxic Substances and Disease
    Registry (ATSDR) and the U.S. Environmental Protection Agency (EPA),
    the Pediatric Environmental Health Specialty Units (PEHSUs) form a
    valuable resource network, with a center in each of the U.S. Federal
    regions. PEHSU professionals provide medical consultation to healthcare
    professionals on a wide range of environmental health issues, from
    individual cases of exposure to advice regarding large-scale community
    issues. PEHSUs also provide information and resources to school, child
    care, health and medical, and community groups to help increase the
    public's understanding of children's environmental health, and help
    inform policymakers by providing data and background on local or
    regional environmental health issues and implications for specific
    populations or areas. For example, following the gulf oil spill in
    2010, the PEHSUs quickly produced and released a series of factsheets
    and advisories in multiple languages for local patients and health
    professionals. We urge the Committee to fully fund ATSDR's portion of
    this program in fiscal year 2012.
        In conclusion, investments in programs that protect and promote
    children's health will be repaid by healthier children with brighter
    futures, an outcome we can all support. That is why CEHN asks you to
    give priority to these programs. Thank you for the opportunity to
    comment. CEHN's staff and I would be happy to answer any questions you
    may have.
                                     ______

             Prepared Statement of the Coalition for Health Funding
        The Coalition for Health Funding is pleased to provide the Senate
    Labor, Health and Human Services, Education and Related Agencies
    Appropriations Subcommittee with a statement for the record on fiscal
    year 2012 funding levels for health agencies and programs. Since 1970,
    the Coalition for Health Funding has advocated for sufficient and
    sustained discretionary funding for the public health continuum to meet
    the mounting and evolving health challenges confronting the American
    people.
        Our Nation's strength is inextricably linked to our health.
    Evidence abounds--from the Department of Defense to the U.S. Chamber of
    Commerce--that healthy Americans are stronger on the battlefield, have
    higher academic achievement, and are more productive in school and on
    the job. Federal funding helps discover cures and fuel innovation,
    ensure the safety of our drugs, food, water, and air, prevent disease,
    protect and respond in times of crisis, train healthcare professionals,
    and provide care to our Nation's most vulnerable. Much of what public
    health does--and the impact of Federal investment in it--is such a part
    of Americans' daily living that it is often invisible and almost always
    taken for granted. For example, Federal health funding has:
      --Improved and saved the lives of many of those suffering from
            illnesses through scientific innovation and discovery.
      --Prevented unnecessary and costly injuries through seat belt and
            helmet laws, mandatory airbags, and car seats for infants and
            toddlers.
      --Promoted safe and healthy foods through dietary guidelines and food
            labeling that help Americans better understand what we eat and
            how to eat better.
      --Improved the health of mothers and reduced birth defects and infant
            deaths through recommendations to take folic acid during early
            stages of pregnancy, place babies on their backs to prevent
            Sudden Infant Death Syndrome, and avoid tobacco and alcohol use
            during pregnancy.
      --Combated tobacco addiction by regulating advertisements, imposing
            age limits on tobacco purchases, and instituting smoking bans
            in public places, cutting smoking rates by nearly half and
            reducing the number of smoking-related deaths and illnesses and
            the opportunity and real costs associated with them.
      --Treated and eradicated infectious diseases through vaccines,
            preventing epidemics and saving lives.
      --Improved the environment through bans on asbestos in household
            products and lead in paint and gasoline.
      --Protected the American people in all communities from infectious,
            occupational, environmental, and terrorist threats.
        These are just some of the ways in which Federal funding for public
    health has changed our lives and those of our children for the better.
    Still, Federal funding is necessary to further improve, save, and
    protect those in America and around the world. The treatments and cures
    for many devastating diseases are just out of reach. Racial,
    socioeconomic, and geographic health disparities persist. Costly and
    often preventable chronic conditions such as asthma, diabetes, heart
    disease and obesity--particularly among young people--are on the rise
    and threaten military readiness, academic achievement, and societal
    productivity. The failure to prioritize behavioral health issues
    continues to have stunning, debilitating social and economic
    consequences. Oral health is still not widely recognized as a
    healthcare priority in spite of the fact that tooth decay remains a
    common chronic disease among all ages and is preventable.
        The Coalition for Health Funding's 70 national, member
    organizations--representing the interests of more than 100 million
    patients, healthcare providers, public health professionals, and
    scientists--support the belief that the Federal Government is an
    essential partner with State and local governments and the nonprofit
    and private sectors in improving health. A pressing and immediate goal
    is to build the capacity of our public health system to address
    America's mounting health needs under the weight of a fragile economy,
    an aging population, a health workforce shortage, and persisting
    declines in health status.
        Given current fiscal challenges, the Coalition for Health Funding
    appreciates the efforts of the President and Congress to maintain
    funding for many critical health programs in the final fiscal year 2011
    spending legislation. Nevertheless, the Coalition remains concerned
    about prospects for future cuts to health programs. The Coalition
    supports fiscal responsibility, but not at the expense of America's
    health and well-being. Cuts to federally funded health services and
    scientific research will not significantly reduce the deficit, nor make
    a dent in the national debt; discretionary health spending represents
    less than 2 percent of all Federal spending. These cuts adversely
    affect American families, cost jobs, and ultimately compromise
    America's global competitiveness and economic growth.
        The Coalition for Health Funding organized more than 470 national,
    State, and local organizations and six former Surgeons General in a
    letter that urged Congress to increase discretionary health funding.
    The following list summarizes the Coalition for Health Funding's fiscal
    year 2012 funding recommendations for health agencies under the
    subcommittee's jurisdiction.
    National Institutes of Health (NIH)
        The Coalition supports $35 billion in fiscal year 2012 for NIH, a
    14.4 percent increase over the fiscal year 2011 funding level and a 10
    percent increase over the President's fiscal year 2012 request. The
    partnership between NIH and America's scientific research community is
    a national investment in improving the health and quality of life of
    all Americans. As the primary Federal agency responsible for conducting
    and supporting medical research, NIH-funded research drives scientific
    innovation and develops new and better diagnostics, improved prevention
    strategies, and more effective treatments.
        NIH-funded research also contributes to the Nation's economic
    strength by creating skilled, high-paying jobs; new products and
    industries; and improved technologies. More than 83 percent of NIH
    research funding is awarded to more than 3,000 universities, medical
    schools, teaching hospitals, and other research institutions, located
    in every State. The Nation's longstanding, bipartisan commitment to NIH
    has established the United States as the world leader in medical
    research and innovation. Other countries, such as China and India, are
    increasing their funding of scientific research because they understand
    its critical role in spurring technological advances and other
    innovations. If the United States is to continue to compete in a
    global, information-based economy, it too must continue to invest in
    research programs such as NIH.
    Centers for Disease Control and Prevention (CDC)
        The Coalition for Health Funding recommends a level of $7.7 billion
    for CDC's core programs in fiscal year 2012, a 36 percent increase over
    fiscal year 2011 and a 31 percent increase over the President's fiscal
    year 2012 request. This amount is representative of what CDC needs to
    fulfill its core mission in fiscal year 2012; activities and programs
    that are essential to protect the health of the American people. CDC
    continues to be faced with unprecedented challenges and
    responsibilities, ranging from chronic disease prevention, eliminating
    health disparities, bioterrorism preparedness, to combating the obesity
    epidemic. In addition, CDC funds community programs in injury control;
    health promotion efforts in schools and workplaces; initiatives to
    prevent diabetes, heart disease, cancer, stroke, and other chronic
    diseases; improvements in nutrition and immunization; programs to
    monitor and combat environmental effects on health; prevention programs
    to improve oral health; prevention of birth defects; public health
    research; strategies to prevent antimicrobial resistance and infectious
    diseases; and data collection and analysis on a host of vital
    statistics and other health indicators. It is notable that more than 70
    percent of CDC's budget flows out to States and local health
    organizations and academic institutions, many of which are currently
    struggling to meet growing needs with fewer resources.
    Health Resources and Services Administration (HRSA)
        The Coalition for Health Funding recommends an overall funding
    level of $7.65 billion for HRSA in fiscal year 2012, a 22 percent
    increase over fiscal year 2011 and a 12 percent increase over the
    President's fiscal year 2012 request. HRSA operates programs in every
    State and thousands of communities across the country. It is a national
    leader in providing health services for individuals and families,
    serving as a health safety net for the medically underserved.
        Over the past several years, HRSA has received mostly level
    funding, undermining the ability of its successful programs to grow.
    Additionally, the deep cuts made to the agency in the final fiscal year
    2011 continuing resolution will likely have negative consequences for
    public health. Therefore, the requested minimum level of funding for
    fiscal year 2012 is critical to allow the agency to carry out critical
    public health programs and services that reach millions of Americans,
    including developing the public health and healthcare workforce;
    delivering primary care services through community health centers;
    improving access to care for rural communities; supporting maternal and
    child healthcare programs; providing healthcare to people living with
    HIV/AIDS; and many more. However, much more is needed for the agency to
    achieve its ultimate mission of ensuring access to culturally
    competent, quality health services; eliminating health disparities; and
    rebuilding the public health and healthcare infrastructure.
    Substance Abuse and Mental Health Services Administration (SAMHSA)
        The Coalition for Health Funding recommends an overall funding
    level of $3.671 billion for SAMHSA in fiscal year 2012, an 8.6 percent
    increase over fiscal year 2011 and an 8.4 percent increase over the
    President's fiscal year 2012 request. According to recent results from
    a national survey conducted by SAMHSA, 45.1 million American adults in
    the United States have experienced mental illness over the past year.
    However, only two-thirds of adults in the United States with mental
    illness in the past year received mental health services.
        In fact, suicide claims over 34,000 lives annually, the equivalent
    of 94 suicides per day; one suicide every 15 minutes. In the past year,
    8.4 million adults aged 18 or older thought seriously about committing
    suicide, 2.3 million made a suicide plan, and 1.1 million attempted
    suicide. The funding for community mental health services from SAMHSA
    has never been more critical especially in light of the $2.2 billion
    reduction in State mental health funding for programs serving this
    vulnerable population.
    Agency for Healthcare Research and Quality (AHRQ)
        The Coalition for Health Funding recommends an overall funding
    level of $405 million for AHRQ in fiscal year 2012, a 9 percent
    increase over fiscal year 2011 and a 10 percent increase over the
    President's fiscal year 2012 request. AHRQ funds research and programs
    at local universities, hospitals, and health departments that improve
    healthcare quality, enhance consumer choice, advance patient safety,
    improve efficiency, reduce medical errors, and broaden access to
    essential services--transforming people's health in communities in
    every State around the Nation. Specifically, the science funded by AHRQ
    provides consumers and their healthcare professionals with valuable
    evidence to make the right healthcare decisions for themselves and
    their families. AHRQ's research also provides the basis for protocols
    that reduce hospital-acquired infections, and improve patient
    confidence, experiences, and outcomes.
        The Coalition for Health Funding appreciates this opportunity to
    provide its fiscal year 2012 discretionary health funding
    recommendations and looks forward to working with the Subcommittee in
    the coming weeks and months.
                                     ______

        Prepared Statement of the Coalition for Health Services Research
        The Coalition for Health Services Research (Coalition) is pleased
    to offer this testimony regarding the role of health services research
    in improving our Nation's health. The Coalition's mission is to support
    research that leads to accessible, affordable, high-quality healthcare.
    As the advocacy arm of AcademyHealth, the Coalition represents the
    interests of more than 4,000 scientists and policy experts throughout
    the country and 160 organizations that produce and use research that
    improves health and healthcare. We advocate for the funding to support
    health services research and health data; better access to data and
    information to use in producing this research; and more transparent
    dissemination of the results of this research.
        Health services research studies how to make the healthcare system
    work better and deliver improved outcomes for more people, at great
    value. These scientific findings improve healthcare by informing
    patient and healthcare provider choices; enhancing the quality,
    efficiency, and value of the care patients receive; and improving
    patients' access to care. Health services research both uncovers
    critical challenges confronting our Nation's healthcare system, and
    seeks ways to address them. For example, health services research tells
    us:
      --Only 55 percent of adults receive recommended care and 47 percent
            of children receive indicated care (McGlynn et al, 2003;
            Mangione-Smith et al, 2007).
      --The increased prevalence of obesity is responsible for almost $40
            billion of increased medical spending through 2006, including
            $7 billion in Medicare prescription drug costs (Finkelstein,
            2009).
      --How hospitals were able to achieve more than 60 percent reduction
            in rates of bloodstream infections in very sick patients
            (Pronovost et al, 2006).
      --More than 83,000 excess deaths each year could be prevented in the
            United States if the health disparities could be eliminated
            (Satcher et al, 2005).
      --The percentage of heart attack patients receiving needed
            angioplasties within the recommended 90 minutes of arriving at
            the hospital improved from just 42 percent in 2005 to 81
            percent by 2008 (Agency for Healthcare Research and Quality,
            2011).
        The primary economic rationale for a Government role in funding
    health services research is that the private market would not
    adequately supply for it, since the full economic value of the evidence
    is unlikely to accrue solely to its discoverer. Like any corporation
    making sure it is developing and providing high quality products
    through R&D, the Federal Government has a responsibility to get the
    most out of every taxpayer dollar it spends on Federal health
    programs--Medicare, Medicaid, veterans' and service members'
    healthcare--by funding research that helps enhance their performance.
        Finding new ways to get the most out of every healthcare dollar is
    critical to our Nation's long-term fiscal health. Funding for research
    on the quality, value, and organization of the health system will
    deliver real savings for the Federal Government, employers, insurers,
    and consumers. Research into the merits of different policy options for
    delivery system transformation, patient-centered quality improvement,
    community health, and disease prevention offers policymakers in both
    the public and private sectors the information they need to improve
    quality and outcomes, identify waste, eliminate fraud, increase
    efficiency and value, and promote personal responsibility.
        Despite the positive impact health services research has had on the
    U.S. healthcare system, and the potential for future improvements in
    quality and value, the United States spends less than 1 cent of every
    healthcare dollar on this research; research that can help Americans
    spend their healthcare dollars more wisely and make more informed
    healthcare choices.
        The Coalition for Health Services Research greatly appreciates the
    subcommittee's efforts to increase the Federal investment in health
    services research and health data. We respectfully ask that the
    subcommittee further strengthen capacity of health services research to
    address the pressing challenges America faces in providing access to
    high-quality, efficient care for all its citizens. The following list
    summarizes the Coalition's fiscal year 2012 funding recommendations for
    agencies that support health services research and health data under
    the subcommittee's jurisdiction.
    Agency for Healthcare Research and Quality (AHRQ)
        AHRQ funds research and programs at local universities, hospitals,
    and health departments that improve healthcare quality, enhance
    consumer choice, advance patient safety, improve efficiency, reduce
    medical errors, and broaden access to essential services--transforming
    people's health in communities in every State around the Nation. The
    science funded by AHRQ provides consumers and their healthcare
    professionals with valuable evidence to make the right healthcare
    decisions for themselves and their families. AHRQ's research also
    provides the basis for protocols that prevent medical errors and reduce
    hospital-acquired infections, and improve patient confidence,
    experiences, and outcomes in hospitals, clinics, and physician offices.
        The Coalition joins the Friends of AHRQ--an alliance of more than
    250 health professional, research, consumer, and employer organizations
    that support the agency--in recommending an overall funding level of
    $405 million for AHRQ in fiscal year 2012, a 9 percent increase over
    fiscal year 2011 and a 10 percent increase over the President's fiscal
    year 2012 request. Within the funding provided to AHRQ, the Coalition
    recommends that the subcommittee support:
      --A Breadth of Research Topics.--During the last decade, AHRQ's
            research portfolio has focused predominantly on patient safety
            and healthcare quality. There has been less investment in
            research that provides evidence to improve the efficiency and
            value of the healthcare system itself. The Coalition is
            grateful to the subcommittee for its leadership in building a
            more balanced research agenda at AHRQ, and requests continued
            support for all aspects of research outlined in AHRQ's
            statutory mission, including the ways in which healthcare
            services are organized, delivered, and financed.
      --Innovation through Competition.--Many of the sentinel studies that
            have changed the face of health and healthcare in the United
            States--diagnosis-related groups for hospital payments, check-
            lists for improved patient safety, geographic variation in
            healthcare, re-hospitalizations among Medicare beneficiaries--
            are the result of ingenuity on the part of investigators and
            rigorous, scientific competition. Federal support for
            innovative approaches to problem solving increases
            opportunities for constructive competition and creative
            solutions. The Coalition is grateful to the subcommittee for
            its leadership in recognizing the value of investigator-
            initiated research at AHRQ and requests sustained momentum for
            these competitive, innovative grants that advance discovery and
            the free marketplace of ideas.
      --The Next Generation of Researchers.--At the direction of the
            subcommittee, AHRQ has doubled its investment in training
            grants for the next generation of researchers. Still, training
            grants for new researchers--both physicians and non-
            physicians--fall far short of what is needed to meet growing
            public and private sector demands for health services research.
            The Coalition appreciates the subcommittee's continuing support
            of the next generation of researchers and requests that funding
            for training grants be increased to ensure America stays
            competitive in the global research market.
      --Research Translation and Dissemination.--Health services research
            has great potential to improve health and healthcare when
            widely used by patients, providers, and policymakers. The
            Coalition recommends that the subcommittee support AHRQ's
            research translation and dissemination activities, including
            patient forums, practice-based research centers, and learning
            networks. These programs are designed to move the best
            available research and decisionmaking tools into healthcare
            practice and thus enhance patient choice and improve healthcare
            delivery.
    Centers for Disease Control and Prevention (CDC)
        The National Center for Health Statistics (NCHS) is the Nation's
    principal health statistics agency. Housed within CDC, NCHS provides
    critical data on all aspects of our healthcare system through data
    cooperatives and surveys that serve as a gold standard for data
    collection around the world. The Coalition appreciates the
    subcommittee's leadership in securing steady and sustained funding
    increases for NCHS in recent years. Such efforts have allowed NCHS to
    reinstate some data collection and quality control efforts, continue
    the collection of vital statistics, and enhance the agency's ability to
    modernize surveys to reflect changes in demography, geography, and
    health delivery.
        We join the Friends of NCHS--a coalition of more than 250 health
    professional, research, consumer, industry, and employer organizations
    that support the agency--in endorsing the President's fiscal year 2012
    request of $162 million, a funding level that will build on previous
    investments and put the agency on track to become a fully functioning,
    21st century, national statistical agency.
        The Patient Protection and Affordable Care Act recognizes the need
    for linking the medical care and public health delivery systems by
    authorizing a new CDC research program to study public health systems
    and service delivery. If funded in fiscal year 2012, this program will
    identify effective strategies for organizing, financing, and delivering
    public health services in real-world community settings by, for
    example, comparing State and local health department structures and
    systems in terms of effectiveness and costs. The Coalition urges you to
    appropriate $35 million in fiscal year 2012 for Public Health Services
    and Systems Research at CDC, enabling us to study ways to improve the
    efficiency and effectiveness of public health service delivery.
    National Institutes of Health (NIH)
        NIH reports that it spent $1.1 billion on health services research
    in fiscal year 2010--roughly 3.6 percent of its entire budget--making
    it the largest Federal sponsor of health services research. For fiscal
    year 2012, the Coalition joins the Ad Hoc Group for Medical Research in
    requesting $35 billion for NIH in fiscal year 2012, which would, based
    on historical funding levels, provide roughly $1.3 billion for the
    agency's health services research portfolio. The Coalition believes
    that NIH should increase the proportion of its overall funding that
    goes to health services research to ensure that discoveries from
    clinical trials are effectively translated into health services. We
    also encourage NIH to foster greater coordination of its health
    services research investment across its institutes.
    Centers for Medicare and Medicaid Services (CMS)
        Steady funding reductions for the Office of Research, Development
    and Information have hindered CMS's ability to meet its statutory
    requirements and conduct new research to strengthen public insurance
    programs--including Medicare, Medicaid, and the Children's Health
    Insurance Program--which together cover nearly 100 million Americans
    and comprise almost half of America's total health expenditures. As
    these Federal entitlement programs continue to pose significant budget
    challenges for both Federal and State governments, it is critical that
    we adequately fund research to evaluate the programs' efficiency and
    effectiveness and seek ways to manage their projected spending growth.
        The Coalition supports an fiscal year 2012 base funding level of
    $40 million for CMS's discretionary research and development budget.
    This funding is a critical down payment to help CMS restore research to
    evaluate its programs, analyze pay for performance and other tools for
    updating payment methodologies, and further refine service delivery
    methods.
        In conclusion, the accomplishments of health services research
    would not be possible without the leadership and support of this
    subcommittee. Health services research will continue to yield valuable
    scientific evidence in support of improved quality, accessibility, and
    affordability of healthcare. We urge the subcommittee to accept our
    fiscal year 2012 funding recommendations for the Federal agencies
    funding health services research and health data.
        If you have questions or comments about this testimony, please
    contact our Washington, DC, representative, Emily Holubowich at
    eholubowich@dc-crd.com.
                                     ______

        Prepared Statement of the Coalition for International Education
        Mr. Chairman and Members of the Subcommittee: We are pleased to
    submit the views of the Coalition for International Education on fiscal
    year 2012 funding for the Higher Education Act, Title VI and the Mutual
    Educational and Cultural Exchange Act, Section 102(b)(6), commonly
    known as Fulbright-Hays. The Coalition for International Education
    consists of over 30 national higher education organizations with
    interest in the U.S. Department of Education's international and
    foreign language education programs. The Coalition represents the
    Nation's 3,300 colleges and universities, and organizations
    encompassing various academic disciplines, as well as the international
    exchange and foreign language communities.
        We express our deep appreciation for the Subcommittee's long-time
    support for the U.S. Department of Education's premier international
    and foreign language education programs noted above. We recognize the
    difficult decisions Congress and the Administration faced on education
    spending cuts for the remainder of fiscal year 2011, and now face for
    fiscal year 2012. However, we are deeply concerned over the severe and
    disproportionate $50 million or 40 percent cut to the Title VI/
    Fulbright-Hays programs under H.R. 1473, the final fiscal year 2011
    Continuing Resolution agreement. Title VI/Fulbright-Hays contain 14
    small ``pipeline'' programs, 12 of which are under $20 million. A cut
    of this magnitude will seriously weaken our Nation's world-class
    international education capacity, which has taken decades to build and
    would be impossible to easily recapture. Among the first casualties
    likely will be the high-cost, low-enrollment critical language programs
    needed for national security, such as Pashto or Urdu.
        Today we strongly urge the Appropriations Committee to safeguard
    these programs by providing funding for them that is equal to their
    fiscal year 2010 funding levels in the fiscal year 2012 appropriations
    bill. For the International and Foreign Language Studies account, we
    urge a total of $125.881 million, which includes $108.360 million for
    Title VI-A&B; $15.576 million for Fulbright-Hays 102(b)(6); and $1.945
    million for the Institute for International Public Policy, Title VI-C.
        After 9/11, Congress began a decade of enhancements to Title VI/
    Fulbright because of the sudden awareness of an urgent need to improve
    the Nation's in-depth knowledge of world areas and transnational
    issues, and fluency of U.S. citizens in foreign languages.
    Unfortunately these gains and many program enhancements on strategic
    world areas will be eliminated unless funding is restored to fiscal
    year 2010 levels.
        We believe maintaining a strong Federal role in these programs is
    critical to supporting our Nation's long-term national security, global
    leadership, economic competitiveness capabilities, as well as mutual
    understanding and collaboration around the world. Successful U.S.
    engagement in these areas, at home or abroad, relies on Americans with
    global competence, including foreign language skills and the ability to
    understand and function in different cultural and business
    environments.
    Background and Federal Role
        In 1958 at the height of the cold war, Congress created NDEA-Title
    VI out of a sense of crisis about U.S. ignorance of other countries and
    cultures. Fulbright 102(b)(6) was created in 1961 and placed with Title
    VI to provide complementary overseas training. These programs have
    served as the lynchpin for producing international specialists for more
    than five decades, and continue to do so. Improving over time to
    address new global challenges and expanded needs across the Nation's
    workforce, 14 Title VI/Fulbright-Hays programs support activities to
    improve capabilities and knowledge throughout the educational pipeline,
    from K-12 through the graduate levels and advanced research, with
    emphasis on the less commonly-taught languages and areas, such as
    China, Russia, India and the Muslim world. Today they are the Federal
    Government's most comprehensive programs supporting the development of
    high quality national capacity in international, foreign language and
    business education and research. A March 2007 report by the National
    Academies of Sciences (NAS) concluded, ``Title VI/Fulbright-Hays serve
    as our Nation's foundational programs for building U.S. global
    competence.''
        This Federal-university partnership ensures resources and knowledge
    are available to meet national needs that are not priorities of
    individual States or universities. Federal resources are essential
    incentives to develop and sustain high-cost programs in the less
    commonly-taught languages and world areas, and provide extensive
    outreach and collaboration among educational institutions, government
    agencies, and corporations. Most of these programs would not exist
    without Federal support, especially at a time when State/local
    governments and institutions of higher education are financially
    strapped.
    Why Investing in Title VI/Fulbright-Hays Is Important
        The NAS reported in 2007: ``A pervasive lack of knowledge about
    foreign cultures and foreign languages in this country threatens the
    security of the United States as well as its ability to compete in the
    global marketplace and produce an informed citizenry.''
        Government Needs.--The quantity, level of expertise, and
    availability of U.S. personnel with high-level expertise in foreign
    languages, cultures, and political, economic and social systems
    throughout the world do not match our national strategic needs at home
    or abroad. Some 80 Federal agencies depend in part on proficiency in
    more than 100 foreign languages; in 1985, only 19 agencies identified
    such requirements.

        ``Foreign language skills are vital to effectively communicate and
    overcome language barriers encountered during critical operations and
    are an increasingly key element to the success of diplomatic efforts,
    military operations, counterterrorism, law enforcement and intelligence
    missions, as well as to ensure access to Federal programs and services
    to Limited English Proficient (LEP) populations within the United
    States.'' David Maurer Testimony on Foreign Language Capabilities.
    Departments of Homeland Security, Defense, and State Could Better
    Assess their Foreign Language Needs and Capabilities and Address
    Shortfalls, GAO, July 2010
        ``As of October 31, 2008, 31 percent of Foreign Service officers in
    overseas language-designated positions (LDP) did not meet both the
    foreign languages speaking and reading proficiency requirements for
    their positions. State continues to face foreign language shortfalls in
    regions of strategic interest--such as the Near East and South and
    Central Asia, where about 40 percent of officers in LDPs did not meet
    requirements. Past reports by GAO, State's Office of the Inspector
    General, and others have concluded that foreign language shortfalls
    could be negatively affecting U.S. activities overseas.'' Comprehensive
    Plan Needed to Address Persistent Foreign language Shortfalls, GAO,
    September 2009.

        Workforce Needs.--National security is increasingly linked to
    commerce, and U.S. business is widely engaged around the world with
    joint ventures, partnerships, and economic linkages that require its
    employees to have international expertise both at home and abroad.

        ``Most of the growth potential for U.S. businesses lies in overseas
    markets. Already, one in five U.S. manufacturing jobs is tied to
    exports. Foreign consumers, the majority of whom primarily speak
    languages other than English, represent significant business
    opportunities for American producers, as the United States is home to
    less than 5 percent of the world's population. American companies lose
    an estimated $2 billion a year due to inadequate cross-cultural
    guidance for their employees in multicultural situations.'' Education
    for Global Leadership, Committee for Economic Development, 2006.

        Education Needs.--Education institutions at all levels are
    challenged to keep up with rapidly expanding 21st century needs for
    global competence.
      -- Although higher education foreign language enrollments have
            increased and diversified over the past decade, according to
            the Modern Language Association's 2010 survey, enrollments are
            only 8.7 percent of total student enrollments, well behind the
            1960 high point of 16 percent.
      -- Only 5 percent of all higher education students taking foreign
            languages study non-European languages spoken by roughly 85
            percent of the world's population.
      -- Less than 2 percent of students in U.S. postsecondary education
            study abroad, and only about half studied outside Western
            Europe. Yet, an educational experience abroad is an essential
            element for achieving foreign language fluency, learning how to
            function in other cultures, and developing mutual understanding
            with others beyond our borders.
      -- U.S. educational institutions from K-16 face a shortage of
            teachers and faculty with international knowledge and expertise
            across the professions and across types of higher education
            institutions. This problem is especially acute for foreign
            language teachers of the less commonly taught languages.
    What Title VI/Fulbright-Hays Programs Do
        Title VI/Fulbright programs produce U.S. experts, prepare Americans
    for the global workplace, and generate knowledge on the foreign
    languages and business, economic, political, social, cultural and
    regional affairs of other countries and world areas. Grantees also
    engage in extensive outreach and collaboration across the educational
    spectrum, and with business, government, the media and the general
    public. Title VI-funded centers are relied upon for their expertise by
    Federal agencies, corporations, and local school districts. Their many
    accomplishments include the following:
    Language and Culture
        Through several pipeline programs, Title VI institutions provide
    the major, and often the only, source of national expertise and
    research on non-European countries and their languages.
        Title VI institutions account for 21 percent of undergraduate
    enrollment and 56 percent of graduate enrollment in the less commonly
    taught languages (LCTLs) such as Arabic and Chinese. For the least
    commonly taught languages such as Pashto and Urdu, Title VI
    institutions account for 49 percent of undergraduate and 78 percent of
    graduate enrollments.
        Title VI institutions provide instruction and R&D in over 130
    languages and in all world areas, and have the capacity to teach over
    200 languages. Because of the high cost per student, many of these
    languages would not be taught on a regular basis but for Title VI/
    Fulbright support. In contrast, the Defense Language Institute (DLI)
    and the Foreign Service Institute (FSI) together offer instruction in
    only 75 LCTLs.
        Title VI/Fulbright programs support advanced research abroad in
    international, area and language studies--such as through the Fulbright
    programs and overseas research centers--that otherwise would have few
    or no other funding sources.
        Title VI programs support the development and maintenance of world
    class digital information resources in international, area and foreign
    language studies--using modern technologies for accessibility--that
    exist no where else in the world.
         Title VI/Fulbright programs provide opportunity and access to all
    types of institutions of higher education, including minority-serving
    institutions, community colleges, and small and medium-sized 4-year
    institutions. With seed funding from the Undergraduate International
    Studies and Foreign Language, Institute for International Public Policy
    and Fulbright programs, training, fellowship, scholarship and study
    abroad opportunities are provided to students, faculty and
    administrators.
         With enhancements provided by Congress between 2000-08, Title VI
    National Resource Centers increased annual job placements in key
    sectors. 2008 placements and percent increase over 2000: Federal
    Government 1,515 (+32 percent), U.S. military 552 (+20 percent),
    international organizations 1,567 (+22 percent), and higher education
    3,414 (+51 percent).
        During this same period, the NRCs have seen triple digit increases
    in courses and enrollments in critical languages. Between 2000 and
    2008, enrollments in Arabic increased from 5,218 to 16,721, in Chinese
    from 9,637 to 23,724, in Persian from 1,231 to 3,878, in Turkish from
    594 to 1,602, and in Urdu from 221 to 904.
        Examples of renowned graduates include Secretary of Defense Robert
    Gates, General John Abizaid, former Ambassador to Russia James Collins,
    advisor to six Secretaries of State Aaron David Miller, and NY Times
    Pulitzer prize-winning journalist Anthony Shadid.
    International Business
        Title VI supports two important programs that internationalize
    business education, train Americans for the global workplace, and help
    U.S. small and mid-size businesses engage emerging markets: Centers for
    International Business Education and Research (CIBERs) and Business and
    International Education (BIE).
        CIBERs offer training at all levels of education in all 50 States,
    including training for managers already active in the workforce, and
    research on cutting edge issues affecting the U.S. business
    environment, the Nation's global economic competitiveness and homeland
    security.
        Before these programs were established, few business education
    programs in the United States incorporated a global dimension. Over 2
    million students have taken international business courses through
    CIBER programs and over 160,000 faculty have gained international
    business and cultural expertise through faculty programs, domestically
    and abroad.
        Over 42,000 language faculty have participated in over 900
    international business language workshops, and 4.5 million students
    across the United States have benefited from enhanced commercial
    foreign language instruction.
    Outreach
        Title VI/Fulbright grantees provide access to international
    knowledge to other institutions of higher education, government,
    business, K-12 and the public through web resources, seminars, training
    and other means. Many educators, government agencies, nonprofit groups
    and corporations depend on these resources. Without Title VI/Fulbright
    funding, this outreach would disappear.
        Title VI National Resource Centers provide training and
    consultation for foreign language and area staff in many government
    agencies. For example, the U.S. Army Foreign Area Officer (FAO) Program
    sends its officers to Title VI centers for their M.A. in language and
    area studies training and has done so since the inception of the FAO
    program three decades ago.
        Title VI Language Resource Centers (LRC) train an estimated 2,000
    teachers annually, and develop resources in critical languages used by
    educators and government agencies. For example, an LRC recently
    developed a free iPad app that provides tutorials in Pashto for U.S.
    soldiers in Afghanistan.
        CIBER and BIE grantees work closely with the U.S. Department of
    Commerce and with the local District Export Councils on export
    development. In response to President Obama's 2010 National Export
    Initiative (NEI), the CIBERs continue to expand the global knowledge
    base of U.S. companies, enabling and assisting them to export their
    goods and services especially to the BRIC and other emerging markets.
    By enabling small and mid-sized U.S. business to increase exports,
    CIBER/BIE activities support job creation in America and reduction of
    the trade deficit.
        Title VI grantees also work extensively with minority-serving
    institutions of higher education, community colleges and K-12 on
    language and culture programs, as well as with the media to promote
    citizen understanding of complex global issues.
        Clearly, this Federal-higher education partnership pays dividends
    that vastly outweigh the small 0.2 percent investment within the
    Department of Education's budget.
                                     ______

          Prepared Statement of the Coalition for Workforce Solutions
        I represent The Coalition for Workforce Solutions (CWS), a national
    organization exclusively representing employers, workforce development
    providers, vendors and service organizations that operate and utilize
    One-Stop Career Centers, Temporary Assistance for Needy Families
    initiatives, career and technical education programs and workforce
    investment services. Members of CWS are proud to play a role in our
    workforce system as it promotes economic growth while giving
    unemployed, underemployed and disadvantaged workers an opportunity to
    gain new skills.
        Today, while the Nation faces many complex challenges in light of
    mass layoffs and business realignments, the private sector is showing
    signs of recovery and businesses new and old need increased assistance
    in addressing their workforce needs. And our national network of WIA
    supported workforce services is in a unique position not only to train
    workers for economic recovery, but to match large and small employers
    with qualified workers in advanced manufacturing, healthcare, energy
    and other high-growth sectors. As the economy grows, our workforce
    system should be maintained and strengthened, not reduced or targeted
    for elimination.
        We understand the budget issues and the need for debt reduction. We
    are confident that through integration of workforce services there is
    the capacity to maintain the existing level of service to the job
    seekers and employers. We look to the State of Florida and Texas as the
    model of integrated services for replication nationwide. This will
    ensure our workforce development and job-training system continues its
    vital support for businesses of all sizes to create and retain jobs,
    provide needed skills and transition assistance to workers, and enhance
    economic growth through the private sector in thousands of communities
    around the country.
        Our Nation's workforce systems funded through WIA have become
    critical partners in regional economic development efforts--from
    directly supporting efforts to recruit new businesses (by offering
    access to skilled workers and employment and training incentives), to
    saving money for local businesses as they begin to rehire workers. The
    programs also assist businesses to avert layoffs through skills
    upgrading, and support businesses that are closing or downsizing. These
    partnerships with employers and economic development services are
    critical to helping businesses survive and contribute to regional
    economic growth and prosperity. Now is not the time to take away these
    vital services when economic growth is paramount to our recovery and
    competitiveness.
        WIA has experienced a 234 percent increase in demand for services
    since the onset of the recession and demand remains steady as the
    economy grows. It is easy to see why this is so: the one-stop system
    supported with WIA funds fosters community partnerships that drive job
    creation and economic recovery efforts while also providing vital labor
    market information, skills assessments, career guidance, counseling,
    employment assistance, support and training services to jobseekers and
    workers who need help in getting good jobs.
        In every State and region, the workforce system addresses the needs
    of business so that local companies can remain competitive. By building
    relationships with community development organizations and local
    officials, businesses are provided with a collaborative network of
    support that is best-suited to the needs of employers. Only this system
    can provide businesses with the resources they can use to survive and
    thrive in this difficult economic time.
        In fact, the workforce system is the only system of its kind to
    engage employers and address the kind of compelling challenges that
    business face in the following areas:
      --Reducing turnover in entry level occupations in high growth
            industries such as healthcare through early immersion and
            career ladder programs.
      --Finding the talent that advanced manufacturing companies need to
            compete by training workers in new skills and providing the
            next generation of workers a path to the modern workforce.
      --Supporting economic development and business attraction activities
            so that new employers and manufacturers get assistance in
            determining local infrastructure, specific fits for training
            needs, and whatever it takes to be successful.
      --Preparing youth in high demand IT careers as well as providing soft
            skills training, job search preparation, coaching and the life
            transforming skills that businesses need to develop a stable,
            high-quality workforce.
      --Improving hiring efficiency such that employers improve their
            application conversion rate by 50 percent through collaborative
            partnerships with the workforce system that produce qualified
            candidates with the right skill-sets, dedication and motivation
            that employers need.
        Businesses as well as jobseekers and workers benefit from WIA
    services. Research indicates that the workforce system produces a high
    return on investment. Last year, over 8 million job-seekers utilized
    the workforce system and over 4.3 million of them got jobs. While this
    is less than the normal 80 to 85 percent placement rate common in
    stronger economic times, the recent job environment had four jobseekers
    for every one vacancy. However, when jobs were simply not available,
    the system placed many of the unemployed in education and training
    programs that will lead to good new jobs.
        The system is also effective. According to an Upjohn Institute
    Study, positive and statistically significant results were found for
    WIA Adult Program participants and for the Dislocated Worker Program.
    Furthermore, these employment and training services were shown to
    reduce reliance on public assistance. The average duration on TANF
    public assistance also was reduced by several percentage points for
    those participating in WIA or TANF welfare-to-work programs. One can
    conclude from a variety of studies that WIA training services raise
    employment rates and earnings while reducing reliance on TANF.
        Many CWS members are private businesses that struggle everyday with
    budgets, so we can appreciate the need to make tough decisions. Since
    job creation is a priority for the Congress and since workers pay taxes
    and reduce pressure on public programs, maintaining support for the
    workforce system should remain a top priority. The workforce system is
    a critical partner in the Nation's economic recovery as it trains and
    retrains workers to meet the demands of our changing economy. In our
    judgment, this system is essential to addressing the employment needs
    of the more than 14 million unemployed in this country--we cannot
    afford to lose this valuable resource.
        Nevertheless, Congress recently reduced WIA's three State/local
    program sections by about $307 million below the fiscal year 2010
    levels enacted in Public Law 111-117. Overall, the last CR provides
    about $2.8 billion for job-training State grants for adult employment,
    youth activities, and dislocated workers. The more than $1 billion in
    reductions to key job training and education programs equate to more
    than 10 percent less than fiscal year 2010 enacted levels.
        While funding for Program Year 2011 is now set, the spending
    agreement covers only the first quarter of the next WIA program year
    ending September 30, 2011. Funding for the final three quarters will be
    contained in the fiscal year 2012 appropriations.
        Many WIA programs have received funding reductions in real dollar
    terms in recent years--these programs are significantly underfunded
    already relative to their mission. Congress should use the findings of
    duplication and overlap in workforce programs not to make further
    reductions but rather to work with the House Education and Workforce
    Committee to achieve better coordination and integration of services.
        Despite the significant cuts in the latest CR, the bill represents
    substantial progress for thousands of jobseekers and employers across
    the country who informed their policymakers on the critical benefits of
    our workforce system. We are encouraged to see that Congress has
    rejected the severest cuts proposed early this year and we hope there
    is a more accurate picture for fiscal year 2012 emerging of how WIA
    programs help employers find qualified workers and train workers for
    new careers.
        In short, CWS will work with Members of this Committee, the
    authorizing committees and other Members of Congress as they consider
    policies to better align planning and service delivery, and strengthen
    the overall system. As issues develop, there will be discussions about
    expectations for the future of the workforce system. Here are some
    issues of primary importance to CWS:
      --Enhancing WIA accountability and driving high performance;
      --Empowering Workforce Investment Boards to play a strategic role
            that promotes coordination and integration of services across
            federally funded systems;
      --Serving disadvantaged and underserved populations; and
      --Sharing and promoting best practices throughout the system.
        CWS believes that WIA's core services and training have paid off in
    terms of higher employment rates and improved earnings for dislocated
    workers, the unemployed and disadvantaged youth and adults. As Members
    of the Committee examine the facts concerning WIA services, we trust
    that they will agree that the workforce system provides vital services
    to businesses and jobseekers. Thank you for your consideration of my
    testimony.
                                     ______

       Prepared Statement of the Coalition for the Advancement of Health
                 Through Behavioral and Social Science Research
        Mr. Chairman and Members of the Subcommittee, the Coalition for the
    Advancement of Health Through Behavioral and Social Science Research
    (CAHT-BSSR) appreciates and welcomes the opportunity to comment on the
    fiscal year 2012 appropriations for the National Institutes of Health
    (NIH). CAHT-BSSR includes 14 professional organizations, scientific
    societies, coalitions, and research institutions concerned with the
    promotion of and funding for research in the social and behavioral
    sciences. Collectively, we represent more than 120 professional
    associations, scientific societies, universities, and research
    institutions.
        CAHT-BSSR would like to thank the Subcommittee and the Congress for
    their continued support of the NIH. Strong sustained funding is
    essential to national priorities of better health and economic
    revitalization. Providing adequate resources in fiscal year 2012 that
    allow the NIH to keep up with the rising costs of biomedical,
    behavioral, and social sciences research will help NIH begin to prepare
    for the era beyond recovery. We recognize that these are difficult
    times for our Nation, but at the same time, it is essential that
    funding in fiscal year 2012 and beyond allow the agency to resume
    steady, sustainable growth of the foundation of knowledge built through
    NIH-funded research at more than 3,000 universities, medical schools,
    teaching hospitals, and research institutions. CAHT-BSSR supports the
    NIH fiscal year 2012 request of $31.7 billion, at a minimum, and joins
    the Ad Hoc Group for Medical Research in its request for $35 billion in
    funding for NIH in fiscal year 2012.
        NIH Behavioral and Social Sciences Research.--NIH supports
    behavioral and social science research throughout most of its 27
    institutes and centers. The behavioral and social sciences regularly
    make important contributions to the well-being of this Nation. Due in
    large part to the behavioral and social science research sponsored by
    the NIH, we are now aware of the enormous contribution behavior makes
    to our health. At a time when genetic control over diseases is
    tantalizingly close but not yet possible, knowledge of the behavioral
    influences on health is a crucial component in the Nation's battles
    against the leading causes of morbidity and mortality: obesity, heart
    disease, cancer, AIDS, diabetes, age-related illnesses, accidents,
    substance use and abuse, and mental illness.
        As a result of the strong congressional commitment to the NIH in
    years past, our knowledge of the social and behavioral factors
    surrounding chronic disease health outcomes is steadily increasing. The
    NIH's behavioral and social science portfolio has emphasized the
    development of effective and sustainable interventions and prevention
    programs targeting those very illnesses that are the greatest threats
    to our health, but the work is just beginning.
        From global warming to unlocking the secrets of memory; from self
    destructive behavior, such as addiction, to lifestyle factors that
    determine the quality of life, infant mortality rate and longevity; the
    grandest challenge we face is understanding the brain, behavior, and
    society. Nearly 125 million Americans are living with one or more
    chronic conditions, like heart disease, cancer, diabetes, kidney
    disease, arthritis, asthma, mental illness and Alzheimer's disease.
    Significant factors driving the increase in healthcare spending in the
    United States are the aging of the U.S. population, and the rapid rise
    in chronic diseases, many of which can be caused or exacerbated by
    behavioral factors. Obesity may be the result of sedentary behavior and
    poor diet; and addictions, resulting in health problems caused by
    tobacco and other drug use. Behavioral and social sciences research
    supported by NIH is increasing our knowledge about the factors that
    underlie positive and harmful behaviors, and the context in which those
    behaviors occur.
        CAHT-BSSR continues to applaud the Congress' and NIH's recognition
    that the ``scientific challenges in developing an integrated science of
    behavior change are daunting.'' The agency's efforts to launch the
    basic behavioral and social science research trans-NIH initiative,
    Opportunity Network for Basic Behavioral and Social Sciences Research
    (OppNet), likewise, is applauded. OppNet is designed to examine the
    important scientific opportunities that cut across the structure of NIH
    and designed to look for strategic opportunities to build areas of
    research where there are gaps that have the potential to affect the
    missions of multiple institutes and centers. Research results could
    lead to new approaches for reducing risky behaviors and improving
    health.
        Equally, we commend the agency's support of the ``Science of
    Behavior Change'' Common Fund Initiative included in the third cohort
    of research areas for the Common Fund. We agree with the goals of this
    Common Fund Pilot to ``establish the groundwork for a unified science
    of behavior change that capitalizes on both the emerging basic science
    and the progress already made in the design of behavioral interventions
    in specific disease areas. By focusing basic research on the
    initiation, personalization, and maintenance of behavior change, and by
    integrating work across disciplines, this Common Fund effort and
    subsequent trans-NIH activity could lead to an improved understanding
    of the underlying principles of behavior change. This should drive a
    transformative increase in the efficacy, effectiveness, and (cost)
    efficiency of many behavioral interventions.''
        With the recent passage of healthcare reform legislation, there has
    been the accompanying and appropriate attention to the issue of
    personalized healthcare. CAHT-BSSR believes that personalization needs
    to reflect genes, behaviors, and environments. And as the agency has
    acknowledged with its recent support of the Science of Behavior Change
    initiative, assessing behavior is critical to helping individuals see
    how they can improve their health. It is also critical to helping
    healthcare systems see where to put resources for behavior change.
    Fortunately, the NIH acknowledges the need to focus less on finding the
    ``magic answer'' and, at the same time, recognizes that healthcare is
    different from region to region across the country. Full
    personalization needs to consider the environmental, community, and
    neighborhood circumstances that govern how individuals' genes and
    behavior will influence their health. For personalized healthcare to be
    realized, we need a sophisticated understanding of the interplay
    between genetics and the environment, broadly defined.
        In fiscal year 2012, NIH priorities include establishment of the
    National Center for Advancing Translational Sciences (NCATS) intended
    to align and bring together a number of trans-NIH programs that do not
    have a specific disease focus in one organization. As with development
    of more effective drugs, surgical techniques and medical devices, the
    development of more powerful health-related behavioral interventions is
    dependent on improving the understanding of human behavior, and then
    translating that knowledge into new and more effective interventions
    with enduring effects. It is critical that the NIH support for
    translational research extends to translation research designed to
    adapt findings from basic behavioral and/or social science research to
    develop behavioral interventions directed at improving health-related
    behaviors such as adequate physical activity and nutrition, learning
    and learning disabilities, and preventing or reducing health-risking
    behaviors including tobacco, alcohol, and/or drug abuse, and
    unprotected sexual activity. CAHT-BSSR strongly believes that the
    translation of behavioral interventions is a critical part of the NCATS
    initiative and must be accompanied by sufficient staff expertise and
    resources to manage research on the translation of behavioral
    interventions into communities.
        CAHT-BSSR applauds the NIH's recognition of a unique and compelling
    need to promote diversity in health-related research. The agency
    expects these efforts to lead to: the recruitment of the most talented
    researchers from all groups; an improvement in the quality of the
    educational and training environment; a balanced perspective in the
    determination of research priorities; an improved ability to recruit
    subjects from diverse backgrounds into clinical research; and an
    improved capacity to address and eliminate health disparities. Numerous
    studies provide evidence that the biomedical and educational enterprise
    will directly benefit from broader inclusion.
        NIH recognizes that developing a more diverse and academically
    prepared workforce of individuals in STEM (science, technology,
    engineering, and math) disciplines will benefit all aspects of
    scientific and medical research and care. CAHT-BSSR applauds the
    agency's recognition that, to remain competitive in the 21st century
    global economy, the Nation must foster new opportunities, approaches,
    and technologies in math and science education.
        This recognition extends to the need for a coordinated effort to
    bolster STEM education nationwide, starting at the earliest stages in
    education. Unfortunately, the narrow perception of ``science''
    persists, and the social and behavioral sciences are often excluded in
    discussion of STEM issues and remain outside of the science education
    curriculum. The considerable activity on STEM education provides the
    opportunity to improve the recognition of social and behavioral
    sciences as ``science.''
        In 2010, the NIH commissioned the Institute of Medicine (IOM) to do
    a study surrounding LGBT (lesbian, gay, bisexual, and transgender)
    health issues, research gaps and opportunities. The recently released
    study, The Health of Lesbian, Gay, Bisexual, and Transgender People,
    examined the current state of knowledge on LGBT health, including
    general health concerns and health disparities, identified research
    gaps and opportunities; and outlined a research agenda which reflects
    the most pressing areas, specifically demographic research, social
    influences, healthcare inequities, intervention research, and
    transgender-specific health needs.
             nih office of behavioral and social sciences research
        The NIH Office of Behavioral and Social Sciences Research (OBSSR),
    authorized by Congress in the NIH Revitalization Act of 1993 and
    established in 1995, serves as a convening and coordinating role among
    the institutes and centers at NIH. In this capacity, OBSSR develops,
    coordinates, and facilitates the social and behavioral science research
    agenda at NIH; advises the NIH director and directors of the 27
    institutes and centers; informs NIH and the scientific and lay publics
    of social and behavioral science research findings and methods; and
    trains scientists in the social and behavioral sciences. For fiscal
    year 2012, CAHT-BSSR supports a budget of $38.2 million for OBSSR. This
    sum reflects the Administration's request of $28 million for OBSSR and
    includes the $10 million needed to support the NIH-wide commitment to
    carry out OppNet, an initiative strongly supported by the Subcommittee.
    The OppNet initiative has made significant progress since its start.
    Thus far, OppNet has awarded 35 competitive revisions to add basic
    science projects to existing research project grants. Eight competitive
    revisions to Small Business Innovation Research/Small Business
    Technology and Transfer projects have been awarded. OppNet has also
    provided the much-needed training in basic social and behavioral
    sciences research.
        In fiscal year 2012, OBSSR intends partner with the NIH institutes
    and centers and other Federal agencies to fund Mobile Technology
    Research (mHealth) to Enhance Health. Recent advances in mobile
    technologies and the use of these technologies in daily life have
    created opportunities for research applications that were not
    previously possible, such as assessing behavioral and psychological
    states in real time. To make use of this technology as effective as
    possible there is a need to integrate the behavioral, social sciences,
    and clinical research fields. The NIH mHealth Summer Institute is
    designed to address the lack of integration of these fields.
        Over the years, OBSSR has sponsored summer training institutes for
    scientists interested in social and behavioral science research areas.
    The interest in these training sessions have been overwhelming and have
    exceeded the Office's capacity to provide the opportunity for
    scientists and researchers to gain critical training in these areas.
    These institutes include training in: systems science methodology and
    health; randomized clinical trials involving behavioral interventions;
    dissemination and implementation research in health; and mobile health.
    The Dissemination and Implementation Research in Health training
    institute, for example, features a faculty of leading experts from a
    variety of behavioral and social science disciplines and is designed to
    empower scientists to conduct this research. Drawing from these
    disciplines, dissemination and implementation research uses approaches
    and methods that in the past have not been taught comprehensively in
    most graduate degree programs. Given the demand for the training these
    institutes provide and the potential this research has for propelling
    the science forward, CAHT-BSSR believes that greater collaboration with
    the NIH institutes and centers is needed to meet the demand.
        CAHT-BSSR would be pleased to provide any additional information on
    these issues. Below is a list of coalition member societies. Again, we
    thank the Subcommittee for its generous support of the National
    Institutes of Health and for the opportunity to present our views.
                                   caht-bssr
    American Association of Geographers
    American Educational Research Association
    American Psychological Association
    American Sociological Association
    Association of Population Centers
    Consortium of Social Science Associations
    Council on Social Work Education
    Federation of Associations in Behavioral & Brain Sciences
    National Association of Social Workers
    National Communication Associations
    Population Association of America
    Society for Behavioral Medicine
    Society for Research in Child Development
    The Alan Guttmacher Institute (AGI)
                                     ______

         Prepared Statement of the Coalition of Heritable Disorders of
                               Connective Tissue
        Chairman Tom Harkin, Chairman, and Richard Ranking Member Shelby,
    and members of the Subcommittee: the Coalition of Heritable Disorders
    of Connective Tissue thanks you for the opportunity to submit testimony
    regarding the fiscal year 2012 budget for the National Heart, Lung and
    Blood Institute (NHLBI), the National Institute of Arthritis,
    Musculoskeletal and Skin Diseases, (NIAMS), and the NIH Office of
    Research Information Services/Office of Extramural Research. We are
    extremely grateful for the Subcommittee's strong support of the NIH,
    particularly as it relates to life threatening genetic disorders such
    as Heritable Disorders of Connective Tissue. Thanks to your leadership,
    we are at a time of unprecedented hope for patients with these
    diseases.
        It is estimated that over 1 million people in the United States are
    affected by Heritable Disorders of Connective Tissue (HDCT). These
    disorders manifest themselves in many areas of the body, including the
    heart, eyes, skeleton, lungs and blood vessels. Connective tissue is
    the ``glue'' that holds the body together. These disorders are
    progressive conditions caused by genetic mutations and cause
    deterioration in each of these body systems. The most life-threatening
    are those which affect the aorta and the heart--the most disabling are
    orthopedic and ophthalmological.
        Some 60 years ago, Victor McKusick, the ``father'' of modern
    medical genetics, described and coined the term ``heritable disorders
    of connective tissues.'' These disorders included over 200 such rare
    disorders, among which were the Marfan syndrome, Weill-Marchesani
    syndrome, Ehlers-Danlos syndrome, Cutis Laxa, Osterogenesis imperfecta,
    the chondrodysplasias, and Pseudoxanthoma elasticum (Heritable
    Disorders of Connective Tissue, McKusick, Va 1972).
        Awareness of these disorders has grown through the years due to
    collaborative research. Clues to the underlying causes of these
    diseases were obtained from the major manifestations found in the
    connective tissue and elaboration of connective tissue pathways
    involving identified disease genes and their protein products uncovered
    additional disease genes with related connective tissue manifestations.
    Identification of disease genes have led to surprising new information
    regarding important connective tissue pathways depending on the history
    of the particular disorder. Thus, the concept of the heritable
    disorders of connective tissue have reiterated and epitomized important
    lessons regarding how the connective tissue integrates cellular and
    organ function.
    National Heart Lung and Blood Institute
        Thanks to research funded by the NHLBI, we have seen amazing
    responses to HDCT disorders with cardiovascular disease. In the 1960s
    there was no intervention available, not even surgery for heart defects
    and dissection, this before the development of the ``heart-lung''
    machine. It was not so long ago, when in the early 1960s, a 13 year old
    girl with Marfan syndrome was sent home from the hospital to die since
    there was no surgical intervention possible for her dissecting
    aneurysm. Early on, surgery required replacing the aortic valve with an
    animal's heart, further research used a mechanical valve, and then came
    the sturdy composite graft, which became the ``Cadillac'' of surgical
    repair. Although the valve sparing method was used throughout this
    time, it has been continually improved to address the compromised
    tissue regarding longevity. Now we are seeing additional
    ``translational'' clinical trials, which look at therapies for
    prevention as well as surgical response. It is important to remember
    these amazing leaps and bounds in medical, surgical and technological
    advancement.
        NHLBI support has been essential in promoting research
    collaboration. The Pediatric Heart Network, a cooperative network of
    pediatric cardiovascular clinical research centers, serves as a data
    coordinating center to promote the exchange of information to evaluate
    therapeutic and management strategies for children and adults with
    congenital and genetic heart defects.
        NHLBI funded Clinical Trials in the use of Losarton have led to
    exciting new findings and pointed the way in future research
    directions. It has inspired current concepts of architectural and
    signaling pathways underlying the various heritable disorders of
    connective tissue in order to integrate these concepts in new
    productive ways. For example, can the recent advances in treating
    Marfan syndrome with TGF beta inhibitors and Losarton be applied to
    other heritable disorders of connective tissue? Does TGF beta signaling
    play pathological roles in other disorders? For another example, is
    there an important adhesion junction of architectural pathway that
    connects the vascular smooth muscle cell to the extracellular matrix?
    And, again: How do cell surface receptors (integrin and growth factor
    receptors) coordinate architectural and signaling pathways in
    connective tissue disorders? All pointing to future research avenues.
    National Institute of Arthritis, Musculoskeletal and Skin Diseases
        The collaboration of NHLBI and NIAMS has provided an even greater
    overview of the information gleaned from the Losarton clinical trial
    and a global view of these mult-system disorders. The muscular and
    orthopedic involvement is being addressed by the NIAMS. Through NIAMS
    support, there is a meeting in July, which is devoted to
    ``Translational'' avenues grown of current research progress in the
    understanding of heritable disorders of connective tissue. Great
    progress in the understanding of HDCT has been made over the past 15
    years through NIAMS supported workshops on Heritable Disorders of
    Connective Tissue. Symposia have been convened in 1990, 1995, and 2000.
    In 1990 and 1995, the emphasis was on finding the genes for the various
    heritable disorders and understanding whether mutations could be
    correlated with specific phenotypes. Many of these goals have been met,
    due to research supported in large part by the NIAMS. In 2000, meeting
    themes were intentionally broader, focusing on multidisciplinary
    approaches and common themes in matrix biology in order to (1) promote
    a better understanding of pathogenesis of connective tissue disorders,
    (2) stimulate new collaborations between investigators, and (3)
    identify areas in which rapid progress could be made. In the decade
    since the 2000 Workshop, tremendous progress has been made, leading
    notably to new therapies. An example of this is Marfan syndrome, for
    which a clinical trial is underway to test for a therapy, which may
    prove to play a pivotal role in preventing heart disease. Epidermolysis
    bullosa is another disease--for which a research has improved prospects
    for new therapies, as well as for a number of other heritable disorders
    of connective tissue.
        Research has emphasized an understanding of the role of cells in
    developing treatments for connective tissue disorders. The success of
    bone marrow transplantation in treating Epidermolysis Bullosa has
    called attention to this area. While connective tissue researchers have
    been interested in stem cell treatments--Osteogenesis imperfecta, for
    example--more discussion and emphasis in this area are needed.
        The impact of this collaboration between these similar disease
    entities in heritable disorders of connective tissue continues to be of
    major importance. We are moving rapidly from the ``bench to the
    patient,'' from basic research to the important translational benefit
    of research findings to treatments which directly benefit the patient.
    The collaboration between the basic research and clinical studies is
    what we are able to focus on in these disorders for the benefit of all
    disease groups.
    NIH/Office of Research Information Services/Office of Extramural
            Research--RePorter
        The National Institute of Health (NIH) has established the NIH
    RePorter, or research/condition/disease category (RCDC) which provides
    easy retrieval of information on scientific projects and studies. This
    excellent new tool provides information on research results, expediting
    access and the avoidance of duplication and is located in the Office of
    Research Information Services/Office of Extramural Research. It
    provides access to research information on all disease groups. We urge
    the inclusion of the category ``Heritable Disorders of Connective
    Tissue'' (HDCT) in order to facilitate the exchange of information in
    the research community of these similar disorders.
        What is so important about the study of these disorders is their
    very complexity--with genetic origins, requiring basic science for
    understanding, and clinical trials in order to maximize the
    translational advantages of this research. The mutations of HDCT affect
    all body systems and require particular depth of investigation. This
    very complexity informs the researcher, as well as contributes to the
    understanding of other more common disorders. Research on these
    disorders in all of the body systems, will ``spill'' over into research
    into many of the categories identified in both the short range and the
    long range strategic plans for NHLBI and NIAMS, and provide benefits
    for many diseases beyond the scope of HDCT.
    About the Coalition of Heritable Disorders of Connective Tissue (CHDCT)
        The CHDCT is a nonprofit voluntary health organization founded in
    1989, dedicated to saving lives and improving the quality of life for
    individuals and families affected by any 1 of the over 200 Heritable
    Disorders of Connective Tissue. The mission is to raise awareness of
    these disabling and often deadly disorders and to support and promote
    research and collaboration between researchers in the field.
        We thank you for this opportunity to thank the Committee for its
    past support and to voice the interests and concerns of the CHCDT
    member organizations relating to future priorities of NHLBI and the
    NIAMS.
                                     ______

    Prepared Statement of the Commissioned Officers Association of the U.S.
                             Public Health Service
        On behalf of the Commissioned Officers Association of the U.S.
    Public Health Service, Inc. (COA), and in the context of the
    President's fiscal year 2012 budget request, I respectfully ask to
    submit this statement for the record. I speak for our Association's
    members, all of whom are active-duty or retired officers of the
    Commissioned Corps of the U.S. Public Health Service (USPHS).
        We respectfully make two funding requests: Support for a pilot
    program to recruit and train public health doctors, dentists, and
    nurses for careers in the Commissioned Corps of the U.S. Public Health
    Service (USPHS), and support for the establishment of a USPHS Ready
    Reserve component. Congress authorized both programs last year, and
    directed the Department of Health and Human Services to implement them.
                       u.s. public health sciences track
        First, we ask this subcommittee to approve $30 million to establish
    a scaled-back version of the public health workforce training program
    for would-be USPHS officers that was authorized by the Patient
    Protection and Affordable Care Act (Public Law 111-148). This pilot
    program would be based first at the Uniformed Services University of
    the Health Sciences (USUHS), which is the dedicated medical school and
    research institute for uniformed services personnel (Army, Navy, Air
    Force, Public Health Service.) Additional schools would be selected by
    the Surgeon General as provided for in law.
    Background and Rationale
        USPHS health professionals serve the health needs of the Nation's
    most underserved populations. They also serve side-by-side with Armed
    Forces personnel at home and abroad, on joint training missions, and
    even in forward operating bases in combat zones. USPHS psychiatric
    nurses have treated injured soldiers under fire in Afghanistan. At
    home, USPHS psychologists and other mental health specialists have been
    detailed to the military to treat returning soldiers and Marines
    suffering from traumatic brain injury and post-traumatic stress
    disorder. The PHS Commissioned Corps is a public health and national
    security force multiplier.
        The original proposal, set forth in Section 5315 of PPACA, would
    have established a ``U.S. Public Health Sciences Track'' providing for
    a total of 850 annual scholarships for medical, dental, nursing, and
    public health students who commit to public service careers in the
    USPHS. Such a program would be the first of its kind, the first
    dedicated pipeline into the USPHS Commissioned Corps.
    Funding
        The PPACA provisions authorizing the U.S. Public Health Sciences
    Track also identified an existing source of funds within the Department
    of Health and Human Services (DHHS). Support was to come from the
    Public Health and Social Services Emergency Fund. The law directed the
    DHHS Secretary to ``transfer from the Public Health and Social Services
    Emergency Fund such sums as may be necessary'' (Sec. 274). The language
    in the PPACA is clear and straightforward, but, for reasons unknowable
    to this Association, the directed funding transfer has not occurred.
                              usphs ready reserve
        This Association's second request is for sufficient funding to
    establish a Ready Reserve component within the USPHS Commissioned
    Corps. We ask the subcommittee to appropriate $12,500,000 annually
    through fiscal year 2014 for this purpose. Creation of a USPHS Ready
    Reserve was approved by Congress last year as part of the PPACA
    (Section 5210). Lawmakers wanted to bring the structure of the USPHS
    into line with that of its sister services in the Department of
    Defense; that objective is articulated several times in the text of the
    legislation.
        The text of the law speaks to congressional intent with unusual
    specificity. Lawmakers wanted to establish a USPHS Ready Reserve Corps
    ``for service in time of national emergency;'' that is, to enhance the
    capability of the USPHS to respond to natural disasters, terrorist
    incidents, and other public health emergencies ``both foreign and
    domestic.'' This reflects the growing realization that protection of
    the public's health is a fundamental component of national security.
        Congress intended that USPHS Ready Reserve personnel would be
    ``available on short notice.'' They would be ``available and ready for
    involuntary calls to active duty during national emergencies and public
    health crises.'' They would be available for ``backfilling critical
    positions left vacant'' when active-duty USPHS personnel are deployed
    in response to public health emergencies, both foreign and domestic''
    and, finally, they would also ``be available for service assignments in
    isolated, hardship, and medically underserved communities.'' Absent the
    appropriated funding necessary to meet these legal obligations, the
    Nation has no public health emergency response capacity.
                                   conclusion
        This Association recognizes, of course, that start-up and even
    continued funding of various provisions of PPACA are a matter of
    ongoing debate and very much in doubt. But these two provisions--
    creation of a USPHS Ready Reserve and establishment of a pilot program
    at USUHS--warrant broad bipartisan support. They are modest, practical,
    and well thought-through, and they speak to the short-term and long-
    term national security needs of this country.
        I would be pleased to expand on these points or to answer any
    questions. I can be reached at the COA offices at 301-731-9080, ext.
    211.
                                     ______

         Prepared Statement of the Council of Academic Family Medicine
        On behalf of the Council of Academic Family Medicine (CAFM)
    (Association of Departments of Family Medicine, Association of Family
    Medicine Residency Directors, North American Primary Care Research
    Group, and Society of Teachers of Family Medicine), we are pleased to
    submit testimony on behalf of several programs under the jurisdiction
    of the Health Resources and Services Administration (HRSA) and the
    Agency for Healthcare Research and Quality (AHRQ). We thank you for
    your continued support for programs that encourage the development of
    primary care physicians to serve our countries healthcare needs. Your
    fiscal year 2011 committee passed budget was encouraging as a signal of
    your recognition for the need to invest in these important health
    professions and workforce programs.
        Members of both parties agree there is much that must be done to
    support primary care production and nourish the development of a high
    quality, highly effective primary care workforce to serve as a
    foundation for our healthcare system. Providing strong funding for
    these programs is essential to the development of a robust workforce
    needed to provide this foundation.
    Primary Care Training and Enhancement
        The Primary Care Training and Enhancement Program (Title VII
    Section 747 of the Public Health Service Act) has a long history of
    providing indispensible funding for the training of primary care
    physicians. With each successive reauthorization, Congress has modified
    the Title VII health professions programs to address relevant workforce
    needs. The most recent authorization directs the Health Resources and
    Services Administration (HRSA) to prioritize training in the new
    competencies relevant to providing care in the patient-centered medical
    home model. It also calls for the development of infrastructure within
    primary care departments for the improvement of clinical care and
    research critical to primary care delivery, as well as innovations in
    team management of chronic disease, integrated models of care, and
    transitioning between healthcare settings.
        Key advisory bodies such as the Institute of Medicine (IOM) and the
    Congressional Research Service (CRS) have also called for increased
    funding. The IOM (December 2008) pointed to the drastic decline in
    Title VII funding and described these health professions workforce
    training programs as ``an undervalued asset.'' The CRS found that
    reduced funding to the primary care cluster has negatively affected the
    programs during a time when more primary care is needed (February
    2008).
        According to the Robert Graham Center, (Title VII's decline:
    Shrinking investment in the primary care training pipeline, Oct. 2009),
    ``the number of graduating U.S. allopathic medical students choosing
    primary care declined steadily over the past decade, and the proportion
    of minorities within this workforce remains low.'' Unfortunately, this
    decline coincides with a decline in funding of primary care training
    funding--funding that we know is associated with increased primary care
    physician production and practice in underserved areas. The report goes
    on to say that ``the Nation needs renewed or enhanced investment in
    programs like Title VII that support the production of primary care
    physicians and their placement in underserved areas.''
        Title VII has a profound impact on States across the country and is
    vital to the continued development of a workforce designed to care for
    the most vulnerable populations and meet the needs of the 21st century.
    Attached are just a few examples of the impact Title VII has across the
    country in States like Alabama, Kansas, Ohio, Rhode Island, Tennessee,
    Texas, and Washington. Included are examples of opportunities lost
    through the lack of robust funding for the program.
        We urge the Congress to appropriate at least $140 million for the
    health professions program, Primary Care Training and Enhancement
    authorized under Title VII, Section 747 of the Public Health Service
    Act in fiscal year 2012 as requested in the President's budget.
    Rural Physician Training Grants
        ``Rural Physician Training Grants,'' Title VII Section 749B of the
    Public Health Service Act, were developed to increase the supply of
    rural physicians by authorizing grants to medical schools which
    establish or expand rural training. The program would provide grants to
    produce rural physicians of all specialties. It would help medical
    schools recruit students most likely to practice medicine in
    underserved rural communities, provide rural-focused training and
    experience, and increase the number of medical graduates who practice
    in underserved rural communities.
        According to a July 2007 report of the Robert Graham Center
    (Medical school expansion: An immediate opportunity to meet rural
    healthcare needs), data show that although 21 percent of the U.S.
    population lives in rural areas, only 10 percent of physicians practice
    there. The Graham Center study describes the educational pipeline to
    rural medical practice as ``long and complex.'' There are multiple
    tactics needed to reverse this situation, and this grant program
    includes several of them. Strategies to increase the number of
    physicians practicing in rural areas include ``increasing the number of
    rural-background students in medical school, selecting the ``right''
    students and giving them the ``right'' content and experiences to train
    them for rural practice.'' This is exactly what this grant program is
    designed to do.
        We request the Committee provide the fully authorized amount of $4
    million in fiscal year 2012 for Title VII Section 749B Rural Physician
    Training Grants.
    Teaching Health Centers
        Teaching Health Centers (THC) are community health centers or other
    similar venues that sponsor residency programs and provide residents
    with their ambulatory training experiences in the health center. This
    training in the community, rather than solely at the hospital bedside
    is one of the hallmarks of family medicine training. However, payment
    issues have always caused a tension and struggle between the hospital,
    which currently receives reimbursement for residents it sponsors when
    they train in the hospital, and programs that require training in non-
    hospital settings. This program is designed to provide residency
    programs and community health centers grant funding to plan for a
    transition in sponsorship, or the establishment of new programs. There
    are already 11 community-based entities from states across the country
    that have committed to train 44 primary care residents, demonstrating
    early success in this program.
        We are pleased that THC's operations are currently funded through a
    mandatory appropriations trust fund of $230 million over 5 years, and
    it is essential that these important centers continue to be funded
    through this mandatory appropriation. Despite the positive impact that
    family medicine and other primary care residency training programs have
    on those community-based entities that initiate them, a multitude of
    challenges make it clear that many of these entities would have
    difficulty doing the same without adequate and predictable financing.
    Converting this program to discretionary funding also would deter other
    entities from making the business decisions necessary to expand
    residency training (e.g., securing commitments from key stakeholders to
    agree to train new or additional residents, applying for accreditation
    if not already part of an eligible consortia, and hiring new faculty)
    since funding over the next few years would be subject to the annual
    appropriations process.
    Teaching Health Center Development Grants
        If this program is to be effective, there must be funds for the
    planning grants to establish newly accredited or expanded primary care
    residency programs. Teaching Health Center Development Grants are
    important to help establish these innovative programs.
        We recommend the Committee appropriate the full authorized amount
    for the new Title VII Teaching Health Centers development grants of at
    least $10 million for fiscal year 2012.
    AHRQ
        Research related to the most common acute, chronic, and comorbid
    conditions that primary care clinicians care for on a daily basis is
    lacking. Research in these areas is vital because the overall health of
    a population is directly linked to the strength of its primary
    healthcare system. AHRQ supports research to improve healthcare
    quality, reduce costs, advance patient safety, decrease medical errors,
    and broaden access to essential services. This research is key to
    helping create a robust primary care system for our Nation--one that
    delivers higher quality of care and better health while reducing the
    rising cost of care. Despite this need, little is known about how
    patients can best decide how and when to seek care, introduce and
    disseminate new discoveries into real life practice, and how to
    maximize appropriate care. Ample funding for AHRQ can help researchers
    address these problems confronting our health system today.
        We recommend the Committee fund AHRQ at a level of at least $405
    million for fiscal year 2012
    Primary Care Extension Program
        The Primary Care Extension Program was modeled after the successful
    United States Agriculture Extension Service. This program, under Title
    III of the Public Health Service Act, is designed to support and assist
    primary care providers with the adoption and incorporation of
    techniques to improve community health. As the authors of an article
    describing this concept (JAMA, June 24, 2009) have stated, ``To
    successfully redesign practices requires knowledge transfer,
    performance feedback, facilitation, and HIT support provided by
    individuals with whom practices have established relationships over
    time. The farming community learned these principles a century ago.
    Primary care practices are like small farms of that era, which were
    geographically dispersed, poorly resourced for change, and inefficient
    in adopting new techniques or technology but vital to the Nation's
    well-being.''
        Congress agreed with the authors that ``practicing physicians need
    something similar to the agricultural extension agent who was so
    transformative for farming,'' and authorized this program at $120
    million for fiscal year 2011 and 2012.
        We recommend the Committee fund the Primary Care Extension program
    at the authorized level of $120 million for fiscal year 2012.
    Title VII Testimonials from the field
        Brown University.--``Our Title VII grant is devoted to training
    students in the care of the underserved. In our first year, we have
    already recruited two new Community Health Center clinical training
    sites for our medical students. Our first student at one of the two
    sites decided, after his family medicine rotation, to change his career
    path from Urology to Family Medicine.'' An additional grant has allowed
    for the development of a curriculum centered around the Patient
    Centered Medical Home and Practice transformation and has started
    transforming family medicine practices in Rhode Island. David Anthony,
    Director of Medical School Education, and Jeffrey Borkan, MD, PhD,
    Chair, Department of Family Medicine
        East Tennessee State University.--We were able to use a Title VII
    grant to establish health fairs, including health screening exams, for
    rural and underserved communities in northeast Tennessee and southwest
    Virginia. We started small, but now there are 6 health fairs per year,
    including 2-3 days per event. During the fairs, the average number of
    visits per site is 180 and we estimate 27,000 visits in 11 years (1999-
    2010). John Franko MD, Chair and Professor, Department of Family
    Medicine
        The Ohio State University.--With Title VII grants, ``We were able
    to establish a four-track university program--university, academic,
    urban, and rural, which allowed us to provide a unique training
    experience involving a diverse population. We have been able to
    successfully match students in all tracks. We have also been able to
    provide primary care to the community in settings that were previously
    physician shortage areas. Finally, we were able to develop training
    modules for community medicine that address real issues, such as
    domestic violence, alcohol and substance abuse, teenage pregnancy,
    obesity, etc.'' W. Fred Miser, MD, Associate Professor of Family
    Medicine
        University of Kansas School of Medicine.--The school applied for
    but did not receive funding for a program designed to help educate
    volunteer community physician educators. 29 percent of Kansas Medical
    students go into family medicine but the school has struggled with
    faculty development education, this is necessary to teach our community
    physicians the skills necessary to efficiently and effectively teach.
    Rick Kellerman MD, Professor and Chair, Department of Family and
    Community Medicine
        University of South Alabama.--The Department of Family Medicine
    applied for but did not receive funding for a program designed to allow
    us to train residents in a simulated environment to ensure experiences
    with patients with disability, access and mental health problems. Allen
    Perkins, MD, MPH, Professor and Char, Department of Family Medicine
        University of Texas Health Science Center at San Antonio.--Title
    VII grants are helping the program transition to be core transitional
    laboratories for the NIH's Clinical and Translational Science Awards
    (CTSA) efforts and have helped in getting support for a new a Practice
    Based Research Network Resource Center for community engagement. Carlos
    Roberto Jaen, MD PhD FAAFP, Professor of Epidemiology and Health
    Statistics
        WWAMI (a partnership between the University of Washington School of
    Medicine and the States of Wyoming, Alaska, Montana, and Idaho).--Title
    VII grants have helped fund over 30 faculty positions across the States
    of Washington, Wyoming, Alaska, Montana, and Idaho. These grants have
    helped fund the development of areas of scholarship for residency
    programs in Montana, assisted in the training of fellows that became
    Residency Directors at other programs, and funded faculty development
    programs delivered with televideo to rural areas in Wyoming. Ardis
    Davis MSW,University of Washington Department of Family Medicine,
    Teaching Associate
        Thomas Jefferson Medical School.--Title VII grants have allowed us
    to expand our successful rural Physician Shortage Area and Urban
    Underserved Programs, teach all of our students about the Patient
    Centered Medical Home in all 4 years of medical school, and train over
    1,400 students, residents, and faculty in community medicine and
    population health. We have also expanded the infrastructure and rigor
    of our research fellowship, doubling the publication outcomes of our
    research fellows over the past 2 years. Howard Rabinowitz, Department
    of Family and Community Medicine
                                     ______

           Prepared Statement of the Council on Social Work Education
        On behalf of the Council on Social Work Education (CSWE), I am
    pleased to offer this written testimony to the Senate Appropriations
    Subcommittee on Labor, Health and Human Services, Education, and
    Related Agencies for inclusion in the official Committee record. I will
    focus my testimony on the importance of fostering a skilled,
    sustainable, and diverse social work workforce to meet the healthcare
    needs of the Nation through professional education, training and
    financial support programs at the Department of Health and Human
    Services (HHS) and the Department of Education (ED).
        CSWE is a nonprofit national association representing more than
    3,000 individual members as well as 650 master's and baccalaureate
    programs of professional social work education. Founded in 1952, this
    partnership of educational and professional institutions, social
    welfare agencies, and private citizens is recognized by the Council for
    Higher Education Accreditation (CHEA) as the single accrediting agency
    for social work education in the United States. Social work education
    focuses students on leadership and direct practice roles helping
    individuals, families, groups, and communities by creating new
    opportunities that empower people to be productive, contributing
    members of their communities.
        Social work is rooted in a tradition of social justice, with a
    central mission of eliminating inequities by helping vulnerable
    populations navigate societal and personal challenges. Social workers
    are embedded in a variety of settings, such as schools, hospitals,
    Veteran health facilities, rehabilitation centers, social service
    agencies, child welfare organizations, assisted living centers, nursing
    homes, and faith-based organizations, which allows us to reach diverse
    segments of the population and play a significant role in the lives of
    Americans from all walks of life. For example, we provide psychosocial
    support for individuals and families to help them cope with disease,
    such as Alzheimer's disease and cancer; we assist families who struggle
    with homelessness and un- or underemployment; we work with families
    dealing with domestic violence, including child and spousal abuse; and
    we work with children in school or afterschool settings to ensure that
    they meet their full academic potential and to help them cope with
    issues they may be experiencing in their home lives. As you can see,
    social workers have an important role to play in all aspects of daily
    life.
        Unfortunately, recruitment and retention in social work continues
    to be a serious challenge that threatens the workforce's ability to
    meet societal needs. The U.S. Bureau of Labor Statistics estimates that
    employment for social workers is expected to grow faster than the
    average for all occupations through 2018, particularly for social
    workers specializing in the aging population and working in rural
    areas. In addition, the need for mental health and substance abuse
    social workers is expected to grow by almost 20 percent over the 2008-
    2018 decade.\1\
    ---------------------------------------------------------------------------
        \1\ U.S. Bureau of Labor Statistics. 2009. Occupational Outlook
    Handbook, 2010-11 Edition: Social Workers, http://data.bls.gov/cgi-bin/
    print.pl/oco/ocos060.htm. Retrieved April 13, 2011.
    ---------------------------------------------------------------------------
        Recruitment into the social work profession faces many obstacles,
    the most prevalent being low wages coupled with high educational debt.
    For example, the median annual wage for child, family, and school
    social workers in May 2008 was $39,530, while the wage for mental
    health and substance abuse social workers was $37,210. While a
    bachelor's degree (BSW) is necessary for most entry-level positions, a
    master's degree (MSW) is the terminal degree for social work practice,
    which significantly contributes to the debt load of social work
    graduates entering careers with low starting wages. According to the
    2007-2008 National Postsecondary Student Aid Study conducted by the
    National Center for Education Statistics at ED, 72 percent of students
    graduating from MSW programs incurred debt to earn their graduate
    degree. The average debt was approximately $35,500. The percentage of
    MSW students borrowing money is 17 percent higher than the average for
    all master's degrees and the amount borrowed is approximately $5,000
    higher than the average for all master's degrees. These difficult
    realities have made recruitment and retention of social workers an
    ongoing challenge.
        CSWE understands and appreciates the tough funding decisions
    Congress is faced with this year. However, we urge you to consider the
    needs of our frontline workforce if we are to see real progress in
    meeting the healthcare and societal demands of the Nation. The below
    recommendations for fiscal year 2012 would help to ensure that we are
    fostering a sustainable, skilled, and diverse workforce that will be
    able to keep up with the increasing demand for social work services.
    health resources and services administration (hrsa) title vii and title
                        viii health professions programs
        CSWE urges the Subcommittee to provide $762.5 million for the Title
    VII and Title VIII health professions programs at HRSA in fiscal year
    2012. HRSA's Title VII and Title VIII health professions programs
    represent the only Federal programs designed to train healthcare
    providers in an interdisciplinary way to meet the healthcare needs of
    all Americans, including the underserved and those with special needs.
    These programs also serve to increase minority representation in the
    healthcare workforce through targeted programs that improve the
    quality, diversity, and geographic distribution of the health
    professions workforce. The Title VII and Title VIII programs provide
    loans, loan guarantees and scholarships to students, and grants to
    institutions of higher education and nonprofit organizations to help
    build and maintain a robust healthcare workforce. Social workers and
    social work students are eligible for Title VII funding.
        The Title VII and Title VIII programs were reauthorized in 2010,
    which helped to improve the efficiency of the programs as well as
    enhance efforts to recruit and retain health professionals in
    underserved communities. Allow me to highlight a few of the programs
    that are of critical importance to the training of social workers.
      --Mental and Behavioral Health Education and Training.--Recognizing
            the severe shortages of mental and behavioral health providers
            within the healthcare workforce, a new Title VII program was
            authorized in the Patient Protection and Affordable Care Act
            (Public Law 111-148). This program--Mental and Behavioral
            Health Education and Training Grants--would provide grants to
            institutions of higher education (schools of social work and
            other mental health professions) for faculty and student
            recruitment and professional education and training. The
            President's budget request includes $17.9 million for these
            grants in fiscal year 2012. This funding would allow for
            approximately 10 grants in graduate social work education, 17
            grants in graduate psychology education, 12 grants for
            professional child and adolescent mental health education, and
            6 grants for paraprofessional child and adolescent mental
            health. This is the only program in the Federal Government that
            is explicitly focused on recruitment and retention of social
            workers and other mental and behavioral health professionals.
            CSWE strongly urges the Subcommittee to provide $17.9 million
            for the Title VII Mental and Behavioral Health Education and
            Training Grants in fiscal year 2012.
      --Geriatrics Health Professions Training.--Within the overall request
            for HRSA's Title VII and Title VIII programs, CSWE urges the
            Subcommittee to appropriate $46.5 million for Geriatrics Health
            Professions Programs. This includes the Geriatric Academic
            Career Incentive Awards (GACA), Geriatric Education Centers
            (GEC), and Geriatric Career Incentive Awards. As mentioned
            earlier, the reauthorization that occurred last year made
            enhancement to the Title VII and Title VIII programs.
            Specifically, the reauthorization enhanced the geriatrics
            programs to allow additional health professions--such as social
            workers and other mental healthcare providers--to participate.
            Rapid job growth is anticipated for gerontological social
            workers. In fact, the demand for geriatric social workers is
            expected to increase by 45 percent by 2015, faster than the
            average of all other occupations \2\. Additional funding for
            these programs is needed to ensure that the geriatric workforce
            is adequately equipped to deal with the aging population, which
            is only expected to grow to breaking-point levels within the
            next several years.
    ---------------------------------------------------------------------------
        \2\ Hooyman, N., and Unutzer, J. 2011. ``A Perilous Arc of Supply
    and Semand: How Can America Meet the Multiplying Mental Health Care
    Needs of an Again Populations.'' Generations 34 (4): 36-42.
    ---------------------------------------------------------------------------
      substance abuse and mental health services administration (samhsa)
                          minority fellowship program
        The goal of the SAMHSA Minority Fellowship Program (MFP) is to
    achieve greater numbers of minority doctoral students preparing for
    leadership roles in the mental health and substance abuse fields.
    According to SAMHSA, minorities make up approximately one-fourth of the
    population, but only about 10 percent of mental health providers are
    ethnic minorities. CSWE is a grantee of this critical program and
    administers funds to exceptional minority social work students. For
    fiscal year 2012, CSWE urges the Subcommittee to appropriate $7.5
    million to the SAMHSA Minority Fellowship Program. This would include
    $6.882 million for the Center for Mental Health Services, where the
    majority of MFP funds are administered; $71,000 for the Center for
    Substance Abuse Prevention; and $547,000 for the Center for Substance
    Abuse Treatment.
        The program has helped support doctoral-level professional
    education for over 1,000 ethnic minority social workers, psychiatrists,
    psychologists, psychiatric nurses, and family and marriage therapists
    since its inception. Still, the program continues to struggle to keep
    up with the demands that are plaguing our health professions. Severe
    shortages of mental health professionals often arise in underserved
    areas due to the difficulty of recruitment and retention in the public
    sector. Nowhere are these shortages more prevalent than in Indian
    Country, where mental illness and substance abuse go largely untreated
    and incidences of suicide continue to increase. Studies have shown that
    ethnic minority mental health professionals practice in underserved
    areas at a higher rate than non-minorities. Furthermore, a direct
    positive relationship exists between the numbers of ethnic minority
    mental health professionals and the utilization of needed services by
    ethnic minorities.
        The $7.5 million request would be used to substantially increase
    access to professional education and training for additional minority
    mental health and substance abuse professionals, in turn helping to
    ensure that underserved minority populations receive the mental health
    and substance abuse services they so desperately need. President
    Obama's fiscal year 2012 budget request includes flat funding for the
    MFP at about $4.9 million. Funding the MFP at $7.5 million would
    directly encourage more social workers of minority backgrounds to
    pursue doctoral degrees in mental health and substance abuse and will
    turnout more minority mental health professionals equipped to provide
    culturally competent, accessible mental health and substance abuse
    services to diverse populations.
                  department of education student aid programs
        CSWE supports full funding to keep the maximum Pell Grant at $5,550
    in fiscal year 2012. While Congress is understandably focused on
    identifying a solution that will place the Pell Grant program on solid
    ground in regards to its fiscal future, we urge you to remember that
    these grants help to ensure that all students, regardless of their
    economic situation, can achieve higher education. Moreover, as
    described above with regard to the SAMHSA Minority Fellowship Program,
    one goal of social work education is recruiting students from diverse
    backgrounds (which includes racial, economic, religious, and other
    forms of diversity) with the hope that they will return to serve
    diverse communities once they have completed their education. In many
    cases, this includes encouraging social workers to return to their own
    communities and apply the skills they have acquired through their
    social work education to individuals, groups, or families in need.
    Without support such as Pell Grants, many low-income individuals would
    not be able to access higher education, and in turn, would not acquire
    skills needed to best serve in the communities that would most benefit
    from their service.
        The Graduate Assistance in Areas of National Need (GAANN) program
    provides graduate traineeships in critical fields of study. Currently,
    social work is not defined as an area of national need for this
    program; however it was recognized by Congress as an area of national
    need in the Higher Education Opportunity Act of 2008. We are hopeful
    that ED will recognize the importance of including social work in the
    GAANN program in future years. Inclusion of social work would help to
    significantly enhance graduate education in social work, which is
    critically needed in the country's efforts to foster a sustainable
    health professions workforce. CSWE urges the Subcommittee to provide
    $31 million for the GAANN Program. However, if social work was to be
    added by the Department as a new area of national need, additional
    resources would need to be provided so as not to take funding away from
    the already determined areas of national need.
        Thank you for the opportunity to express these views. Please do not
    hesitate to call on the Council on Social Work Education should you
    have any questions or require additional information.
                                     ______

      Prepared Statement of the Crohn's and Colitis Foundation of America
        Mr. Chairman and members of the Subcommittee, thank you for the
    opportunity to submit testimony on behalf of the 1.4 million Americans
    living with Crohn's disease and ulcerative colitis. My name is Gary
    Sinderbrand and I have the privilege of serving as the Chairman of the
    National Board of Trustees for the Crohn's and Colitis Foundation of
    America. CCFA is the Nation's oldest and largest voluntary organization
    dedicated to finding a cure for Crohn's disease and ulcerative
    colitis--collectively known as inflammatory bowel diseases.
        Let me express at the outset how appreciative we are for the
    leadership this Subcommittee has provided in advancing funding for the
    National Institutes of Health.
        Mr. Chairman, Crohn's disease and ulcerative colitis are
    devastating inflammatory disorders of the digestive tract that cause
    severe abdominal pain, fever and intestinal bleeding. Complications
    include arthritis, osteoporosis, anemia, liver disease and colorectal
    cancer. We do not know their cause, and there is no medical cure. They
    represent the major cause of morbidity from digestive diseases and
    forever alter the lives of the people they afflict--particularly
    children. I know, because I am the father of a child living with
    Crohn's disease.
        Seven years ago, during my daughter, Alexandra's sophomore year in
    college, she was taken to the ER for what was initially thought to be
    acute appendicitis. After a series of tests, my wife and I received a
    call from the attending GI who stated coldly: Your daughter has Crohn's
    disease, there is no cure and she will be on medication the rest of her
    life. The news froze us in our tracks. How could our vibrant, beautiful
    little girl be stricken with a disease that was incurable and has
    ruined the lives of countless thousands of people?
        Over the next several months, Alexandra fluctuated between good
    days and bad. Bad days would bring on debilitating flares which would
    rack her body with pain and fever as her system sought equilibrium. Our
    hearts were filled with sorrow as we realized how we were so incapable
    of protecting our child.
        Her doctor was trying increasingly aggressive therapies to bring
    the flares under control.
        Asacol, Steroids, Mercaptipurine, Methotrexate and finally
    Remicade. Each treatment came with its own set of side effects and
    risks. Every time A would call from school, my heart would jump before
    I picked up the call in fear of hearing that my child was in pain as
    the flares had returned. Ironically, the worst call came from one of
    her friends to report that A was back in the ER and being evaluated by
    a GI surgeon to determine if an emergency procedure was needed to clear
    an intestinal blockage that was caused by the disease. Several hours
    later, a brilliant surgeon at the University of Chicago, removed over a
    foot of diseased tissue from her intestine. The surgery saved her life,
    but did not cure her. We continue to live every day knowing that the
    disease could flare at any time with devastating consequences.
        Mr. Chairman, I will focus the remainder of my testimony on our
    appropriations recommendations for fiscal year 2012.
                      recommendations for fiscal year 2012
    Centers For Disease Control And Prevention
                Inflammatory Bowel Disease Epidemiology Program
        As I mentioned earlier, CCFA estimates that 1.4 million people in
    the United States suffer from IBD, but there could be many more. We do
    not know the exact number due to the complexity of these diseases and
    the difficulty in identifying them. The Centers for Disease Control and
    Prevention's Inflammatory Bowel Disease Program is helping answer this
    and many other important questions related to these challenging
    conditions. This program is the only one of its kind and its
    accomplishments have been applauded by the CDC.
        CCFA has been a proud partner with CDC in conducting the research
    funded under the epidemiology program. For the first 2 years of the
    project the Foundation worked collaboratively with Kaiser Permanente in
    California to better understand the incidence and prevalence of IBD,
    the natural history of the disease, and why patients respond
    differently to the same therapy. This research has resulted in 11
    publications to date and another 11 papers to be submitted to high-
    quality peer-reviewed journals. Topics include but are not limited to
    the following:
      --Incidence and Prevalence of IBD
      --Patterns of Care and Outcomes in IBD
      --Qualitative study of provider opinions
      --Utilization of biologics (Infliximab)
      --Disparities in Mortality
      --Myelosuppression during Thiopurine Therapy for Inflammatory Bowel
            Disease: Implications for Monitoring Recommendations
      --Severity and Flare Algorithms
      --Disparities in Surveillance for Colorectal Cancer
      --Pediatric Epidemiology
        In 2007, our focus shifted to the establishment of the ``Ocean
    State Crohn's & Colitis Area Registry'' or OSCCAR. Under the leadership
    of Dr. Bruce Sands, this study is being conducted jointly by
    investigators at the Massachusetts General Hospital and Rhode Island
    Hospital/Brown University. The State of Rhode Island is an excellent
    location to conduct a population-based IBD study because; (1) it is a
    small State geographically; (2) it has a diverse ethnic and
    socioeconomic population that does not tend to migrate out of State:
    and (3) a small number of gastroenterologists treat essentially all IBD
    patients within the State. Since 2007, Dr. Sands has been able to
    recruit virtually all GI physicians in Rhode Island to refer patients
    into the study. To date, almost 310 patients have been recruited, 89 of
    whom are pediatric patients. All of this progress will be lost if the
    program is eliminated in 2012.
        The goals of the OSCCAR study moving forward are to: (1) describe
    the age and sex adjusted incidence rate of Crohn's disease and
    ulcerative colitis; (2) describe variations in presenting symptoms
    among children, men and women with newly diagnosed disease; (3)
    identify factors that predict resistance to steroids, including
    clinical characteristics and blood test markers that could be useful to
    treating physicians; (4) identify predictors of the need for surgery;
    and (5) describe factors that predict either impaired quality of life
    or a benign course of disease. Mr. Chairman, to ensure that this
    important epidemiological work moves forward in fiscal year 2012, CCFA
    recommends an appropriation of $680,000 (fiscal year 2010 level).
                Pediatric Inflammatory Bowel Disease Patient Registry
        Mr. Chairman, the unique challenges faced by children and
    adolescents battling IBD are of particular concern to CCFA. In recent
    years we have seen an increased prevalence of IBD among children,
    particularly those diagnosed at a very early age. To combat this
    alarming trend CCFA, in partnership with the North American Society for
    Pediatric Gastroenterology, Hepatology and Nutrition, has instituted an
    aggressive pediatric research campaign focused on the following areas:
      --Growth/Bone Development.--How does inflammation cause growth
            failure and bone disease in children with IBD?
      --Genetics.--How can we identify early onset Crohn's disease and
            ulcerative colitis?
      --Quality Improvement.--Given the wide variation in care provided to
            children with IBD, how can we standardize treatment and improve
            patients' growth and well-being?
      --Immune Response.--What alterations in the childhood immune system
            put young people at risk for IBD, how does the immune system
            change with treatment for IBD?
      --Psychosocial Functioning.--How does diagnosis and treatment for IBD
            impact depression and anxiety among young people? What
            approaches work best to improve mood, coping, family function,
            and quality of life.
        The establishment of a national registry of pediatric IBD patients
    is central to our ability to answer these important research questions.
    Empowering investigators with HIPPA compliant information on young
    patients from across the Nation will jump-start our effort to expand
    epidemiologic, basic and clinical research on our pediatric population.
    We encourage the Subcommittee to support our efforts to establish a
    Pediatric IBD Patient Registry with the CDC in fiscal year 2012.
    National Institutes of Health
        Throughout its 40 year history, CCFA has forged remarkably
    successful research partnerships with the NIH, particularly the
    National Institute of Diabetes and Digestive and Kidney Diseases
    (NIDDK), which sponsors the majority of IBD research, and the National
    Institute of Allergy and Infectious Diseases (NIAID). CCFA provides
    crucial ``seed-funding'' to researchers, helping investigators gather
    preliminary findings, which in turn enables them to pursue advanced IBD
    research projects through the NIH. This approach led to the
    identification of the first gene associated with Crohn's--a landmark
    breakthrough in understanding this disease.
        Mr. Chairman, NIDDK-sponsored research on IBD has been a remarkable
    success story. In 2008, a consortium of researchers from the United
    States, Canada, and Europe identified 21 new genes for Crohn's disease.
    This discovery, funded in part by the NIDDK, brings the total number of
    known genes associated with Crohn's disease to more than 30 and
    provides new avenues for the development of promising treatments. We
    are grateful for the leadership of Dr. Stephen James, Director of
    NIDDK's Division of Digestive Diseases and Nutrition, for aggressively
    pursuing this and other promising areas of research.
        CCFA's scientific leaders, with significant involvement from NIDDK,
    have developed an ambitious research agenda entitled ``Challenges in
    Inflammatory Bowel Diseases.'' In addition, CCFA-affiliated
    investigators played a leading role in developing the recommendations
    on IBD in the new NIH National Commission on Digestive Diseases
    strategic plan. We look forward to working with the NIDDK to advance
    the cutting-edge science called for in these two roadmaps.
        For fiscal year 2012, CCFA joins with other voluntary patient and
    medical organizations in recommending an appropriation of $35 billion
    for the NIH. Once again Mr. Chairman, thank you very much for the
    opportunity to submit our views for your consideration.
                                     ______

              Prepared Statement of the Cystic Fibrosis Foundation
        On behalf of the Cystic Fibrosis Foundation and the 30,000
    Americans with cystic fibrosis (CF), we are pleased to submit the
    following testimony with our requests for fiscal year 2012 Labor,
    Health and Human Services, and Education Appropriations.
                             about cystic fibrosis
        Cystic fibrosis is a life-threatening genetic disease for which
    there is no cure. People with CF have two copies of a defective gene,
    known as CFTR, which causes the body to produce abnormally thick,
    sticky mucus that clogs the lungs and results in fatal lung infections.
    The thick mucus in those with CF also obstructs the pancreas, making it
    difficult for patients to absorb nutrients from food.
        Since its founding, the CF Foundation has maintained its focus on
    promoting research and improving treatments for CF. More than 30 drugs
    are now in development to treat CF; some treat the basic defect of the
    disease, while others target its symptoms. Through the research
    leadership of the Cystic Fibrosis Foundation, people with CF are living
    into their 30s, 40s and beyond. This improvement in the life expectancy
    for those with CF can be attributed to research advances and to the
    teams of CF caregivers who offer specialized care. Although life
    expectancy has improved dramatically, we continue to lose young lives
    to this disease.
        The promise for people with CF lies in research. In the past 6
    years, the Cystic Fibrosis Foundation has invested over $1 billion in
    its medical programs of drug discovery, drug development, research, and
    care focused on life-sustaining treatments and a cure for CF. A greater
    investment is necessary, however, to accelerate the pace of discovery
    and development of CF therapies.
            sustaining the federal investment in biomedical research
        This Committee and Congress are to be commended for their support
    for biomedical research through the years. It is vital that we continue
    to sufficiently fund the NIH, so that it can capitalize on scientific
    advances and maintain the momentum generated by the doubling of funds
    and the infusion from the American Recovery and Reinvestment Act
    (ARRA). These increases in funding brought a new era in drug discovery
    that has benefited all Americans.
        Cutting discretionary health spending by 13.5 percent, as has been
    proposed, would halt this progress. Deep cuts would have a detrimental
    effect on the fight against many of our most serious diseases, stifle
    scientific opportunities, and result in high-wage job loss in all 50
    States. In 2007, NIH grants and contracts created and supported more
    than 350,000 jobs across the United States, an important contribution
    to the American economy.
        We urge this Committee and Congress to maintain robust investment
    in biomedical research at the NIH so it can fund critical research
    today that will provide the care and cures of tomorrow.
              strengthening clinical research and drug development
        The Cystic Fibrosis Foundation has been recognized for its unique
    research approach, which encompasses everything from basic research
    through Phase 4 post-marketing monitoring of drug safety, and has
    created the infrastructure required to accelerate the development of
    new CF therapies. As a result, we now have a pipeline of more than 30
    potential therapies that are being examined to treat people with CF.
        One such treatment is VX-770, a drug being developed by Vertex
    Pharmaceuticals that was discovered in collaboration with CFF. This
    promising therapy targets the physiological defect that causes CF in
    patients with a particular type of genetic mutation, as opposed to only
    addressing symptoms of the disease. In late February 2011 we learned
    that Phase 3 clinical trial data of VX-770 showed profound improvements
    in lung function and other health measures in CF patients, and a New
    Drug Application is expected to be submitted to the FDA for review
    later this year. This new treatment is a direct result of the
    Foundation's innovative research agenda, advancing from bench to
    bedside through the Foundation's research program which speeds the
    creation of new CF therapies.
        The Foundation is a leader in creating a clinical trials network to
    achieve greater efficiency in clinical investigation. Because the CF
    population is small, a higher proportion of people with the disease
    must partake in clinical trials than in most other diseases. This
    unique challenge prompted the Foundation to streamline our clinical
    trials processes. As a result, research conducted by the Foundation is
    more efficient than ever before and we are a model for other disease
    groups.
        While the CF Foundation has made great progress in creating a more
    efficient drug development process for cystic fibrosis, still more
    needs to be done for other rare diseases, many of which have no
    treatments available. The Federal Government has the opportunity to
    make a real difference in this regard, and we are hopeful that the
    Committee will direct the national health agencies to encourage all
    investigators and institutions receiving Federal funding to advance
    novel methodologies and mechanisms for translating basic research into
    therapies that can benefit patients.
    Advancing Translational Science
        The CF Foundation strongly urges this Committee and Congress to
    support funding for NIH's proposed National Center for Advancing
    Translational Sciences (NCATS), which will house the Institutes'
    existing translational science programs while establishing and
    providing a more focused, integrated, and systematic approach for
    linking basic discovery to therapeutic development.
        The existing programs to be housed under NCATS are integral to
    translating basic science into treatments and will benefit from funding
    for the new center. These programs include Clinical and Translational
    Science Awards (CTSA), discussed in further detail below, and the newly
    authorized Cures Acceleration Network (CAN), both designed to transform
    the way in which clinical and translational research is conducted and
    funded. The Therapeutics for Rare and Neglected Diseases (TRND) program
    will also be housed in the new center. NIH Director Collins has
    specifically cited the Cystic Fibrosis Foundation's Therapeutics
    Development Network (TDN), which plays a pivotal role in accelerating
    the development of new treatments for cystic fibrosis patients, as an
    exemplar for TRND's innovative therapeutics development model.
        The Foundation's investment in pharmaceutical and biotech companies
    can also serve as a model for the new center's overall mission. NCATS,
    like CFF, will promote public-private partnerships and convene cross-
    sector collaborations between industry, government, academia, and
    others to advance drug development, as well as provide services and
    resources for high throughput screening, assay development, and
    preclinical modeling. Prioritizing these initiatives through a
    standalone center at NIH has the potential to greatly accelerate the
    development of drugs for diseases that have historically received
    little pharmaceutical industry attention. In addition, integrating
    translational science programs from throughout NIH into one center will
    help bring greater efficiency to the Institutes' pursuit of this
    important research. Once again, we applaud NIH Director Collins for
    spearheading NCATS and look forward to working with him as this new
    initiative is implemented.
    Clinical and Translational Science Awards (CTSA)
        The CTSA program, soon to be housed in NCATS, encourages novel
    approaches to clinical and translational research, enhances the
    utilization of informatics, and strengthens the training of young
    investigators. Key to the success of CTSAs is the parallel maintenance
    of infrastructure support for Clinical Research Centers (CRC). Without
    a mechanism to offset clinical research costs, young investigators or
    Principle Investigators (PIs) studying rare diseases for which there is
    limited funding will not be able to continue to conduct clinical
    research. It is important that all NIH institutes recognize that there
    is a significant cost associated with the conduct of well designed and
    safe clinical trials, and not all of these costs can be borne by the
    CTSAs. Congress should direct the NIH to cover costs that used to be
    borne by the General Clinical Research Centers (GCRCs) through
    individual research grants.
        Support should also be directed toward the continuation and
    expansion of research networks, such as NIH's pediatric liver disease
    consortium at the National Institute of Diabetes, Digestive, and Kidney
    Diseases (NIDDK). This successful collaboration is helping researchers
    discover treatments not only for CF liver disease but for other
    diseases that affect thousands of children each year.
                           supporting drug discovery
        The Cystic Fibrosis Foundation's clinical research is fueled by a
    vigorous drug discovery effort comprised of early stage translational
    research into successful treatments for this disease. Several research
    projects at the NIH will expand our knowledge about the disease, and
    could eventually be the key to controlling or curing cystic fibrosis.
    Opportunities in Animal Models
        The Cystic Fibrosis Foundation is encouraged by the NIH's
    investment in a research program at the University of Iowa to study the
    effects of CF in a pig model. The program, funded through research
    awards from both the National Heart, Lung, and Blood Institute (NHLBI)
    and the Cystic Fibrosis Foundation, bears great promise to help make
    significant developments in the search for a cure. While a company has
    been established to produce the animals, the infrastructure and
    extensive animal husbandry required to keep the animals alive and
    conduct research on them is available at few academic institutions.
    Such barriers have greatly limited widespread adoption of these
    valuable research tools. We urge additional funding to create a common
    facility that would enable researchers from multiple institutions to
    conduct research with these models.
    Understanding CFTR Folding and Trafficking
        The data that emerged from the VX-770 Phase 2 and 3 clinical
    trials, discussed above, is proof that the way in which this drug
    targets the physiological defect that causes CF, called CFTR protein
    function modulation, is a viable therapeutic approach. However, this
    exciting data was obtained from patients with a specific CF mutation
    which affects only approximately 4 percent of CF patients. More
    research is needed to understand other genetic mutations, the most
    common of which is called F508del. F508del causes multiple negative
    effects, including misfolding and poor activation properties of the
    CFTR protein. We encourage the Committee to increase investment in
    genetic research that can help scientists to better understand the
    F508del mutation. This will facilitate CF drug discovery and has the
    potential to benefit not just those with cystic fibrosis, but also
    those with other protein misfolding diseases.
    Personalized Medicine
        Strong Federal and private investment in research is bringing
    personalized medicine into the forefront. As we gain a deeper
    understanding of many diseases and their accompanying genetic profiles,
    we understand the great challenge of personalizing therapies. While
    exciting and promising for patients, it is also expensive, complex, and
    scientifically challenging. For instance, CF doctors are facing
    difficulties in delivering appropriate care to CF patients, as
    insurance providers will not cover certain combinations of medicines
    that clinicians have found are effective for cystic fibrosis in
    particular when there is no formal clinical data to support it. This
    puts patients in a difficult position, as these clinical trials are
    expensive and unlikely to be performed by pharmaceutical companies,
    especially for treatment of a small, targeted population. As such we
    urge the Committee to provide sustained Federal investment in
    personalized medicine, to help move this burgeoning field forward and
    advance exciting scientific discoveries.
                supporting greater access to quality health care
        We are making remarkable strides in our fight against cystic
    fibrosis, but people who live with it face greater obstacles each year,
    as high medical costs can prevent them from accessing appropriate
    medical care. Healthcare for a CF patient costs $64,000 per year on
    average, 15 times more than that of the average person. Because of high
    costs, nearly a quarter of CF patients delay getting medical care or
    skip treatments their providers recommend to enhance and lengthen their
    life.
        The Foundation sees some promise in a number of provisions in the
    new healthcare reform law that increase access to health insurance
    coverage for those with rare and chronic diseases, a critical tool in
    decreasing out of pocket costs for patients. These provisions include
    those allowing children to remain on their parents' insurance until
    they are 26; prohibiting insurance companies from denying or rescinding
    coverage based on a pre-existing condition; banning annual and lifetime
    caps on coverage; and the expansion of Medicaid eligibility.
        The new law is not perfect, however, and we are concerned that
    while the provisions listed above will ensure continuity of coverage
    and greater access to care for those with CF and other chronic
    diseases, more must be done to reduce the financial burden so many
    families face in affording their care, especially in these challenging
    economic times.
        While we urge Congress to explore new options to help make care
    more affordable and reduce shifting costs to patients, we ask that
    provisions that have the potential to provide desperately needed relief
    to people with cystic fibrosis be retained, and that they are
    sufficiently funded so that those with rare and chronic diseases can
    access the care they need.
        In addition, the Foundation wishes to applaud the formation of the
    Patient Centered Outcomes Research Institute (PCORI) and urges the
    Committee to support this important entity. PCORI, a private non-profit
    institute created by the Patient Protection and Affordable Care Act,
    will support and direct research that gives patients, doctors, and
    others the information they need make informed decisions about the most
    effective and appropriate methods for preventing and treating health
    conditions. The CF Foundation has had great success in improving
    quality of care for cystic fibrosis patients through the development
    and administration of a comprehensive patient registry and the
    collection of comprehensive data on outcomes and practice patterns for
    use in comparative effectiveness research, and we are confident that
    dedicating a national institute to such pursuits will improve care for
    all Americans.
        The Cystic Fibrosis Foundation has devoted our own resources to
    developing treatments through drug discovery, clinical development, and
    clinical care. Several of the drugs in our pipeline show remarkable
    promise in clinical trials and we are increasingly hopeful that these
    discoveries will bring us even closer to a cure. However, sufficient
    investment in basic science, translational science, clinical research,
    and drug development programs at NIH is needed to continue these
    successes not only for CF but for all rare diseases. Additionally,
    funding for programs that promote access and quality of care will help
    achieve a greater quality of life for those living with chronic
    diseases like cystic fibrosis.
        We urge the Committee to consider these factors as you craft the
    fiscal year 2012 Labor, Health and Human Services, and Education
    Appropriations legislation, and stand ready to work with NIH and
    Congressional leaders on the challenging issues ahead. Thank you for
    your consideration.
                                     ______

         Prepared Statement of the Digestive Disease National Coalition
    Summary of Fiscal Year 2012 Recommendations
        $35 billion for the National Institutes of Health (NIH) at an
    increase of 12 percent over fiscal year 2011. Increase funding for the
    National Cancer Institute (NCI), the National Institute of Diabetes and
    Digestive and Kidney Diseases (NIDDK) and the National Institute of
    Allergy and Infectious Diseases (NIAID) by 12 percent.
        Continue focus on digestive disease research and education at NIH,
    including the areas of inflammatory bowel disease (IBD), hepatitis and
    other liver diseases, irritable bowel syndrome (IBS), colorectal
    cancer, endoscopic research, pancreatic cancer, and celiac disease.
        $50 million for the Centers for Disease Control and Prevention's
    (CDC) hepatitis prevention and control activities.
        $50 million for the Center for Disease Control and Prevention's
    (CDC) colorectal cancerscreening and prevention program.
        Chairman Rehberg, thank you for the opportunity to again submit
    testimony to the Subcommittee. Founded in 1978, the Digestive Disease
    National Coalition (DDNC) is a voluntary health organization comprised
    of 29 professional societies and patient organizations concerned with
    the many diseases of the digestive tract. The DDNC promotes a strong
    Federal investment in digestive disease research, patient care, disease
    prevention, and public awareness. The DDNC is a broad coalition of
    groups representing disorders such as Inflammatory Bowel Disease (IBD),
    Hepatitis and other liver diseases, Irritable Bowel Syndrome (IBS),
    Pancreatic Cancer, Ulcers, Pediatric and Adult Gastroesophageal Reflux
    Disease, Colorectal Cancer, and Celiac Disease.
        Mr. Chairman, the social and economic impact of digestive disease
    is enormous and difficult to grasp. Digestive disorders afflict
    approximately 65 million Americans. This results in 50 million visits
    to physicians, over 10 million hospitalizations, collectively 230
    million days of restricted activity. The total cost associated with
    digestive diseases has been conservatively estimated at $60 billion a
    year.
        The DDNC would like to thank the Subcommittee for its past support
    of digestive disease research and prevention programs at the National
    Institutes of Health (NIH) and the Centers for Disease Control and
    Prevention (CDC).
        Specifically the DDNC recommends: $2.16 billion for the National
    Institute of Diabetes and Digestive and Kidney Disease (NIDDK); and $35
    billion for the NIH.
        We at the DDNC respectfully request that any increase for NIH does
    not come at the expense of other Public Health Service agencies. With
    the competing and the challenging budgetary constraints the
    Subcommittee currently operates under, the DDNC would like to highlight
    the research being accomplished by NIDDK which warrants the increase
    for NIH.
    Inflammatory Bowel Disease
        In the United States today about 1 million people suffer from
    Crohn's disease and ulcerative colitis, collectively known as
    Inflammatory Bowel Disease (IBD). These are serious diseases that
    affect the gastrointestinal tract causing bleeding, diarrhea, abdominal
    pain, and fever. Complications arising from IBD can include anemia,
    ulcers of the skin, eye disease, colon cancer, liver disease,
    arthritis, and osteoporosis. The cause of IBD is still unknown, but
    research has led to great breakthroughs in therapy.
        In recent years researchers have made significant progress in the
    fight against IBD. The DDNC encourages the subcommittee to continue its
    support of IBD research at NIDDK and NIAID at a level commensurate with
    the overall increase for each institute. The DDNC would like to applaud
    the NIDDK for its strong commitment to IBD research through the
    Inflammatory Bowel Disease Genetics Research Consortium. The DDNC urges
    the Consortium to continue its work in IBD research. Therefore the DDNC
    and its member organization the Crohn's and Colitis Foundation of
    America encourage the CDC to continue to support a nationwide IBD
    surveillance and epidemiological program in fiscal year 2012.
    Viral Hepatitis: A Looming Threat to Health
        The DDNC applauds all the work NIH and CDC have accomplished over
    the past year in the areas of hepatitis and liver disease. The DDNC
    urges that funding be focused on expanding the capability of State
    health departments, particularly to enhance resources available to the
    hepatitis State coordinators. The DDNC also urges that CDC increase the
    number of cooperative agreements with coalition partners to develop and
    distribute health education, communication, and training materials
    about prevention, diagnosis and medical management for viral hepatitis.
        The DDNC supports $50 million for the CDC's Hepatitis Prevention
    and Control activities. The hepatitis division at CDC supports the
    hepatitis C prevention strategy and other cooperative nationwide
    activities aimed at prevention and awareness of hepatitis A, B, and C.
    The DDNC also urges the CDC's leadership and support for the National
    Viral Hepatitis Roundtable to establish a comprehensive approach among
    all stakeholders for viral hepatitis prevention, education, strategic
    coordination, and advocacy.
    Colorectal Cancer Prevention
        Colorectal cancer is the third most commonly diagnosed cancer for
    both men and woman in the United States and the second leading cause of
    cancer-related deaths. Colorectal cancer affects men and women equally.
        The DDNC recommends a funding level of $50 million for the CDC's
    Colorectal Cancer Screening and Prevention Program. This important
    program supports enhanced colorectal screening and public awareness
    activities throughout the United States. The DDNC also supports the
    continued development of the CDC-supported National Colorectal Cancer
    Roundtable, which provides a forum among organizations concerned with
    colorectal cancer to develop and implement consistent prevention,
    screening, and awareness strategies.
    Pancreatic Cancer
        In 2006, an estimated 33,730 people in the United States will be
    found to have pancreatic cancer and approximately 32,300 will die from
    the disease. Pancreatic cancer is the fifth leading cause of cancer
    death in men and women. Only lout of 4 patients will live 1 year after
    the cancer is found and only 1 out of 25 will survive 5 or more years.
        The National Cancer Institute (NCI) has established a Pancreatic
    Cancer Progress Review Group charged with developing a detailed
    research agenda for the disease. The DDNC encourages the Subcommittee
    to provide an increase for pancreatic cancer research at a level
    commensurate with the overall percentage increase for NCI and NIDDK.
    Irritable Bowel Syndrome (IBS)
        IBS is a disorder that affects an estimated 35 million Americans.
    The medical community has been slow in recognizing IBS as a legitimate
    disease and the burden of illness associated with it. Patients often
    see several doctors before they are given an accurate diagnosis. Once a
    diagnosis of IBS is made, medical treatment is limited because the
    medical community still does not understand the pathophysiology of the
    underlying conditions.
        Living with IBS is a challenge, patients face a life of learning to
    manage a chronic illness that is accompanied by pain and unrelenting
    gastrointestinal symptoms. Trying to learn how to manage the symptoms
    is not easy. There is a loss of spontaneity when symptoms may intrude
    at any time. IBS is an unpredictable disease. A patient can wake up in
    the morning feeling fine and within a short time encounter abdominal
    cramping to the point of being doubled over in pain and unable to
    function.
        Mr. Chairman, much more can still be done to address the needs of
    the nearly 35 million Americans suffering from irritable bowel syndrome
    and other functional gastrointestinal disorders. The DDNC recommends
    that NIDDK increase its research portfolio on Functional
    Gastrointestinal Disorders and Motility Disorders.
    Digestive Disease Commission
        In 1976, Congress enacted Public Law 94-562, which created a
    National Commission on Digestive Diseases. The Commission was charged
    with assessing the state of digestive diseases in the United States,
    identifying areas in which improvement in the management of digestive
    diseases can be accomplished and to create a long-range plan to
    recommend resources to effectively deal with such diseases.
        The DDNC recognizes the creation of the National Commission on
    Digestive Diseases, and looks forward to working with the National
    Commission to address the numerous digestive disorders that remain in
    today's diverse population.
    Conclusion
        The DDNC understands the challenging budgetary constraints and
    times we live in that this Subcommittee is operating under, yet we hope
    you will carefully consider the tremendous benefits to be gained by
    supporting a strong research and education program at NIH and CDC.
    Millions of Americans are pinning their hopes for a better life, or
    even life itself, on digestive disease research conducted through the
    National Institutes of Health. Mr. Chairman, on behalf of the millions
    of digestive disease sufferers, we appreciate your consideration of the
    views of the Digestive Disease National Coalition. We look forward to
    working with you and your staff.
    Digestive Disease National Coalition
        The Digestive Disease National Coalition was founded 30 years ago.
    Since its inception, the goals of the coalition have remained the same:
    to work cooperatively to improve access to and the quality of digestive
    disease healthcare in order to promote the best possible medical
    outcome and quality of life for current and future patients with
    digestive diseases.
                                     ______

         Prepared Statement of the Dystonia Medical Research Foundation
        Summary of recommendations for fiscal year 2012:
      --$35 Billion for the National Institutes of Health (NIH) and
            concurrent percentage increases across its institutes and
            centers.
      --Expand dystonia research at NIH through the National Institute on
            Neurological Disorders and Stroke (NINDS), the National
            Institute on Deafness and other Communication Disorders
            (NIDCD), the National Eye Institute (NEI), and the National
            Institute on Child Health and Human Development (NICHD).
      --Continue to advance dystonia research through partnerships with the
            Office of Rare Diseases Research (ORDR) and the Rare Diseases
            Clinical Research Network (RDCRN).
      --$100 million for the Cures Acceleration Network (CAN)
        Dystonia is a neurological movement disorder characterized by
    involuntary muscle spasms that cause the body to twist, repetitively
    jerk, and sustain postural deformities. Focal dystonia affects specific
    parts of the body, while generalized dystonia affects multiple parts of
    the body at the same time. Some forms of dystonia are genetic but
    dystonia can also be caused by injury or illness. Although dystonia is
    a chronic and progressive disease, it does not impact cognition,
    intelligence, or shorten a person's life span. Conservative estimates
    indicate that between 300,000 and 500,000 individuals suffer from some
    form of dystonia in North America alone. Dystonia does not
    discriminate, affecting all demographic groups. There is no known cure
    for dystonia and treatment options remain limited.
        Although little is known regarding the causes and onset of
    dystonia, two therapies have been developed and proved particularly
    useful to control patients' symptoms. Botulinum toxin (Botox/Myobloc)
    injections and deep brain stimulation (DBS) have shown varying degrees
    of success alleviating dystonia symptoms. Until a cure is discovered,
    the development of management therapies such as these remains vital,
    and more research is needed to fully understand the onset and
    progression of the disease in order to better treat patients.
    Dystonia Research at the National Institutes of Health (NIH)
        Currently, dystonia research at NIH is conducted through the
    National Institutes on Neurological Disorders and Stroke (NINDS), the
    National Institute on Deafness and Other Communication Disorders
    (NIDCD), the National Eye Institute (NEI), and the Office of the
    Director.
        The majority of dystonia research at NIH is conducted through
    NINDS. NINDS has utilized a number of funding mechanisms in recent
    years to study the causes and mechanisms of dystonia. These grants
    cover a wide range of research including the genetics and genomics of
    dystonia, the development of animal models of primary and secondary
    dystonia, molecular and cellular studies in inherited forms of
    dystonia, epidemiology studies, and brain imaging. DMRF works to
    support NINDS in conducting critical research and advancing the
    understanding of dystonia.
        NIDCD has funded many studies on brainstem systems and their role
    in spasmodic dysphonia. Spasmodic dysphonia is a form of focal dystonia
    which involves involuntary spasms of the vocal cords causing
    interruptions of speech and affecting voice quality. In addition, NEI
    focuses some of its resources on the study of blepharospasm.
    Blepharospasm is an abnormal, involuntary blinking of the eyelids which
    can cause blindness due to a patient's inability to open their eyelids.
    DMRF encourages partnerships between NINDS, NIDCD and NEI to further
    dystonia research.
        When ORDR initiated the second phase of the Rare Disease Clinical
    Research Network at NIH, they provided funding for an additional 19
    grants aimed at studying the natural history, epidemiology, diagnosis,
    and treatment of rare diseases. This includes the Dystonia Coalition,
    which facilitates collaboration between researchers, patients, and
    patient advocacy groups to advance the pace of clinical research on
    cervical dystonia, blepharospasm, spasmodic dysphonia, craniofacial
    dystonia, and limb dystonia. Working primarily through NINDS and ORDR,
    the RDCRN holds great hope for advancing understanding and treatment of
    primary focal dystonias.
        Treatment for dystonia is highly individualized, and many dystonia
    patients do not respond to the current available therapies. The study
    of potential dystonia therapies is critical for the community. The
    Cures Acceleration Network (CAN) promises to advance the development of
    ``high need cures,'' particularly by reducing the barriers between
    research discovery and clinical trials in areas that the private sector
    is unlikely to pursue in an adequate or timely way. DMRF supports this
    initiative and asks that it be funded at $100 million, as requested in
    the President's budget.
        In summary, the DMRF recommends the following for fiscal year 2012:
      --$35 billion for NIH and a proportional increase for its Institutes
            and Centers.
      --Increased portfolio of dystonia research at NIH through the
            National Institute on Neurological Disorders and Stroke, the
            National Institute on Deafness and Other Communication
            Disorders, the National Eye Institute, and the National
            Institute on Child Health and Human Development.
      --Continued partnerships on dystonia research between the Office of
            Rare Diseases Research, other NIH Institutes and Centers, the
            Rare Diseases Clinical Research Network, and the dystonia
            patient community.
      --$100 million for the Cures Acceleration Network
    The Dystonia Medical Research Foundation (DMRF)
        The Dystonia Medical Research Foundation was founded over 30 years
    ago and has been a membership-driven organization since 1993. Since our
    inception, the goals of DMRF have remained to advance research for more
    effective treatments of dystonia and ultimately find a cure; to promote
    awareness and education; and support the needs and well being of
    affected individuals and their families.
        Thank you for the opportunity to present the views of the dystonia
    community, we look forward to providing any additional information.
                                     ______

               Prepared Statement of the Elder Justice Coalition
        The Elder Justice Coalition (EJC) thanks you for providing an
    opportunity to submit testimony as you consider an fiscal year 2012
    Labor-HHS and Education Appropriations bill. The EJC is a 705 member
    strong, non-partisan organization dedicated to advocating for funding
    for the Elder Justice Act (EJA), a bipartisan bill authored by Rep.
    Pete King (NY) and sponsored by Rep. Tammy Baldwin (WI) and Rep. Janice
    Schakowsky (IL). Senator Orrin Hatch (UT) was the sponsor of the Senate
    version of the bill. The EJA was passed over a year ago. Authorized
    funding for the EJA is $195 million per year for 4 years, but first
    time funding has yet to be appropriated.
        Since passage of the EJA, a year later, vulnerable older adults who
    should be protected by the law are confronted with the same threats
    they faced a year ago. This is a sad reality given the increasing
    severity of elder abuse in this country. The most recent study
    estimates that 14.1 percent of non-institutionalized older adults
    nationwide had experienced some form of elder abuse in the past year.
    According to a recent National Institute of Justice study, almost 11
    percent of people ages 60 and older (5.7 million) faced some form of
    elder abuse in 2009. Financial exploitation of older adults is
    increasingly alarming. A 2009 report by the MetLife Mature Market
    Institute and the National Committee for the Prevention of Elder Abuse
    (NCPEA) estimates that seniors lose a minimum of $2.5 billion each
    year. A study of financially exploited older persons in one State found
    that 9 percent of the victims had to turn to Medicaid for their care
    after their own funds were stolen. Elder financial exploitation
    undoubtedly represents a large drain on Medicaid throughout the
    country.
        In his proposed budget for fiscal year 2012, President Obama
    included $21.5 million for Elder Justice Act funding. The proposed
    funding would benefit States and local communities and create jobs. Of
    the $21.5 million, $16.5 million was included for State adult
    protective services, the first and front line responders to cases of
    elder abuse in the home. Of these funds, $1.5 million would be used to
    prevent and address elder abuse within Tribal nations.
        APS workers are faced with increasing and complex caseloads while
    both Federal and State funding for these programs lag behind.
    Currently, there is no dedicated Federal funding stream for State APS
    agencies. A recently released report outlines the challenges APS faces
    and notes that Federal leadership on elder abuse prevention is lacking.
    Another report points to an overall increase in calls to adult
    protective services. Over $100 million is authorized for State APS
    programs in fiscal year 2012 and we urge the Subcommittee to use the
    President's budget proposal, $21.5 million, as the minimum amount for
    APS funding. Strengthening APS will enhance its ability to protect both
    older victims and their assets before it is too late.
        The President also included an increase of $5 million for the Long-
    Term Care Ombudsman Program to improve resident advocacy to elders and
    adults with disabilities who reside in a long-term care setting. The
    Long-Term Care Ombudsman Program is a critical tool in the fight
    against elder abuse yet, consistently underfunded.
        We urge you to include a minimum appropriation of $21.5 million for
    the Elder Justice Act in your fiscal year 2012 Labor-HHS Appropriations
    bill. We thank you for your consideration and please feel free to
    contact me with questions or concerns.
                                     ______

             Prepared Statement of the Eldercare Workforce Alliance
        Mr. Chairman and Members of the Subcommittee: We are writing on
    behalf of the Eldercare Workforce Alliance (EWA), which is comprised of
    28 national organizations united to address the immediate and future
    workforce crisis in caring for an aging America. As the Subcommittee
    begins consideration of funding for programs in fiscal year 2012, the
    Alliance \1\ asks that you consider $54.9 million in funding for the
    geriatrics health professions and direct-care worker training programs
    that are authorized under Titles VII and VIII of the Public Health
    Service Act as follows: $46.5 million for Title VII Geriatrics Health
    Professions Programs; $3.4 million for direct care workforce training;
    and $5 million for Title VIII Comprehensive Geriatric Education
    Programs.
    ---------------------------------------------------------------------------
        \1\ The positions of the Eldercare Workforce Alliance reflect a
    consensus of 75 percent or more of its members. This testimony reflects
    the consensus of the Alliance and does not necessarily represent the
    position of individual Alliance member organizations.
    ---------------------------------------------------------------------------
        Geriatrics health profession and direct-care worker training
    programs are integral to ensuring that America's healthcare workforce
    is prepared to care for the Nation's rapidly expanding population of
    older adults.
        The first of the baby boomers began to turn 65 this year. Within 20
    years, one in five Americans will be over 65; 90 percent of those
    Americans will have one or more chronic conditions. Despite the growing
    need for services, there is a growing shortage of health professionals
    and direct-care workers with specialized training in geriatrics and an
    even greater shortage of the geriatrics faculty needed to train the
    entire workforce.
        In 2008, the Institute of Medicine (IOM) issued a ground-breaking
    report, Retooling for an Aging America: Building the Health Care
    Workforce, which spotlighted these shortages and their impact on
    eldercare. The report called for an expansion of geriatrics faculty
    development awards to include additional professional disciplines,
    increased training for the direct-care workforce, and other efforts to
    create a healthcare workforce with adequate capacity to care for older
    adults. The Eldercare Workforce Alliance was established to encourage
    policymakers to act on the IOM's recommendations for addressing the
    eldercare workforce crisis.
        The enactment of the Patient Protection and Affordable Care Act
    (ACA) was a historic moment for healthcare in this country. ACA makes
    important strides toward addressing the severe and growing shortages of
    healthcare providers with the skills and training to meet the unique
    healthcare needs of our Nation's growing aging population.
        ACA includes provisions from the Retooling for an Aging America Act
    (S. 245 and H.R. 468 in the 111th Congress), sponsored by Senator Kohl
    (D-WI) and Representative Schakowsky (D-IL). These provisions enhance
    existing and establish new geriatrics programs in an effort to build
    the capacity of the healthcare workforce needed to care for older
    adults, as recommended in the IOM report.
        We very much appreciate the funding for the Title VII Geriatrics
    Health Professions programs that President Obama included in his fiscal
    year 2012 budget. We urge you to appropriate adequate funds for
    geriatrics training programs in fiscal year 2012 so that we can
    immediately begin to realize the healthcare workforce goals set forth
    in health reform. Specifically, the Eldercare Workforce Alliance
    requests $54.9 million in total funding for the following programs
    under Title VII and VIII of the Public Health Service Act:
    Title VII Geriatrics Health Professions Appropriations Request: $46.5
            Million
        Title VII Geriatrics Health Professions programs are the only
    Federal programs that: (1) increase the number of faculty with
    geriatrics expertise in a variety of disciplines; and (2) offer
    critically important geriatrics training to the entire healthcare
    workforce.
      --Geriatric Academic Career Awards (GACA).--The goal of this program
            is to promote the development of academic clinician educators
            in geriatrics.
          Program Accomplishments.--In Academic Year 2009-2010, GACA funded
            84 non-competing continuation awards. GACA awardees provided
            approximately 60,000 health professionals with
            interdisciplinary geriatrics training. In turn, these trainees
            provided culturally competent quality healthcare to over
            525,000 underserved and uninsured patients in acute care
            services, geriatric ambulatory care, long-term care, and
            geriatric consultation services settings.
          In 2010, HRSA expanded the awards to be available to more
            disciplines. EWA advocated for this expansion and we now want
            to ensure that there is adequate funding for this vital
            program. Our request of $5.3 million, as reflected in the
            President's budget, includes necessary support for 68 Geriatric
            Academic Career Awardees, promoting the development of
            clinician educators.
      --Geriatric Education Centers (GEC).--The goal of the Geriatric
            Education Centers is to provide quality interdisciplinary
            geriatric education and training to geriatrics specialists and
            non-specialists, including family caregivers and direct care
            workers.
          Program Accomplishments.--In Academic Year 2009-2010, the GEC
            grantees provided clinical training to 54,167 health
            professional students and to 20,791 interdisciplinary teams in
            multiple settings.
          As part of the ACA, Congress authorized a supplemental grant
            award program that will train additional faculty through a
            mini-fellowship program. The program requires awarded faculty
            to provide training to family caregivers and direct care
            workers. Our funding request of $22.7 million, as reflected in
            the President's budget plus $2.7 million for the supplemental
            grants, includes support for the core work of 45 GECs and for
            the 24 GECs that would be funded to undertake development of
            mini-fellowships under the supplemental grants program included
            in ACA.
      --Geriatric Training Program for Physicians, Dentists, and Behavioral
            and Mental Health Professions.--The goal of the GTPD is to
            increase the supply of quality and culturally competent
            geriatric clinical faculty and to retrain mid-career faculty in
            geriatrics. This program supports training additional faculty
            in medicine, dentistry, and behavioral and mental health so
            that they have the expertise, skills and knowledge to teach
            geriatrics and gerontology to the next generation of health
            professionals in their disciplines.
          Program Accomplishments.--In Academic Year 2009-2010, 11 non-
            competing continuation grants were supported. Forty-nine
            physicians, dentists, and psychiatric fellows received support
            to provide geriatric care to 20,078 older adults across the
            care continuum. Geriatric physician fellows provided healthcare
            to 12,254 older adults. Geriatric dental fellows provided
            healthcare to 4,073 older adults. Geriatric psychiatry fellows
            provided healthcare to 3,751 older adults.
          Our funding request of $8.5 million, as reflected in the
            President's budget, includes support for 13 institutions to
            continue this important faculty development program.
      --Geriatric Career Incentive Awards Program.--Congress has authorized
            this new program created through the ACA, which offers grants
            to foster greater interest among a variety of health
            professionals in entering the field of geriatrics, long-term
            care, and chronic care management. President Obama included $10
            million in his fiscal year 2012 budget to establish this awards
            program. Our funding request of $10 million, as reflected in
            the President's budget, includes support for implementation of
            this new program.
    Title VII Direct-Care Worker Training Program Appropriations Request:
            $3.4 million
        Direct-care workers help older adults who need long-term services
    and supports including assistance with activities of daily living (e.g.
    eating, bathing, dressing, toileting). Expanded training opportunities
    for these essential workers are critical to ensuring an adequate
    geriatrics workforce. According to current employment projections, more
    than 1 million new direct care workers will be needed by 2018 in order
    to meet the growing need for care.
      --Training Opportunities for Direct Care Workers.--As part of the
            ACA, Congress approved an advanced training program for direct
            care workers, administered by HHS. Although President Obama's
            budget did not include this vital training program, EWA urges
            Congress to fund it in order to enhance direct care worker
            skills and knowledge, and thereby, improve the quality of care
            for older adults. EWA's funding request of $3.4 million
            includes support to establish this unique grant program at
            community colleges as they look to increase the geriatrics
            knowledge and expertise of the direct care workforce.
    Title VIII Geriatrics Nursing Workforce Development Programs
            Appropriations Request: $5 million
        These programs, administered by the HRSA, are the primary source of
    Federal funding for advanced education nursing, workforce diversity,
    nursing faculty loan programs, nurse education, practice and retention,
    comprehensive geriatric education, loan repayment, and scholarship.
      --Comprehensive Geriatric Education Program.--The goal of this
            program is to provide quality geriatric education to
            individuals caring for the elderly. This program supports
            additional training for nurses who care for the elderly;
            development and dissemination of curricula relating to
            geriatric care; and training of faculty in geriatrics. It also
            provides continuing education for nurses practicing in
            geriatrics.
          Program Accomplishments.--In Academic Year 2009-2010, 27 CGEP
            grantees provided education and training to [suggest adding all
            of these together--total of x professionals in nursing, home
            health, as well as lay people] 3,030 Registered Nurses/
            Registered Nursing Students; 260 Advanced Practice Nurses; 221
            Faculty; 110 Home Health Aides; 483 Licensed Practical/
            Vocational Nurses & LPN students; 730 Nurse Assistants/Patient
            Care Associates; 810 Allied Health Professionals and 929 lay
            persons, guardians, activity directors. The CGEP grantees
            provided 459 educational course offerings in the care of the
            elderly on a variety of topics to 6,846 participants.
      --Traineeships for Advanced Practice Nurses.--Through the ACA, the
            Comprehensive Geriatric Education Program is being expanded to
            include advanced practice nurses who are pursuing long-term
            care, geropsychiatric nursing or other nursing areas that
            specialize in care of elderly.
          Our funding request of $5 million, as reflected in the
            President's budget, includes funds that will continue the
            training of nurses caring for the elderly and offer 200
            traineeships to nurses under the newly implemented traineeship
            program.
        Without additional funds in these programs, we will fail to ensure
    that America's healthcare workforce will be prepared to care for older
    Americans. We understand that the Committee faces difficult budget
    decisions. However, we strongly believe that by investing in these
    programs, which create geriatrics faculty and offer the training that
    is needed to ensure a competent workforce, we will be delivering better
    care to America's older adults. Healthcare dollars will be saved from
    better care coordination and health outcomes, and the workforce will
    grow as more people are trained, recruited and retained in the field of
    geriatrics.
        On behalf of the members of the Eldercare Workforce Alliance, we
    commend you on your past support for geriatric workforce programs and
    ask that you join us in expanding the geriatrics workforce at this
    critical time--for all older Americans deserve quality of care, now and
    in the future.
        Thank you for your consideration.
                                     ______

                  Prepared Statement of the FSH Society, Inc.
        Honorable Senator Harkin, Mr. Chairman, Honorable Senator Shelby,
    Ranking Member, Subcommittee members and members of the U.S. Senate
    Appropriations Committee, Subcommittee on Labor, Health and Human
    Services, Education and Related Agencies thank you for the opportunity
    to submit this testimony.
        I am Daniel Paul Perez, of Bedford, Massachusetts, President and
    CEO of the FSH Society, Inc. and an individual who has lived with
    facioscapulohumeral muscular dystrophy (FSHD) for 48 years. FSHD is
    also known as facioscapulohumeral muscular disease, FSH muscular
    dystrophy and Landouzy-Dejerine muscular dystrophy. For hundreds of
    thousands of men, women, and children the major consequence of
    inheriting the most prevalent form of muscular dystrophy is a lifelong
    progressive and severe loss of all skeletal muscles. FSHD is a
    crippling and life shortening disease. No one is immune, it is
    genetically and spontaneously (by mutation) transmitted to children and
    it affects entire family constellations.
        My testimony seeks to address the urgent need for NIH to redress
    and increase funding for research on FSHD.
        A consortium of European partners known as Orphanet, led by the
    French government research agency, INSERM (Insitut National de la Sante
    et de la Recherche Medicale), that is comparable to the United States.
    NIH, which includes both government and private members, has issued new
    epidemiology and prevalence data for hundreds of diseases that ranks
    FSHD as the first and most prevalent muscular dystrophy. The ``Orphanet
    Series'' report November 2010, ``Prevalence of Rare Diseases'' report
    can be found at Internet web site: (http://www.orpha.net/orphacom/
    cahiers/docs/GB/Prevalence_of_rare_diseases_by_alphabetical_list.pdf).
    FSHD is presented as the third most prevalent muscular dystrophy in the
    Muscular Dystrophy Community Assistance, Research and Education
    Amendments of 2001 and 2008 (the MD-CARE Act). This new data changes
    the findings as listed in the MD-CARE Act. FSHD is 40 percent more
    prevalent than Duchenne muscular dystrophy (DMD), now recognized as the
    second most prevalent dystrophy.

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

        Figures from the online NIH database RCDC RePORT and the NIH
    Appropriations History for Muscular Dystrophy report provided by NIH/OD
    Budget Office & NIH OCPL show that from the inception of the MD CARE
    Act 2001, funding has more than quadrupled from $21 million to $86
    million in fiscal year 2010 for muscular dystrophy. In fiscal year
    2010, total muscular dystrophy funding grew by 3.6 percent ($3 million/
    $83 million) over the previous fiscal year.
        In fiscal year 2010, FSHD funding represented 7 percent of the NIH-
    wide muscular dystrophy budget ($6 million/$86 million). In the
    previous year, FSHD represented 6 percent of the total muscular
    dystrophy funding ($5 million/$83 million). FSHD funding as a
    percentage of overall NIH muscular dystrophy funding has been level
    over the last 9 years.

       NATIONAL INSTITUTES OF HEALTH (NIH) FSHD FUNDING AND APPROPRIATIONS
                              [Dollas in millions]
    ------------------------------------------------------------------------
                                                                  FSHD as a
                                                                  Percentage
                                                                   of Total
                     Fiscal Year                       FSHD          NIH
                                                     Research      Muscular
                                                                  Dystrophy
                                                                   Funding
    ------------------------------------------------------------------------
    2006.........................................          $1.7            4
    2007.........................................           3              5
    2008.........................................           3              5
    2009.........................................           5              6
    2010.........................................           6              7
    ------------------------------------------------------------------------
    Sources: NIH/OD Budget Office & NIH OCPL & NIH RCDC RePORT.

        We highly commend the NIH on the ease of use and the continued
    accuracy of the Research Portfolio Online Reporting Tool (RePORT)
    report ``Estimates of Funding for Various Research, Condition, and
    Disease Categories (RCDC)'' with respect to reporting projects on
    muscular dystrophy.
        Now that FSHD has been established as the most prevalent muscular
    dystrophy, and in light of recent advances in research it makes no
    sense that FSHD remains the most underfunded dystrophy by the NIH and
    in the Federal research agency system (CDC, DOD and FDA). Given FSHD's
    prevalence, disease burden, the overall percentage of funding of the
    muscular dystrophy research portfolio and major mechanistic
    breakthroughs on FSHD etiology in 2010 and 2011, we ask Congress to
    urge NIH to provide a catalyst for scientific opportunity in FSHD.
        Inter-dystrophy funding changes and comparisons year after year
    clearly depicts that NIH FSHD funding needs to be increased and set
    right. Intra-dystrophy funding changes are misleading as a large change
    in a small number is still an anemic amount. In fiscal year 2010, the
    most prevalent muscular dystrophy, FSHD, received a $1 million increase
    from NIH to $6 million, up 20 percent from $5 million. In fiscal year
    2010, the second most prevalent, Duchenne (DMD/BMD) type, received a $5
    million increase from NIH to $38 million, up 15 percent from $33
    million. In fiscal year 2010, the third most prevalent myotonic
    dystrophy (DM) type, received $1 million less from NIH to $12 million
    down 8 percent from $13 million. There is an obvious funding disparity
    as the first and third most prevalent dystrophies combined, each with
    major breakthroughs in the past 2 years, are receiving less than half
    of NIH funding that the second prevalent dystrophy with its disease
    causing gene being discovered 25 years ago.
        The MD CARE Act mandates the NIH Director to intensify efforts and
    research in the muscular dystrophies, including FSHD, across the entire
    NIH. It should be very concerning that: (1) in the last 9 years
    muscular dystrophy has quadrupled to $86 million and that FSHD has
    remained on average at 5 percent of the NIH muscular dystrophy
    portfolio; (2) FSHD, the most prevalent muscular dystrophy is far
    underrepresented based on percentage of overall NIH dystrophy funding
    given its prevalence and disease burden; and (3) that both FSHD and DM
    have had extraordinary major breakthroughs in understanding the disease
    mechanism in the current and past fiscal years and NIH funding remains
    level in one and has declined in the other.

                                                  [Dollars in millions]
    ----------------------------------------------------------------------------------------------------------------
                                                                         NIH Funding         Percentage of Total MD
                                                                 --------------------------      funding at NIH
                       Muscular Dystrophy Type                                             -------------------------
                                                                  Fiscal Year  Fiscal Year  Fiscal Year  Fiscal Year
                                                                      2009         2010         2009         2010
    ----------------------------------------------------------------------------------------------------------------
    FSHD........................................................           $5           $6            6            7
    DMD/BMD.....................................................           33           38           40           44
    DM..........................................................           13           12           16           14
    ----------------------------------------------------------------------------------------------------------------

        Two major breakthroughs on FSHD occurred in fiscal year 2010 and
    fiscal year 2011 that make it urgent for the NIH to redress funding for
    FSHD. On August 19, 2010, a paper titled, ``A Unifying Genetic Model
    for Facioscapulohumeral Muscular Dystrophy'' [Science 24 September
    2010: Vol. 329 no. 5999 pp. 1650-1653] was published online in the top-
    rated journal by a group of researchers who started their careers in
    FSHD research with post-doctoral fellowships from the FSH Society. This
    paper was a major breakthrough in understanding how FSHD works. It made
    the front page of the New York Times on the following day. The Times
    article ``Reanimated `Junk' DNA Is Found to Cause Disease,'' quoted Dr.
    Francis Collins, a human geneticist and Director of the National
    Institutes of Health saying, ``If we were thinking of a collection of
    the genome's greatest hits, this would go on the list.'' Dr. Collins
    went on to say, ``Well, my gosh, . . . here's a simple disease with an
    incredibly elaborate mechanism. To come up with this sort of mechanism
    for a disease to arise--I don't think we expected that.'' Professor
    David E. Housman, FSH Society Scientific Advisory Committee Chairman
    and a geneticist at Massachusetts Institute of Technology (M.I.T.), was
    quoted saying, ``Scientists will now be looking for other diseases with
    similar causes, and they expect to find them. As soon as you understand
    something that was staring you in the face and leaving you clueless,
    the first thing you ask is, `Where else is this happening?' ''
        Two months later, another paper was published that originated with
    seminal funding from the FSH Society that made a second critical
    advance in determining the cause of FSHD. ``Facioscapulohumeral
    Dystrophy: Incomplete Suppression of a Retrotransposed Gene'' was
    published in PLoS Genetics, October 28, 2010, that made a second
    critical advance in FSHD. The research shows that FSHD is caused by the
    inefficient suppression of a gene that may be normally expressed only
    in early development. The international team of researchers led by
    Stephen Tapscott, M.D., Ph.D., a member of the Hutchinson Center's
    Biology Division thinks that the work will lead to new approaches for
    therapy and new insights into human evolution of disease.
        The international FSHD clinical and research community recently
    came together at the DHHS NIH Eunice Kennedy Shriver National Institute
    of Child Health and Human Development (NICHD) Boston Biomedical
    Research Institute Senator Paul D. Wellstone MD CRC for FSHD. Almost 90
    scientists working on FSHD globally met at the 2010 FSH Society FSHD
    International Research Consortium, held October 21-22, 2010 to identify
    areas of scientific opportunity in FSHD that need funding. The summary
    and recommendations of the group state that given the recent
    developments in our definition of FSHD, that within 1 to 2 years
    evidence-based intervention strategies, therapeutics, and trials need
    to be planned and conducted. Our immediate priorities should be to
    confirm that the DUX4 gene hypothesis is valid. Then we must understand
    the normal DUX4 function. Finally, we must understand the naturally
    occurring variability to enable us to manipulate the disease in our
    favor. We need to be prepared for this new era in the science of FSHD
    by accelerating efforts in the following 10 areas: Shareable protocols;
    common and shareable materials and data by the whole community;
    corroborate and verify DUX4 finding; FSHD alleles in context of
    population genetics need to be defined; biomarkers; FSHD clinical
    evaluation scales/systems need be defined under one agreed standard;
    Working Groups/animal and mouse model working group consortium; model
    systems for mechanistic, intervention work and advancement to clinical
    trials; Epigenetics/Genetics; clinical trials readiness.
        To read the expanded summary and recommendations of the group
    please go to online file at: http://www.fshsociety.org/assets/pdf/
    IRCWorkshop2010WorkingConsensusOfPrioritiesGalley.pdf.
        It is impossible to justify the current low level of FSHD funding
    in the current context of muscular dystrophy budget at the NIH. We have
    worked hard with our scientific colleagues and member patients and
    families to build the corpus of knowledge to understand FSHD. We have
    made great progress in understanding our own disease. We have worked
    side by side with the NIH directors, program and legislative staff the
    whole distance to these remarkable discoveries. Still, there has been a
    confounding and recalcitrant lack of traction at NIH for funding in
    FSHD. Our request to the NIH--increase FSHD funding now!
        NIH constantly reminds us that the NIH system of peer-review
    delivers the best science from investigator initiated grant
    applications, thus delivering quality science to the American taxpayer.
    NIH is receiving more and more grant applications on FSHD. As a
    nonprofit volunteer health agency that funds breakthrough research
    based on peer-review mechanics and on a shoe-string compared to NIH, we
    appreciate the need for peer review, the need to fund the best science
    and also the need to recalibrate the process to ensure that pragmatic
    and necessary choices are being pursued in the advent of paradigmatic
    changes in a disease. We FSHD patients and fellow citizens appreciate
    this as taxpayers as well.
        What it comes down to is--the choice of ``the best science'' in a
    disease area and how this has been achieved. This is difficult to
    measure except in hindsight e.g. what hypotheses represent the best
    science. The Director of NIH said, set this down, take note, this is 1
    of the 10 greatest discoveries in human genomics and that we never
    expected diseases to be caused by unwanted RNA from reanimated junk
    DNA. The implications are enormous. FSHD has an incredibly elaborate
    mechanism that we did not expect. We now know that inadvertent
    expression of DUX4 from a stretch of reactivated ``junk-DNA'' causes
    muscle disease known as FSHD. It is clear that this type of research
    does not and has not done well in peer-review and it is obvious by the
    fact that funding is dwarfed. Looking back at the recent NIH Request
    For Proposals (RFAs) that covered FSHD we can see that all of the
    breakthrough D4Z4 DUX4 gene grant applications went unfunded by NIH.
    Perhaps the study sections need to be pulled apart and examined in the
    broader context of muscular dystrophy. Perhaps comparing Duchenne,
    Myotonic and FSHD is now much akin to determining the best science in
    computer science and biology combined. Computer science and biology
    seems an obvious apples to oranges comparison. We are saddened that the
    most brilliant work on FSHD was turned away by the NIH. It is crystal
    clear, if not completely black and white, that FSHD is not achieving
    the goals of parity in funding as set down in mandates set forth in the
    MD CARE Acts 2001/2008 and by the NIH Action Plan for the Dystrophies
    submitted to the Congress by the NIH.
        As you know, we are impressed with the efforts of NIH staff and
    Muscular Dystrophy Coordinating Committee (MDCC) on behalf of the
    community of patients and their families with muscle disease and the
    research community pursuing solutions for all of us. We recognize in
    particular the efforts and hard work of the following NIH staff: Story
    Landis, Ph.D. and John D. Porter, Ph.D. of National Institute of
    Neurological Disorders and Stroke (NINDS); Stephen I. Katz, M.D., Ph.D.
    and Glen H. Nuckolls, Ph.D. and Vittorio Satorelli, Ph.D., National
    Institute of Arthritis and Musculoskeletal and Skin Disease (NIAMS);
    James W. Hanson, M.D. and Ljubisa Vitkovic, M.D., Ph.D., (NICHD).
        The pace of discovery and numbers of experts in the field of
    biological science and clinical medicine working on FSHD are rapidly
    expanding. Many leading experts are now turning to work on FSHD not
    only because it is one of the most complicated and challenging problems
    seen in science, but because it represents the potential for great
    discoveries, insights into stem cells and transcriptional processes and
    new ways of treating human disease.
        We request this year in fiscal year 2012, immediate help for those
    of us coping with and dying from FSHD. We ask NIH to fund research on
    facioscapulohumeral muscular dystrophy (FSHD) at a level of $35 million
    in fiscal year 2012. In view of the tremendous breakthroughs in FSHD
    research that may rewrite genetics, we implore the NIH to immediately
    address the inadequacy in FSHD muscular dystrophy funding.
        We implore the Appropriations Committee to request that the
    Director of NIH, the Chair, and Executive Secretary of the Federal
    advisory committee MDCC to increase the amount of FSHD research and
    projects in its portfolios using all available passive and pro-active
    mechanisms and interagency committees.
        We request that NIH be more proactive in facilitating grant
    applications (unsolicited and solicited) from new and existing
    investigators and through new and existing mechanisms, special
    initiatives, training grants and workshops--to bring knowledge of FSHD
    to the next level.
        We ask NIH to consider increasing the scope and scale of the
    existing DHHS U.S. NIH Senator Paul D. Wellstone Muscular Dystrophy
    Cooperative Research Centers (U54) to double or triple their size--they
    are financially under-powered as compared to their potential. These
    centers have provided an excellent source of human biomaterials and are
    a catalyst for research, clinical research and training on muscular
    dystrophy. We ask NIH to develop funding mechanisms to help expand work
    from NIH Wellstone Centers outward to address needs and priorities of
    the scientific communities.
        We ask NIH for more than one Wellstone center solely dedicated to
    FSHD. There needs to be one-half dozen groups with 6 to 10 people
    solely working on FSHD across the United States to assure continuity in
    FSHD efforts.
        We strongly support research discovery through the use of post-
    doctoral and clinical training fellowships--a model that has worked
    very effectively for us. It produces results and progeny. Yet, NIH has
    only a few fellows in dystrophy. We request that NIH issue an RFA to
    exclusively fund 12 new post-doctoral fellows and four clinical fellows
    a year on an ongoing basis for the next 5 years on FSHD. We ask that
    FSHD be the pilot dystrophy for such initiative.
        We request that the Director of the NIH initiate solely for FSHD an
    RFA for Specialized Centers (P50s) to encourage multidisciplinary
    research approaches on the complexity of FSHD.
        We request that the Director of the NIH redress the low level of
    funding in FSHD by issuing an RFA exclusively for FSHD to allow it to
    be a prototype disease in the newly forming National Center for
    Advancing Translational Sciences. This will help advance the
    translational science in FSHD and catalyze the development of novel
    diagnostics and therapeutics for FSHD.
        We request that the Directors of the NIH develop, through an RFA
    for FSHD, a central place where clinical trials can be designed and run
    on animal models of FSHD (mouse, dog, sheep, etc.). It is cost
    prohibitive to have each U54, P01, P50 funding infrastructure to
    support these resources. We ask that FSHD be the proof-of-concept
    disease for such a facility.
        Thanks to your efforts and the efforts of your Committee, Mr.
    Chairman, the Congress, the NIH and the FSH Society are all working to
    promote progress in FSHD. Our successes are continuing and your support
    must continue and increase.
        Mr. Chairman, thank you for this opportunity to testify before your
    committee.
                                     ______

        Prepared Statement of the Federation of American Societies for
                              Experimental Biology
        The Federation of American Societies for Experimental Biology
    (FASEB) urges Congress to make investment in the National Institutes of
    Health (NIH) an urgent national priority and respectfully requests an
    appropriation of $35 billion for the agency in fiscal year 2012. This
    figure represents an increase that responds to the effects of inflation
    on the current program level and is needed to continue ongoing
    initiatives and prevent severe damage to the Nation's capacity for
    innovation in its fight against disease.
        As a federation of 23 scientific societies, FASEB represents more
    than 100,000 life scientists and engineers, making it the largest
    coalition of biomedical research associations in the United States.
    FASEB's mission is to advance health and welfare by promoting progress
    and education in biological and biomedical sciences, including the
    research funded by NIH, through service to its member societies and
    collaborative advocacy. FASEB enhances the ability of scientists and
    engineers to improve--through their research--the health, well-being,
    and productivity of all people.
        NIH is the driving force behind our Nation's leadership in
    biomedical science and the dramatic improvements in our health and
    quality of life. Because of NIH and the research it supports, we stand
    on the brink of an era of enormous potential progress against the
    ravages of disease. NIH funds the research of more than 325,000
    scientists at over 3,000 universities, medical schools, and other
    research institutions across the United States. Eighty percent of NIH
    funding is distributed through competitive grants to researchers in
    nearly every congressional district and the U.S. territories. More than
    130 Nobel Prize winners have received support from the agency. NIH
    considers many different perspectives in establishing scientific
    priorities and identifies and, within the limits of its budget, funds
    the most promising and highest quality research to address them. NIH is
    also training the next generation of researchers to ensure that the
    United States continues to be a global leader in advancing medical
    science.
    Improving Health, Saving Lives
        Research funded by NIH has produced an outstanding legacy. NIH-
    funded discovery has meant that more than 1 million lives per year are
    saved due to therapies to prevent heart attacks and stroke. That alone
    has increased American life expectancy by 4 years. Biomedical research
    discovery has also meant that since 2002 deaths from cancer have
    steadily declined; and in the past 30 years, survival rates for
    childhood cancers have increased from less than 50 percent to over 80
    percent. More recent advances include:
      --Improving Treatments for Acute Myeloid Leukemia (AML).--
            Investigators have discovered mutations in a gene that affects
            the treatment prognosis for some patients with AML, an
            aggressive blood cancer that kills 9,000 Americans annually.
            The findings may help guide future treatment strategies for
            individuals with AML, as well as lead to more effective
            therapies for patients who carry the mutations.
      --Increasing Pediatric Cancer Survival Rates.--A new form of
            immunotherapy has significantly improved survival rates of
            children with neuroblastoma, a deadly nervous system cancer
            responsible for 12 percent of all cancer deaths in children
            under age 15. The new therapy has dramatically increased the
            percentage of children who were alive and free of disease
            progression after 2 years.
      --Reversing Aspects of Aging.--Researchers have reversed age-related
            degeneration in a mouse model of aging. While the findings
            don't prove that natural aging could be halted or reversed,
            they may lead to new strategies to combat certain age-related
            conditions.
      --Rapidly Detecting Tuberculosis (TB).--Scientists have developed an
            automated test that can rapidly and accurately detect TB and
            drug-resistant TB in patients. The finding could pave the way
            for earlier diagnosis and more targeted treatment of this
            disease. TB kills about 1.8 million people each year, and drug-
            resistant TB is a growing threat. The new test makes it
            possible to detect TB and drug resistance in a single clinic
            visit and perhaps begin treatment immediately.
    Predictable and Sustainable Funding Will Drive Innovation and Progress
        Our leadership in biomedical research has made us the envy of the
    rest of the world. Our dominant position in the discovery of new drugs
    and therapies is the result of research conducted by scientists and
    engineers in academia and in the biotech firms that they have
    started.\1\ A study published in the February 9 issue of the New
    England Journal of Medicine found that 153 new drugs approved by the
    U.S. Food and Drug Administration during the past 40 years were
    discovered at least in part by public sector research institutions
    (universities, research hospitals, nonprofit research institutes, and
    Federal laboratories), highlighting the increasingly important role of
    the public sector in the development of pharmaceuticals and other
    medical interventions.\2\ At present, the NIH budget is insufficient to
    fund all of the promising research that needs to be done. Less than one
    in five research proposals can be funded. Over the past 6 years, the
    number of research project grants funded by NIH has declined in almost
    every year, and the agency is now funding 2,000 fewer grants that it
    did in 2004. Due to the extreme competition for support, NIH grant
    applicants have pared their funding requests to the bare minimum needed
    to fulfill the goal of their research.
    ---------------------------------------------------------------------------
        \1\ R. Kneller, Nature Reviews: Drug Discovery 9 (November) 2010.
        \2\ Ashley J. Stevens, D.Phil., Jonathan J. Jensen, M.B.A., Katrine
    Wyller, M.B.E., Patrick C. Kilgore, B.S., Sabarni Chatterjee, M.B.A.,
    Ph.D., and Mark L. Rohrbaugh, Ph.D., J.D. The Role of Public-Sector
    Research in the Discovery of Drugs and Vaccines, New England Journal of
    Medicine, February 9, 2011.
    ---------------------------------------------------------------------------
        If we fail to continue to capitalize on our investment, others
    will. We have built laboratories, trained young researchers, and
    initiated exciting new projects. Potentially revolutionary new avenues
    of research hold promise for earlier screening and better therapies,
    but these advances will not become a reality unless the NIH budget is
    sustained and enhanced to meet inflation's demands. Failure to continue
    our commitment to biomedical research will terminate important
    scientific investigations, stunt graduate training, and discourage
    young scientists who are the key to our future.
        The NIH budget is currently $34 billion (including supplemental
    appropriations). Exciting new initiatives at NIH are poised to
    accelerate our progress in the search for cures, and it would be tragic
    if we could not capitalize on the many opportunities before us. A
    modest increase over the current program level is needed to continue
    ongoing initiatives and prevent severe damage to our capacity for
    innovation. Maintaining our current level of effort requires an
    increase equal to the biomedical research and development price index
    (BRDPI), which the Bureau of Economic Analysis in the U.S. Department
    of Commerce estimates will be 3 percent in fiscal year 2012.
        A small fraction of our Federal budget, research funding generates
    an enormous return in new technologies and improved quality of life.
    Boom and bust cycles are wasteful and inefficient strategies for
    funding science. The Nations medical research agency needs sustainable
    and predictable budget growth to maximize the return on this investment
    in the health and longevity of all Americans. To that end, FASEB
    recommends an appropriation of $35 billion for NIH in fiscal year 2012.
    Thank you for the opportunity to offer FASEB's support for NIH.
                                     ______

      Prepared Statement of Friends of the Health Resources and Services
                                 Administration
        The Friends of HRSA is a nonprofit and non-partisan alliance of
    more than 180 national organizations, collectively representing
    millions of public health and healthcare professionals, academicians
    and consumers. The coalition's principal goal is to ensure that HRSA's
    broad health programs have continued support in order to reach the
    populations presently underserved by the Nation's patchwork of health
    services.
        HRSA operates programs in every State and territory and thousands
    of communities across the country and is a national leader in providing
    health services for individuals and families. The agency serves as a
    health safety net for the medically underserved, including the 50
    million Americans who were uninsured in 2009 and 60 million Americans
    who live in neighborhoods where primary healthcare services are scarce.
    To respond to these challenges, it is the best professional judgment of
    the members of the Friends of HRSA that the agency will require an
    overall funding level of at least $7.65 billion for fiscal year 2012.
        While we recognize the reality of the current fiscal climate, our
    request of $7.65 billion represents the minimum amount necessary for
    HRSA to continue to meet the healthcare needs of the American public.
    Anything less will undermine the efforts of HRSA programs to improve
    access to quality healthcare for millions of our neediest citizens.
    Additionally, the Friends of HRSA coalition members remain concerned
    about the deep cuts made to the agency in the final fiscal year 2011
    Continuing Resolution and the negative consequences for public health.
    Therefore, the requested minimum level of funding for fiscal year 2012
    is essential to allow the agency to carry out critical public health
    programs and services that reach millions of Americans, including
    training for public health and healthcare professionals, providing
    primary care services through community health centers, improving
    access to care for rural communities, supporting maternal and child
    healthcare programs, and providing healthcare to people living with
    HIV/AIDS. However, much more is needed for the agency to achieve its
    ultimate mission of ensuring access to culturally competent, quality
    health services; eliminating health disparities; and rebuilding the
    public health and healthcare infrastructure.
        Our $7.65 billion fiscal year 2012 HRSA funding request is based
    upon recommendations provided by coalition members to support HRSA
    programs including:
      --Health Professions programs support the education and training of
            primary care physicians, nurses, dentists, dental hygienists
            physician assistants, nurse practitioners, public health
            personnel, mental and behavioral health professionals,
            optometrists, pharmacists, and other allied health providers;
            improve the distribution and diversity of health professionals
            in medically underserved communities; and ensure a sufficient
            and capable health workforce able to provide care for all
            Americans and respond to the growing demands of our aging and
            increasingly diverse population. In addition, the Patient
            Navigator Program helps individuals in underserved communities,
            who suffer disproportionately from chronic diseases, navigate
            the health system.
      --Primary Care programs support community health centers operating in
            more than 8,000 communities in every State and territory,
            improving access to cost-effective and high-quality primary and
            preventive care in rural and urban underserved areas. In
            addition, the Health Centers program targets the country's most
            vulnerable populations, including migrant and seasonal farm
            workers, homeless individuals and families, and those living in
            public housing.
      --Maternal and Child Health Flexible Maternal and Child Health Block
            Grants, Healthy Start and other programs provide services,
            including prenatal and postnatal care, newborn screening tests,
            immunizations, school-based health services, mental health
            services, and well-child care for more than 34 million
            uninsured and underserved women and children not covered by
            Medicaid or the Children's Health Insurance Program, including
            children with special needs.
      --HIV/AIDS programs provide assistance to metropolitan and other
            areas most severely affected by the HIV/AIDS epidemic; support
            comprehensive care, drug assistance and support services for
            people living with HIV/AIDS; provide education and training for
            health professionals treating people with HIV/AIDS; and address
            the disproportionate impact of HIV/AIDS on women and
            minorities.
      --Family Planning Title X programs provide reproductive healthcare
            and other preventive services for more than 5 million low-
            income women at over 4,500 clinics nationwide. These programs
            improve maternal and child health outcomes, prevent unintended
            pregnancies, and reduce the rate of abortions.
      --Rural Health programs improve access to care for the 60 million
            Americans who live in rural areas. Rural Health Outreach and
            Network Development Grants, Rural Health Research Centers,
            Rural and Community Access to Emergency Devices Program, and
            other programs are designed to support community-based disease
            prevention and health promotion projects, help rural hospitals
            and clinics implement new technologies and strategies, and
            build health system capacity in rural and frontier areas.
      --Special Programs include the Organ Procurement and Transplantation
            Network, the National Marrow Donor Program the C.W. Bill Young
            Cell Transplantation Program, and National Cord Blood
            Inventory. Strong funding would facilitate an increase in
            organ, marrow, and cord blood transplantation.
        Greater investment is necessary to sufficiently fund HRSA services
    and programs that continue to face increasing demands. We urge you to
    consider HRSA's role in building the foundation for health service
    delivery and ensuring that vulnerable populations receive quality
    health services, while continuing to strengthen our Nation's health
    safety net programs. By supporting, planning for and adapting to change
    within our healthcare system, we can build on the successes of the past
    and address new gaps that may emerge in the future.
        We appreciate the Subcommittee's hard work in advocating for HRSA's
    programs in a climate of competing priorities. The members of the
    Friends of HRSA thank you for considering our fiscal year 2012 request
    for $7.65 billion for HRSA in the fiscal year 2012 Labor, Health and
    Human Services, Education, and Related Agencies Appropriations bill and
    are grateful for this opportunity to present our views to the
    Subcommittee.
                                     ______

     Prepared Statement of Friends of the National Center on Birth Defects
               and Developmental Disabilities Advocacy Coalition
        The Friends of NCBDDD Advocacy Coalition recommends that Congress
    provide at least $144 million in fiscal year 2012 to sustain the vital
    programs and activities funded by NCBDDD. Furthermore, we call on
    Congress to ensure any program modifications do no harm for children
    and adults currently served by the Center and that funds intended to
    directly benefit the targeted populations not be diverted.
        CDC's National Center on Birth Defects and Developmental
    Disabilities (NCBDDD) works to prevent birth defects and developmental
    disabilities and help people with disabilities and blood disorders live
    the healthiest life possible. It is the only CDC Center whose primary
    mission is focused on birth defects, disability and blood disorders.
    2011 marks the 10th year of the Center's accomplishments.
        NCBDDD impacts millions of our Nation's most vulnerable: infants
    and children, people with disabilities, and people with blood
    disorders. During times of increasing fiscal constraint, NCBDDD is
    committed to finding strategic approaches to support and strengthen
    core public health activities for these vulnerable and underserved
    populations. Public health is the science and art of preventing disease
    and disability, promoting physical and behavioral wellness, supporting
    personal responsibility, and prolonging life in communities where
    people live, work, and learn. Building upon the latest science and
    evidence-based research, the Center has identified key priorities to
    these populations to ensure continued public health advancements are
    made, as well as demonstrating sound returns on investments.
    Child Health and Development--Assuring Child Health
                Division of Birth Defects and Developmental Disabilities
        Success in this NCBDDD program area includes rapidly translating
    research findings into prevention strategies that prevent birth defects
    and developmental disabilities, focusing attention on the importance of
    early care and special intervention services for children born with a
    birth defect or developmental disability, and supporting parents in
    helping their children grow into healthy, safe, productive members of
    society.
    Health and Development for People with Disabilities--Improving the
            Health of People with Disabilities
                Division of Human Development and Disability
        This spectrum of NCBDDD activities promotes healthy development and
    reduces health disparities across the life course for persons with or
    at risk of disability. Program goals include: Improving the health and
    developmental outcomes for children, improving the quality of life and
    life expectancy for people with disabilities, and eliminating health
    disparities faced by persons of all ages living with disabilities.
    Public Health Approach to Blood Disorders
                Division of Blood Disorders
        The history of NCBDDD activities in this area includes bleeding and
    clotting disorders, hemoglobinopathies and blood product safety. The
    future of blood disorders is predicated on building upon our past
    successes and expanding our public health activities to begin
    addressing the most prevalent, costly, and debilitating bleeding and
    clotting disorders.
    CDC's National Center on Birth Defects and Developmental Disabilities
            (NCBDDD) Focus on Public Health-Social Impact-Safety Net Need
            of the Populations Served
        The Friends advocacy coalition calls on congressional appropriators
    and the administration to continue to focus the Center's programs on
    outcomes that affect positive public health, positive social impact,
    and the safety net purpose. These include:
    Assuring Child Health
        Decrease or eliminate birth defects and developmental disabilities
    occurring due to known causes.
        Improve longer term outcomes of children with birth defects,
    autism, and other developmental disabilities, and eliminate racial/
    ethnic disparities in these outcomes.
        Identify preventable risk factors of birth defects and
    developmental disabilities, and develop appropriate interventions to
    reduce these risks.
        Increase early identification and intervention for infants and
    young children with disabling conditions.
        Mediate the impact of poverty on developmental outcomes for young
    children.
    Improving the Health of People with Disabilities
        Change individual health behaviors to improve health in children,
    youth, and adults with disabilities.
        Improve healthcare access and screening for children, youth, and
    adults with disabilities.
        Reduce the incidence of secondary conditions by increasing health
    promotion and wellness interventions for children and adults with
    disabilities.
        Improve public health surveillance systems to track the health,
    development, and participation of persons with disabilities across the
    life course.
        Implement fully the Section 4302 ``Patient Protection and
    Affordable Care Act'' intent, expectations, and requirements in
    ``Understanding Health Disparities: Data Collection and Analysis''
    including ``disability status'' as well as Section 5307 ``Cultural
    Competency, Prevention, and Public Health'' including ``individuals
    with disabilities training.''
    Public Health Approach to Blood Disorders
        Improve the life expectancy of people with Sickle Cell Disease.
        Reduce the morbidity and mortality related to bleeding disorders in
    women.
        Reduce the incidence of DVT/PE, and prevent related mortality and
    serious morbidity.
        Prevent emerging morbidities of people with bleeding disorders.
    Positive Outcomes
        These outcomes should positively affect several social impact goals
    to improve the life situation of persons with disabilities and other
    challenges. These include:
      --Seamless, positive, and helpful transitions from one of life's
            stages to the next stage in life, such as the transition from
            high school to adulthood and work.
      --Promotion and support of independent living in the community--a
            community participation that encourages and promotes self-
            direction.
      --Continued coordinated efforts to assist parents and consumers make
            informed medical and life decisions.
      --Focused activities with the goal of reducing the severity of
            disability.
                                     ______

     Prepared Statement of the Friends of the National Institute on Aging
                                     (NIA)
        The Friends of the NIA is a coalition of 50 academic, patient-
    centered and not-for-profit organizations that conduct, fund or
    advocate for scientific endeavors to improve the health and quality of
    life for Americans as we age. As a coalition, we support the
    continuation and expansion of NIA research activities and seek to raise
    awareness about important scientific progress in the area of aging
    research currently sponsored by the Institute.
        To ensure that progress in Nation's biomedical, social, and
    behavioral research is sustained, the Coalition endorses the NIH fiscal
    year 2012 request, $31.7 billion, as a floor and joins the Ad Hoc Group
    for Medical Research in supporting $35 billion for NIH as a ceiling.
    Given the unique funding challenges facing the NIA, and the range of
    promising scientific opportunities in the vast, diverse field of aging
    research, the Friends of NIA ask the subcommittee to recommend NIA
    receive $1.4 billion in fiscal year 2012--an amount endorsed by the
    Leadership Conference on Aging.
    The NIA Mission
        Established in 1974, NIA leads the national scientific effort to
    understand the nature of aging in order to promote the health and well
    being of older adults. NIA's mission is three-fold: (1) Support and
    conduct genetic, biological, clinical, behavioral, social, and economic
    research related to the aging process, diseases and conditions
    associated with aging, and other special problems and needs of older
    Americans; (2) Foster the development of research- and clinician-
    scientists for research on aging; and (3) Communicate information about
    aging and advances in research on aging with the scientific community,
    healthcare providers, and the public. The NIA fulfills this mission by
    supporting both extramural research at universities and medical centers
    across the United States and intramural research at laboratories in
    Baltimore and Bethesda, Maryland.
    Research Activities and Advances
        Adding to its strong record of progress throughout its 37-year
    history, recent NIA-supported activities and advances have contributed
    to improving the health and well-being of older people worldwide. Below
    is a summary of some of these most recent activities and advances.
    Alzheimer's Disease
        Alzheimer's disease (AD) is the most common cause of dementia in
    the elderly. Between 2.6 million and 5.1 million Americans aged 65
    years and older may have AD, with a predicted increase to 13.2 million
    by 2050. While researchers have achieved greater understanding of the
    disease, there is no cure. In light of the exploding aging population,
    which by 2030 is expected to reach 72 million Americans ages 65 or
    older, scientists are in a race against time to prevent an
    unprecedented AD epidemic threatening our older population.
        NIA is the lead Federal research agency for Alzheimer's disease
    (AD). In this regard, the Institute coordinates trans-NIH AD
    initiatives and encourages collaboration with other Federal agencies
    and private research entities. As illustration of its leadership role,
    NIA partnered with the McKnight Brain Research Foundation to support
    the 2010 Cognitive Aging Summit. This meeting, a follow-up to a 2007
    summit, brought together experts in a variety of research fields to
    discuss advances in understanding brain and behavioral changes
    associated with normal aging, including clinical translational research
    for prevention of age-related cognitive decline.
        As part of its ongoing AD Neuroimaging Initiative (ADNI), the
    largest public-private partnership currently in AD research, NIA-funded
    researchers continued to make important progress in 2010. Phase two is
    underway to define changes in brain structure and function as people
    transition from normal cognitive aging to mild cognitive impairment
    (MCI is often a precursor to Alzheimer's) to AD. Using imaging
    techniques and biomarker measures in blood and cerebrospinal fluid
    (CSF), ADNI investigators have already established a method and
    standard of testing levels of AD characteristic tau and beta-amyloid
    proteins in the CSF, correlated levels of these proteins with changes
    in cognition over time, and determined that changes in these two
    protein levels in the CSF may signal the onset of mild AD.
        Genetic research on AD is also yielding important insights into the
    disease. In 2009 and 2010, several new candidate risk factors gene,
    including CR1, CLU, PICALM and SORL1, were identified. Identification
    of new pathways that contribute to the development of AD will provide
    novel avenues for drug targeting. As part of another initiative, the AD
    Translational Initiative, 40 compounds are being studied. In addition,
    industry partners are considering several compounds that NIH funded in
    the pre-clinical phase for full-scale clinical testing. In total, NIH
    currently supports 38 clinical trials, including both pilot and large
    scale trials, of a wide range of interventions to prevent, slow, or
    treat AD and/or cognitive decline. Any one or more of these trials may
    hold the key to curing or preventing this terrible disease.
        In a major announcement, revised clinical diagnostic criteria for
    AD dementia were published in the April 19, 2011 issue of Alzheimer's &
    Dementia: The Journal of the Alzheimer's Association, marking the first
    time in 27 years clinical diagnostic criteria and research guidelines
    for earlier stages of AD have been revised. The revised guidelines
    cover the full spectrum of the disease as it gradually changes over
    many years. They describe the earliest pre-clinical stages of the
    disease, mild cognitive impairment, and dementia due to AD's pathology.
    The guidelines also address the use of imaging and biomarkers in blood
    and spinal fluid that may help determine whether changes in the brain
    and those in body fluids are due to AD. The guidelines outline some new
    approaches for clinicians and provide scientists with more advanced
    guidelines for moving forward with research on diagnosis and
    treatments.
    Increasing Healthy Life Span
        Through its Division of Aging Biology, NIA supports research to
    improve understanding of the basic biological mechanisms underlying the
    process of aging and age-related diseases. The program's primary goal
    is to provide the biological basis for interventions in the process of
    aging, which is the major risk factor for many chronic diseases
    affecting older people. Recent significant findings that could help
    advance understanding of a range of chronic diseases, include the
    discovery of the drug rapamycin, which has been shown to extend median
    lifespan in a mouse model. Grantees supported by this program have also
    identified genetic pathways that regulate the maintenance of the stem
    cell microenvironment in aging tissues.
        In fiscal year 2012, the Institute intends to continue supporting
    the Interventions Testing Program to extend median and/or maximal life
    span in a mouse model; an initiative to determine cell fates in various
    tissues of aged mammals, under both normal and injury conditions; and
    studies to identify neural, neuroendocrine, and other mechanisms that
    influence age-related changes in bone metabolism and health.
    Behavioral and Social Science Research
        The Division of Behavioral and Social Research Program supports
    social and behavioral research to increase understanding of the aging
    process at the individual, institutional, and societal levels. Research
    areas include the behavioral, psychological, and social changes
    individuals undergo throughout the adult lifespan; participation of
    older people in the economy, families, and communities; the development
    of interventions to improve the health and cognition of older adults;
    and the societal impact of population aging and of trends in labor
    force participation, including fiscal effects on the Medicare and
    Social Security programs. The Division also leads numerous trans-NIH
    behavioral and social science research initiatives, such as the ongoing
    Behavioral Economics initiatives.
        One of the Division's signature projects, the Health and Retirement
    Study (HRS), is recognized as the Nation's leading source of combined
    data on health and financial circumstances of Americans over age 50.
    HRS data have been cited in over 1,700 scientific papers and have
    informed findings regarding the effects of early-life exposures on
    later-life health, variables associated with cognitive and functional
    decline in later life, and trends in retirement, savings, and other
    economic behaviors. In 2010, NIA expanded the HRS to increase minority
    representation and conduct genome-wide scans of a subset of
    participants. Also, in 2010, HRS data were used by scientists who found
    that older adults who survive hospitalization involving severe sepsis,
    a serious medical condition caused by an overwhelming immune response
    to severe infection, are at higher risk for cognitive impairment and
    physical limitations than older adults hospitalized for other reasons.
    Funding Challenges
        In November 2010, Nature magazine featured an article, ``Funding
    crisis hits U.S. ageing research,'' describing funding challenges
    facing the NIA and the field of aging research. The article reported
    that ``in 2010, a researcher submitting a grant application for any
    single deadline had only an 8 percent chance of winning funding''--
    falling from 12 percent in 2009. Dr. Richard Hodes, NIA Director, is
    quoted as saying the currently funding dilemma ``threaten[s] the
    viability of ageing research'' and expresses concern, in particular,
    about the effect the declining success rates could have on the morale
    of the next generation of scientists and on their ability to compete
    successfully for an NIA grant. The dire implications of the Institute's
    declining success rates is one reason, among others, that the Friends
    of NIA ask the Subcommittee to support $1.4 billion, an increase of
    $300 million, for the Institute in fiscal year 2012.
    Conclusion
        We thank you, Mr. Chairman, and the Subcommittee for supporting the
    NIA and, again, for the opportunity to express our support for the
    Institute and its important research.
                                     ______

                 Prepared Statement of Futures Without Violence
        Futures Without Violence, formerly Family Violence Prevention Fund,
    has worked for 30 years to end violence against women and children
    around the world, and is proud to be a co-chair the nonpartisan Funding
    to End Domestic and Sexual Violence Coalition, a coalition of over 30
    national organizations committed to domestic violence, dating violence,
    sexual assault, and stalking. As the National Health Resource Center on
    Domestic Violence, we provide critical information to thousands of
    healthcare providers, institutions, domestic violence service
    providers, government agencies, researchers and policy makers each
    year. Our public education campaigns, conducted in partnership with The
    Advertising Council, have shaped public awareness and changed social
    norms for 15 years.
        Violence Against Women Health Initiative (HHS Office of Women'
    Health).--I wish to request $3.375 million for the Violence Against
    Women Health Initiative as authorized by the Violence Against Women and
    Department of Justice Reauthorization Act of 2005 (Public Law 109-162);
    the President's fiscal year 2012 budget requested $3 million for this
    Initiative. The Violence Against Women Health Initiative is a
    consolidation of two Violence Against Women Act 2005 programs (Grants
    to Foster Public Health Partnerships and Education and Training of
    Health Care Providers), and a top LHHS priority by the Funding to End
    Domestic and Sexual Violence Coalition. The Violence Against Women
    Health Initiative through the Office of Women's Health, with additional
    support by the Administration on Children and Families, provides
    funding to public health programs that integrate domestic and sexual
    violence assessment and intervention into basic care, as well as
    encourages collaborations between healthcare providers, public health
    programs, and domestic and sexual violence programs. The field is
    already seeing impressive results. We strongly support the continued
    need to engage health providers to prevent and respond to violence and
    abuse. Our other priorities are listed at the end of my testimony.
        Domestic and sexual violence is a critical healthcare problem and
    one of the most significant social determinants of health for women and
    girls. Nearly one in four women in the United States reports
    experiencing violence by a current or former spouse or boyfriend at
    some point in her life, and one in six women reported experiencing a
    completed sexual assault. The Centers for Disease Control and
    Prevention (CDC) conservatively estimates that intimate partner rape,
    physical assault and stalking costs the healthcare system $8.3 billion
    annually from direct injuries and services. In addition to the
    immediate trauma caused by abuse, it contributes to a number of chronic
    health problems. The CDC classifies violence and abuse as a
    ``substantial public health problem in the United States.''
        Children who experience childhood trauma, including witnessing
    incidents of domestic violence, are at a greater risk of having serious
    adult health problems including tobacco use, substance abuse, cancer,
    heart disease, depression and a higher risk for unintended pregnancy.
    Twenty years of research links childhood exposure to violence with
    chronic health conditions including obesity, asthma, arthritis, and
    stroke. It is worth noting that victims, particularly of sexual
    violence, are linked with obesity. A meta-analysis of research on the
    impact of adult intimate partner violence finds that victims of
    domestic violence are at increased risk for conditions such as heart
    disease, stroke, hypertension, cervical cancer, chronic pain including
    arthritis, neck and pain, and asthma. In addition to injuries, adult
    intimate partner violence also contributes to a number of mental health
    problems including depression and PTSD, risky health behaviors such as
    smoking, alcohol and substance abuse, and poor reproductive health
    outcomes such as unintended pregnancy, pregnancy complications, post
    partum depression, poor infant health outcomes and sexually transmitted
    infections including HIV.
        But early identification and treatment of victims can financially
    benefit the healthcare system. Initial findings from one study found
    that hospital-based domestic violence interventions may reduce
    healthcare costs by at least 20 percent. Preventing abuse or associated
    health risks and behaviors clearly could have long term implications
    for decreasing chronic disease and costs. Because of the long-term
    impact of abuse on a patient's health, the Violence Against Women
    Health Initiative is integrating assessment for current and lifetime
    physical or sexual violence exposure and interventions into routine
    care. Regular, face-to-face screening of patients by skilled healthcare
    providers markedly increases the identification of victims of intimate
    partner violence, as well as those who are at risk for verbal,
    physical, and sexual abuse. Routine inquiry of all patients, as opposed
    to indicator-based assessment, increases opportunities for both
    identification and effective interventions, validates violence and
    abuse as a central and legitimate healthcare issue, and enables
    providers to assist both victims and their children.
        When victims or children exposed to violence and abuse are
    identified early, providers may be able to break the isolation and
    coordinate with domestic or sexual violence advocates to help patients
    understand their options, live more safely within the relationship, or
    safely leave the relationship. Expert opinion suggests that such
    interventions in adult health settings may lead to reduced morbidity
    and mortality. Assessment for exposure to lifetime abuse has major
    implications for primary prevention and early intervention to end the
    cycle of violence.
        Just as the healthcare system has always played an important role
    in identifying and preventing other serious public health problems, I
    believe it can and must play a pivotal role in domestic and sexual
    violence prevention and intervention. It is clear that by funding these
    innovative and life-saving health provisions, we can help save the
    lives of victims of violence and greatly reduce healthcare expenses.
        In order to advance necessary and needed health goals, I urge you
    to fund the following LHHS programs accordingly:
    Violence Against Women Health Initiative at $3.375 million
        The existing program, entitled ``Project Connect: A Coordinated
    Public Health Initiative to Prevent Violence Against Women,'' is
    working with two southern California tribes and eight States (Arizona,
    Georgia, Ohio, Iowa, Maine, Michigan, Texas, Virginia) to change how
    adolescent health, reproductive health, and home visiting programs
    respond to sexual and domestic violence. The Initiative is developing
    and distributing education and training materials to respond to abuse
    across the lifespan. Research demonstrates that women in these programs
    are at high risk for abuse, and that there are evidence-based
    interventions that can improve maternal and child health, and decreases
    the risks for unplanned pregnancy, poor pregnancy outcomes and further
    abuse. These sites provide much-needed services for women in abusive
    relationships including historically medically underserved communities
    that have high rates of domestic and sexual violence, such as rural/
    frontier areas, immigrant women, and Native Americans. UC Davis School
    of Medicine is implementing an evaluation plan to measure the
    effectiveness of both the clinical intervention and policy change
    efforts.
        The approach includes creating and disseminating:
      --Enhanced clinical interventions to respond to domestic and sexual
            violence, including training and supporting materials for
            providers and health systems,
      --Patient education materials on the connection between abuse and
            their health,
      --Policy and systems change at the local, State and national level,
      --National training of providers through an eLearning platform,
      --Pilot programs to offer basic health services within domestic and
            sexual violence programs, and
      --Evaluation and research on the health impact of abuse and the
            impact of health-based interventions.
        In the first year using fiscal year 2009 funding, the Initiative
    had a significant impact:
      --With over 1,500 providers from 50 clinical sites receiving
            training, programs serving over 200,000 women will integrate
            assessment for abuse into routine care and offer help when
            needed, using an evidence-based and setting-specific clinical
            intervention.
      --New education materials for providers and patients/clients have
            been developed, including:
      --New training curriculum for home visitation programs
      --New safety cards for adolescents talking about healthy
            relationships
      --Twelve new video vignettes an electronic distance learning platform
            that will be used to train providers in adolescent,
            reproductive and maternal and child health programs nationwide.
      --Coordinated State level teams of public health and domestic and
            sexual violence partners have been formed to create lasting
            health policy and coordinated response to victims. Examples of
            policy change include adding assessment of domestic and sexual
            violence into statewide nursing guidelines, and improving data
            collection by adding new questions about domestic and sexual
            violence to statewide surveillance systems.
        This year, the sites are continuing this work but building on the
    momentum by:
      --Implementing an e-learning platform to train tens of thousands of
            additional physicians, nurses, and students. Beginning in
            Spring 2011, the free online CME trainings will be offered to
            Project Connect sites, as well as national health associations,
            such as the American College of Obstetricians and
            Gynecologists.
      --Offering basic health services on site in select domestic and
            sexual violence programs in each Project Connect site. Program
            strategies include: utilizing mobile health vans, stationing
            public health nurses in family violence programs, integrating
            basic health assessment questions into domestic violence
            shelter intake, and partnering with local providers for ongoing
            care.
      --Evaluating the impact of Project Connect's clinical intervention on
            the health and safety of victims of abuse. In addition to the
            initiative-wide evaluation of provider behavior change, four
            sites have partnered with local universities to conduct an in-
            depth evaluation of the effect that integrating the assessment
            of domestic and sexual violence into clinical settings has on
            clients.
      --Disseminating information on best practice models for integration
            in other States/tribes and service settings. Plans include an
            educational briefing and development of a report outlining
            model programs.
     Report Language under Centers for Disease Control and Prevention
            Injury Prevention and Control regarding Domestic and Sexual
            Violence
        In VAWA 2005, Congress approved a program entitled ``Research on
    Effective Interventions to Address Violence Against Women'' at $5
    million through CDC and ARHQ to support research and evaluation on
    effective interventions in the healthcare setting to improve victim's
    health and safety and prevent initial victimization. This authorized
    program from Public Law 109-162 has not been funded. The President's
    fiscal year 2012 budget recommends $20 million of the Prevention and
    Public Health Fund go to unintentional injuries through CDCs Injury
    Prevention and Control. To fulfill the need recognized by the earlier
    VAWA program, I respectfully recommend the following report language:
        ``The Committee finds that domestic and sexual violence is a
    healthcare problem and one of the most significant social determinants
    of health for women and girls. In addition to the immediate trauma
    caused by abuse, it contributes to a number of chronic health problems.
    The CDC classifies violence and abuse as a ``substantial public health
    problem in the United States.'' As part of the budget request to fund
    unintentional injury prevention activities from the Prevention and
    Public Health Fund, the Committee supports a portion of the funding
    support the prevention of intentional injuries from lifetime exposure
    to intimate partner violence, child maltreatment, youth violence, and
    sexual violence.''
    Proposed Report Language under HHS Office of Adolescent Health
            regarding Teen Dating Violence and Communities of Color
        The work by the Office of Adolescent Health to create and
    administer the Teen Pregnancy Prevention Program in such a short time
    period has been remarkable. That said, adolescents from communities of
    color are disproportionately affected by teenage pregnancy, and
    research also shows that teenage dating violence and abuse are
    associated with higher levels of teenage pregnancy and unplanned
    pregnancy. Adolescent girls in physically abusive relationships are
    three times more likely to become pregnant than non-abused girls. To
    fulfill the promise of the Office of Adolescent Health to holistically
    address teen pregnancy prevention, I respectfully recommend the
    following report language:

        ``The Committee strongly urges the Secretary, through the Office of
    Adolescent Health, to include teen dating violence prevention and
    healthy relationship strategies within existing adolescent health
    working groups and better integrate preventing violence and abuse as a
    strategy to prevent teen and unplanned pregnancy within communities of
    color. Further, the Committee strongly urges the Secretary, though the
    Office of Adolescent Health, to conduct a review of the evidence-based
    programs chosen by the Teen Pregnancy Prevention Program and issue a
    report to determine which programs address teen dating violence and
    healthy relationship strategies as a means to prevent teen pregnancy.''

        In addition, I ask that you at least meet the President's fiscal
    year 2012 request of $135 million for the Family Violence Prevention
    and Services Act (FVPSA) under ACF, the Nation's only designated
    Federal funding source for domestic violence shelters and services. As
    we are all committed to both the prevention of violence and abuse and
    to the health and safety of victims, I urge you to fund these critical
    programs.
                                     ______

         Prepared Statement of the Global Health Technologies Coalition
        Chairman Harkin, Ranking Member Shelby and members of the
    Committee, thank you for the opportunity to provide testimony on the
    fiscal year 2012 appropriations funding for the National Institutes of
    Health (NIH) and the Centers for Disease Control and Prevention (CDC).
    We appreciate your leadership in promoting the importance of
    international development, in particular global health. We hope that
    your support will continue. I am submitting this testimony on behalf of
    the Global Health Technologies Coalition (GHTC), a group of nearly 40
    nonprofit organizations working together to advance U.S. policies which
    can accelerate the development of new global health innovations--
    including new vaccines, drugs, diagnostics, microbicides, and other
    tools--to combat global health diseases. The GHTC's members strongly
    believe that to meet the global health needs of tomorrow, it is
    critical to invest in research today so that the most effective health
    solutions are available when we need them, and that the U.S. Government
    has a historic and unique role in doing so. My testimony reflects the
    needs expressed by our member organizations \1\ which include nonprofit
    advocacy organizations, policy think-tanks, implementing organizations,
    and many others. One-third of our members are also nonprofit product
    development partnerships, which work with partners in the private
    biotechnology and pharmaceutical and medical device sectors, as well as
    public research institutions, academia, and nongovernmental
    organizations to develop new and more effective life-saving
    technologies for the world's most pressing health issues. We strongly
    urge the Committee to continue its established support for global
    health research and development (R&D) by (1) sustaining and protecting
    the U.S. investment in global health research and product development,
    (2) instructing NIH and CDC, in collaboration with other agencies
    involved in global health, to continue their commitment to global
    health in their R&D programs, and (3) requiring leaders at U.S.
    agencies to put plans in place to ensure that global health R&D is
    efficient, coordinated and streamlined.
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        \1\ GHTC member list: http://www.ghtcoalition.org/coalition-
    members.php.
    ---------------------------------------------------------------------------
    Critical need for new global health tools
        Our Nation's investments have made historic strides in promoting
    better health around the world: nearly 6 million people living with
    HIV/AIDS now have access to life-saving medicines, new, cost-effective
    tools help us diagnose diseases quicker and more efficiently than ever
    before, and innovative new vaccines are making significant dents in
    childhood mortality. While we must increase access to these and other
    proven, existing health tools to tackle global health problems, it is
    just as critical that we continue to invest in developing the next
    generation of tools to stamp out disease and address current and
    emerging threats. For instance, newer, more robust, and easier to use
    antiretroviral drugs, particularly for infants and young children, are
    needed to treat (and prevent) HIV and even a 50 percent effective AIDS
    vaccine could prevent 1 million HIV infections every year. Drug-
    resistant tuberculosis is on the rise globally, including in the United
    States, however the only vaccine on the market is insufficient at 90
    years old, and most therapies are more than 50 years old, extremely
    toxic, and exorbitantly expensive. New tools are also urgently needed
    for fatal neglected tropical diseases such as sleeping sickness for
    which diagnostic tools are inadequate, and the few drugs that are
    available are toxic and difficult to use. There are many very promising
    technology candidates in the R&D pipeline to address these and other
    health issues; however, these tools will never be available if the
    support needed to continue R&D is not protected and sustained.
    Research and US global health efforts
        The United States is at the forefront of innovation in global
    health technologies. For example, as recently as December, a new
    meningitis vaccine costing less than 50 cents per dose developed by the
    Meningitis Vaccine Project--a partnership between the World Health
    Organization and the international nonprofit PATH--was distributed for
    the first time in Africa--the development and implementation of which
    was supported through strategic funding and scientific expertise from
    the CDC, NIH, U.S. Food and Drug Administration (FDA), and the U.S.
    Agency for International Development (USAID).
        The NIH is the largest funder of global health research in the U.S.
    Government, and the agency has recently demonstrated a growing interest
    in global health issues. NIH Director Francis Collins made global
    health one of his top five priorities for the future of NIH, stating,
    ``. . . the world has seen us as the soldier to the world. Might we not
    do better both in terms of our benevolence and our diplomacy by being
    more of a doctor to the world? \2\ The NIH's Fogarty International
    Center recently began collaborating with the Department of Health and
    Human Services' Health Research Services Administration and the U.S.
    Department of State's Office of the U.S. Global AIDS Coordinator on the
    Medical Education Partnership Initiative to develop, expand, and
    enhance models of medical education. This includes enhancing the
    capacity of local individuals to conduct research on global health
    diseases. Also recently, the Therapeutics for Rare and Neglected
    Diseases (TRND) program at the NIH launched five pilot projects to spur
    drug development for diseases including schistosomiasis and hookwoom.
    Each of these efforts build on the historic work carried out by the
    agency which contributes to improved health around the world.
    ---------------------------------------------------------------------------
        \2\ NIH all-hands town meeting, 17 August 2009. http://
    videocast.nih.gov/Summary.asp?File=15247.
    ---------------------------------------------------------------------------
        With operations in more than 54 countries, the CDC is engaged in
    many global health research efforts. The work of CDC scientists has led
    to major advances against devastating diseases, including the
    eradication of smallpox and early identification of the disease that
    became known as AIDS. Although CDC is known for its expertise and
    participation in HIV, TB, and malaria programs, it also operates
    several activities for neglected diseases in its National Center for
    Zoonotic, Vector-Borne, and Enteric Diseases.
    Leveraging the private sector for innovation
        NIH, CDC, USAID and other agencies involved in global health R&D
    regularly collaborate with the private sector in developing,
    manufacturing, and introducing important technologies such as those
    described above through public-private partnerships, including product-
    development partnerships. These partnerships leverage public-sector
    expertise in developing new tools, partnering with academia, large
    pharmaceutical companies, the biotechnology industry, and governments
    in developing countries to drive greater development of products for
    neglected diseases for which private industries have not historically
    invested. This unique model has generated twelve new global health
    products and has enormous potential for continued success if robustly
    supported.
        In order to more fully engage the private sector in developing
    products for global health R&D, additional market-based incentives are
    needed. With little-to-no commercial drive to develop new drugs and
    vaccines for diseases that primarily affect the developing world,
    financial incentives and innovative financing must be pursued. No
    single incentive scheme or financing mechanism is capable of filling
    all the gaps and encouraging the full range of R&D activities across
    all of the diseases and products that the developing world urgently
    needs. A portfolio of incentives and financing mechanisms that can fill
    the multiple gaps in the product development pipeline for multiple
    diseases is needed. NIH should be applauded for its participation in
    the small business innovation research awards and a patent pool for HIV
    medicines, and additional efforts in this area are encouraged. The
    development of new incentive strategies is critical for long-term,
    meaningful private-sector engagement in global health.
    Innovation as a smart economic choice
        Global health R&D brings life-saving tools to those who need them
    most, however the benefits these efforts bring are much broader than
    preventing and treating disease. Global health R&D is also a smart
    economic investment in the United States, where it drives job creation,
    spurs business activity, and benefits academic institutions. Biomedical
    research, including global health, is a $100 billion enterprise in the
    United States. In a time of global financial uncertainty, it is
    important that the United States support industries, such as global
    health R&D, which build the economy at home and abroad.
        History has shown that investing in global health research not only
    saves lives but is also a cost-effective approach to addressing health
    challenges. And an investment made today can help save significant
    money in the future. In the United States alone, for example, polio
    vaccinations during the last 50 years have resulted in a net savings of
    $180 billion, funds that would have otherwise been spent to treat those
    suffering from polio. In addition, new therapies to treat drug-
    resistant tuberculosis have the potential to reduce the price of
    tuberculosis treatment by 90 percent and cut health system costs
    significantly. The United States has made smart investments in research
    in the past that have resulted in lifesaving breakthroughs for global
    health diseases, as well as important advances in diseases endemic to
    the United States. We must now build on those investments to turn those
    discoveries into new vaccines, drugs, tests, and other tools.
    Recommendations
        In this time of fiscal constraint, support for global health
    research that improves the lives of people around the world--while at
    the same time creating jobs and spurring economic growth at home--
    should unquestionably be one of the Nation's highest priorities. In
    keeping with this value, the GHTC respectfully requests that the
    Committee do the following:
      --Sustain and protect U.S. investments in global health research and
            product development within both the CDC and NIH budgets. We ask
            that this not come at the expense of robust funding for the
            entire set of global public health accounts, all of which
            complement each other and ultimately serve the common goal of
            building a healthier and more prosperous world.
      --Instruct all U.S. agencies in its jurisdiction to continue their
            commitment to global health in their R&D programs by developing
            actions plans, including metrics to measure progress. The
            Committee shall request that leaders at NIH and CDC work with
            leaders at other U.S. agencies to ensure that efforts in global
            health R&D are coordinated, efficient, and streamlined by
            establishing transparency mechanisms designed to show what
            global health R&D efforts are taking place and how U.S.
            agencies are collaborating with each other to make efficient
            use of the U.S. investment.
      --Request relevant agencies report on their progress to Congress and
            be made publicly available. Past accounting of the health R&D
            activities at individual agencies, such as Research, Condition,
            and Disease Categorization at NIH, have been very helpful in
            coordinating efforts between agencies and informing the public
            and such efforts should be expanded to include neglected
            disease categorization and extended to provide a comprehensive
            picture of this investment from all agencies involved in global
            health R&D.
        We respectfully request that the Committee consider inclusion of
    the following language in the report on the fiscal year 2012 State and
    Foreign Operations appropriation legislation:

        ``The Committee recognizes the urgent need for new global health
    technologies in the fight against global health diseases, and the
    critical contribution that the NIH, CDC, and FDA make to this cause
    through their health research and training portfolios, operations
    research and regulatory capabilities. The Committee also acknowledges
    the urgent need to sustain and protect U.S. investment in this
    important research by fully funding these three agencies to carry out
    their work.
        ``New global health products such as drugs, vaccines, diagnostics,
    and devices are cost-effective public health interventions that play an
    important role in improving global health and are vital in stopping
    pandemics. The Committee understands the positive impact that global
    health research and development has on the U.S. economy through the
    creation of U.S. jobs and the development of foreign markets for U.S.
    products. NIH is widely recognized as the world leader in basic
    research, and has supplied invaluable breakthroughs that have led to
    new health tools, saving millions of lives globally. Through its
    Fogarty International Center, NIH harnesses its wealth of expertise to
    train the next generation of health scientists.
        ``The Committee directs the CDC, FDA, and NIH to each create
    metrics to measure progress and to develop concrete plans to prioritize
    and incorporate global health research, product development, and
    regulation into their U.S. global health and development strategies.
    The Committee directs CDC, FDA, and NIH to work with each other as well
    as the Department of State, the U.S. Agency for International
    Development, and the Office of the U.S. Global AIDS Coordinator to
    ensure that these efforts are coordinated, efficient, and streamlined
    across the agencies involved in implementing the President's Global
    Health Initiative. CDC, FDA, and NIH shall each make the documentation
    and results of these efforts available to Congress and the public.''

        As a leader in science and technology, the United States has the
    ability to capitalize upon our strengths to help reduce illness and
    death and ultimately eliminate disabling and fatal diseases for people
    worldwide, contributing to a healthier world and a more stable global
    economy. Sustained investments in global health research to develop new
    drugs, vaccines, tests, and other health tools--combined with better
    access to existing methods to prevent and treat disease--present the
    United States with an opportunity to dramatically alter the course of
    global health while building political and economic security across the
    globe.
        On behalf of the members of the GHTC, I would like to extend my
    gratitude to the Committee for the opportunity to submit written
    testimony for the record.
                                     ______

            Prepared Statement of Goodwill Industries International
        Mr. Chairman, Ranking Member, and Members of the Subcommittee, on
    behalf of Goodwill Industries International (GII), I appreciate this
    opportunity to submit written testimony on Goodwill's priorities for
    fiscal year 2012 funding programs administered by the U.S. Departments
    of Labor, Health and Human Services, and Education.
        Goodwill Industries International (GII) represents 158 local and
    autonomous Goodwill Industries agencies in the United States that help
    people with barriers to employment to participate in the workforce. One
    of Goodwill Industries' greatest strengths continues to be its
    entrepreneurial approach to sustaining its mission. In 2010, Goodwill
    raised more than $4 billion in its retail stores and other social
    enterprises and invested 84 percent of its privately raised revenues to
    supplement Federal investments in programs that give people the skills
    they need to reenter the workforce. Goodwill provided job training,
    employment services, and supportive services to nearly 2.5 million
    people, placing more than 170,000 people in jobs and employing 97,000.
    Nearly 160,000 people were referred to Goodwill from the workforce
    system or a State Vocational Rehabilitation Agency. In addition to our
    efforts to help people find jobs and advance in careers, Goodwill
    understands that many people need additional supportive services--child
    care, reliable transportation, stable housing, counseling and
    assistance in adjusting to the workplace, assistive technology--to
    ensure their success.
        Now more than ever, with unemployment slowly declining from the
    highest levels experienced in a generation, local Goodwill agencies are
    on the front lines of the fragile recovery assisting people with
    employment barriers, including individuals with disabilities, older
    workers, and Temporary Assistance to Needy Families (TANF) recipients
    who are struggling to find and keep jobs during a stubbornly tight job
    market. In addition in 2010, Goodwill's collective investment in these
    services eclipsed the Department of Labor's combined investment in
    WIA's adult, youth, and dislocated workers.
        While Goodwill is proud of these and other achievements, they are
    truly the result of a public-private partnership. As the fragile
    recovery from the worst recession since the Great Depression continues
    and unemployment rates slowly decline from near 10 percent, Goodwill
    understands the difficult challenge that appropriators face as they
    struggle to reduce the deficit while stretching limited resources to
    support an ever-increasing list of national priorities. Reducing the
    deficit is a serious issue that will require all to make sacrifices to
    address the Nation's spending problem while investing in integrated
    strategies that build upon and leverage existing resources that will
    address our Nation's revenue problem. Therefore, Goodwill was very
    concerned about the drastic cuts to the workforce system that were
    proposed in the fiscal year 2011 continuing resolution (H.R. 1) that
    was passed by the House of Representatives earlier this year, and
    thanks the Senate for its efforts to mitigate the cuts in the final
    fiscal year 2011 spending deal. As Congress works to develop its
    spending bills for fiscal year 2012, Goodwill is again concerned
    because the House budget allocation for Labor, Health and Human
    Services, and Education is $18 billion less than the amount agreed to
    in the final fiscal year 2011 budget deal.
        Goodwill is aggressively moving to increase its capacity to do more
    to help people find jobs and advance in careers during and after these
    difficult times. Goodwill is working to open more stores and attended
    donation centers in order to create jobs and generate more privately
    raised revenues to invest in people who are facing employment
    challenges in the communities that local Goodwill agencies serve. In
    addition, Goodwill is more committed than ever to partnering with
    stakeholders at the Federal, State, and local levels by contributing
    the resources and expertise of local Goodwill agencies in support of
    public efforts and investments.
        While our agencies care about a range of Federal funding sources,
    Goodwill urges Congress to provide funding for the Department of
    Labor's Senior Community Service Employment Program (SCSEP); the
    Workforce Investment Act's adult, dislocated worker, and youth funding
    streams; summer jobs for youth; and the Department of Education's
    Vocational Rehabilitation programs.
    Senior Community Service Employment Program (SCSEP)
        Workers who are 55 and older have multiple barriers to employment
    and will be among the last rehired as the economy improves.
    Furthermore, according to the Bureau of Labor Statistics, the
    unemployment rate for older workers (over 55 years old) was 6.2 percent
    in April, 2011. While older workers are less likely to be unemployed
    than their younger counterparts, older workers who do lose their jobs
    face significant odds of finding another one. The average time spent
    looking for a job by someone between the ages of 55 and 64 is 44.6
    weeks. Those over the age of 64 also spend nearly 1 year seeking work
    for an average of 43.9 weeks. Older workers are more likely to be laid
    off from industries that are in structural decline. This population may
    be less likely to go back to school as they have other financial
    burdens and are less mobile due to home ownership. Finally, these
    workers may face age discrimination when applying for a new job.
    Therefore, Goodwill is alarmed by the Administration's proposal to cut
    funding for the Community Services Employment for Older Americans
    program (also called the Senior Community Service Employment Program)
    by 45 percent which will result in the elimination of services to
    nearly 50,000 low income older workers who badly in need of assistance.
        SCSEP helps provide low-income older workers with community
    services employment and private sector job placements. Preserving SCSEP
    funding is critical as it is the only program targeted to helping low
    income seniors regain employment, as this population is experiencing
    the toughest employment prospects in a generation. Goodwill is a
    national SCSEP grantee with providers around the country. While many
    individuals assume that SCSEP is for much older workers and question
    the type of training received, 42 percent of Goodwill's SCSEP
    participants are between the ages of 55 and 59. In 2010, SCSEP
    participants contributed nearly 1.4 million community service hours and
    our private sector placements averaged a starting wage of $9.75 per
    hour.
        In recent years, Congress has demonstrated its commitment to older
    workers by providing an additional $120 million for SCSEP in the
    Recovery Act, and a $250 million increase in fiscal year 2010. These
    funds have allowed local Goodwill agencies to better address our
    waiting list of participants and help many older workers with part-time
    employment. Private sector placement wages also increased. Goodwill
    very much appreciates the monumental investment that the Congress has
    placed on helping older workers to survive the economic crisis.
    However, as SCSEP program providers prepare for a cut in funding,
    community service hours have been cut, new enrollees have not been
    accepted, and additional classroom training that has an added cost have
    been reduced or eliminated. Should SCSEP be cut further, it will result
    in a loss of professional staff and it will be more difficult to get
    out to non-urban areas since rural communities will have fewer slots.
        Goodwill urges the Subcommittee to reject the Administration's
    proposed cuts to SCSEP. At a minimum Congress should fund SCSEP at no
    less than $600 million, which will allow a restoration of assistance to
    an additional 24,000 participants, nearly half of the participants cut
    from the program by funding reductions in the fiscal year 2011
    Continuing Resolution.
    Workforce Investment Act
        Funding for the Workforce Investment Act's youth, adult, and
    dislocated worker formulas is one of Goodwill's top funding priorities
    for fiscal year 2012. Most Goodwill agencies have people referred to
    them through the workforce system. In addition, several agencies are
    one-stop lead operators or operators in association with other service
    providers, and are active on state and local workforce boards.
        It should be noted that, in 2002, when the unemployment rate was
    5.8 percent, combined funding for WIA's youth, adult, and dislocated
    worker funding streams was more that $3.67 billion. Since then, funding
    has steadily eroded; and nearly 10 years later, at a time when the
    unemployment rate remains much higher--around 9 percent--the
    Administration proposes just $2.96 billion for WIA's three main funding
    streams, nearly 20 percent less than the fiscal year 2002 level.
    Furthermore, the Administration proposes to divert 8 percent to
    contribute to the creation of a Workforce Innovation Fund to ``support
    and test promising approaches to training, and breaking down program
    silos, building evidence about effective practices, and investing in
    what works.''
        Goodwill believes that a Workforce Innovation Fund is a promising
    idea, is very interested in the details, and is encouraged by the
    Administration's efforts to increase interagency collaborations and
    leverage resources provided by community-based organizations, however
    the proposed Workforce Innovation Funds should be paid for with funds
    in addition to, rather than at the expense of, existing WIA formula
    funds--in fiscal year 2012 and beyond.
        In 2010, the workforce system served more than 8 million people,
    placing more than half in jobs while helping others to access education
    and training aimed at improving their future employment prospects. As
    noted earlier, Goodwill is doing all it can to help people who have
    been affected by the recession. In fact in 2010, Goodwill's collective
    investment in job training and employment services eclipsed the
    Department of Labor's combined investment in WIA's adult, youth, and
    dislocated workers. Some agencies have, in fact, been doing more than
    they can by deliberately using their reserves in order to provide help
    to more people than their current revenues support. If not now, when?
    Therefore, Goodwill is very concerned the continued delay in
    reauthorizing WIA may put the whole system at risk, causing many
    Goodwill agencies to wonder how they would respond to the dramatic
    increase in requests for services if the workforce system were to be
    dismantled completely. Most agencies would be forced to turn away
    people in need or risk being overleveraged to the brink.
        Goodwill understands that this Subcommittee faces a difficult
    challenge in stretching limited resources to cover a range of
    priorities; however the workforce system is vastly under-funded and
    preservation of WIA's formula funding streams should be a high
    priority. Therefore, Goodwill urges Congress to sustain WIA's adult,
    dislocated worker, and youth funding streams at current funding levels
    at a minimum. Before diverting funds from WIA's already underfunded
    programs, Congress should reauthorize WIA and include provisions that
    would establish the Workforce Innovation Fund without jeopardizing
    existing funds for WIA's three core funding streams.
    Vocational Rehabilitation (VR) Funding
        Goodwill Industries has a long history of helping people with
    disabilities to participate in the workforce despite the challenges
    their disabilities present. Years of inadequate funding for VR have
    left the system stretched much too thin to serve all who are eligible
    for assistance. As a result, most State VR agencies have Orders of
    Selection, a provision within the Rehabilitation Act that requires
    State VR agencies, when faced with a shortage of funds to meet the
    demand for services, to prioritize the provision of services to
    eligible people based on the severity of people's disabilities. In
    addition, reduced funding for WIA has placed an additional strain on
    mandatory partner programs, including VR, which are being asked to
    contribute more funding to pay for infrastructure and other costs
    associated with the operation of one-stop centers.
        Goodwill supports the Administration's intent to increase multi-
    system collaboration and support for youth with disabilities who are
    transitioning from education to the workforce. The Administration's
    fiscal year 2012 budget proposes to increase funding for VR State
    agencies by $57 million, while diverting $30 million of VR's State
    grant funds to contribute to a new Workforce Innovation Fund. Funding
    for the Rehabilitation Services Administration's Migrant and Seasonal
    Farmworker program, Projects with Industry, and Supported Employment
    would be eliminated, thus offsetting the increase by $50 million.
        For more than two decades, Goodwill has offered supported
    employment as a part of its service array. According to Goodwill
    Industries International's Annual Statistical Report, participation in
    local Goodwill agencies' supported employment programs has grown
    dramatically in recent years from providing 270,000 coaching sessions
    in 2007 to 630,000 sessions in 2009.
        Goodwill is intrigued by the Administration's proposal to stimulate
    system collaboration by creating a Workforce Innovation Fund; however,
    Goodwill believes that funding for the Workforce Innovation Fund should
    not come at the expense of existing and already inadequate funds for
    the VR system.
        Goodwill thanks the Subcommittee for considering these requests,
    and looks forward to working with the Subcommittee to help government
    meet the serious challenges our nation faces.
                                     ______

                Prepared Statement of the Harlem Children's Zone
        Thank you for this opportunity to support comprehensive services
    for poor children and the U.S. Department of Education's (ED) Promise
    Neighborhoods program which we believe will break the cycle of
    generational poverty for hundreds of thousands of poor children.
        Like the work at the Harlem Children's Zone (HCZ), the Promise
    Neighborhoods program has already begun to transform the odds for
    entire communities. High-achieving schools are at the core of Promise
    Neighborhoods, but it is not only about creating a successful school.
    It is about programs for children from birth through college and
    career, supporting families and rebuilding community. Doing this
    changes the trajectory of an entire community.
        In the mid-1990s it became clear to the HCZ team that despite
    heroic efforts at saving poor children, success stories remained the
    exception. Our piecemeal approach was of limited value against a
    perfect storm of problems and challenges. So the HCZ Project was
    created in Central Harlem to work with kids, their families and their
    community. Starting with one building, HCZ has grown to 97 blocks. Last
    year, the HCZ Project served 15,508 clients including 8,838 youth and
    6,670 adults. HCZ, Inc., which includes the HCZ Project plus our Beacon
    Centers and Preventive Foster Care programs, served 23,556 clients
    including 10,541 youth and 13,015 adults.
        Now, over a decade later, the Children's Zone model is working.
    Parents are reading more to their children. Four year olds are ready
    for kindergarten. Students are closing the black-white achievement gap
    in several subjects. Teenagers are graduating from high school and this
    school year, over 600 of them who attended traditional public schools
    are in college. HCZ helps parents file for taxes including the Earned
    Income Tax Credit (EITC) and last tax season, families collectively
    received over $8 million.
        HCZ's theory of change is embodied in the application of all of the
    following five principles:
      --Serve an entire neighborhood comprehensively and at scale.
      --Create a pipeline of high-quality programs that starts from birth
            and continues to serve children until they graduate from
            college. Provide parents with supports as well.
      --Build community among residents, institutions, and stakeholders,
            who help to create the environment necessary for children's
            healthy development.
      --Evaluate program outcomes; create a feedback loop that cycles data
            back to management for use in improving and refining program
            offerings; and hold people accountable.
      --Cultivate a culture of success rooted in passion, accountability,
            leadership, and teamwork.
        The HCZ model is not cheap. On average, HCZ spends $5,000 per
    child each year to ensure children's success. For far less money than
    is already spent, just on incarceration, we can educate, graduate our
    children, and bring them back to our communities ready to be
    successful, productive citizens. We think the choice is obvious.
        HCZ's achievements are not magic. They are a result of hard work
    and a comprehensive effort.
        This same type of hard work and comprehensive effort is happening
    in countless communities across the country. To provide a sense of the
    level of interest in the Promise Neighborhoods program, when the
    Department of Education offered the first round of planning grants in
    fiscal year 2010's budget, over 339 communities competed for just 21
    grants. Additionally, over 100 of these communities scored over 80,
    leading Secretary of Education Arne Duncan to note that there would
    have been more grants if resources were available. Just 7 months later,
    these communities are going strong. For example:
    Buffalo, New York
        The Buffalo Promise Initiative, which is led by M&T's Westminster
    Foundation, is collaborating with the John R. Oishei Foundation, Read
    to Succeed Buffalo, the City of Buffalo, Buffalo Public Schools, United
    Way of Buffalo and Erie County, Catholic Charities, Buffalo Urban
    League, and the University at Buffalo to serve 11,000 residents in a 1-
    square mile, low-income neighborhood. The Buffalo Promise Initiative is
    a vital counterpoint to the challenges brought about in Buffalo due to
    a shift away from industrially focused jobs, a shrinking population,
    and increasing poverty. A comprehensive approach is blooming,
    addressing the needs and hopes of children and their families in a
    changing Buffalo.
    Indianola, Mississippi
        The Indianola Promise Community (IPC) is located in Indianola,
    Mississippi, in the heart of the Mississippi Delta and the birthplace
    of musician B.B. King. The Delta Health Alliance is the lead agency for
    this unique public policy initiative. The Indianola Promise Community
    unites healthcare, education, community, and faith-based services to
    provide Indianola residents the chance to realize their promise as
    active members and leaders in their town and neighborhoods. The Delta
    Health Alliance has teamed up with a number of nonprofit organizations
    and government agencies, including the local school district, the
    municipal government, Mississippi State University, the county
    hospital, and the Children's Defense Fund, to develop a comprehensive
    collaborative with the ability to take on a number of pressing
    challenges.
        Although Indianola has a number of obstacles to overcome, leaders
    from all aspects of the community have joined together to make the IPC
    a success. The Delta Health Alliance is integrating more than a dozen
    of their preexisting services and adding new programs and new partners
    into a robust set of resources. The goal is to create a set of
    integrated services for children and their families. The IPC engages
    with all community service providers to prevent the duplication of
    resources and highlight service gaps. Community members also serve on
    the Steering Committee that oversees the work of the project.
    Northern Cheyenne Reservation
        The rich and deep history of the Northern Cheyenne community and
    their commitment to engage their members is apparent in their plans to
    develop a thriving Promise Neighborhood for their community. The
    Promise Neighborhood is located on the Northern Cheyenne Reservation
    and the surrounding communities of Colstrip and Ashland in southeast
    Montana. The land is sprawling, approximately 700 square miles, and
    approximately 7,300 people live within the Neighborhood.
        The Boys and Girls Club of Northern Cheyenne Nation (BGCNCN), the
    Promise Neighborhood lead partner, believes in ``systemic,
    collaborative, strengths-based and culturally appropriate approaches''
    to youth and community development that will comprehensively address
    the disadvantages that the community faces.
        The Boys and Girls Club has established relationships with local
    communities, and thus is an excellent lead partner for this initiative.
    All of the primary institutions that serve young people in the area are
    involved in collaborating during this planning year. The Promise
    Neighborhood has the full support of the Northern Cheyenne government,
    local schools and agencies, Chief Dull Knife College, and a number of
    nonprofits. All are working together to specifically create and
    implement in- and out-of-school strategies and services that will
    support the academic achievement, healthy development, cultural
    awareness and connectedness, and college and career success of the
    Neighborhood's children. Some of the BGCNCN's programs for youth
    include a Native American Mentoring Program, a diabetes prevention
    program, leadership groups, and a computer lab. The planning phase has
    brought these groups together to begin a more concerted effort to
    assess and develop a pipeline of programs that will benefit the youth
    and community.
    San Antonio, Texas
        The Eastside Promise Neighborhood in San Antonio, Texas is led by
    the United Way and has a strong partnership with the City of San
    Antonio. San Antonio Mayor Julian Castro and other community leaders
    are major supporters of the initiative. The Promise Neighborhood
    initiative is part of the City's larger plan to support the struggling
    Eastside, including the development of affordable housing, education,
    environment, and other supports, and developing a strategic framework
    that speaks to the community's core problems.
        The Promise Neighborhood initiative, with its set of partners like
    the San Antonio Independent School District, Family Service
    Association, Housing Authority, City Year, Trinity University, San
    Antonio for Growth on the Eastside (SAGE), and the Urban Land
    Institute, is working hard to coordinate the supports and resources in
    the neighborhood to activate their collective vision for community
    transformation. The planning and coordination of resources going into
    the community as a part of the Promise Neighborhood initiative fits
    into the City's broader Eastside Reinvestment Plan aiming to shift away
    from siloed and uncoordinated services on the Eastside.
        Because parents are a key element to their children's success,
    Eastside Promise Neighborhood has a commitment to parental engagement
    and capacity-building through focus groups, community meetings during
    which the community shapes the agenda, and parentally focused career
    and empowerment groups through initiatives like the United Way's
    Family-School-Community Partnership.
        This asset-based approach and vision ensures more efficient and
    effective use of neighborhood talent, resources, rich opportunities for
    young people through high quality neighborhood schools and engaged
    parents, and a solid physical infrastructure including high-quality
    housing in the neighborhood to support the community. The community
    looks to be on the right path toward stabilizing and empowering the
    Eastside to stay, grow, graduate and . . . stay.
        To support all of the Promise Neighborhoods' efforts, HCZ,
    PolicyLink and the Center for the Study of Social Policy joined
    together to create the Promise Neighborhoods Institute at PolicyLink
    (PNI). Supported solely by private philanthropic dollars, PNI provides
    communities with a system of support, resources, and information to
    help them in local Promise Neighborhoods efforts. PNI is already
    supporting 38 Promise Neighborhoods--including 21 funded by the U.S.
    Department of Education. PNI has three goals:
      --Ensure the 21 Federal planning grantees are successful and
            transition to implementation.
      --Support an additional 17 communities in their planning efforts and
            transition to implementation.
      --Foster a national learning network that enable communities to learn
            from their peers and leverage resources in order to
            significantly improve the educational and developmental
            outcomes of children and youth in the Nation's most distressed
            communities.
        To accomplish these goals, PNI offers:
      --Site visits designed to assess community need and implement a
            comprehensive and personalized package of technical assistance
            services that help communities learn, make systemic,
            organizational and programmatic improvements and achieve
            measurable and sustainable results.
      --Promise Neighborhood Network conferences to share best practices.
      --Trainings on topics such as how to attract funding and talk to the
            media.
      --Webinars and discussions moderated by experts in the field.
      --A website--PromiseNeighborhoodsInstitute.org--featuring in-depth
            resources and tools.
        Since its launch, PNI has:
      --Developed a rich menu of technical assistance that is based on what
            works.
      --Grown a robust community of practice that is being accessed by more
            than 2,000 people.
      --Implemented a feedback loop to continually refine city, county,
            State, and Federal public policy and philanthropic approaches.
      --Mobilized neighborhood leaders to advocate for integrated
            neighborhood revitalization investments to become the norm in
            solving some of the Nation's most intractable problems
            affecting poor children and families.
        In the current planning phase, Promise Neighborhoods are getting
    ready to apply for full implementation. They are developing strategic
    business plans to estimate revenues and cover costs. Part of this
    includes the development of data systems for how they will track and
    evaluate data to make sure that they can document success, and catch
    and deal with challenges. In addition, they are developing powerful
    partnerships with schools and with organizations and agencies so they
    can provide children and families with the supports and services that
    are needed for success from cradle to college and career. We look
    forward to continuing to work with the Promise Neighborhoods grantees
    and others as they transition from planning to implementation. And, we
    look forward to seeing the results of their efforts.
        We urge the Committee to support Promise Neighborhoods with
    resources for new sites to engage in planning, and for robust support
    for implementation in communities across the country. Thank you for
    your consideration. If you should need additional information about The
    Promise Neighborhoods program please contact Judith Bell from
    PolicyLink (Judith@policylink.org) or Katie Shoemaker at HCZ
    (kshoemaker@hcz.org).
                                     ______

      Prepared Statement of the Health Professions and Nursing Education
                                   Coalition
        The members of the Health Professions and Nursing Education
    Coalition (HPNEC) are pleased to submit this statement for the record
    in support of the fiscal year 2012 budget request of $762.5 million for
    the health professions education programs authorized under Titles VII
    and VIII of the Public Health Service Act and administered through the
    Health Resources and Services Administration (HRSA). HPNEC is an
    informal alliance of more than 60 national organizations representing
    schools, programs, health professionals, and students dedicated to
    ensuring the healthcare workforce is trained to meet the needs of the
    country's growing, aging, and diverse population. For a complete list
    of HPNEC members, visit http://www.aamc.org/advocacy/hpnec/members.htm.
        As you know, the Title VII and VIII health professions and nursing
    programs provide education and training opportunities to a wide variety
    of aspiring healthcare professionals, both preparing them for careers
    in the health professions and helping bring healthcare services to our
    rural and underserved communities. An essential component of the
    healthcare safety net, the Title VII and Title VIII programs are the
    only Federal programs designed to train healthcare providers in
    interdisciplinary settings to meet the needs of the country's special
    and underserved populations, as well as increase minority
    representation in the healthcare workforce. Through loans, loan
    guarantees, and scholarships to students, and grants and contracts to
    academic institutions and nonprofit organizations, the Title VII and
    Title VIII programs fill the gaps in the supply of health professionals
    not met by traditional market forces.
        Authorized since 1963, the Title VII and Title VIII education and
    training programs are designed to help the workforce adapt to the
    evolving healthcare needs of the ever-changing American population. In
    an effort to renew and update Titles VII and VIII to meet current
    workforce challenges, the programs were reauthorized in 2010--the first
    reauthorization in the past decade. Reauthorization not only improved
    the efficiency of the Title VII and Title VIII programs, but also laid
    the groundwork for innovative programs with an increased focus on
    recruiting and retaining professionals in underserved communities.
        HPNEC is grateful for the Subcommittee's longstanding support of
    these important workforce programs. While we are keenly aware that the
    Subcommittee continues to face difficult decisions as it seeks to
    improve the Nation's fiscal health, a continued congressional
    commitment to programs supporting healthcare workforce development is
    essential to the physical health and prosperity of the American people.
    The country faces a critical disparity between the supply of practicing
    healthcare providers and the increasing demand for care, with HRSA
    estimating that over 33,000 additional health practitioners are needed
    to alleviate existing shortages. Destabilizing funding for the Title
    VII and Title VIII programs would reduce education and training support
    for primary care physicians, nurses, and other health professionals,
    exacerbating shortages and further straining the Nation's already
    fragile healthcare system. We recognize that relative to other Federal
    programs, HRSA's fiscal year 2011 operating plan imposes modest cuts to
    most Title VII and Title VIII programs, and we look forward to working
    with the subcommittee to prevent any further erosion to Federal support
    for health professions training.
        Failure to fully fund the programs would jeopardize activities to
    train professionals across all disciplines to coordinate care for the
    Nation's expanding elderly population; limit training opportunities for
    providers to meet the unique needs of the Nation's sick and ailing
    children; severely impact the distribution of professionals practicing
    in rural and underserved communities; and hinder efforts to recruit and
    retain a diverse and culturally competent workforce. To ensure the
    healthcare workforce is equipped to address these issues, a strong
    commitment to the Title VII and Title VIII programs is essential.
        The existing Title VII and Title VIII programs can be considered in
    seven general categories:
      --The Primary Care Medicine and Oral Health Training programs, now
            authorized separately, provide for the education and training
            of primary care physicians, physician assistants, and dentists,
            to improve access and quality of healthcare in underserved
            areas. Two-thirds of all Americans interact with a primary care
            provider every year. Approximately one-half of primary care
            providers trained through these programs go on to work in
            underserved areas, compared to 10 percent of those not trained
            through these programs. The General Pediatrics, General
            Internal Medicine, and Family Medicine programs provide
            critical funding for primary care training in community-based
            settings and have been successful in directing more primary
            care physicians to work in underserved areas. They support a
            range of initiatives, including medical student training,
            residency training, faculty development and the development of
            academic administrative units. These programs also enhance the
            efforts of osteopathic medical schools to continue to emphasize
            primary care medicine, health promotion, and disease
            prevention, and the practice of ambulatory medicine in
            community-based settings. Recognizing that all primary care is
            not only provided by physicians, the primary care cluster also
            provides grants for Physician Assistant programs to encourage
            and prepare students for primary care practice in rural and
            urban Health Professional Shortage Areas. The General
            Dentistry, Pediatric Dentistry, and Public Health Dentistry
            programs provide grants to dental schools and hospitals to
            create or expand primary care and public health dental
            residency training programs.
      --Because much of the Nation's healthcare is delivered in areas far
            removed from health professions schools, the Interdisciplinary,
            Community-Based Linkages cluster provides support for
            community-based training of various health professionals. These
            programs are designed to provide greater flexibility in
            training and to encourage collaboration between two or more
            disciplines. These training programs also serve to encourage
            health professionals to return to such settings after
            completing their training. The Area Health Education Centers
            (AHECs) provide clinical training opportunities to health
            professions and nursing students in rural and other underserved
            communities by extending the resources of academic health
            centers to these areas. AHECs, which have substantial State and
            local matching funds, form networks of health-related
            institutions to provide education services to students, faculty
            and practitioners. Geriatric Health Professions programs
            support geriatric faculty fellowships, the Geriatric Academic
            Career Award, and Geriatric Education Centers, which are all
            designed to bolster the number and quality of healthcare
            providers caring for our older generations. Given America's
            burgeoning aging population, there is a need for specialized
            training in the diagnosis, treatment, and prevention of disease
            and other health concerns of older adults. The Mental and
            Behavioral Health Education and Training Programs help mitigate
            the growing shortages of mental and behavioral health providers
            by providing grants for training social workers, child and
            adolescent mental health professionals, and paraprofessionals
            working with children and adolescents. They also provide grants
            to doctoral, internship, and postdoctoral programs through the
            Graduate Psychology Education program, which supports
            interdisciplinary training of psychology students with other
            health professionals for the provision of mental and behavioral
            health services to underserved populations (i.e., older adults,
            children, chronically ill, and victims of abuse and trauma,
            including returning military personnel and their families),
            especially in rural and urban communities.
      --The purpose of the Minority and Disadvantaged Health Professionals
            Training programs is to improve healthcare access in
            underserved areas and the representation of minority and
            disadvantaged healthcare providers in the health professions.
            Minority Centers of Excellence support programs that seek to
            increase the number of minority health professionals through
            increased research on minority health issues, establishment of
            an educational pipeline, and the provision of clinical
            opportunities in community-based health facilities. The Health
            Careers Opportunity Program seeks to improve the development of
            a competitive applicant pool through partnerships with local
            educational and community organizations. The Faculty Loan
            Repayment and Faculty Fellowship programs provide incentives
            for schools to recruit underrepresented minority faculty. The
            Scholarships for Disadvantaged Students make funds available to
            eligible students from disadvantaged backgrounds who are
            enrolled as full-time health professions students.
      --The Health Professions Workforce Information and Analysis program
            provides grants to institutions to collect and analyze data on
            the health professions workforce to advise future
            decisionmaking on the direction of health professions and
            nursing programs. The Health Professions Research and Health
            Professions Data programs have developed a number of valuable,
            policy-relevant studies on the distribution and training of
            health professionals, including the Eighth National Sample
            Survey of Registered Nurses, the Nation's most extensive and
            comprehensive source of statistics on registered nurses. In
            conjunction with the reauthorization of the Title VII programs
            and in recognition of the need for better health workforce data
            to inform both public and private decisionmaking, the National
            Center for Workforce Analysis serves as a source of data and
            information on the health workforce for the Nation.
      --The Public Health Workforce Development programs are designed to
            increase the number of individuals trained in public health, to
            identify the causes of health problems, and respond to such
            issues as managed care, new disease strains, food supply, and
            bioterrorism. The Public Health Traineeships and Public Health
            Training Centers seek to alleviate the critical shortage of
            public health professionals by providing up-to-date training
            for current and future public health workers, particularly in
            underserved areas. Preventive Medicine Residencies, which
            receive minimal funding through Medicare GME, provide training
            in the only medical specialty that teaches both clinical and
            population medicine to improve community health. The Title VII
            reauthorization reorganized this cluster to include a focus on
            loan repayment as an incentive for health professionals to
            practice in disciplines and settings experiencing shortages.
            The Pediatric Subspecialty Loan Repayment Program offers loan
            repayment for pediatric medical subspecialists, pediatric
            surgical specialists, and child and adolescent mental and
            behavioral health specialists, in exchange for services in
            areas where these types of professionals are in short supply.
            The Public Health Workforce Loan Repayment Program provides
            loan repayment for public health professionals accepting
            employment with Federal, State, local, and tribal public health
            agencies.
      --The Nursing Workforce Development programs under Title VIII provide
            training for entry-level and advanced degree nurses to improve
            the access to, and quality of, healthcare in underserved areas.
            These programs provide the largest source of Federal funding
            for nursing education, providing loans, scholarships,
            traineeships, and programmatic support that, between fiscal
            year 2006 and 2009, supported over 347,000 nurses and nursing
            students as well as numerous academic nursing institutions, and
            healthcare facilities. Healthcare entities across the Nation
            are experiencing a crisis in nurse staffing, caused in part by
            an aging workforce and capacity limitations within the
            educational system. Each year, nursing schools turn away tens
            of thousands of qualified applications at all degree levels due
            to an insufficient number of faculty, clinical sites, classroom
            space, clinical preceptors, and budget constraints. At the same
            time, the need for nursing services and licensed, registered
            nurses is expected to increase significantly over the next 20
            years. The Advanced Education Nursing program awards grants to
            train a variety of advanced practice nurses, including nurse
            practitioners, certified nurse-midwives, nurse anesthetists,
            public health nurses, nurse educators, and nurse
            administrators. Workforce Diversity grants support
            opportunities for nursing education for students from
            disadvantaged backgrounds through scholarships, stipends, and
            retention activities. Nurse Education, Practice, and Retention
            grants are awarded to help schools of nursing, academic health
            centers, nurse-managed health centers, State and local
            governments, and other healthcare facilities to develop
            programs that provide nursing education, promote best
            practices, and enhance nurse retention. The Loan Repayment and
            Scholarship Program repays up to 85 percent of nursing student
            loans and offers full-time and part-time nursing students the
            opportunity to apply for scholarship funds. In return these
            students are required to work for at least 2 years of practice
            in a designated nursing shortage area. The Comprehensive
            Geriatric Education grants are used to train RNs who will
            provide direct care to older Americans, develop and disseminate
            geriatric curriculum, train faculty members, and provide
            continuing education. The Nurse Faculty Loan program provides a
            student loan fund administered by schools of nursing to
            increase the number of qualified nurse faculty.
      --The loan programs under Student Financial Assistance support
            financially needy and disadvantaged medical and nursing school
            students in covering the costs of their education. The Nursing
            Student Loan (NSL) program provides loans to undergraduate and
            graduate nursing students with a preference for those with the
            greatest financial need. The Primary Care Loan (PCL) program
            provides loans covering the cost of attendance in return for
            dedicated service in primary care. The Health Professional
            Student Loan (HPSL) program provides loans covering the cost of
            attendance for financially needy health professions students
            based on institutional determination. The NSL, PCL, and HPSL
            programs are funded out of each institution's revolving fund
            and do not receive Federal appropriations. The Loans for
            Disadvantaged Students program provides grants to health
            professions institutions to make loans to health professions
            students from disadvantaged backgrounds.
        By improving the supply, distribution, and diversity of the
    Nation's healthcare professionals, the Title VII and Title VIII
    programs not only prepare aspiring professionals to meet the country's
    workforce needs, but also help to improve access to care across all
    populations. The multi-year nature of health professions education and
    training, coupled with unprecedented existing and looming provider
    shortages across many disciplines and in many communities, necessitate
    a strong, continued, and reliable commitment to the Title VII and Title
    VIII programs.
        While HPNEC members understand of the immense fiscal pressures
    facing the Subcommittee, we respectfully urge support for $762.5
    million for the Title VII and VIII programs, a commitment essential not
    only to the development and training of tomorrow's healthcare
    professionals but also to our Nation's efforts to provide needed
    healthcare services to underserved communities. We forward to working
    with Senators to prioritize the health professions programs in fiscal
    year 2012 and into the future.
                                     ______

                Prepared Statement of the Hepatitis B Foundation
        Highlighting the urgent need to address the public health
    challenges of chronic hepatitis B by strengthening programs at the
    Centers for Disease Control and Prevention, and the National Institutes
    of Health.
        Mr. Chairman, my name is Dr. Timothy Block, and I am the President
    and Co-Founder of the Hepatitis B Foundation and its research
    institute, the Institute for Hepatitis and Virus Research. I also serve
    as the President of the Pennsylvania Biotechnology Center and am a
    professor at Drexel University College of Medicine. My wife Joan, and
    I, and another couple, Paul and Janine Witte, from Pennsylvania started
    the Hepatitis B Foundation 20 years ago to find a cure for this serious
    chronic liver disease and provide information and support to those
    affected.
        Thank you for giving the Hepatitis B Foundation (HBF) the
    opportunity to provide testimony to the Subcommittee as you begin to
    consider funding priorities for fiscal year 2012. We are grateful to
    the Members of this Subcommittee for their interest and strong
    leadership for efforts to control and find cures for hepatitis B.
        Today, the HBF is the only national nonprofit organization solely
    dedicated to finding a cure and improving the lives of those affected
    by hepatitis B worldwide through research, education and patient
    advocacy. Our scientists focus on drug discovery for hepatitis B and
    liver cancer, and early detection markers for liver cancer. HBF staff
    manages a comprehensive website which receives almost 1 million
    visitors each year, a national patient conference and outreach
    services. HBF public health professionals conduct research initiatives
    to advance our mission.
        The hepatitis B virus (HBV) is the world's major cause of liver
    cancer--and while other cancers are declining, liver cancer is the
    fastest growing in incidence in the United States. Without
    intervention, as many as 100 million worldwide will die from a HBV-
    related liver disease, most notably liver cancer. In the United States,
    up to 2 million Americans have been chronically infected and more than
    5,000 people die each year from complications due to HBV.
        HBV is 100 times more infectious than the HIV/AIDS virus. Yet,
    hepatitis B can be prevented with a safe and effective vaccine.
    Unfortunately, for those who are chronically infected with HBV, the
    vaccine is too late. There are, however, promising new treatments for
    HBV. We are getting close to solutions but lack of sustained support
    for public health measures and scientific research is threatening
    progress. New research has confirmed that early detection and treatment
    significantly reduces healthcare costs, morbidity and mortality. The
    growing incidence of liver cancer, while most other cancer rates are on
    the decline, represents examples of serious shortcomings in our system.
    In the United States, 20,000 babies are born to mothers infected with
    HBV each year, and as many as 1,200 newborns will be chronically
    infected with the hepatitis B virus. More needs to be done to prevent
    new infections.
    HHS Interagency Working Group on Viral Hepatitis
        Last year, the Department of Health and Human Services put together
    an Interagency Working Group on Hepatitis to put together an Action
    Plan on Viral Hepatitis. This action plan will describe opportunities
    for HHS to respond to the 2010 Institute of Medicine (IOM) review of
    the viral hepatitis challenge in the United States and the IOM
    recommendations to prevent and build the capacity and collaborations
    essential for reducing the number of viral hepatitis infections and
    ameliorating the health and economic consequences of viral hepatitis
    among persons chronically infected. The Hepatitis B Foundation is very
    supportive of the efforts of the Working Group and is hopeful that its
    recommendations will result in actions to address the chronic
    underfunding of viral hepatitis prevention, research and outreach
    programs within the Department. We look forward to the release of the
    Hepatitis Action Plan in May of this year.
        Mr. Chairman, as you know the two Federal agencies that are
    critical to the effort to help people concerned with hepatitis B are:
    the Centers for Disease Control and Prevention (CDC), and the National
    Institutes of Health (NIH).
    The Centers for Disease Control
        CDC's Division of Viral Hepatitis (DVH), the centerpiece of the
    Federal response to controlling, reducing and preventing the suffering
    and deaths resulting from viral hepatitis, is chronically underfunded.
    DVH is included in the National Center for HIV/AIDS, Viral Hepatitis,
    STD, and TB Prevention at the CDC, and is responsible for the
    prevention and control of viral hepatitis. DVH is currently (prior to
    finalization of the fiscal year 2011 continuing resolution) funded at
    $19.8 million, approximately $6 million less than its funding level in
    fiscal year 2003. In the President's fiscal year 2012 budget proposal,
    DVH is funded at $25 million, an increase of $5.2 million. The HBF is
    very supportive of this increase and joins the hepatitis community in
    urging the Committee to fund the President's request for the Division
    of Viral Hepatitis.
        The responsibility for addressing the problem of hepatitis should
    not lie solely with the Division. In view of the preventable nature of
    these diseases, the Hepatitis B Foundation feels that the National
    Center for Chronic Disease Prevention should also include a targeted
    effort focused on the prevention of chronic viral hepatitis which
    adversely impacts 5 million Americans. Specifically, we ask that the
    Committee include language urging the Center to help insure that the
    Prevention and Public Health Funds, particularly the Community
    Transformations Grants, are available to support viral hepatitis
    prevention projects.
        Furthermore, there are 400 million people chronically infected with
    hepatitis B worldwide, with more than 120 million of these individuals
    in China. While hepatitis B transmission requires direct exposure to
    infected blood, worldwide misinformation about the disease has fueled
    inappropriate discrimination against individuals with this vaccine-
    preventable and treatable bloodborne disease. HBF urges the Committee
    to instruct the CDC to initiate global programs to increase the rate of
    vaccination, reduce mother-child transmission and promote educational
    programs to prevent the disease and to reduce discrimination targeted
    against individuals with the disease.
    The National Institutes of Health
        We depend upon the NIH to fund research that will lead to new and
    more effective interventions to treat people with hepatitis B and liver
    cancer. The Hepatitis B Foundation joins with the Ad Hoc Group for
    Biomedical Research and requests a funding level of $35 billion for the
    National Institutes of Health in fiscal year 2012.
        We thank the Committee for their continued investment in the NIH.
    Sustaining progress in medical research is essential to the twin
    national priorities of smarter healthcare and economic revitalization.
    With additional investment, the Nation can seize the unique opportunity
    to build on the tremendous momentum emerging from the strategic
    investment in NIH made through the 2009 American Recovery and
    Reinvestment Act (ARRA). NIH invested those funds in a range of
    potentially revolutionary new avenues of research that will lead to new
    early screenings and new treatments for disease.
        In fiscal year 2010, NIH spent approximately $70 million on
    hepatitis B funding overall including $4 million of onetime funding
    from the American Recovery and Reinvestment Act. It is estimated that
    in fiscal year 2011 hepatitis B funding will return to the base level
    of $66 million. Additional funding could make transformational advances
    in research leading to better treatments for HBV. The Hepatitis B
    Foundation recommends that at a minimum, funding allocated for HBV
    research in fiscal year 2012 be increased at the same rate recommended
    for NIH overall and, therefore, funded at $75.7 million.
        The current leadership of the NIH has performed admirably with the
    limited resources they are provided; however, more is needed. While a
    number of cancers have achieved 5-year survival rates of over 80
    percent and the average 5-year survival rate for all cancers has
    increased from 50 percent in 1971 to 66 percent, significant challenges
    still remain for other types of cancers, particularly the most deadly
    forms of cancer. In fact, nearly half of the 562,340 cancer deaths in
    2009 were caused by eight forms of cancer with 5-year relative survival
    rates of less than 50 percent: ovary (45.5 percent), brain (35.0
    percent), myeloma (34.9 percent), stomach (24.7 percent), esophagus
    (15.8 percent), lung (15.2 percent), liver (11.7 percent), and pancreas
    (5.1 percent). It is no coincidence that cancers with significantly
    better 5 year survival rates, such as breast, prostate, colon,
    testicular, and chronic myelogenous leukemia, also have early detection
    tools, and in many cases, several effective treatment options thanks to
    research programs championed and supported by Congress. By contrast,
    research into the cancers with the lowest 5-year survival rates has
    been relatively under-funded, and as a result, these cancers have no
    early detection or treatment tools.
        The Hepatitis B Foundation requests the establishment of a targeted
    cancers program at the National Cancer Institute (NCI) for the high
    mortality cancers. It should include a strategic plan for progress, an
    annual report from NCI to Congress, and a new grant program
    specifically focused on the deadly cancers. Additionally, the Hepatitis
    B Foundation urges a stronger focus on liver cancer and urges the
    funding of a series of Specialized Programs of Research Excellence
    (SPOREs) focused on liver cancer. While SPOREs currently exist for
    every other major cancer, none currently exist that are focused on
    liver cancer.
    Prevention Fund
        The Patient Protection and Affordable Care Act included the
    creation of a Prevention and Public Health Fund, to be used to reduce
    chronic disease rates and to address health disparities. To further
    clarify the intended use of these funds, earlier this year, the
    National Prevention, Health Promotion and Public Health Council that
    was established to advice on the use of these funds, released a report
    with recommendations. Included in the report were recommendations that
    ``opportunities be expanded within communities and populations at
    greatest risk for diseases such as Viral Hepatitis B and C'' and that
    there be an increased use of the ``the most effective and highest
    impact evidence-based clinical preventive services and medications,
    such as screening and treatment for chronic viral hepatitis.''
    Therefore, it is our view that insuring the Prevention Funds resources
    can be used for viral hepatitis prevention projects would help address
    this urgent need to help close the gap between diagnosis and access to
    care for hepatitis patients. We urge the Committee to include language
    in both the Office of the Secretary and the CDC's National Center for
    Chronic Disease Prevention to insure that Prevention Funds,
    specifically Community Transformation Grants, be eligible to viral
    hepatitis initiatives.
                             summary and conclusion
        While the HBF recognizes the demands on our Nation's resources, we
    believe the ever-increasing health threats and expanding scientific
    opportunities continue to justify higher funding levels for the CDC's
    Division of Viral Hepatitis and the National Institutes of Health.
        Significant progress has been made in developing better treatments
    and cures for the diseases that affect humankind due to your leadership
    and the leadership of your colleagues on this Subcommittee. Significant
    progress has also similarly been made in the fight against hepatitis B.
        In conclusion, we specifically request the following for fiscal
    year 2012:
      --Fund the CDC's Division of Viral Hepatitis at $25 million;
      --Language urging the HHS and the National Center for Chronic Disease
            Prevention to help insure that the Prevention and Public Health
            Funds, particularly the Community Transformations Grants, are
            available to support viral hepatitis prevention projects.
      --Initiate global programs at the CDC to increase the rate of
            vaccination, reduce mother-child transmission and promote
            educational programs to prevent the disease and to reduce
            discrimination targeted against individuals with the disease;
      --Provide $35 billion for the National Institutes of Health,
            including a $9.7 million increase per year for hepatitis B
            research;
      --Establish a targeted cancers program at the NCI; and
      --Fund a series of Specialized Programs of Research Excellence
            (SPOREs) focused on liver cancer at the NCI.
        The Hepatitis B Foundation appreciates the opportunity to provide
    testimony to you on behalf of our constituents and yours.
                                     ______

               Prepared Statement of the HIV Medicine Association
        The HIV Medicine Association (HIVMA) of the Infectious Diseases
    Society of America (IDSA) represents more than 4,500 physicians,
    scientists and other healthcare professionals who practice on the
    frontline of the HIV/AIDS pandemic. Our members provide medical care
    and treatment to people with HIV/AIDS throughout the United States,
    lead HIV prevention programs and conduct research to develop effective
    HIV prevention and treatment options. We work in communities across the
    country and around the globe as medical providers and researchers
    dedicated to the field of HIV medicine.
        We appreciate the importance of addressing the fiscal challenges
    facing our Nation, but the continued fragile state of the economy makes
    it imperative to set priorities to ensure that our Nation has a strong
    healthcare safety-net, effective programs for preventing infectious
    diseases like HIV and a robust scientific research agenda.
        The U.S. investment in HIV/AIDS programs has revolutionized HIV
    care globally, making HIV treatment one of the most effective medical
    interventions available. A vibrant research agenda and rapid public
    health implementation of scientific findings have transformed the HIV
    epidemic, reducing morbidity and mortality due to HIV disease by nearly
    80 percent in the United States.
        Implementation of healthcare reform and the administration's plans
    for a National HIV/AIDS Strategy offer promise for making significant
    progress in reducing the impact of the domestic HIV epidemic. However,
    their success will depend on maintaining adequate investments in the
    healthcare safety net, and in prevention, public health and research
    programs. The funding requests in our testimony largely reflect the
    consensus of the Federal AIDS Policy Partnership (FAPP), a coalition of
    HIV organizations from across the country, and are estimated to be the
    amounts necessary to sustain and strengthen our investment in
    combatting HIV disease.
    Health Care Reform
        We urge full funding of the President's fiscal year 2012 request
    level for healthcare reform programs supported with discretionary
    funding under the Patient Protection and Affordable Care Act (ACA), in
    particular: health workforce education and training programs under
    Titles VII and VIII of the Public Health Service Act (PHSA); healthcare
    quality improvement programs, and the Community Health Centers program.
    HIV/AIDS Bureau of the Health Resources and Services Administration
        We urge you to increase funding for the Ryan White program by $371
    million in fiscal year 2011 with at least an increase of $65.8 million
    over the fiscal year 2010 level for Part C. At minimum, we strongly
    urge you to support the President's proposed fiscal year 2012 increase
    of $88.3 million for the Ryan White program, including a $5.1 million
    increase for Part C. Part C of the Ryan White Program funds
    comprehensive HIV care and treatment--services that are directly
    responsible for the dramatic decreases in AIDS-related mortality and
    morbidity over the last decade. On average it costs $3,501 per person
    per year to provide the comprehensive outpatient care and treatment
    available at Part C funded programs, including lab work, STD/TB/
    Hepatitis screening, ob/gyn care, dental care, mental health and
    substance abuse treatment, and case management. Part C funding covers a
    small percentage of the total cost of providing comprehensive care with
    some programs receiving $450 or lower per patient per year to cover
    care.
        The Ryan White Program generally is underfunded and Part C of the
    program is disproportionately and severely underfunded. The Centers for
    Disease Control and Prevention estimate that there are more than 1.1
    million persons living with HIV/AIDS and approximately 240,000, or
    almost 1 in 4, of these individuals receive services from Part C
    medical providers. Of the 240,000 patients, approximately 1 out of 3 is
    uninsured, and 2 out of 3 are underinsured.
        While the patient caseload in Part C programs has been rising,
    funding for Part C has effectively decreased due to flat funding and
    funding cuts at the clinic level. Part C programs expect a continued
    increase in patients due to higher diagnosis rates and economic-related
    declines in insurance coverage. During this economic downturn people
    with HIV across the country are relying on Part C comprehensive
    services more than ever. As a result of consistently increasing
    caseloads and limited funding, Part C clinics are taking dramatic steps
    that adversely impact their ability to serve patients, including:
    Limiting primary care services; discontinuing critical services such as
    laboratory monitoring; suffering eviction from institutional-based
    clinic sites; laying off staff; and operating only 4 days/week.
        The HIV medical clinics funded through Part C have been in dire
    need of increased funding for years, but new pressures are creating a
    crisis in communities across the country. An increase in funding is
    critical to prevent additional staffing and service cuts and ensure the
    public health of our communities.
    National Institutes of Health (NIH)--Office of AIDS Research
        HIVMA supports the medical research community's requested increase
    of $4 billion over the fiscal year 2010 level for all research programs
    at the NIH, including at least a $400 million increase for the NIH
    Office of AIDS. This level of funding is vital to sustain the pace of
    research that will improve the health and quality of life for millions
    of Americans. At minimum, we urge you to support the President's
    proposed fiscal year 2012 increase of $1 billion for the NIH.
        A continued robust AIDS research portfolio is essential to sustain
    and to accelerate our progress in offering more effective prevention
    technologies; developing new and less toxic therapy; and supporting the
    basic research necessary to continue our work developing a vaccine that
    may end the deadliest pandemic in human history.
        We appreciate the many difficult decisions that Congress faces this
    year, but urge you to recognize the importance of investing in HIV
    prevention, treatment and research now to avoid the much higher cost
    that individuals, communities and broader society will incur if we fail
    to support these programs. We must seize the opportunity to limit the
    toll of this deadly infectious disease on our planet and to save the
    lives of millions who are infected or at risk of infection here in the
    United States and around the globe.
    Center for Disease Control and Prevention's (CDC) National Center for
            HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP)
        HIVMA strongly urges total fiscal year 2012 funding of $1.953
    billion for the CDC's NCHHSTP, an increase of $834.1 million over the
    fiscal year 2010 level, including increases of: $515.3 million for HIV
    prevention and surveillance, $20.2 million for viral hepatitis and
    $85.9 million for tuberculosis prevention.
        Every 9\1/2\ minutes a new HIV infection happens in the United
    States with more than 60 percent of new cases occurring among African
    Americans and Hispanic/Latinos. Despite the known benefit of effective
    treatment, 21 percent of people living with HIV in the United States
    are still not aware of their status and as many as 36 percent of people
    newly diagnosed with HIV progress to AIDS within 1 year of diagnosis. A
    sustained commitment to HIV prevention funding is critical to enhance
    HIV/AIDS surveillance and expand HIV testing and linkage to care, in
    order to lower HIV incidence and prevalence in the United States. We
    appreciate that the President proposed a $68.8 million increase for HIV
    prevention at the CDC, and at a bare minimum we strongly urge the
    Committee to at least meet this request.
        Finally, we strongly support adequate funding for science-based,
    comprehensive sex education programs. We are pleased that the fiscal
    year 2011 continuing resolution provides $109 million for the Teen
    Pregnancy Prevention Program, which focuses on reducing the risks of
    pregnancy and sexually transmitted diseases through proven and
    successful models. We urge the Committee to adopt report language
    supporting true, comprehensive sex education that promotes healthy
    behaviors and relationships for all young people, including lesbian,
    gay, bisexual, and transgender youth, including an explicit focus on
    prevention of HIV and other STDs.
    CDC--Tuberculosis
        Tuberculosis is the major cause of AIDS-related mortality worldwide
    and the second leading infectious disease killer. Congress passed
    landmark legislation in the Comprehensive Tuberculosis Elimination Act
    of 2008 to shore up State TB control programs, to enhance U.S. capacity
    to address drug-resistant tuberculosis; and to develop new drugs,
    diagnostics and vaccines.
        State budget cuts have hit local TB control programs hard, and the
    CDC Division of TB Elimination has seen some budget reductions in the
    last 2 fiscal years. Our ability to respond to TB within our own
    borders is being compromised as a result. We must do better. Finally,
    we are beginning to see exciting new tools to combat tuberculosis after
    decades of little or no productive research and development in this
    area. We have an exciting new diagnostic test that can identify drug-
    susceptible and drug-resistant TB very quickly. There are a number of
    new drugs in clinical trials for both drug resistant and drug-
    susceptible TB. There are promising new TB vaccine candidates being
    tested. Now, resources are needed more urgently than ever to follow
    through on the research and development in progress and to ensure that
    these new tools reach the public health officials on the ground who
    need them. We respectfully request fiscal year 2012 funding for the CDC
    Division of TB Elimination at a level of $231 million. At minimum, we
    urge full funding of the President's fiscal year 2012 budget request of
    $143.6 million for this program.
    CDC--Viral Hepatitis
        A much more substantial commitment to Hepatitis co-infection is
    urgently needed, in addition to funding for core public health services
    and tracking of chronic cases of hepatitis. Co-infection is a serious
    health threat for nearly one-third of our HIV patients, and has an
    enormous impact on morbidity and mortality. Furthermore, with the
    advent of the recently approved protease inhibitors, providing funding
    to enable this population to receive treatment and/or access clinical
    trials becomes absolutely critical. We strongly urge you to boost
    funding for viral hepatitis at the CDC by $20.2 million over the fiscal
    year 2010 level million for a total funding of $40 million. At the very
    least, we urge you to support the President's proposed fiscal year 2012
    increase of $5.2 million to respond to the viral Hepatitis epidemic.
    Agency for Health Care Quality and Research (AHRQ)
        HIVMA urges the Committee to provide $2.2 million, a $200,000
    increase over the fiscal year 2010 level for the HIV Research Network
    (HIVRN), the only significant HIV work being done at AHRQ. The HIVRN is
    a consortium of 18 HIV primary care sites co-funded by AHRQ and HRSA to
    evaluate healthcare utilization and clinical outcomes in HIV infected
    children, adolescents and adults in the United States. The Network
    analyzes and disseminates information on the delivery and outcomes of
    healthcare services to people with HIV infection. These data help to
    improve delivery and outcomes of HIV care in the United States and to
    identify and address disparities in HIV care that exist by race,
    gender, and HIV risk factor. The HIVRN is a unique source of
    information on the cost and cost-effectiveness of HIV care in the
    United States at a time when data on comparative cost and effectiveness
    of healthcare is particularly needed to inform health systems reform
    and the development and implementation of a National HIV/AIDS Strategy.
                                     ______

                    Prepared Statement of Howard University
        Mr. Chairman and members of the subcommittee, thank you for the
    opportunity to present my views before you today. I am Dr. Eve
    Higginbotham, Senior Vice-President and Executive Dean for Howard
    University Health Sciences. I am the senior health official at Howard,
    with responsibilities for our College of Medicine, College of
    Dentistry, College of Pharmacy, Nursing, and Allied Health, Louis
    Stokes Health Sciences Library, and the Howard University Hospital.
    Howard University is the only Historically Black College or University
    (HBCU) with so many aspects of the health sciences housed at one
    institution. For that reason, we are poised to continue to impact the
    education of minorities and others dedicated to improving the health of
    all Americans.
        Mr. Chairman, Howard University Health Sciences has made historic
    contributions to the reduction of health disparities, and it is because
    of programmatic activity like the Title VII Health Professionals
    Training programs that we are able to address a critical national need.
    Persistent and severe staffing shortages exist in a number of the
    health professions, and chronic shortages exist for all of the health
    professions in our Nation's most medically underserved communities.
    Furthermore, even after the landmark passage of health reform, it is
    important to note that our Nation's health professions workforce does
    not accurately reflect the racial composition of our population. For
    example while blacks represent approximately 15 percent of the U.S.
    population, only 2-3 percent of the Nation's health professions
    workforce is black. Mr. Chairman, I would like to share with you how
    your committee can help HUHS continue our efforts to help provide
    quality health professionals and close our Nation's health disparity
    gap.
        There is a well established link between health disparities and a
    lack of access to competent healthcare in medically underserved areas.
    As a result, it is imperative that the Federal Government continue its
    commitment to minority health professions institutions and minority
    health professional training programs to continue to produce healthcare
    professionals committed to addressing this unmet need--even in austere
    financial times.
        An October 2006 study by the Health Resources and Services
    Administration (HRSA), entitled ``The Rationale for Diversity in the
    Health Professions: A Review of the Evidence'' found that minority
    health professionals serve minority and other medically underserved
    populations at higher rates than non-minority professionals. The report
    also showed that; minority populations tend to receive better care from
    practitioners who represent their own race or ethnicity, and non-
    English speaking patients experience better care, greater
    comprehension, and greater likelihood of keeping follow-up appointments
    when they see a practitioner who speaks their language. Studies have
    also demonstrated that when minorities are trained in minority health
    profession institutions, they are significantly more likely to: (1)
    serve in rural and urban medically underserved areas, (2) provide care
    for minorities and (3) treat low-income patients.
        As you are aware, Title VII Health Professions Training programs
    are focused on improving the quality, geographic distribution and
    diversity of the healthcare workforce in order to continue eliminating
    disparities in our Nation's healthcare system. These programs provide
    training for students to practice in underserved areas, cultivate
    interactions with faculty role models who serve in underserved areas,
    and provide placement and recruitment services to encourage students to
    work in these areas. Health professionals who spend part of their
    training providing care for the underserved are up to 10 times more
    likely to practice in underserved areas after graduation or program
    completion.
        In fiscal year 2012, funding for the Title VII Health Professions
    Training programs must at the very least be maintained, especially the
    funding for the Minority Centers of Excellence (COEs) and Health
    Careers Opportunity Program (HCOPs). In addition, the funding for the
    National Institutes of Health (NIH)'s National Institute on Minority
    Health and Health Disparities (NIMHD), as well as the Department of
    Health and Human Services (HHS)'s Office of Minority Health (OMH),
    should be preserved.
        Minority Centers of Excellence.--COEs focus on improving student
    recruitment and performance, improving curricula in cultural
    competence, facilitating research on minority health issues and
    training students to provide health services to minority individuals.
    COEs were first established in recognition of the contribution made by
    four historically black health professions institutions to the training
    of minorities in the health professions. Congress later went on to
    authorize the establishment of ``Hispanic'', ``Native American'' and
    ``Other'' Historically black COEs. For fiscal year 2012, I recommend a
    funding level of $24.602 million for COEs.
        Health Careers Opportunity Program (HCOP).--HCOPs provide grants
    for minority and non-minority health profession institutions to support
    pipeline, preparatory and recruiting activities that encourage minority
    and economically disadvantaged students to pursue careers in the health
    professions. Many HCOPs partner with colleges, high schools, and even
    elementary schools in order to identify and nurture promising students
    who demonstrate that they have the talent and potential to become a
    health professional. For fiscal year 2012, I recommend a funding level
    of $22.133 million for HCOPs.
    National Institutes of Health
        Research Centers at Minority Institutions.--The Research Centers at
    Minority Institutions program (RCMI), currently administered by the
    National Center for Research Resources, has a long and distinguished
    record of helping our institutions develop the research infrastructure
    necessary to be leaders in the area of health disparities research.
    Although NIH has received unprecedented budget increases in recent
    years, funding for the RCMI program has not increased by the same rate.
    Therefore, the funding for this important program grow at the same rate
    as NIH overall in fiscal year 2012.
        National Institute on Minority Health and Health Disparities.--The
    National Institute on Minority Health and Health Disparities (NIMHD) is
    charged with addressing the longstanding health status gap between
    minority and nonminority populations. The NIMHD helps health
    professions institutions to narrow the health status gap by improving
    research capabilities through the continued development of faculty,
    labs, and other learning resources. The NIMHD also supports biomedical
    research focused on eliminating health disparities and develops a
    comprehensive plan for research on minority health at the NIH.
    Furthermore, the NIMHD provides financial support to health professions
    institutions that have a history and mission of serving minority and
    medically underserved communities through the Centers of Excellence
    program. For fiscal year 2012, I recommend funded increases
    proportional with the funding of the over NIH.
    Department of Health and Human Services
        Department of Health and Human Services' Office of Minority
    Health.--Specific programs at OMH include: assisting medically
    underserved communities with the greatest need in solving health
    disparities and attracting and retaining health professionals;
    assisting minority institutions in acquiring real property to expand
    their campuses and increase their capacity to train minorities for
    medical careers; supporting conferences for high school and
    undergraduate students to interest them in healthcareers, and
    supporting cooperative agreements with minority institutions for the
    purpose of strengthening their capacity to train more minorities in the
    health professions. The OMH has the potential to play a critical role
    in addressing health disparities. For fiscal year 2012, I recommend a
    funding level of $65 million for the OMH.
    Department of Education
        Howard University Academic, Research, and Hospital Support.--The
    Department of Education maintains support for Howard University's
    academic programs, research programs, construction activities, and the
    Howard University Hospital. Howard University has played a historic
    role in providing access to postsecondary educational opportunities for
    students from traditionally underrepresented backgrounds, especially
    African Americans. For this reason, and others, Howard is supported
    annually with a Federal appropriation. The direct Federal appropriation
    accounts for approximately 50 percent of the Howard University's
    operating costs, including nearly $29 million for the operation of the
    Howard Hospital--a staple of care for residents in Northwest
    Washington, DC. In fiscal year 2012, an appropriation of $235 million
    is suggested to continue the vital programs and services which we
    provide.
        Mr. Chairman, please allow me to express my appreciation to you and
    the members of this subcommittee. With your continued help and support,
    Howard University's Health Sciences can help this country to overcome
    health disparities. Congress must be careful not to eliminate, paralyze
    or stifle programs that have been proven to work. HUHS seeks to close
    the ever widening health disparity gap. If this subcommittee will give
    us the tools, we will continue to work towards the goal of eliminating
    that disparity everyday.
        Thank you, Mr. Chairman, and I welcome every opportunity to answer
    questions for your records.
                                     ______

       Prepared Statement of the International Foundation for Functional
                           Gastrointestinal Disorders
        Thank you for the opportunity to present the views of the
    International Foundation for Functional Gastrointestinal Disorders
    (IFFGD) regarding the importance of functional gastrointestinal (GI)
    and motility disorders research.
        Established in 1991, IFFGD is a patient-driven nonprofit
    organization dedicated to assisting individuals affected by functional
    GI disorders, and providing education and support for patients,
    healthcare providers, and the public at large. The IFFGD also works to
    advance critical research on functional GI and motility disorders, in
    order to provide patients with better treatment options, and to
    eventually find a cure. IFFGD has worked closely with NIH on a number
    of priorities, including the NIH State-of-the-Science Conference on the
    Prevention of Fecal and Urinary Incontinence in Adults through NIDDK,
    the National Institute of Child Health and Human Development (NICHD),
    and the Office of Medical Applications of Research (OMAR). I have
    served on the National Commission on Digestive Diseases (NCDD), which
    released a long-range road map for digestive disease research in 2009,
    entitled Opportunities and Challenges in Digestive Diseases Research:
    Recommendations of the National Commission on Digestive Diseases.
        The need for increased research, more effective and efficient
    treatments, and the hope for discovering a cure for functional GI and
    motility disorders are close to my heart. My own personal experiences
    of suffering from functional GI and motility disorders motivated me to
    establish IFFGD 20 years ago. I was shocked to discover that despite
    the high prevalence of these conditions among all demographic groups
    worldwide, such an appalling lack of dedicated research existed. This
    lack of research translates into a dearth of diagnostic tools,
    treatments, and patient supports. Even more shocking is the lack of
    awareness among both the medical community and the general public,
    leading to significant delays in diagnosis, frequent misdiagnosis, and
    inappropriate treatments including unnecessary medication and surgery.
    It is unacceptable for patients to suffer unnecessarily from the
    severe, painful, life-altering symptoms of functional GI and motility
    disorders due to a lack of awareness and education.
        The majority of functional GI disorders have no cure and treatment
    options are limited. Although progress has been made, the medical
    community still does not completely understand the mechanisms of the
    underlying conditions. Without a known cause or cure, patients
    suffering from functional GI disorders face a lifetime of chronic
    disease management, learning to adapt to intolerable, disruptive
    symptoms. The medical and indirect costs associated with these diseases
    are enormous; estimates range from $25-$30 billion annually. Economic
    costs spill over into the workplace, and are reflected in work
    absenteeism and lost productivity. Furthermore, the emotional toll of
    these conditions affects not only the individual but also the family.
    Functional GI disorders do not discriminate, effecting all ages, races
    and ethnicities, and genders.
    Irritable Bowel Syndrome (IBS)
        IBS, one of the most common functional GI disorders, strikes all
    demographic groups. It affects 30 to 45 million Americans,
    conservatively at least 1 out of every 10 people. Between 9 to 23
    percent of the worldwide population suffers from IBS, resulting in
    significant human suffering and disability. IBS as a chronic disease is
    characterized by a group of symptoms that may vary from person to
    person, but typically include abdominal pain and discomfort associated
    with a change in bowel pattern, such as diarrhea and/or constipation.
    As a ``functional disorder'', IBS affects the way the muscles and
    nerves work, but the bowel does not appear to be damaged on medical
    tests. Without a definitive diagnostic test, many cases of IBS go
    undiagnosed or misdiagnosed for years. It is not uncommon for IBS
    suffers to have unnecessary surgery, medication, and medical devices
    before receiving a proper diagnosis. Even after IBS is identified,
    treatment options are sorely lacking and vary widely from patient to
    patient. What is known is that IBS requires a multidisciplinary
    approach to research and treatment.
        IBS can be emotionally and physically debilitating. Due to
    persistent pain and bowel unpredictability, individuals who suffer from
    this disorder may distance themselves from social events, work, and
    even may fear leaving their home. Stigma surrounding bowel habits may
    act as barrier to treatment, as patients are not comfortable discussing
    their symptoms with doctors. Because IBS symptoms are relatively common
    and not life-threatening, many people dismiss their symptoms or attempt
    to self-medicate using over-the-counter medications. In order to
    overcome these barriers to treatment, ensure more timely and accurate
    diagnosis, and reduce costly unnecessary procedures, educational
    outreach to physicians and the general public remain critical.
    Fecal Incontinence
        At least 12 million Americans suffer from fecal incontinence.
    Incontinence is neither part of the aging process nor is it something
    that affects only the elderly. Incontinence crosses all age groups from
    children to older adults, but is more common among women and the
    elderly of both sexes. Often it is a symptom associated with various
    neurological diseases and many cancer treatments. Yet, as a society, we
    rarely hear or talk about the bowel disorders associated with spinal
    cord injuries, multiple sclerosis, diabetes, prostate cancer, colon
    cancer, uterine cancer, and a host of other diseases.
        Courses of fecal incontinence include: damage to the anal sphincter
    muscles; damage to the nerves of the anal sphincter muscles or the
    rectum; loss of storage capacity in the rectum; diarrhea; or pelvic
    floor dysfunction. People who have fecal incontinence may feel ashamed,
    embarrassed, or humiliated. Some don't want to leave the house out of
    fear they might have an accident in public. Most attempt to hide the
    problem for as long as possible. They withdraw from friends and family,
    and often limit work or education efforts. Incontinence in the elderly
    burdens families and is the primary reason for nursing home admissions,
    an already huge social and economic burden in our aging population.
        In November 2002, IFFGD sponsored a consensus conference entitled,
    Advancing the Treatment of Fecal and Urinary Incontinence Through
    Research: Trial Design, Outcome Measures, and Research Priorities.
    Among other outcomes, the conference resulted in six key research
    recommendations including more comprehensive identification of quality
    of life issues; improved diagnostic tests for affecting management
    strategies and treatment outcomes; development of new drug treatment
    compounds; development of strategies for primary prevention of fecal
    incontinence associated with childbirth; and attention to the stigmas
    that apply to individuals with fecal incontinence.
        In December 2007, IFFGD collaborated with NIDDK, NICHD, and OMAR on
    the NIH State-of-the-Science Conference on the Prevention of Fecal and
    Urinary Incontinence in Adults. The goal of this conference was to
    assess the state of the science and outline future priorities for
    research on both fecal and urinary incontinence; including, the
    prevalence and incidence of fecal and urinary incontinence, risk
    factors and potential prevention, pathophysiology, economic and quality
    of life impact, current tools available to measure symptom severity and
    burden, and the effectiveness of both short and long term treatment.
    For fiscal year 2012, IFFGD urges Congress to review the Conference's
    Report and provide NIH with the resources necessary to effectively
    implement the report's recommendations.
    Gastroesophageal Reflux Disease (GERD)
        Gastroesophageal reflux disease, or GERD, is a common disorder
    affecting both adults and children, which results from the back-flow of
    acidic stomach contents into the esophagus. GERD is often accompanied
    by persistent symptoms, such as chronic heartburn and regurgitation of
    acid. Sometimes there are no apparent symptoms, and the presence of
    GERD is revealed when complications become evident. One uncommon but
    serious complication is Barrett's esophagus, a potentially pre-
    cancerous condition associated with esophageal cancer. Symptoms of GERD
    vary from person to person. The majority of people with GERD have mild
    symptoms, with no visible evidence of tissue damage and little risk of
    developing complications. There are several treatment options available
    for individuals suffering from GERD. Nonetheless, treatment response
    varies from person to person, is not always effective, and long-term
    medication use and surgery expose individuals to risks of side-effects
    or complications.
        Gastroesophageal reflux (GER) affects as many as one-third of all
    full term infants born in America each year. GER results from an
    immature upper gastrointestinal motor development. The prevalence of
    GER is increased in premature infants. Many infants require medical
    therapy in order for their symptoms to be controlled. Up to 25 percent
    of older children and adolescents will have GER or GERD due to lower
    esophageal sphincter dysfunction. In this population, the natural
    history of GER is similar to that of adult patients, in whom GER tends
    to be persistent and may require long-term treatment.
    Gastroparesis
        Gastroparesis, or delayed gastric emptying, refers to a stomach
    that empties slowly. Gastroparesis is characterized by symptoms from
    the delayed emptying of food, namely: bloating, nausea, vomiting, or
    feeling full after eating only a small amount of food. Gastroparesis
    can occur as a result of several conditions, including being present in
    30 percent to 50 percent of patients with diabetes mellitus. A person
    with diabetic gastroparesis may have episodes of high and low blood
    sugar levels due to the unpredictable emptying of food from the
    stomach, leading to diabetic complications. Other causes of
    gastroparesis include Parkinson's disease and some medications,
    especially narcotic pain medications. In many patients the cause of the
    gastroparesis cannot be found and the disorder is termed idiopathic
    gastroparesis. Over the last several years, as more is being found out
    about gastroparesis, it has become clear this condition affects many
    people and the condition can cause a wide range of symptom severity.
    Cyclic Vomiting Syndrome
        Cyclic vomiting syndrome (CVS) is a disorder with recurrent
    episodes of severe nausea and vomiting interspersed with symptom free
    periods. The periods of intense, persistent nausea, vomiting, and other
    symptoms (abdominal pain, prostration, and lethargy) lasts hours to
    days. Previously thought to occur primarily in pediatric populations,
    it is increasingly understood that this crippling syndrome can occur in
    a variety of age groups including adults. Patients with these symptoms
    often go for years without correct diagnosis. The condition leads to
    significant time lost from school and from work, as well as substantial
    medical morbidity. The cause of CVS is not known. Better understanding,
    through research, of mechanisms that underlie upper gastrointestinal
    function and motility involved in sensations of nausea, vomiting and
    abdominal pain is needed to help identify at risk individuals and
    develop more effective treatment strategies.
    Support for Critical Research
        IFFGD urges Congress to fund the NIH at level of $35 billion for
    fiscal year 2012, an increase of 13 percent over fiscal year 2011. This
    funding level will help preserve the initial investment in healthcare
    innovation established by the American Recovery and Reinvestment Act of
    2009. Strengthening and preserving our Nation's biomedical research
    enterprise fosters economic growth, and supports innovations that
    enhance the health and well-being of the Nation.
        Concurrent with overall NIH funding, the IFFGD supports growth of
    research activities on functional GI and motility disorders,
    particularly through NIDDK and the Office of Research on Women's Health
    (ORWH). Increased support for NIDDK and ORWH will facilitate necessary
    expansion of the research portfolio on functional GI and motility
    disorders necessary to grow the medical knowledge base and improve
    treatment. Such support would also expedite the implementation of
    recommendations from the National Commission on Digestive Diseases. It
    is also vitally important for NIDDK to work to expand its research on
    the impact these disorders have on pediatric populations, in addition
    the adult population.
        Following years of near level-funding at NIH, research
    opportunities have been negatively impacted across all NIH Institutes
    and Centers, including NIDDK. With the expiration of funding from the
    American Recovery and Reinvestment Act of 2009, medical researchers run
    the risk of ``falling off a cliff'', stalling, if not losing promising
    research from that 2 year period. For this reason, IFFGD encouraged
    support for initiatives such as the Cures Acceleration Network (CAN),
    authorized in the Patient Protection and Affordable Coverage Act. IFFGD
    urges the Subcommittee to show strong leadership in pursuing a
    substantial funding increase for CAN through the fiscal year 2012
    appropriations process.
        Thank you for the opportunity to present the views of the
    functional GI disorders community.
                                     ______

           Prepared Statement of the International Myeloma Foundation
        The International Myeloma Foundation (IMF) appreciates the
    opportunity to submit written comments for the record regarding fiscal
    year 2012 funding for myeloma cancer programs. The IMF is the oldest
    and largest myeloma foundation dedicated to improving the quality of
    life of myeloma patients while working toward prevention and a cure.
        To ensure that myeloma patients have access to the comprehensive,
    quality care that they need and deserve, the IMF advocates ongoing and
    significant Federal funding for myeloma research and its application.
    The IMF stands ready to work with policymakers to advance policies and
    programs that work toward prevention and a cure for myeloma and for all
    other forms of cancer.
    Myeloma Background
        The second most common blood cancer worldwide, multiple myeloma (or
    myeloma) is a cancer of plasma cells in the bone marrow. It is called
    ``multiple'' myeloma because the cancer can occur at multiple sites in
    multiple bones. Each year approximately 20,000 Americans are diagnosed
    with myeloma and 10,000 lose their battle with this disease.
        Although the incidence of many cancers is decreasing, the number of
    myeloma cases is on the rise. Once a disease of the elderly, it is now
    being found in increasing numbers in people under the age of 65. The
    2009 President's Cancer Panel Report suggests that much of the increase
    in cancer incidence is being caused by environmental toxins. To give
    just one example supporting this hypothesis, a recently published study
    in The Journal of Occupational and Environmental Medicine, suggests a
    link between blood cancers like myeloma and exposure to the toxic dust
    at Ground Zero.
        In recent years significant gains have been made, extending myeloma
    patients' lives and improving their quality of life. Furthermore,
    progress begun in myeloma is already helping patients with other blood
    cancers and even solid tumors. It is important to maintain that
    momentum.
      --There is no cure for myeloma.
      --Remissions are not always permanent.
      --Additional treatment options are essential.
        Living with the disease, myeloma patients can suffer debilitating
    fractures and other bone disorders, severe side effects of certain
    treatments, and other problems that profoundly affect their quality of
    life, and significantly impact the cost of their healthcare.
    Sustain and Seize Cancer Research Opportunities
        Myeloma research is producing extraordinary breakthroughs--leading
    to new therapies that translate into longer survival and improved
    quality of life for myeloma patients and potentially those with other
    forms of cancer as well. Myeloma was once considered a death sentence
    with limited options for treatment, but today myeloma is an example of
    the progress that can be made and the work that still lies ahead in the
    war on cancer. Many myeloma patients are living proof of what
    innovative drug development and clinical research can achieve--
    sequential remissions, long-term survival, and good quality of life.
    Our Nation has benefited immensely from past Federal investment in
    biomedical research at the National Institutes of Health (NIH) and the
    IMF advocates $35 billion for NIH in fiscal year 2012.
        A study in the Journal of Clinical Oncology projects that the
    number of new cancer cases diagnosed each year will jump 45 percent
    over the next 20 years. In multiple myeloma an even greater increase
    (57 percent) is projected, and we are already seeing increasing
    diagnoses in patients under age 65, including patients in their 30s, in
    what was once a rare disease of the elderly.
        While a number of cancers have achieved 5-year survival rates of
    over 80 percent since passage of the National Cancer Act of 1971,
    significant challenges still remain for other cancers. In fact, nearly
    half of the 562,490 cancer deaths in 2010 were caused by just eight
    forms of cancer with 5-year survival rates of 45 percent or less--one
    of which is myeloma. Yet, myeloma and these other cancers have
    historically also received the least amount of Federal funding. As we
    have seen mortality rates of diseases such as breast cancer, prostate
    cancer, AIDS, and childhood leukemia greatly reduced through targeted,
    comprehensive, and well-funded programs that have led to earlier
    detection and superior forms of treatment, so too must we shine a
    brighter light on myeloma and the other seven deadly cancers to achieve
    this same goal for them. The IMF urges Congress to allocate $5.740
    billion to the National Cancer Institute (NCI) in fiscal year 2012 to
    continue our battle against myeloma.
    Boost Our Nation's Investment in Myeloma Prevention, Early Detection,
            and Awareness
        As the Nation's leading prevention agency, the Centers for Disease
    Control and Prevention (CDC) plays an important role in translating and
    delivering at the community level what is learned from research.
    Therefore, the IMF advocates $6 million for the Geraldine Ferraro Blood
    Cancer Program. Authorized under the Hematological Cancer Research
    Investment and Education Act of 2002, this program was created to
    provide public and patient education about blood cancers, including
    myeloma.
        With grants from the Geraldine Ferraro Blood Cancer Program, the
    IMF has successfully promoted awareness of myeloma, particularly in the
    African-American community and other underserved communities. IMF
    accomplishments include the production and distribution of more than
    4,500 copies of an informative video which addresses the importance of
    myeloma awareness and education in the African-American community to
    churches, community centers, inner-city hospitals, and Urban League
    offices around the country, increased African-American attendance at
    IMF Patient and Family Seminars (these seminars provide invaluable
    treatment information to newly diagnosed myeloma patients), increased
    calls by African-American myeloma patients, family members, and
    caregivers to the IMF's myeloma Hotline, and the establishment of
    additional support groups in inner city locations in the United States
    to assist underserved areas with myeloma education and awareness
    campaigns. Furthermore, the more than 90 IMF-affiliated patient support
    groups in the United States also made this effort their main goal
    during Myeloma Awareness Week in October 2005.
        An allocation of $6 million in fiscal year 2012 will allow this
    important program to continue to provide patients--including those
    populations at highest risk of developing myeloma--with educational,
    disease management and survivorship resources to enhance treatment and
    prognosis.
        Additionally, the IMF is concerned about the consolidation plan for
    chronic disease programs at the CDC outlined in the President's fiscal
    year 2012 budget. This would be a substantial change in the chronic
    disease program where the Geraldine Ferraro Blood Cancer Program is
    currently housed. While we agree that there are health issue areas that
    share risk factors such as healthy eating and maintaining an active
    lifestyle that make sense to consolidate, unfortunately those are not
    risk factors for myeloma. We urge the CDC to maintain the programs like
    the Geraldine Ferraro Blood Cancer Program as a stand-alone program
    which would cease to exist under the proposed consolidation plan.
    Conclusion
        The IMF stands ready to work with policymakers to advance policies
    and support programs that work toward prevention and a cure for
    myeloma. Thank you for this opportunity to discuss the fiscal year 2012
    funding levels necessary to ensure that our Nation continues to make
    gains in the fight against myeloma.
                                     ______

         Prepared Statement of the Interstate Mining Compact Commission
        We are writing in support of the fiscal year 2012 budget request
    for the Mine Safety and Health Administration (MSHA), which is part of
    the U.S. Department of Labor. In particular, we urge the Subcommittee
    to support a full appropriation for grants to States for safety and
    health training of our Nation's miners pursuant to section 503(a) of
    the Mine Safety and Health Act of 1977. MSHA's budget request for State
    grants is $8.941 million. This is the same amount that has been
    appropriated for State training grants by Congress over the past 2
    fiscal years and, as such, does not fully consider inflationary and
    programmatic increases being experienced by the States. We therefore
    urge the subcommittee to restore funding to the statutorily authorized
    level of $10 million for State grants so that States are able to meet
    the training needs of miners and to fully and effectively carry out
    State responsibilities under section 503(a) of the Act.
        The Interstate Mining Compact Commission is a multi-state
    governmental organization that represents the natural resource,
    environmental protection and mine safety and health interests of its 24
    member States. The States are represented by their Governors who serve
    as Commissioners.
        IMCC's member States are concerned that without full funding of the
    State grants program, the federally required training for miners
    employed throughout the United States will suffer. States are
    struggling to maintain efficient and effective miner training and
    certification programs in spite of increased numbers of trainees and
    the incremental costs associated therewith. State grants have flattened
    out over the past several years and are not keeping place with
    inflationary impacts or increased demands for training. The situation
    is of particular concern given the enhanced, additional training
    requirements growing out of the recently enacted MINER Act and MSHA's
    implementing regulations.
        As you consider our request to increase MSHA's budget for State
    training grants, please keep in mind that the States play a
    particularly critical role in providing special assistance to small
    mine operators (those coal mine operators who employ 50 or fewer miners
    or 20 or fewer miners in the metal/nonmetal area) in meeting their
    required training needs.
        We appreciate the opportunity to submit our views on the MSHA
    budget request as part of the overall Department of Labor budget.
    Please feel free to contact us for additional information or to answer
    any questions you may have.
                                     ______

          Prepared Statement of the Interstitial Cystitis Association
        Thank you for the opportunity to present the views of the
    Interstitial Cystitis Association (ICA) regarding the importance of
    public awareness activities and the importance of interstitial cystitis
    (IC) research.
        ICA was founded in 1984 and remains the only nonprofit organization
    dedicated to improving the lives of those living with IC. The
    Association provides an important avenue for advocacy, research, and
    education in matters relating to IC. Since its founding, ICA has acted
    as a voice for those living with IC, including support groups and
    empowering patients. ICA advocates for the expansion of the IC
    knowledge-base and the development of new treatments, including
    investigator initiated research. Finally, ICA works doggedly to educate
    patients, healthcare providers, and the public at large about IC,
    including educational forums and information on how to live with this
    terrible condition.
        IC is a condition that consists of recurring pain, pressure, or
    discomfort in the bladder and pelvic region and is often associated
    with urinary frequency and urgency. An estimated 4-12 million Americans
    have IC, approximately two-thirds of whom are women. The cause of IC is
    unknown and treatment options are limited. Diagnosis is made only after
    excluding other urinary/bladder conditions, possibly causing 1 or more
    years delay between onset of the symptoms and treatment. When
    healthcare providers are not properly educated about IC, patients may
    suffer for years before receiving an accurate diagnosis and appropriate
    treatment.
        The effects of IC are pervasive and insidious, damaging work life,
    psychological well-being, personal relationships, and general health.
    The impact of IC on quality of life is equally as severe as rheumatoid
    arthritis and end-stage renal disease. Health-related quality of life
    in women with IC is worse than in women with endometriosis, vulvodynia,
    and overactive bladder. IC patients have significantly more sleep
    dysfunction, higher rates of depression, increased catastrophizing,
    anxiety, and sexual dysfunction.
    Public Awareness and Education
        As IC is a condition that often takes long periods to diagnosis,
    and this late diagnosis has such a major impact on the lives of
    patients, it is vitally important to continue to educate both the
    public and healthcare providers. The IC Education and Awareness Program
    at the Centers for Disease Control and Prevention (CDC) has played a
    major role in increasing the public's awareness of the devastating
    disease and is the only program in the Nation which promotes public
    awareness of IC. The public outreach of the CDC program includes public
    service announcements on major television networks and the Internet.
    Further, the CDC program has provided resources to make information on
    IC available to patients and the public though videos, booklets,
    publications, presentations, educational kits, websites, blogs,
    Facebook pages, and a YouTube channel. For providers, this program has
    included the development of an IC newsletter with information on IC
    treatments, research, news, and events; targeted mailings to providers;
    and exhibits at national medical conferences.
        In order to continue these vitally important initiatives, which
    have reached thousands of Americans, it is critical that the CDC IC
    Education and Awareness Program be continued and receive a specific
    appropriation of $660,000 for fiscal year 2012.
    Research Through the National Institutes of Health
        The National Institutes of Health (NIH), mainly through the
    National Institute of Diabetes and Digestive and Kidney Diseases
    (NIDDK), maintains a robust research portfolio on IC, including five
    recent major studies yielding significant new information. The RAND IC
    Epidemiology (RICE) study found that nearly 2.7-6.7 percent of adult
    women have symptoms consistent with IC and will prove important to the
    future development of clinical trials and epidemiological studies. The
    IC Genetic Twin study found environmental factors, rather than genetic
    factors, to be substantial risk factors of developing IC. The Events
    Preceding Interstitial Cystitis (EPIC) study has yielded significant
    information linking non-bladder conditions and infectious agents to the
    development of IC in many newly diagnosed IC patients. The findings of
    the EPIC study have been reinforced in a Northwestern University study
    which found that an unusual form of toxic bacterial molecule (LPS) has
    an impact the development of IC as a result of an infectious agent.
    Finally, the Urologic Pelvic Pain Collaborative Research Network
    (UPPCRN) has indicated promising results for a new therapy for IC
    patients.
        Research currently underway and expected to begin in the near
    future also holds great promise to increase our understanding of IC,
    and thus find new treatments and cure. The Multidisciplinary Approach
    to the Study of Chronic Pelvic Pain (MAPP) Syndrome Research Network
    holds great potential to understanding the underlying issues related to
    IC, other conditions possibly associated with IC, and new information
    related to flares of the condition. Additionally, the investigator-
    initiated research portfolio will continue to support research relating
    to fundamental issues relating to IC and pelvic pain, including new
    avenues for interdisciplinary research and new treatment options.
    Finally, NIH will continue to focus on developing new treatment and
    therapies to relieve this condition.
        In order for this positive research to reach its full potential, it
    is essential NIH continue to receive funding which will allow it to
    continue and expand on past and current research. For this reason we
    recommend a funding level of $35 billion for fiscal year 2012. We also
    recommend the continuation of the MAPP study and collaboration between
    NIDDK and the Office of Women's Health on issues related to IC.
        Thank you for the opportunity to present the views of the
    interstitial cystitis community.
                                     ______

      Prepared Statement of the Iowa Statewide Independent Living Council
        I am contacting you regarding the proposed restructuring of the
    Independent Living funding that is outlined in President Obama's 2012
    budget.
        The seven Iowa Centers for Independent Living, along with all the
    other Centers for Independent Living across the country, need your
    help.
        As you may know, Centers for Independent Living (CILs) are
    nonprofit organizations run by people with disabilities for people with
    disabilities. They are authorized by the Federal Rehabilitation Act.
    CILs help people with disabilities to remain independent in their own
    homes and communities, being productive and contributing members of
    society. CILs work to help people remain independent so they are not
    forced to live in institutions such as nursing homes. As I am sure you
    are aware, in the vast majority of cases it is much less costly for a
    person with a disability to remain in their own home and community
    rather than pay for them to be institutionalized, and even more
    importantly people with disabilities have the same right to live
    independently as do people who do not have a disability.
        The Independent Living movement, CILs, and SILCs promote the
    philosophy of consumer control. Consumers, who are people with
    disabilities, control the operations of CILs and SILCs.
        I would like to provide you with some education about the reality
    of what the President's proposed restructuring of Independent Living
    funding will do to many Centers for Independent Living (CILs). I am
    opposed to this restructuring because of the damage it will do to many
    CILs, including the very real possibility that many CILs will have to
    close their doors as they will not be able to fiscally operate under
    this new structure.
        Currently, under the Federal Rehabilitation Act, CILs receive their
    Part C Federal Independent Living funding directly from the Federal
    Rehabilitation Services Administration (RSA). The Federal Part B funds
    are given to the States, in most cases to the State Vocational
    Rehabilitation Services (VR) agency, and the VR does contracts with the
    CILs and the Statewide Independent Living Council (SILC) for these Part
    B Federal funds. The Federal Part C funds do not require a State match
    as they come directly from RSA at the Federal level to the individual
    CILs. The Part B funding does require a State match as it comes
    directly to the state VR agency.
        Combining the Federal Part B and the Federal Part C Independent
    Living funding, and making these funds into a new block grant to States
    for Independent Living funding, is not acceptable for a number of
    reasons, and I would like to outline those reasons.
        Combining these funds into a block grant and giving them to States
    will significantly reduce, if not eliminate, consumer control of
    independent living programs. Prior to the Part C funds being given to
    RSA to distribute directly to CILs, the funds were given out in grants
    to States. There were numerous problems with the State administering
    these grant funds, which is why the funding structure was changed to
    Part C going directly from RSA to CILs. Here are some examples of what
    happened in the past, and these problems will also occur under the
    President's proposed block grant funding:
      --Under the past IL grant process, if the State had a freeze on
            hiring or travel, they would also make the CILs have a freeze
            on travel and hiring. This meant the CILs could not hire staff
            when needed, nor could they travel when needed. So even though
            the consumer controlled CIL Board directed the CIL Executive
            Director to hire a new staff, or directed that staff was to
            travel to attend a national conference, the State would not
            allow the CIL to do these things and would not provide the
            money to do these things, even though these things were an
            allowable use of the Federal grant funds. The State agency
            controlled the CIL, the Consumer Board did not have any
            control.
      --In many States, the Vocational Rehabilitation Services agency has
            procedures for reimbursing funds to the CILs, and in many
            States CILs would submit documentation for reimbursement and it
            would take 3, 4 or 5 months for the VR agency to get the money
            back to the CIL, which caused a great hardship for CILs to be
            able to keep their doors open. Here is one true example. One
            CIL Director re-financed his own house to take out a loan to
            meet staff payroll until the CIL received the reimbursement
            funds for their expenses from the State VR agency. Currently, I
            know this is an issue with the Federal Part B funds that the VR
            agencies give to CILs. It can take up to 4 or 5 months for a
            CIL to get reimbursed for their Part B funds. Fortunately, many
            of those CILs also get Federal Part C funds directly from RSA
            so they have money to cover their expenses until they get the
            Part B reimbursement check from VR. If the President's proposal
            becomes reality, there are many CILs that will most likely have
            to close as they will not have the working capital to pay their
            bills and then wait 4-5 months to get reimbursed by the VR
            agency.
        There are additional concerns to consider.
      --VR agencies are already under stress from State budget cuts, and it
            takes VR staff time to be able to do contracts and
            reimbursements for CILs. If these contracts become bigger, VRs
            will have to hire additional staff to manage these funds and do
            the contracts with the CILs. Where will the money come from for
            the VR agency to do this? Will it be taken out of the combined
            Part B and Part C funds, which means less funds going to CILs
            for direct consumer partner services, and less money to SILCs
            to be able to operate?
      --Currently only the Part B funds require a State match. If you
            combine B and C into one block grant, will State match be
            required for this total amount? If so, where are States going
            to get the State funds to match the additional Part C funds?
            Many States can barely find the match for the Part B funds, so
            it is possible that States will not have funds to match the
            Part C funds too. That means the State will not get the Part C
            funds, and Centers will not have enough funding to keep their
            doors open.
      --Providing direct funding to CILs is required by the Federal
            Rehabilitation Act, and for the President's budget proposal to
            be enacted, the Rehabilitation Act would have be significantly
            altered and then reauthorized.
        These are very real and disturbing concerns. I would like to know
    that President Obama, as well as the Federal legislators, are looking
    at these concerns and how to address them before going ahead with the
    President's proposed restructuring. There must be a better way to do
    this that will maintain consumer partner control of CIL operations, and
    that will allow CILs to fiscally operate without risk of having to
    close their doors, and/or reduce staff and services to consumer
    partners.
                                     ______

    Prepared Statement of the Joint Advocacy Coalition of the: Association
       for Clinical Research Training, Association for Patient-Oriented
                     Research, and Clinical Research Forum
        The Association for Clinical Research Training (ACRT), the
    Association for Patient-Oriented Research (APOR), the Clinical Research
    Forum (CR Forum), and the Society for Clinical and Translational
    Science (SCTS) represent a coalition of professional organizations
    dedicated to improving the health of the public through increased
    clinical and translational research, and clinical research training.
    United by the shared priorities of the clinical and translational
    research community, ACRT, APOR, CR Forum, and SCTS advocate for
    increased clinical and translational research at the National
    Institutes of Health (NIH), the Agency for Healthcare Research and
    Quality (AHRQ), and other Federal science agencies.
        On behalf of ACRT, APOR, CR Forum, and SCTS, I would like to thank
    the Subcommittee for their continued support of clinical and
    translational research, and clinical research training. The creation of
    the Patient-Centered Outcomes Research Institute and National Center
    for the Advancement of Translational Science in healthcare reform will
    provide a much-needed and greatly appreciated boost to comparative
    effectiveness research (CER) at the Federal level, as well as the
    organization of the new National Center for Translational Science
    (NCATS). As outlined by NIH Director Dr. Francis Collins in his five
    priorities for NIH, the translation of basic science to clinical
    treatment is an integral component of modern biomedical research, and a
    necessity to developing the treatments and cures of tomorrow.
        Today, I would like to address a number of issues that cut to the
    heart of the clinical and translational research community's
    priorities, including the Clinical and Translational Science Awards
    program (CTSA) at NIH, career development for clinical researchers, and
    support for CER at the Federal level.
        As our Nation's investment in biomedical research expands to
    provide more accurate and efficient treatments for patients, we must
    continue to focus on the translation of basic science to clinical
    research. The CTSA program at NIH is quickly becoming an invaluable
    resource in this area, but full funding is needed if we are to truly
    take advantage of the CTSA infrastructure.
    Fully Funding and Support for the CTSA Program at NIH
        With its establishment in 2006, the CTSA program at NIH began to
    address the need for increased focus on translational research, or
    research that bridges the gap between basic scientific discoveries and
    the bedside. Originally envisioned as a consortium of 60 academic
    institutions, the CTSA program currently funds 55 academic medical
    research institutions nationwide, and is set to expand to the full 60
    by the end of 2011. The CTSAs have an explicit goal of improving
    healthcare in the United States by transforming the biomedical research
    enterprise to become more effectively translational. Specifically, the
    CTSA program hopes to (1) improve the way biomedical research is
    conducted across the country; (2) reduce the time it takes for
    laboratory discoveries to become treatments for patients; (3) engage
    communities in clinical research efforts; (4) increase training and
    development in the next generation of clinical and translational
    researchers; and (5) accelerate T1 translational science.
        Although the promise of the CTSA program is recognized both
    nationally and internationally, it has suffered from a lack of proper
    funding along with NIH, and the National Center for Research Resources
    (NCRR). In 2006, 16 initial CTSAs were funded, followed by an
    additional 12 in 2007 and 14 in 2008, 4 in 2009, and 9 in 2010. Level-
    funding at NIH curtailed the growth of the CTSAs, preventing recipient
    institutions from fully implementing their programs and causing them to
    drastically alter their budgets after research had already begun. If
    budgets continue to decline, the CTSAs risk jeopardizing not only new
    research but also the research begun by first, second, and third
    generation CTSAs. Professional judgments have determined full funding
    to be at a level of $700 million.
        We recognize the difficult economic situation our country is
    currently experiencing, and greatly appreciate the commitment to
    healthcare Congress has demonstrated through stimulus funding, the
    fiscal year 2011 appropriations process, and through healthcare reform.
    The CTSAs are currently funding 55 academic research institutions
    nationwide at a level of $464 million, with the goal of full
    implementation by late 2011. In order to reach full implementation of
    60 CTSAs by late 2011, and to realize the promise of the CTSAs in
    transforming biomedical research to improve its impact on health, it is
    imperative that the CTSA program receive funding at the level of $700
    million in fiscal year 2012. Without full funding, more CTSAs will be
    expected to operate with fewer resources, curtailing their
    transformative promise.
        A major part of the CTSA program's promise lies in its synergy with
    all of NIH's Institutes and Centers (ICs), and the acceleration and
    facilitation of the ICs' impact. The translation of laboratory research
    to clinical treatment directly benefits patients suffering from complex
    diseases and all fields of medicine. The CTSA program has created
    improved translational research capacity and processes from which all
    NIH's ICs stand to benefit. The development of a formal NIH-wide plan
    to link all ICs to the CTSA program would efficiently capitalize on NIH
    investment and the new opportunities presented by the advent of NCATS
    for clinical and translational science.
        It is our recommendation that the Subcommittee support full
    implementation of the CTSA program by providing $700 million in fiscal
    year 2011, and we ask that the Subcommittee support the development of
    a formal NIH-wide plan to integrate the CTSAs to all of NIH's Institues
    and Centers.
    Continuing Support for Research Training and Career Development
            Programs Through the K Awards
        The future of our Nation's biomedical research enterprise relies
    heavily on the maintenance and continued recruitment of promising young
    investigators. Clinical investigators have long been referred to as an
    ``endangered species'', as financial barriers push medical students
    away from research. This trend must be arrested if we are to continue
    our pursuits of better treatments and cures for patients.
        The K Awards at NIH and AHRQ provide much-needed support for the
    career development of young investigators. As clinical and
    translational medicine takes on increasing importance, there is a great
    need to grow these programs, not reduce them. Career development grants
    are crucial to the recruitment of promising young investigators, as
    well as to the continuing education of established investigators.
    Reduced commitment to the K-12, K-23, K-24, and K-30 awards would have
    a devastating impact on our pool of highly trained clinical
    researchers. Even with the full implementation of the CTSA program, it
    will be critical for institutions without CTSAs to retain their K-30
    Clinical Research Curriculum Awards, as the K-30s remain a highly cost-
    effective method of ensuring quality clinical research training. ACRT,
    APOR, CRF, and SCTS strongly support the ongoing commitment to clinical
    research training through K Awards at NIH and AHRQ.
        We ask the Subcommittee to continue their support for clinical
    research training and career development through the K Awards at NIH
    and AHRQ, in order to promote and encourage investigators working to
    transform biomedical science.
    Continuing Support for CER
        Comparative effectiveness research or ``CER'' emerged at the
    forefront of the healthcare reform debate, capturing the interest of
    lawmakers and the American people. CER is the evaluation of the impact
    of different options that are available for treating a given medical
    condition for a particular set of patients. This broad definition can
    include medications, behavioral therapies, and medical devices among
    other interventions, and is an important facet of evidence-based
    medicine. On behalf of ACRT, APOR, CR Forum, and SCTS, I would like to
    thank the Senate for the creation of the Patient-Centered Outcomes
    Research Institute in the Patient Protection and Affordable Care Act,
    as well as the $1.1 billion included for CER at NIH and AHRQ in the
    American Recovery and Reinvestment Act (ARRA). Both AHRQ and NIH have
    long histories of supporting CER, and the standards for research
    instituted by agencies like NIH and AHRQ serve as models for best
    practices worldwide. Not only are these agencies experienced in CER,
    they are universally recognized as impartial and honest brokers of
    information.
        We are pleased that Congress recognizes the importance of these
    activities and believe that the peer review processes and
    infrastructure in place at NIH and AHRQ ensure the highest quality CER.
    We believe that collaboration between the Patient-Centered Outcomes
    Research Institute, NIH, and AHRQ will motivate all Federal CER
    efforts. In addition to support for the CTSA program at NIH, we
    encourage the Subcommittee to provide continued support for Patient-
    Centered Health Research at AHRQ.
        Thank you for the opportunity to present the views and
    recommendations of the clinical research training community. On behalf
    of ACRT, APOR, CR Forum, and SCTS, I would be happy to be of assistance
    as the appropriations process moves forward.
                                     ______

                Prepared Statement of Lions Clubs International
        Lions Clubs International (LCI) its official charity arm, Lions
    Clubs International Foundation (LCIF), have been world leaders in
    serving the vision, hearing, youth development, disability and
    humanitarian needs of millions of people in America and around the
    world, and we work closely with other NGOs. Since LCIF was founded in
    1968, it has awarded more than 9,000 grants, totaling more than $700
    million for service projects ranging from affordable hearing aids to
    diabetes-prevention. All Administrative costs are paid for through
    interest earned on investments, allowing LCIF to maximize out impact on
    the community and demonstrating the motto ``We Serve.''
        Our current 1.35 million-member global membership, representing
    over 206 countries, serves communities through the following ways:
    protect and preserve sight; provide disaster relief; combat disability;
    promote health; and serve youth. The 12,000 individual clubs
    representing over 375,000 individual citizens in North America are
    constantly expanding to add new programs and its volunteers are working
    to bring health services to as many communities as possible.
        LCI represents the largest and most effective NGO service
    organization presence in the world. Awarded and recognized as the #1
    NGO organization for partnership globally by The Financial Times 2007,
    LCI also holds a four star (highest) rating from the
    CharityNavigator.com (an independent review organization).
        Today, we face many complex challenges in the health and education
    sector, from preventable diseases that cause blindness in children to
    bullying, violence, and drug use among school-aged children. I will
    offer a brief summary of recommendations in programs under the general
    jurisdiction of the Labor-HHS-Education Subcommittee.
                           health and human services
    Domestic Sight Services
        Through our network of foundations and programs across America, LCI
    remains the single largest provider of charitable vision care,
    eyeglasses and hearing care services to needy and indigent people. Some
    of our major sight initiatives include:
      --The Sight for Kids Program in collaboration with Johnson and
            Johnson. The program has provided 6 million vision screenings
            and eye-health education programs for children.
      --Core 4 Preschool Vision Screening program enables LCI to conduct
            screenings for children in preschools. The program strives to
            deliver early detection and treatment for the most common
            vision disorders that can lead to amblyopia or ``lazy eye.''
            LCIF has also provided grants and services to those affected by
            eye conditions that cannot be improved medically.
      --LCI Clubs sponsored ``United We Serve Health Week'' events around
            the country. These Health Week efforts, in conjunction with the
            White House, were effective in bringing awareness to vision
            health issues.
    National Eye Institute--Vision Health Recommendations
        LCI believes that vision loss is a major public health problem that
    increases healthcare costs and reduces productivity and quality of life
    for millions of Americans. LCI played an important role in the creation
    of a free-standing eye institute separate from the then-National
    Institute for Neurological Diseases and Blindness. The National Eye
    Institute Act was signed into law by President Johnson in 1968 as the
    Nation's lead Institute within the NIH to prevent blindness and save
    and restore vision of all Americans. NEI-funded research is resulting
    in treatments and therapies that save vision and restore sight,
    resulting in reduced healthcare costs and higher productivity.
        LCI is concerned that proposals to reduce NIH funding to fiscal
    year 2008 levels would result in NEI funding for fiscal year 2011 at
    $667 million, or a $30 million loss. This would result in 43 fewer
    investigator-initiated research grants to save or restore vision.
    According to the National Association Eye and Vision Research, this
    funding reflects little more than 1 percent of the $68 billion annual
    cost of eye disease and vision impairment in the United States.
        LCI supports fiscal year 2012 NIH funding at $35 billion. This
    funding level would ensure that NIH can maintain the number of multi-
    year investigator-initiated research grants, and enables NEI to build
    upon its record of basic clinical/translational research. We also
    support an increase in NEI funding above the 1.8 percent proposed by
    the President.
    Vision 2020 USA Partnership
        VISION 2020 USA members, including Lions Clubs International, share
    a commitment to blindness prevention, preserving sight, and ensuring
    that all individuals receive the vision and eye healthcare they need
    and deserve. We are particularly interested in ensuring that Congress
    provides for fiscal year 2012 to support the following programs and
    initiatives:
      --Sustainment of at least $3.23 million for vision and eye health
            initiatives at the Centers for Disease Control and Prevention
            (CDC)
      --Support of the Maternal and Child Health Bureau's (MCHB) National
            Center for Children's Vision and Eye Health
        Vision-related conditions affect people across the lifespan from
    childhood through elder years. Fortunately, in children, many serious
    ocular conditions--such as amblyopia, nearsightedness, farsightedness,
    and astigmatism--are treatable, if diagnosed at an early stage. Yet,
    too many children do not receive vision screenings or follow-up
    comprehensive eye examinations and treatment. More than 80 million
    Americans are at risk for a potentially blinding eye disease such as
    diabetic retinopathy, glaucoma, cataract, and age-related macular
    degeneration. If nothing is done, the number of blind Americans is
    expected to double by 2030.
        With fiscal year 2012 appropriations that maintain current funding
    for vision and eye health efforts of the CDC and increased resources
    for the NIH and NEI, these Federal vision and eye health partners will
    have the resources they need to sustain and expand their respective
    efforts and programs to advance the prevention, diagnosis, and
    treatment of vision problems and eye disease.
    Lions Affordable Hearing Aid Project (AHAP)
        LCI is committed to fighting hearing loss as well as blindness. By
    listening to community health organizations across the country, Lions
    Clubs International and their volunteer members became aware of the
    lack of quality and affordable hearing care, especially for people with
    incomes below or at 200 percent of the poverty level. Many people have
    been unable to access other personal and family resources to purchase
    hearing aids, and have been denied State and Federal assistance.
    Fourteen centers have been working to expand output in this area as
    demand continues to rise with a network of mobile health units and
    community based programs that screen more than 2 million people each
    year and provide hearing aids to 14,000 low income patients.
        The statistics are unacceptable: 31 million persons in the United
    States experience some form of hearing loss, yet only 7.3 million opt
    to use hearing aids. According to audiology researchers, the market
    penetration for hearing aids is about 23.6 percent. For every four
    patients that enter a practice needing hearing aids, only one will
    purchase them. The median price tag is $1,900 (2005) for a digital
    hearing aid and prices go as high as $4,000. State Foundations, public
    health departments, and aging departments are in need of assistance in
    this area.
        With the recent 25-30 percent increase in people seeking assistance
    for hearing aids, there is an immediate public imperative to address
    the problem. Federal dollars are stretched, but Federal support in this
    area would have significant public health dividends in difficult
    economic times.
                   ``lions quest''/education/health programs
        LCIF's youth development initiatives, known collectively as ``Lions
    Quest,'' have been a prominent part of school-based K-12 programs since
    1984. Fulfilling its mission to teach responsible decisionmaking,
    effective communications and drug prevention, Lions Quest has been
    involved in training more than 350,000 educators and other adults to
    provide services for over 11 million youth in programs covering 43
    States. LCIF currently invests more than $2 million annually in
    supporting life skills training and service learning, and that funding
    is matched by local Lions, schools and other partners.
        Lions Quest curricula incorporate parent and community involvement
    in the development of health and responsible young people in the areas
    of: life skills development (social and emotional learning), character
    education, drug prevention, service learning, and bullying prevention.
    There is even a physical fitness component to this program that can
    assist Federal goals of reducing obesity in school-aged children.
        These Lions Quest programs provide strong evidence of decreased
    drug use, improved responsibility for students own behavior, as well as
    stronger decisionmaking skills and test scores in math and reading. In
    August 2002, Lions Quest received the highest ``Select'' ranking from
    the University of Illinois at Chicago-based Collaborative for Academic,
    Social and Emotional Learning (CASEL) for meeting standards in life
    skills education, evidence of effectiveness and exemplary professional
    development.
        Lions Quest has extensive experience with Federal programs. Lions
    Quest Skills for Adolescence received a ``Promising Program'' rating
    from the U.S. Department of Education Safe and Drug Free Schools and a
    ``Model'' rating from the U.S. Department of Health and Human Services
    Substance Abuse and Mental Health Services Administration (SAMHSA).
        Lions Quest also has extensive experience of partnering with State
    service commissions to reach more schools and engage more young people
    in service learning. Successful partnerships have been active in
    Michigan, New York, Oklahoma, Tennessee and West Virginia with progress
    being made in Texas and Ohio.
    Social and Emotional Learning Programs
        In addition, Lions Clubs recommends Congressional support for
    social and emotional learning (SEL) programs that stimulate growth
    among schools nationwide through distribution of materials and teacher
    training, and to create opportunities for youth to participate in
    activities that increase their social and emotional skills. Not only do
    SEL curricula contribute to the social and emotional development of
    youth, but they also provide invaluable support to students' school
    success, health, well-being, peer and family relationships, and
    citizenship. While still conducting scientific research and reviewing
    the best available science evidence, over time Lions Clubs and its SEL
    partners have increasingly worked to provide SEL practitioners,
    trainers and school administrators with the guidelines, tools,
    informational resources, policies, training, and support they need to
    improve and expand SEL programming.
        Overall, SEL training programs and curricula have outstanding
    benefits for school-aged children:
      --SEL prevents a variety of problems such as alcohol and drug use,
            violence, truancy, and bullying. SEL programs for urban youth
            emphasize the importance of cooperation and teamwork.
      --Positive outcomes increase in students who are involved in social
            and emotional learning programming by an average of 11
            percentile points over other students.
      --With greater social and emotional desire to learn and commit to
            schoolwork, participants benefit from improved attendance,
            graduation rates, grades, and test scores.
                                   conclusion
        Lions Clubs remains committed to domestic activities such as major
    sight initiatives and positive youth development and youth service
    programs. Today we face great health and educational challenges, and
    Lions Clubs International understands the importance not only of
    community service but of instilling those among members of our next
    generation. The success of nonprofit entities such as Lions Clubs show
    what the service sector can do for economic and social development of
    communities that are especially hard hit by the recession, and we are
    committed to forming more effective alliances and partnerships to
    increase our domestic impact.
                                     ______

              Prepared Statement of the March of Dimes Foundation
        The 3 million volunteers and nearly 1,300 staff members of the
    March of Dimes Foundation appreciate the opportunity to submit Federal
    funding recommendations for fiscal year 2012.
        The March of Dimes was founded in 1938 by President Franklin D.
    Roosevelt to support research to prevent polio. Today, the Foundation
    aims to improve the health of women, infants and children by preventing
    birth defects, premature birth, and infant mortality through scientific
    research, community services, education and advocacy.
        The March of Dimes is a unique partnership of scientists,
    clinicians, parents, members of the business community and other
    volunteers affiliated with 51 chapters and 213 divisions in every
    State, the District of Columbia and Puerto Rico. Additionally, in 1992,
    the March of Dimes extended its mission globally and now operates
    through partnerships in 33 countries on four continents.
        The March of Dimes is aware that the current fiscal environment
    necessitates restrictions on Federal funding increases and program
    expansions. However, it is our hope that these budgetary limitations
    will not put at risk our vital mission on which affected families rely.
    Therefore, the March of Dimes recommends the following funding levels
    for programs and initiatives that are essential investments in maternal
    and child health.
                                 preterm birth
        In 2008, one in eight infants was born preterm (before 37 weeks).
    Preterm birth is the leading cause of newborn mortality (death within
    the first month) and the second leading cause of infant mortality
    (death within the first year). In 2009, the National Center for Health
    Statistics (NCHS) reported that the primary reason for the higher
    infant mortality rate in the United States compared to other high
    resource countries is the greater percentage of preterm births--12.4
    percent in the United States compared to 5.5 percent in Ireland. But
    survival alone does not necessarily result in good health for these
    infants. Among those who survive, one in five faces health problems
    that persist for life. Prematurity-related conditions include cerebral
    palsy, intellectual disabilities, chronic lung disease, blindness and
    deafness. A comprehensive report published by the Institute of Medicine
    in 2007 estimated that preterm births cost the United States more than
    $26 billion in 2005 alone, with costs climbing each year.
        As a result of legislation enacted in 2006 (Public Law 109-450),
    the U.S. Surgeon General sponsored a conference in 2008 of more than
    200 of the country's foremost experts that convened for 2 days to
    develop a strategy to address the costly and serious problems of
    preterm birth. The meeting resulted in an action plan that included
    several overarching themes and recommendations. Among the most
    important were the enhancement of biomedical and epidemiological
    research and strengthening our Nation's data resources that document
    the health status of pregnant women and infants. The Foundation's
    funding requests regarding preterm birth are based on these
    recommendations.
    National Institutes of Health
        The March of Dimes commends members of the Subcommittee for their
    continuing support of the National Children's Study (NCS). For fiscal
    year 2012, the Foundation supports the President's funding
    recommendation of $193.9 million for the NCS and we urge the
    Subcommittee to support this recommendation as well. The NCS is the
    largest and most comprehensive study of children's health and
    development ever planned in the United States. The 37 ``vanguard
    centers'' have recruited nearly 3,000 participants thus far and more
    than 650 children have been born into the study. When fully
    implemented, this study will follow a representative sample of 100,000
    children in the United States from before birth until age 21. The data
    from this important study will help scientists at universities and
    research organizations across the country and around the world identify
    precursors of diseases and develop new strategies for treatment and
    prevention. Specifically, the first data generated by the NCS will
    provide information concerning disorders of birth and infancy,
    including preterm birth and its health consequences. The Foundation
    remains committed to supporting a well-designed NCS that promotes
    research of the highest quality and asks the Subcommittee to do the
    same.
    Eunice Kennedy Shriver National Institute of Child Health and Human
            Development (NICHD)
        For fiscal year 2012, the March of Dimes recommends at least $1.35
    billion for the NICHD. This $30 million increase compared to the fiscal
    year 2011 enacted level will enable NICHD to expand its support for
    preterm birth-related research through the Maternal-Fetal Medicine
    Units, Neonatal Research Network, and Genomic and Proteomic Network for
    Preterm Birth Research. In addition, it will allow for planning grants
    to begin establishing a network of integrated trans-disciplinary
    research centers, as recommended by the Institute of Medicine report
    and the aforementioned 2008 Surgeon General's Conference. The causes of
    preterm birth are multi-faceted and necessitate a coordinated and
    collaborative approach integrating many disciplines. These trans-
    disciplinary centers would serve as a national resource for
    investigators to design and share new research approaches and
    strategies to comprehensively address preterm birth.
    Centers for Disease Control and Prevention--Preterm Birth
        The National Center for Chronic Disease Prevention and Health
    Promotion's Safe Motherhood Program works to promote optimal
    reproductive and infant health. In 2009, CDC created a robust research
    agenda to prevent preterm birth by improving derivation of accurate
    data to understand preterm birth; developing, implementing and
    evaluating prevention methods; and conducting targeted etiologic and
    epidemiologic studies. For fiscal year 2012, the March of Dimes
    recommends a $6 million increase in the CDC's preterm birth budget
    compared to the fiscal year 2011 enacted level (for a total of $8
    million) to strengthen our national data systems and to expand preterm
    birth research as authorized by the PREEMIE Act (Public Law 109-450).
    Centers for Disease Control and Prevention--National Center for Health
            Statistics
        The National Center for Health Statistics' (NCHS) vital statistics
    program collects birth and death data that are used to monitor the
    Nation's health status, set research and intervention priorities, and
    evaluate the effectiveness of existing health programs. It is
    imperative that data collected by NCHS be comprehensive and timely.
    Unfortunately, one-quarter of the States and territories lack the
    capacity to use the most recent (2003) birth certificate format and
    only two-thirds have adopted the most recent (2003) death certificate
    format. The March of Dimes supports the President's recommendation to
    provide $162 million for the NCHS in fiscal year 2012 and urges the
    Subcommittee to support this recommendation in both the bill language
    and in the accompanying committee report as well.
    Health Resources and Services Administration--Healthy Start
        The Maternal and Child Health Bureau's Healthy Start Program is a
    collection of community-based projects focused on reducing infant
    mortality, low birth weight, and racial disparities in perinatal
    outcomes among high-risk populations by strengthening local health
    systems and resources. Communities with Healthy Start programs have
    seen significant improvements in perinatal health outcomes. The March
    of Dimes supports the President's recommendation to provide $105
    million for Healthy Start in fiscal year 2012 and urges the
    Subcommittee to support this recommendation as well.
                                 birth defects
        According to the Centers for Disease Control and Prevention, an
    estimated 120,000 infants in the United States are born with major
    structural birth defects each year. Genetic or environmental factors,
    or a combination of both, can cause various birth defects; yet the
    causes of more than 70 percent are unknown. Many birth defects result
    in childhood and adult disability that require costly, lifelong
    treatments and special care. Additional Federal resources are sorely
    needed to support research to discover causes of all birth defects and
    for the development of effective interventions to prevent or at least
    reduce their prevalence.
    CDC's National Center on Birth Defects and Developmental Disabilities
            (NCBDDD)
        The NCBDDD conducts programs to protect and improve the health of
    children by preventing birth defects and developmental disabilities and
    by promoting optimal development and wellness among children with
    disabilities. For fiscal year 2012, the March of Dimes requests at
    least $144 million for NCBDDD. In addition, we encourage the
    Subcommittee to allocate an additional $5 million specifically to
    support birth defects research and surveillance and an additional $2
    million specifically to support folic acid education. A source for this
    $7 million in additional funding could be the Prevention and Public
    Health Fund. Investing in the work of the NCBDDD will promote wellness
    and preventive strategies aimed at children, reduce health disparities,
    and enable CDC to more effectively support transition to adulthood for
    children with lifelong disabilities.
        Allocating an additional $5 million to support genetic analysis of
    the research samples already obtained through the NCBDDD's National
    Birth Defects Prevention Study--the largest case-controlled study of
    birth defects ever conducted--would be a sound investment. This
    analysis would enable researchers to begin the work needed to translate
    their findings into effective birth defects intervention and treatment
    programs. The study has already yielded rich results. In 2009 alone, 29
    articles regarding risk factors for birth defects--for example maternal
    diabetes, obesity, use of certain medications, and smoking--were
    published in medical and health journals. In addition, this investment
    would make possible the continuation of NCBDDD's State-based birth
    defects surveillance grant program. Surveillance is the backbone of the
    public health network and its support should be a Subcommittee
    priority. Because of the current fiscal situation facing many States,
    funding for State-based surveillance systems is in jeopardy and
    requires increased Federal support to ensure the survival of essential
    birth defects surveillance programs.
        Allocating an additional $2 million to NCBDDD will allow the CDC to
    expand its effective national education campaign aimed at reducing the
    incidence of spina bifida and anencephaly by promoting consumption of
    folic acid. Since the institution of fortification of U.S. enriched
    grain products with folic acid, the rate of neural tube defects has
    decreased by 26 percent. However, CDC estimates that up to 70 percent
    of neural tube defects could be prevented if all women of childbearing
    age consumed 400 micrograms of folic acid daily. To raise awareness
    among women of childbearing age and thereby increase the use of folic
    acid, NCBDDD's national education campaign must be expanded.
        The March of Dimes is very concerned about the Administration's
    recommendation that the NCBDDD's budget lines be consolidated into
    three categories: Child Health and Development, Health and Development
    for People with Disabilities, and Public Health Approach to Blood
    Disorders. As proposed, the Birth Defects and Developmental
    Disabilities budget line would be renamed Child Health and Development
    and existing sub-categories would be eliminated (e.g. Birth Defects,
    Fetal Alcohol Syndrome, Folic Acid). While the March of Dimes
    recognizes and supports program flexibility for CDC management, we are
    concerned that the title ``Child Health and Development'' fails to make
    clear the overall purpose of the programs covered, masking the urgency
    and importance of the need for ongoing support from Congress. We urge
    the Subcommittee to modify the Administration's proposal by retaining
    the term ``Birth Defects'' as a sub-line with the category ``Child
    Health and Development.'' We believe this adjustment is needed to
    ensure that the content of these essential programs to reduce birth
    defects is clearly articulated.
                               newborn screening
        Newborn screening is a vital public health activity used to
    identify genetic, metabolic, hormonal and functional disorders in
    newborns so that treatment can be provided. Screening detects
    conditions in newborns that, if left untreated, can cause disability,
    developmental delays, intellectual disabilities, serious illnesses or
    even death. If diagnosed early, many of these disorders can be
    successfully managed. Across the Nation, State and local governments
    are experiencing significant budget shortfalls. Because of this fiscal
    pressure, discontinuing screening for certain conditions or postponing
    the purchase of necessary technology is a serious threat that, if left
    unresolved, will put infants at risk of permanent disability or even
    death. For fiscal year 2012, an additional $5 million for HRSA's
    heritable disorders program, as authorized by the Newborn Screening
    Saves Lives Act (Public Law 110-204), is necessary to increase support
    for State efforts to improve screening, enhance counseling, and
    increase capacity to reach and educate health professionals and parents
    about newborn screening programs and follow-up services.
                                     other
    Agency for Health Research and Quality (AHRQ)
        AHRQ supports research to improve healthcare quality, reduce costs
    and broaden access to essential health services. For fiscal year 2012,
    the March of Dimes recommends $405 million total for AHRQ to continue
    its important work, including the development and dissemination of
    maternal and pediatric quality measures and comparative effectiveness
    research. Moreover, with the historic enactment of health reform last
    year, AHRQ's research is needed more than ever to build the evidence-
    base that will be used to improve health and healthcare coverage.
    Health Resources and Services Administration--Maternal and Child Health
            Block Grant
        Title V of the Social Security Act, the Maternal and Child Health
    Block Grant, supports a growing number of community-based programs
    (e.g. home visiting, respite care for children with special healthcare
    needs, and supplementary services for pregnant women and children
    enrolled in Medicaid and the State Children's Health Insurance
    Program), but Federal support has not kept pace with increased
    enrollment and demand for these services. For fiscal year 2012, the
    March of Dimes recommends $700 million for the Maternal and Child
    Health Block Grant--$44 million more than the fiscal year 2011 enacted
    level.
    CDC National Immunization Program
        Infants are particularly vulnerable to infectious diseases, which
    is why it is critical to protect them through immunization. In 2008,
    the national estimated immunization coverage among children 19-35
    months of age was 76 percent. The CDC's National Immunization Program
    supports States, communities and territorial public health agencies
    through grants to reduce the incidence of disability and death
    resulting from vaccine-preventable diseases. The March of Dimes is
    requesting $685 million in fiscal year 2012 for the National
    Immunization Program.
    CDC Polio Eradication
        Since its creation as an organization dedicated to research and
    services related to polio, the March of Dimes has been committed to the
    eradication of this disabling disease. We support the Administration's
    Global Polio Eradication Strategic Plan for the remaining endemic
    countries, and urge the Subcommittee to approve the President's request
    for $112 million in fiscal year 2012 to support CDC's Polio Eradication
    Program.
                                    closing
        Thank you for the opportunity to testify on the federally supported
    programs of highest priority to the March of Dimes. The Foundation's
    volunteers and staff in every State, the District of Columbia and
    Puerto Rico look forward to working with Members of this Subcommittee
    to secure the resources needed to improve the health of the Nation's
    mothers, infants and children.

           MARCH OF DIMES FISCAL YEAR 2012 FEDERAL FUNDING PRIORITIES
    ------------------------------------------------------------------------
                                                Fiscal year
                                               2011 funding
                                               (w/prevention  March of Dimes
                     Program                    fund add-on     fiscal year
                                                   where       2012 request
                                                applicable)
    ------------------------------------------------------------------------
    National Institutes of Health (Total)...        $30.77 B           $35 B
        National Children's Study...........        191.05 M         193.9 M
        Common Fund.........................        543.02 M         556.9 M
        National Institute of Child Health            1.32 B          1.35 B
         and Human Development..............
        National Human Genome Research               511.5 M         524.8 M
         Institute..........................
        National Center on Minority Health          209.71 M         214.6 M
         and Disparities....................
    Centers for Disease Control and                   6.26 B           7.7 B
     Prevention (Total).....................
        Birth Defects Research &                      20.3 M          25.3 M
         Surveillance.......................
        Folic Acid Campaign.................           2.8 M           4.8 M
        Immunization........................        525.57 M           685 M
        Polio Eradication...................         101.6 M           112 M
        Preterm Birth (Safe Motherhood).....          1.97 M             8 M
        National Center for Health                  168.68 M           162 M
         Statistics.........................
    Health Resources and Services                     6.29 B          7.65 B
     Administration (Total).................
        Maternal and Child Health Block             656.32 M           700 M
         Grant..............................
        Newborn Screening...................          9.95 M            15 M
        Newborn Hearing Screening...........         18.88 M            19 M
        Community Health Centers............          2.48 B          2.56 B
        Healthy Start.......................        104.36 M           105 M
    Agency for Healthcare Research and              392.05 M           405 M
     Quality (Total)........................
    ------------------------------------------------------------------------

                                     ______

        Prepared Statement of the Meals On Wheels Association of America
        Thank you for the opportunity to present testimony to your
    subcommittee concerning fiscal year 2012 funding for Senior Nutrition
    Programs administered by the Administration on Aging (AoA) within the
    U.S. Department of Health and Human Services (HHS). I am Enid A.
    Borden, President and CEO of the Meals On Wheels Association of America
    (MOWAA), the oldest and largest national organization representing
    local, community-based Senior Nutrition Programs--both congregate and
    home-delivered (commonly referred to as Meals On Wheels)--and the only
    national organization and network dedicated solely to ending senior
    hunger in America. I speak on behalf not only of that national network
    of Senior Nutrition Programs but also for the hundreds of thousands of
    seniors in communities across this Nation who depend upon those
    programs for access to nutritious meals. I speak for them because many
    are behind closed doors, invisible and without a voice of their own.
    But it is not only for those particular seniors that I bring our
    concerns before you. I also speak for those other seniors who like
    their peers need meals, but who do not receive them, not because we
    lack the infrastructure and expertise to serve them but because our
    Senior Nutrition Programs lack the adequate financial resources to
    provide them. At MOWAA we call those individuals the hidden hungry, and
    we call the situation that lets them remain so a national tragedy and
    morally unacceptable circumstance in the richest Nation on earth.
    Those, I realize, are strong words. But they are also carefully chosen
    and in no way hyperbolic. Later I will attempt to put impartial numbers
    to those words, and then some humanity.
        But before I do that, let me stop and offer MOWAA's sincere thanks
    to this Subcommittee, and in particular to you, Mr. Chairman, for your
    longstanding support of Senior Nutrition Programs as well as for your
    leadership in ensuring that these programs received increases in
    appropriations the past several fiscal years. We are quite mindful that
    the chairman's mark of the Senate version of the fiscal year 2011 bill,
    crafted by this Subcommittee and approved by the full Committee,
    contained increases of $38 million above the fiscal year 2010 level for
    these programs. We are grateful for those actions at the same time that
    we are extremely disheartened that the final fiscal year 2011
    continuing resolution did not provide for any increases.
        Today Senior Nutrition Programs are struggling to maintain
    services; many are unable to do so and therefore are forced to reduce
    services. That is today, and as prices of gasoline and food continue to
    climb, more and more programs will find themselves in that predicament.
    More starkly, homebound seniors who cannot shop and prepare meals for
    themselves, who have no other access to nutritious food, will be forced
    to go without meals. The consequences of that are something for which
    we will all pay. I use the word ``pay'' both literally and
    figuratively. If we leave frail seniors languishing in their homes
    without proper nutrition, their health will inevitably fail. If they
    survive, they will end up hospitalized or institutionalized at a cost
    to the Government that far exceeds the cost of providing adequate funds
    to Senior Nutrition Programs to enable them to furnish seniors meals in
    the homes and other settings. Senior Nutrition Programs can provide
    meals for nearly 1 year for roughly the cost of one Medicare day in the
    hospital. We can quantify the savings that can accrue when seniors
    receive nutritious meals immediately following a hospital stay for an
    acute condition.
        Our evidence in this regard is based on 2006 data (in 2006 dollars)
    from a special project that MOWAA carried out in partnership with a
    major national insurance company. The findings were presented in
    December 2006 in Washington at a Leadership Summit sponsored by AoA.
    Through the special partnership, Medicare Advantage patients in select
    markets across the United States were offered without cost to
    themselves 10 meals, delivered by local Meals On Wheels programs,
    immediately following hospital discharge. Participation was purely
    voluntary. Individuals who chose to receive the service were typically
    sicker than those who declined it. Despite this, the insurance data
    show that those seniors who received meals had first month post-
    discharge healthcare costs on average $1,061 lower than those who did
    not. The beneficial affects were also lasting. The third month after
    receiving those meals, the average per person savings were $316.
    Individuals who did not receive meals had both more inpatient hospital
    days and more inpatient admissions per 1,000 than those who did receive
    meals. I cannot calculate the savings had meals been provided to every
    senior who was discharged from the hospital, or even to half of them,
    but I know that it is significant. According to PricewaterhouseCoopers,
    preventable hospital readmissions cost the Nation approximately $25
    billion each year. One out of every five Medicare patients discharged
    from a hospital is readmitted within 30 days at an annual cost to
    Medicare of $17 billion. Given these facts, providing adequate funds
    for Senior Nutrition Programs can only be regarded as a strong and
    demonstrable value proposition. Beyond that, from a human and humane
    perspective, and from the perspective of the value of individuals and
    their liberty--principals on which this Nation was founded and for
    which it still stands--it is the only acceptable and right thing to do.
        As you are well aware, however, the President's fiscal year 2012
    budget proposes continued funding for these programs for another fiscal
    year at the fiscal year 2010 level. If that occurs it will not only be
    costly on the other side of the Federal ledger but it will also be
    nothing less than disastrous for seniors who are already vulnerable. So
    we appeal to this Subcommittee to provide substantial increases above
    the President's request for Title III C1 (Congregate Meals), Title III
    C2 (Home-Delivered Meals) and Nutrition Services Incentive Program
    (NSIP). We ask knowing that the fiscal context in which you are working
    for this fiscal year 2012 appropriation bill is extraordinarily
    challenging, and we ask knowing that providing increases to our
    programs means reducing or eliminating others. But we also ask knowing
    that without such increases vulnerable seniors will go hungry.
        One of the great strengths of community-based Senior Nutrition
    Programs is that they are strong public-private partnerships that rely
    on the community to contribute significant financial support to augment
    those Federal funds furnished through this Labor, Health and Human
    Services, Education and Related Agencies appropriation bill. A host of
    partners give generously, and without them Senior Nutrition Programs
    could not operate. But without a strong Federal commitment in the form
    of adequate appropriations most Senior Nutrition Programs could not
    leverage these other funds effectively. In fiscal year 2009, the last
    year for which AoA has data, only 28.4 percent of the expenditures for
    Title III C2 home-delivered meals were Title III dollars. The remainder
    was from other sources. For Title III C1 congregate meals the Title III
    share was 41 percent. Funds are not the only invaluable resources that
    communities contribute to Senior Nutrition Programs. The programs
    typically rely on volunteers to perform many of the critical functions
    of the operation, such as meal delivery. We are proud to claim what we
    believe to be the largest volunteer army in the world, numbering in the
    neighborhood of 1.7 million individuals each year. Despite all of these
    assets Senior Nutrition Programs will fail to reach the most vulnerable
    elderly in their communities without adequate Federal financial
    support.
        Simply put, Senior Nutrition Programs are lifelines to those men
    and women they serve. Regrettably they are reaching only a small
    proportion of the population needing services. A February 2011
    Government Accountability Office (GAO) report prepared for Senator Herb
    Kohl paints a grim picture. The GAO (GAO-11-237) found that ``. . .
    approximately 9 percent of an estimated 17.6 million low-income older
    adults received meal services like those provided by Title III
    programs. However, many more older adults likely needed services, but
    did not receive them . . . For instance, an estimated 19 percent of
    low-income older adults were food insecure and about 90 percent of
    these individuals did not receive any meal services [emphasis added].
    Similarly approximately 17 percent of those with low incomes had two or
    more types of difficulties with daily activities that could make it
    difficult to obtain or prepare food. An estimated 83 percent of those
    individuals with such difficulties did not receive meal services
    [emphasis added].
        As dire as this report is, we wish to point out that it undercounts
    the percentage of the population needing services that fail to receive
    them. This is due to the fact that the GAO confined their investigation
    to low-income seniors. Title III and NSIP funded meal programs are
    explicitly prohibited by the Older Americans Act (OAA) from means-
    testing and many individuals with incomes above the Federal poverty
    line receive services based on their physical condition, homebound
    status, social or geographic isolation and other factors that create an
    inability to access nutritious food from any other source. If you
    factor individuals meeting these criteria into the equation, the
    percentage of seniors needing meal services but who do not get them
    will certainly increase. Surely our Federal and national commitment to
    our most vulnerable elders should reach more than 10 percent of those
    needing meals.
        Given the current economic situation and the exponential growth of
    the aging population, if funding remains static it is unavoidable that
    the percentage of people needing services to whom Senior Nutrition
    Programs will be able to provide services will erode substantially.
    Sky-rocketing food and fuel prices are having a deleterious impact on
    programs that are dependent upon these two items. MOWAA has determined
    that every 1 cent increase in the price of gasoline results in a
    $250,000 increase in the cost of providing services. Gasoline prices
    for the week of May 9, 2011 were $1.06 higher than for the same week of
    2010. This means that costs nationally of delivering services based on
    this factor alone increased by $26,500,000. It is true that some, but
    not all, of these costs are borne by volunteers who donate the use of
    their vehicles, but as gas prices increase many of these individuals, a
    number of whom are older and on fixed incomes themselves, are either
    requesting reimbursement from programs or suspending their volunteer
    activities. When this happens, Senior Nutrition Programs often must
    bear the costs. The point is that factors far outside the control of
    Senior Nutrition Programs are increasing their costs; so flat funding
    will translate into a significant reduction or curtailment of nutrition
    services to our most vulnerable seniors.
        Last year, MOWAA engaged an expert actuary to examine Federal
    funding for Senior Nutrition Programs for the past two decades. Looking
    at population data and appropriations, he determined a per capita
    commitment to seniors and Senior Nutrition Programs in fiscal year
    1992. Then, taking into account the growth in the ages 60+ and the 85+
    population and the changes in the CPI-U, he projected what the fiscal
    year 2012 total appropriation for Title III C1, Title III C2 and NSIP
    would be in fiscal year 2011 if that per capita commitment were
    maintained. The current year (fiscal year 2011) figure would be
    $1,275,571,000 based on the 60+ population and $1,743,182,000 based on
    the 85+ population. We are not asking for either of those funding
    levels, the latter of which be more than double the current year
    appropriation of $819,474,000 for the three line items combined. But we
    do believe that this provides a reasonable context in which to make
    decisions. Surely the senior citizens of today are as valuable and
    deserving of life sustaining meals as those seniors of two decades ago
    were. Meals are not dispensable. To live and live healthily people must
    eat. To ensure that frail seniors do, Congress must increase funding
    for Senior Nutrition Programs. We respectfully request that increases
    of no less than your Subcommittee originally approved for fiscal year
    2011, that is of at least $38 million for Title III C combined with a
    commensurate increase for NSIP, should be the baseline.
        In closing I would like to thank this Subcommittee again for its
    longstanding support, acknowledge that MOWAA understands the difficulty
    of your task and the boldness of our ``ask'' in this difficult budget
    year. We mean no disrespect. But part of our role, in addition to
    supporting our member Senior Nutrition Programs in providing meals, is
    to call attention to the need to afford those older adults, who
    contributed so much to this Nation, the respect that they are due. It
    is in that spirit that we make our request. As you consider it and as
    you make the difficult funding decisions that the Subcommittee must, we
    respectfully request that you think of Senior Nutrition Programs not
    simply as one of the hundreds of programs supported through the Labor,
    Health and Human Services, Education and Related Agencies appropriation
    bill, but instead as an essential service. For what is more essential
    to the sustaining of life than nutritious food and hydration? Those are
    the fundamental services Senior Nutrition Programs deliver.
        Again, we thank you for the opportunity to present this testimony
    to you.
                                     ______

     Prepared Statement of the Medical Library Association and Association
                     of Academic Health Sciences Libraries
                summary of recommendations for fiscal year 2011
        Continue the commitment to the National Library of Medicine (NLM)
    by increasing funding levels to $402 million for fiscal year 2012.
        Continue to support the medical library community's role in NLM's
    outreach, telemedicine, disaster preparedness and health information
    technology initiatives and the implementation of healthcare reform.
                                  introduction
        The Medical Library Association (MLA) and the Association of
    Academic Health Sciences Libraries (AAHSL) thank the Subcommittee for
    the opportunity to submit testimony regarding fiscal year 2012
    appropriations for the National Library of Medicine (NLM), a division
    of the National Institutes of Health. Working in partnership with other
    parts of the NIH and other Federal agencies, NLM is the key link in the
    chain that translates biomedical research into practice, making the
    results of research readily available worldwide.
        MLA is a nonprofit, educational organization with approximately
    4,000 health sciences information professional members worldwide.
    Founded in 1898, MLA provides lifelong educational opportunities,
    supports a knowledge base of health information research, and works
    with a global network of partners to promote the importance of quality
    information for improved health to the healthcare community and the
    public. AAHSL is composed of the directors of 123 libraries of
    accredited U.S. and Canadian medical schools, and 26 associate members.
    AAHSL's goals are to promote excellence in academic health sciences
    libraries and to ensure that the next generation of health
    practitioners is trained in information seeking skills that enhance the
    quality of information delivery. Together, MLA and AAHSL address health
    information issues and legislative matters of importance to both our
    organizations.
               the importance of annual funding increases for nlm
        We are pleased that the fiscal year 2010 appropriations package
    contained funding increases for NIH and NLM which
        bolstered their baseline budgets, and that the proposed fiscal year
    2011 budget included increases. In today's challenging budget
    environment, we recognize the difficult decisions Congress faces as it
    seeks to improve our Nation's fiscal stability. We appreciate and thank
    the Subcommittee for its commitment to strengthening the NIH and NLM
    budget.
        MLA and AAHSL believe that increased funding for NLM is essential
    to maximize the return on the investment in research conducted by the
    NIH and other organizations. By collecting, organizing, and making the
    results of biomedical information more accessible to other researchers,
    clinicians, business innovators, and the public, NLM enables such
    information be used more efficiently and effectively to drive
    innovation and improve the national's health. This role has become more
    important as the volume of biomedical data produced each year expands
    exponentially driven by the influx of data from high-throughput genome
    sequencing systems and genome-wide association studies. NLM plays a
    critical role in accelerating nationwide deployment of health
    information technology, including electronic health records (EHRs) by
    leading the development, maintenance and dissemination of key standards
    for health data interchange that are now required of certified EHRs.
    NLM also contributes to Congressional priorities related to drug safety
    through its efforts to expand its clinical trial registry and results
    database in response to recent legislation requirements, and to the
    nation's ability to prepare for and respond to disasters.
        We encourage the Subcommittee to continue to provide meaningful
    annual increases for NLM in the coming years and recommend an increase
    to $402 million for fiscal year 2012. Recovery funding and the fiscal
    year 2010 budget increases stimulated the economy and biomedical
    research. For NLM, Recovery Act funding allowed timely and much needed
    increases in support of leading edge research and training in
    biomedical informatics--the kinds of programs that will influence
    future health information technology developments. In fiscal year 2012
    and beyond, it is critical to augment NLM's baseline budget to
    accommodate expansion of its information resources, services, and
    programs which must collect, organize, and make accessible rapidly
    expanding volumes of biomedical knowledge.
    Growing Demand for NLM's Basic Services
        The National Library of Medicine is the world's largest biomedical
    library and the source of trusted health information. Every day,
    medical librarians across the Nation assist clinicians, students,
    researchers, and the public in accessing the information they need to
    save lives and improve health. NLM delivers more than a trillion bytes
    of data to millions of users every day to help researchers advance
    scientific discovery and accelerate its translation into new therapies;
    provides health practitioners with information that improves medical
    care and lowers its costs; and gives the public access to resources and
    tools that promote wellness and disease prevention. Without NLM, our
    Nation's medical libraries would be unable to provide the quality
    information services that our Nation's health professionals, educators,
    researchers and patients have come to expect.
        NLM's data repositories and online integrated services such as such
    as GenBank, PubMed, and PubMed Central are helping to revolutionize
    medicine and advance science to the next important era which includes
    individualized medicine based on an individual's unique genetic
    differences. GenBank, with its international partners, has become the
    definitive source of gene sequence information and organizing, along
    with NLM's other genetic databases, the volumes of data that are needed
    to detect associations between genes and disease and translate that
    knowledge into better diagnosis and treatments. PubMed, with more than
    20 million citations to the biomedical literature, is the world's most
    heavily used source of information about published results of
    biomedical research. Approximately 700,000 new citations are added each
    year, and it is searched more than 2.2 million times each day. PubMed
    Central, NLM's freely accessible digital repository of biomedical
    journal articles, has become a valuable resource for researchers,
    clinicians, consumers and librarians. On a typical weekday more than
    420,000 users download 740,000 full-text articles. We commend the
    Appropriations Committee for its support of the NIH public access
    policy which requires all NIH-funded researchers to deposit their
    final, peer-reviewed manuscripts in NLM's PubMed Central database
    within 12 months of publication. This highly beneficial policy is
    improving access to timely and relevant scientific information,
    stimulating discovery, informing clinical care, and improving public
    health literacy. We ask the Committee to remain a strong voice in
    support of the NIH policy and to support the extension of public access
    policies to other Federal science and education agencies because this
    would bring the benefits of public access to other research disciplines
    and because research in other fields is increasingly relevant to
    biomedicine.
        As the world's largest and most comprehensive medical library,
    NLM's traditional print and electronic collections continue to steadily
    increase each year. These collections stand at more than 11.4 million
    items--books, journals, technical reports, manuscripts, microfilms,
    photographs and images. By selecting, organizing and ensuring permanent
    access to health science information in all formats, NLM is ensuring
    the availability of this information for future generations, making it
    accessible to all Americans, irrespective of geography or ability to
    pay, and ensuring that each citizen can make the best, most informed
    decisions about their healthcare.
        Clearly, NLM is a national treasure which is making a difference in
    patients' lives and healthcare outcomes. For example, an MLA member
    shared that recently a surgeon came to the library 12 minutes before
    surgery to find an article on the complex procedure he was about to
    perform. By searching NLM's PubMed/Medline database, the librarian
    found illustrations that guided the surgeon during surgery enabling him
    to save the man's foot.
         encourage nlm partnerships with the medical library community
    Outreach and Education
        NLM's outreach programs are of interest to both MLA and AAHSL.
    These activities are designed to educate medical librarians, health
    professionals and the general public about NLM's services and to train
    them in the most effective use of these services. NLM has taken a
    leadership role in promoting educational outreach aimed at public
    libraries, secondary schools, senior centers and other consumer-based
    settings. Furthermore, NLM's emphasis on outreach to underserved
    populations assists the effort to reduce health disparities among large
    sections of the American public. One example of NLM's leadership is the
    ``Partners in Information Access'' program which is designed to improve
    the access of local public health officials to information needed to
    prevent, identify and respond to public health threats. With nearly
    6,000 members in communities across the country, the National Network
    of Libraries of Medicine (NNLM) is well positioned to ensure that every
    public health worker has electronic health information services that
    can protect the public's health.
        NLM is also at the forefront of efforts to provide consumers with
    trusted, reliable health information. Its MedlinePlus system provides
    consumer-friendly information on more than 80 topics in English and
    Spanish and has become a top destination for those seeking information
    on the Internet, attracting more than half-million visitors per day.
    Librarians at Louisiana State University's Health Sciences Center
    Medical Library in Shreveport provide in-person support for patients
    and the public seeking health information and have also established
    ``healthelinks.org'', a website with information on diseases and
    conditions, medicines, procedures and surgical operations, lab tests,
    and more from NLM's MedlinePlus system. With help from Congress, NLM,
    NIH and the Friends of NLM launched NIH MedlinePlus Magazine in
    September 2006. This quarterly publication is distributed in doctors'
    waiting rooms and provides the public will access to high-quality,
    easily understood health information. Its readership is now estimated
    at 5 million people nationwide and is poised to grow thanks to the
    launch of a Spanish/English version, NIH MedlinePlus Salud, in January
    2009. NLM also continues to work with medical librarians and health
    professionals to encourage doctors to provide MedlinePlus ``information
    prescriptions'' to their patients, directing them to relevant
    information on NLM's consumer-oriented MedlinePlus information system.
    This initiative also encourages genetics counselors to prescribe the
    use of NLM's Genetic Home Reference website. Using NLM's new
    MedlinePlus Connect utility, a growing number of clinical care
    organizations are implementing specific links from their electronic
    health record systems to relevant patient education materials in
    MedlinePlus, enabling them to achieve an emerging criterion for
    achieving meaningful use of health information technology. MedinePlus
    Connect was recently named a winner in the HHS Innovates competition.
        NLM also provides access to information about clinical research for
    a wide range of diseases. Launched in February 2000, ClinicalTrials.gov
    contains registration information for some 105,000 trials. The database
    is a free and invaluable resource for patients and families who are
    interested in participating in cutting-edge treatments for serious
    illnesses. In recent years, it has become more valuable for patients,
    clinicians, researchers, and others, including librarians, who help
    patients identify relevant trials and provide clinicians and
    researchers with access to information about specific products such as
    new drugs under study. In response to the Food and Drug Administration
    Amendments Act of 2007, NLM has expanded ClinicalTrials.gov to accept
    summary results of clinical trials, including adverse events. Such
    information is not available systematically from other publicly
    accessible resources, and all too often is not published in the
    scientific literature. The system currently contains results for more
    than 3,200 trials, and the Library receives approximately 50 new
    results submission each week. More than 50,000 users visit the site ach
    day.
        MLA and AAHSL applaud the success of NLM's outreach initiatives,
    particularly those initiatives that reach out to the medical libraries
    and health consumers. We ask the Committee to encourage NLM to continue
    to coordinate its outreach activities with the medical library
    community in fiscal year 2012.
    Emergency Preparedness and Response
        NLM has a long history of programs and resources that support
    disaster preparedness and response activities. Building on its
    experiences in responding to Hurricane Katrina, NLM established a
    Disaster Information Management Research Center to collect and organize
    disaster-related health information, ensure effective use of libraries
    and librarians in disaster planning and response, and develop
    information services to assist responders. MLA and NLM are developing a
    Disaster Information Specialization (DIS) program aimed at building the
    capacity of librarians and other interested professionals to provide
    disaster-related health information outreach. Earlier this year, NLM
    convened a Disaster Information Outreach Symposium for information
    professionals across the country. This highly successful program
    addressed strategies for assessing and meeting the information needs of
    disaster managers and responders; communications, social media and
    disasters; using library facilities to support disaster needs during
    response and recovery, workforce development; disaster resources for
    librarians; and tools for providing disaster health information.
    Working with libraries and American publishers, NLM has established an
    Emergency Access Initiative that makes available free full-text
    articles from hundreds of biomedical journals and reference books for
    use by medical teams responding to disasters. This initiative has been
    activated multiple times in the last 15 months to assist relief efforts
    in Japan, Pakistan, and Haiti. It organized and made available health
    information resources relevant to the Gulf Oil spill. MLA and AAHSL see
    a clear role for NLM and the Nation's health sciences libraries in
    disaster preparedness and response activities, and we ask the
    Subcommittee to support NLM's role in this initiative which has a major
    objective of ensuring continuous access to health information and
    effective use of libraries and librarians when disasters occur.
        MLA and AAHSL see a clear role for NLM and the Nation's health
    sciences libraries in disaster preparedness and response activities,
    and we ask the Subcommittee to support NLM's role in this initiative
    which has a major objective of ensuring continuous access to health
    information and effective use of libraries and librarians when
    disasters occur.
    Health Information Technology and Bioinformatics
        NLM has played a pivotal role in creating and nurturing the field
    of medical informatics which is the intersection of information
    science, computer science and healthcare. Health informatics tools
    include computers, clinical guidelines, formal medical terminologies,
    and information and communication systems. For nearly 35 years, NLM has
    supported informatics research, training and the application of
    advanced computing and informatics to biomedical research and
    healthcare delivery including a variety of telemedicine projects. Many
    of today's informatics leaders are graduates of NLM-funded informatics
    research programs at universities across the country. Many of the
    country's exemplary electronic and personal health record systems
    benefits from NLM grant support.
        The importance of NLM's work in health information technology
    continues to grow as the Nation moves toward more interoperable health
    information technology systems. A leader in supporting, licensing,
    developing and disseminating standard clinical terminologies for free
    United States-wide use (e.g., SNOWMED), NLM works closely with the
    Office of the National Coordinator for Health Information Technology
    (ONCHIT) to promote the adoption of interoperable electronic records,
    It has developed tools to make it easier for EHR developers and users
    to implement accepted health data standards in their systems.
        MLA and AAHSL encourage the Subcommittee to continue their strong
    support for NLM's medical informatics and genomic science initiatives,
    at a point when the linking of clinical and genetic data holds
    increasing promise for enhancing the diagnosis and treatment of
    disease. MLA and AAHSL also support health information technology
    initiatives in ONCHIT that build upon initiatives housed at NLM.
    Building and Facility Needs
        The tremendous growth in NLM's basic functions related to the
    acquisition, organization and preservation of its ever-expanding
    collection of biomedical literature, combined with its growing
    contributions to healthcare reform, health information technology, drug
    safety, and exploitation of genomic information is straining the
    Library's physical resources. During times of economic hardship, NLM's
    role becomes increasingly important and it often serves as an archive
    of last resort for medical libraries looking for ways to cut back and
    trim their own collections.
        NLM now houses 1,100 staff in a facility built to accommodate 650.
    This increase in the volume of biomedical information and in the number
    of personnel has led to a serious space shortage. Digital archiving--
    once thought to be a solution to the problem of housing physical
    collections--has only added to the challenge, as materials must often
    be stored in multiple formats and as new digital resources consume
    increasing amounts of data center storage space. As a result, the space
    needed for computing facilities has also grown, and a new facility is
    urgently needed. This need has been recognized by the NLM Board of
    Regents as well as the Subcommittee in Senate Report 108-345 that
    accompanied the fiscal year 2005 appropriations bill. However, the
    economic challenges of the last several years have hampered movement on
    this project.
        While Congress continues to face tremendous funding challenges in
    fiscal year 2012, MLA and AAHSL encourage the Subcommittee to
    acknowledge the need for construction of the new building to take place
    when the Federal budget stabilizes so that information-handling
    capabilities and biomedical research are not jeopardized. At a time
    when medical and health science libraries across the Nation face
    growing financial and space constraints, ensuring that NLM continues to
    serve as the archive of last resort for biomedical collections is
    critical to the medical library community and the public we serve.
        Thank you again for the opportunity to present the views of the
    medical library community.
                                     ______

               Prepared Statement of the Meharry Medical College
        Mr. Chairman and members of the subcommittee, thank you for the
    opportunity to present my views before you today. I am Dr. Wayne J.
    Riley, President and CEO of Meharry Medical College in Nashville,
    Tennessee. I have previously served as vice-president and vice dean for
    health affairs and governmental relations and associate professor of
    medicine at Baylor College of Medicine in Houston, Texas and as
    assistant chief of medicine and a practicing general internist at
    Houston's Ben Taub General Hospital. In all of these roles, I have seen
    firsthand the importance of minority health professions institutions
    and the Title VII Health Professions Training programs.
        Mr. Chairman, time and time again, you have encouraged your
    colleagues and the rest of us to take a look at our Nation and evaluate
    our needs over the next 10 years. I took you seriously and came here
    prepared to offer my best judgments. First, I want to say that it is
    clear that health disparities among various populations and across
    economic status are rampant and overwhelming. Over the next 10 years,
    we will need to be able to deliver more culturally relevant and
    culturally competent healthcare services. Bringing healthcare delivery
    up to this higher standard can serve as our Nation's own preventive
    healthcare agenda keeping us well positioned for the future.
        Minority health professional institutions and the Title VII Health
    Professions Training programs address this critical national need.
    Persistent and severe staffing shortages exist in a number of the
    health professions, and chronic shortages exist for all of the health
    professions in our Nation's most medically underserved communities. Our
    Nation's health professions workforce does not accurately reflect the
    racial composition of our population. For example, African Americans
    represent approximately 15 percent of the U.S. population while only 2-
    3 percent of the Nation's healthcare workforce is African American.
        There is a well established link between health disparities and a
    lack of access to competent healthcare in medically underserved areas.
    As a result, it is imperative that the Federal Government continue its
    commitment to minority health profession institutions and minority
    health professional training programs to continue to produce healthcare
    professionals committed to addressing this unmet need.
        An October 2006 study by the Health Resources and Services
    Administration (HRSA), entitled ``The Rationale for Diversity in the
    Health Professions: A Review of the Evidence'' found that minority
    health professionals serve minority and other medically underserved
    populations at higher rates than non-minority professionals. The report
    also showed that; minority populations tend to receive better care from
    practitioners who represent their own race or ethnicity, and non-
    English speaking patients experience better care, greater
    comprehension, and greater likelihood of keeping follow-up appointments
    when they see a practitioner who speaks their language. Studies have
    also demonstrated that when minorities are trained in minority health
    profession institutions, they are significantly more likely to: (1)
    serve in rural and urban medically underserved areas, (2) provide care
    for minorities and (3) treat low-income patients.
        As you are aware, Title VII Health Professions Training programs
    are focused on improving the quality, geographic distribution and
    diversity of the healthcare workforce in order to continue eliminating
    disparities in our Nation's healthcare system. These programs provide
    training for students to practice in underserved areas, cultivate
    interactions with faculty role models who serve in underserved areas,
    and provide placement and recruitment services to encourage students to
    work in these areas. Health professionals who spend part of their
    training providing care for the underserved are up to 10 times more
    likely to practice in underserved areas after graduation or program
    completion.
        Institutions that cultivate minority health professionals have been
    particularly hard-hit as a result of the cuts to the Title VII Health
    Profession Training programs in fiscal year 2006 and fiscal year 2007
    funding resolution passed earlier this Congress. Given their historic
    mission to provide academic opportunities for minority and financially
    disadvantaged students, and healthcare to minority and financially
    disadvantaged patients, minority health professions institutions
    operate on narrow margins. The cuts to the Title VII Health Professions
    Training programs amount to a loss of core funding at these
    institutions and have been financially devastating.
        Mr. Chairman, I feel like I can speak authoritatively on this issue
    because I received my medical degree from Morehouse School of Medicine,
    a historically black medical school in Atlanta. I give credit to my
    career in academia, and my being here today, to Title VII Health
    Profession Training programs' Faculty Loan Repayment Program. Without
    that program, I would not be the president of my father's alma mater,
    Meharry Medical College, another historically black medical school
    dedicated to eliminating healthcare disparities through education,
    research and culturally relevant patient care.
        Minority Centers of Excellence.--COEs focus on improving student
    recruitment and performance, improving curricula in cultural
    competence, facilitating research on minority health issues and
    training students to provide health services to minority individuals.
    COEs were first established in recognition of the contribution made by
    four historically black health professions institutions (the Medical
    and Dental Institutions at Meharry Medical College; The College of
    Pharmacy at Xavier University; and the School of Veterinary Medicine at
    Tuskegee University) to the training of minorities in the health
    professions. Congress later went on to authorize the establishment of
    ``Hispanic'', ``Native American'' and ``Other'' Historically black
    COEs. For fiscal year 2012, I recommend a funding level of $24.602
    million for COEs.
        Health Careers Opportunity Program (HCOP).--HCOPs provide grants
    for minority and non-minority health profession institutions to support
    pipeline, preparatory and recruiting activities that encourage minority
    and economically disadvantaged students to pursue careers in the health
    professions. Many HCOPs partner with colleges, high schools, and even
    elementary schools in order to identify and nurture promising students
    who demonstrate that they have the talent and potential to become a
    health professional. Over the last three decades, HCOPs have trained
    approximately 30,000 health professionals including 20,000 doctors,
    5,000 dentists and 3,000 public health workers. For fiscal year 12, I
    recommend a funding level of $22.133 million for HCOPs.
    National Institutes of Health (NIH)
        Research Centers at Minority Institutions.--The Research Centers at
    Minority Institutions program (RCMI) at the National Center for
    Research Resources has a long and distinguished record of helping our
    institutions develop the research infrastructure necessary to be
    leaders in the area of health disparities research. Although NIH has
    received unprecedented budget increases in recent years, funding for
    the RCMI program has not increased by the same rate. Therefore, the
    funding for this important program grow at the same rate as NIH overall
    in fiscal year 2012.
        National Institute on Minority Health and Health Disparities.--The
    National Institute on Minority Health and Health Disparities (NIMHD) is
    charged with addressing the longstanding health status gap between
    minority and nonminority populations. The NIMHD helps health
    professional institutions to narrow the health status gap by improving
    research capabilities through the continued development of faculty,
    labs, and other learning resources. The NIMHD also supports biomedical
    research focused on eliminating health disparities and develops a
    comprehensive plan for research on minority health at the NIH.
    Furthermore, the NIMHD provides financial support to health professions
    institutions that have a history and mission of serving minority and
    medically underserved communities. For fiscal year 2012, I recommend
    that this Institute's funding grow proportionally with the funding of
    the NIH.
    Department of Health and Human Services
        Office of Minority Health: Specific programs at OMH include:
      -- Assisting medically underserved communities with the greatest need
            in solving health disparities and attracting and retaining
            health professionals,
      --Assisting minority institutions in acquiring real property to
            expand their campuses and increase their capacity to train
            minorities for medical careers,
      --Supporting conferences for high school and undergraduate students
            to interest them in healthcareers, and
      --Supporting cooperative agreements with minority institutions for
            the purpose of strengthening their capacity to train more
            minorities in the health professions.
        The OMH has the potential to play a critical role in addressing
    health disparities. For fiscal year 2012, I recommend a funding level
    of $65 million for the OMH.
    Department of Education
        Strengthening Historically Black Graduate Institutions Program.--
    The Department of Education's Strengthening Historically Black Graduate
    Institutions program (Title III, Part B, Section 326) is extremely
    important to MMC and other minority serving health professions
    institutions. The funding from this program is used to enhance
    educational capabilities, establish and strengthen program development
    offices, initiate endowment campaigns, and support numerous other
    institutional development activities. In fiscal year 2012, an
    appropriation of $65 million is suggested to continue the vital support
    that this program provides to historically black graduate institutions.
        Mr. Chairman, please allow me to express my appreciation to you and
    the members of this subcommittee. With your continued help and support,
    Meharry Medical College along with other minority health professions
    institutions and the Title VII Health Professions Training programs can
    help this country to overcome health and healthcare disparities.
    Congress must be careful not to eliminate, paralyze or stifle the
    institutions and programs that have been proven to work. Meharry and
    other minority health professions schools seek to close the ever
    widening health disparity gap. If this subcommittee will give us the
    tools, we will continue to work towards the goal of eliminating that
    disparity as we have done for 1876.
        Thank you, Mr. Chairman, for this opportunity.
                                     ______

             Prepared Statement of the Morehouse School of Medicine
        Mr. Chairman and members of the subcommittee, thank you for the
    opportunity to present my views before you today. I am Dr. John E.
    Maupin, President of Morehouse School of Medicine (MSM) in Atlanta,
    Georgia. I have previously served as President of Meharry Medical
    College, executive vice-president at Morehouse School of Medicine,
    director of a community health center in Atlanta, and deputy director
    of health in Baltimore, Maryland. In all of these roles, I have seen
    firsthand the importance of minority health professions institutions
    and the Title VII Health Professions Training programs.
        I want to say that minority health professional institutions and
    the Title VII Health Professionals Training programs address a critical
    national need. Persistent and sever staffing shortages exist in a
    number of the health professions, and chronic shortages exist for all
    of the health professions in our Nation's most medically underserved
    communities. Furthermore, our Nation's health professions workforce
    does not accurately reflect the racial composition of our population.
    For example while blacks represent approximately 15 percent of the U.S.
    population, only 2-3 percent of the Nation's health professions
    workforce is black. Morehouse is a private school with a very public
    mission of educating students from traditionally underserved
    communities so that they will care for the underserved. Mr. Chairman, I
    would like to share with you how your committee can help us continue
    our efforts to help provide quality health professionals and close our
    Nation's health disparity gap.
        There is a well established link between health disparities and a
    lack of access to competent healthcare in medically underserved areas.
    As a result, it is imperative that the Federal Government continue its
    commitment to minority health profession institutions and minority
    health professional training programs to continue to produce healthcare
    professionals committed to addressing this unmet need.
        An October 2006 study by the Health Resources and Services
    Administration (HRSA), entitled ``The Rationale for Diversity in the
    Health Professions: A Review of the Evidence'' found that minority
    health professionals serve minority and other medically underserved
    populations at higher rates than non-minority professionals. The report
    also showed that; minority populations tend to receive better care from
    practitioners who represent their own race or ethnicity, and non-
    English speaking patients experience better care, greater
    comprehension, and greater likelihood of keeping follow-up appointments
    when they see a practitioner who speaks their language. Studies have
    also demonstrated that when minorities are trained in minority health
    profession institutions, they are significantly more likely to: (1)
    serve in rural and urban medically underserved areas, (2) provide care
    for minorities and (3) treat low-income patients.
        As you are aware, Title VII Health Professions Training programs
    are focused on improving the quality, geographic distribution and
    diversity of the healthcare workforce in order to continue eliminating
    disparities in our Nation's healthcare system. These programs provide
    training for students to practice in underserved areas, cultivate
    interactions with faculty role models who serve in underserved areas,
    and provide placement and recruitment services to encourage students to
    work in these areas. Health professionals who spend part of their
    training providing care for the underserved are up to 10 times more
    likely to practice in underserved areas after graduation or program
    completion.
        Given the historic mission, of institutions like MSM, to provide
    academic opportunities for minority and financially disadvantaged
    students, and healthcare to minority and financially disadvantaged
    patients, minority health professions institutions operate on narrow
    margins. The slow reinvestment in the Title VII Health Professions
    Training programs amounts to a loss of core funding at these
    institutions and have been financially devastating.
        Mr. Chairman, I feel like I can speak authoritatively on this issue
    because I received my dental degree from Meharry Medical College, a
    historically black medical and dental school in Nashville, Tennessee. I
    have seen first hand what Title VII funds have done to minority serving
    institutions like Morehouse and Meharry. I compare my days as a student
    to my days as president, without that Title VII, our institutions would
    not be here today. However, Mr. Chairman, since those funds have been
    slowly replenished, we are standing at a cross roads. This committee
    has the power to decide if our institutions will go forward and thrive,
    or if we will continue to try to just survive. We want to work with you
    to eliminate health disparities and produce world class professionals,
    but we need your assistance.
        Minority Centers of Excellence: COEs focus on improving student
    recruitment and performance, improving curricula in cultural
    competence, facilitating research on minority health issues and
    training students to provide health services to minority individuals.
    COEs were first established in recognition of the contribution made by
    four historically black health professions institutions (the Medical
    and Dental Institutions at Meharry Medical College; The College of
    Pharmacy at Xavier University; and the School of Veterinary Medicine at
    Tuskegee University) to the training of minorities in the health
    professions. Congress later went on to authorize the establishment of
    ``Hispanic'', ``Native American'' and ``Other'' Historically black
    COEs. For fiscal year 2012, I recommend a funding level of $24.602
    million for COEs.
        Health Careers Opportunity Program (HCOP): HCOPs provide grants for
    minority and non-minority health profession institutions to support
    pipeline, preparatory and recruiting activities that encourage minority
    and economically disadvantaged students to pursue careers in the health
    professions. Many HCOPs partner with colleges, high schools, and even
    elementary schools in order to identify and nurture promising students
    who demonstrate that they have the talent and potential to become a
    health professional. Over the last three decades, HCOPs have trained
    approximately 30,000 health professionals including 20,000 doctors,
    5,000 dentists and 3,000 public health workers. For fiscal year 2012, I
    recommend a funding level of $22.133 million for HCOPs.
    National Institutes of Health (NIH)
        National Institute on Minority Health and Health Disparities.--The
    National Institute on Minority Health and Health Disparities (NIMHD) is
    charged with addressing the longstanding health status gap between
    minority and nonminority populations. The NIMHD helps health
    professional institutions to narrow the health status gap by improving
    research capabilities through the continued development of faculty,
    labs, and other learning resources. The NIMHD also supports biomedical
    research focused on eliminating health disparities and develops a
    comprehensive plan for research on minority health at the NIH.
    Furthermore, the NIMHD provides financial support to health professions
    institutions that have a history and mission of serving minority and
    medically underserved communities through the Minority Centers of
    Excellence program. For fiscal year 2012, I recommend a funding
    increase proportional to any increase given to the NIH for the NIMHD.
        Research Centers at Minority Institutions.--The Research Centers at
    Minority Institutions program (RCMI), currently administered at the
    National Center for Research Resources, has a long and distinguished
    record of helping our institutions develop the research infrastructure
    necessary to be leaders in the area of health disparities research.
    Although NIH has received unprecedented budget increases in recent
    years, funding for the RCMI program has not increased by the same rate.
    Therefore, the funding for this important program grow at the same rate
    as NIH overall in fiscal year 2012.
    Department of Health and Human Services
        Office of Minority Health.--Specific programs at OMH include: (1)
    Assisting medically underserved communities with the greatest need in
    solving health disparities and attracting and retaining health
    professionals; (2) Assisting minority institutions in acquiring real
    property to expand their campuses and increase their capacity to train
    minorities for medical careers; (3) Supporting conferences for high
    school and undergraduate students to interest them in healthcareers,
    and (4) Supporting cooperative agreements with minority institutions
    for the purpose of strengthening their capacity to train more
    minorities in the health professions. The OMH has the potential to play
    a critical role in addressing health disparities, and with the proper
    funding this role can be enhanced. For fiscal year 2012, I recommend a
    funding level of $65 million for the OMH.
    Department of Education
        Strengthening Historically Black Graduate Institutions.--The
    Department of Education's Strengthening Historically Black Graduate
    Institutions program (Title III, Part B, Section 326) is extremely
    important to MSM and other minority serving health professions
    institutions. The funding from this program is used to enhance
    educational capabilities, establish and strengthen program development
    offices, initiate endowment campaigns, and support numerous other
    institutional development activities. In fiscal year 2012, an
    appropriation of $65 million is suggested to continue the vital support
    that this program provides to historically black graduate institutions.
        Mr. Chairman, please allow me to express my appreciation to you and
    the members of this subcommittee. With your continued help and support,
    Morehouse School of Medicine along with other minority health
    professions institutions and the Title VII Health Professions Training
    programs can help this country to overcome health and healthcare
    disparities. Congress must be careful not to eliminate, paralyze or
    stifle the institutions and programs that have been proven to work. MSM
    and other minority health professions schools seek to close the ever
    widening health disparity gap. If this subcommittee will give us the
    tools, we will continue to work towards the goal of eliminating that
    disparity as we have since our founding day.
        Thank you, Mr. Chairman, and I welcome every opportunity to answer
    questions for your records.
                                     ______

              Prepared Statement of the National AHEC Organization
        The National AHEC Organization (NAO) is the professional
    organization representing Area Health Education Centers (AHECs). Our
    message is simple:
      --The Area Health Education Center program is effective and provides
            vital services and national infrastructure.
      --Area Health Education Centers are the workforce development,
            training and education machine for the Nation's healthcare
            safety-net programs.
        AHEC is one of the Title VII Health Professions Training programs,
    originally authorized at the same time as the National Health Service
    Corps (NHSC) to create a complete mechanism to provide primary care
    providers for Community Health Centers (CHCs) and other direct
    providers of healthcare services for underserved areas and populations.
    The plan envisioned by creators of the legislation was that the CHCs
    would provide direct service. The NHSC would be the mechanism to fund
    the education of providers and supply providers for underserved areas
    through scholarship and loan repayment commitments. The AHEC program
    would be the mechanism to recruit providers into primary health
    careers, diversify the workforce, and develop a passion for service to
    the underserved in these future providers, i.e. Area Health Education
    Centers are the workforce development, training and education machine
    for the Nation's healthcare safety-net programs. The AHEC program is
    focused on improving the quality, geographic distribution and diversity
    of the primary care healthcare workforce and eliminating the
    disparities in our Nation's healthcare system.
        AHECs develop and support the community based training of health
    professions students, particularly in rural and underserved areas. They
    recruit a diverse and broad range of students into health careers, and
    provide continuing education, library and other learning resources that
    improve the quality of community-based healthcare for underserved
    populations and areas.
        The Area Health Education Center program is effective and provides
    vital services and national infrastructure. Nationwide, over 379,000
    students have been introduced to health career opportunities, and over
    33,000 mostly minority and disadvantaged high school students received
    more than 20 hours each of health career exposure. Over 44,000 health
    professions students received training at 17,530 community-based sites,
    and furthermore; over 482,000 health professionals received continuing
    education through AHECs. AHECs perform these education and training
    services through collaborative partnerships with Community Health
    Centers (CHCs) and the National Health Service Corps (NHSC), in
    addition to Rural Health Clinics (RHCs), Critical Access Hospitals,
    (CAHs), Tribal clinics and Public Health Departments.
    Justification for Recommendations
        Imbalances in our healthcare system result in marked inequities in
    access to and quality of healthcare services. This perpetuates
    disparities in health status and the under-representation of minority
    and disadvantaged individuals in the healthcare workforce. AHEC
    programs play a key role in correcting these inequities and
    strengthening the Nation's healthcare safety net.
        In order to continue the progress that the Title VII Health
    Professions Training programs, especially AHECs, have already made
    toward their goal, an additional Federal investment is required. NAO
    recommends that the AHEC program is funded at $75 million. Investment
    at this level and at this time will be the first step toward full
    investment at the authorized level of $125 million.
                                     ______

    Prepared Statement of the National Alliance for Eye and Vision Research
                               executive summary
        NAEVR requests fiscal year 2012 NIH funding at $35 billion, which
    reflects a $3 billion increase over President Obama's proposed funding
    level of $32 billion. Funding at $35 billion, which reflects NIH net
    funding levels in both fiscal year 2009 and fiscal year 2010, ensures
    it can maintain the number of multi-year investigator-initiated
    research grants, the cornerstone of our Nation's biomedical research
    enterprise.
        The vision community commends Congress for $10.4 billion in NIH
    funding in the American Recovery and Reinvestment Act (ARRA), as well
    as fiscal year 2009 and fiscal year 2010 funding increases that enabled
    NIH to keep pace with biomedical inflation after 6 previous years of
    flat funding that resulted in a 14 percent loss of purchasing power.
    Fiscal year 2012 NIH funding at $35 billion enables it to meet the
    expanded capacity for research--as demonstrated by the significant
    number of high-quality grant applications submitted in response to ARRA
    opportunities--and to adequately address unmet need, especially for
    programs of special promise that could reap substantial downstream
    benefits, as identified by NIH Director Francis Collins, M.D., Ph.D. in
    his top five priorities. As President Obama has stated repeatedly, most
    recently during the 2011 State of the Union Address, biomedical
    research has the potential to reduce healthcare costs, increase
    productivity, and ensure the global competitiveness of the United
    States.
        NAEVR requests that Congress increase NEI funding above the 1.8
    percent proposed by the President--even if it does not fund NIH at $35
    billion--since the proposed increase does not match biomedical
    inflation.
        In 2009, Congress spoke volumes in passing S. Res. 209 and H. Res.
    366, which designated 2010-2020 as The Decade of Vision, in which the
    majority of 78 million Baby Boomers will turn 65 years of age and face
    greatest risk of aging eye disease. This is not the time for a less-
    than-inflationary increase that nets a loss in the NEI's purchasing
    power, which eroded by 18 percent in the fiscal year 2003-fiscal year
    2008 timeframe. NEI-funded research is resulting in treatments and
    therapies that save vision and restore sight, which can reduce
    healthcare costs, maintain productivity, ensure independence, and
    enhance quality of life.
      the bipartisan nih support displayed at the subcommittee's march 30
    hearing with secretary sebelius demonstrates the value of increased and
                             timely appropriations
        NAEVR was pleased to hear the level of bipartisan support expressed
    for NIH at the March 30 Senate L-HHS Appropriations Subcommittee
    hearings with Department of Health and Human Services (DHHS) Secretary
    Kathleen Sebelius and was especially impressed by two sets of comments:
      --Senate Ranking Member Richard Shelby (R-AL) cautioned against
            across-the-board cuts and urged Congress to sustain programs
            that are effective--where he cited NIH as ``one of the most
            results-driven aspects of our entire Federal budget.'' He added
            that ``research conducted at NIH reduces disabilities, prolongs
            life, and is an essential component to the health of all
            Americans. NIH programs consistently meet their performance and
            outcomes measures, as well as achieve their overall mission.''
            These comments are stated so well that NAEVR will not expand
            upon them, other than to cite vision examples in the next
            sections.
      --Senator Barbara Mikulski (D-MD) noted that a government shutdown,
            NIH cuts, or delayed appropriations, individually or in
            combination, will have far-reaching consequences, especially
            for academic Institutions across the country which receive
            funding.
          To demonstrate that point, in late January 2011, NAEVR hosted 11
            domestic and 6 international members of the Association for
            Research in Vision and Ophthalmology (ARVO) in Capitol Hill
            visits. They educated staff that a cutback to the fiscal year
            2008 level would reduce NEI funding by $30 plus million and
            reduce the number of grants by 43--any one of which could hold
            the key to saving or restoring vision. The advocates also
            described the impact of delayed appropriations, in terms of
            continuity of research and retention of trained staff. If a
            department does not have bridge or philanthropic funding to
            retain staff while awaiting full funding of awards, it will
            need to let staff go, and that usually means a highly trained
            person is lost to another area of research or an institution in
            another State, or even another country.
     fiscal year 2012 nih funding at $35 billion enables the nei to build
    upon the impressive record of basic and clinical/translational research
    that meets nih's top five priorities and was funded through fiscal year
            2009/2010 arra and increased ``regular'' appropriations
        NEI's research addresses the preemption, prediction, and prevention
    of eye disease through basic, translational, epidemiological, and
    comparative effectiveness research which also address the top five NIH
    priorities, as identified by Dr. Collins: genomics, translational
    research; comparative effectiveness; global health, and empowering the
    biomedical enterprise.
        With respect to translational research, in June 2010, NEI hosted a
    Translational Research and Vision conference as the last of a series of
    NIH-campus based educational events recognizing its 40th anniversary
    (previous events addressed genetics/genomics, optical imaging, stem
    cell therapies, and the latest glaucoma research). In keynote comments,
    Dr. Collins recognized NEI as a leader in translational research. He
    specifically cited NEI's leadership in ocular genetics, noting that NEI
    has worked collaboratively with other NIH Institutes, especially the
    National Human Genome Research Institute (NHGRI) to elucidate the basis
    of eye disease and to develop treatments. As NEI Director Paul Sieving,
    M.D., Ph.D. has stated, one-quarter of all genes identified to date are
    associated with eye disease/visual impairment.
        Dr. Collins also lauded the NEI's use of Genome-Wide Association
    Studies (GWAS) to determine the increased risk of developing age-
    related macular degeneration (AMD) from gene variants in the Complement
    Factor H (CFH) immune pathway, noting that ``this was the first
    demonstration that GWAS is a useful tool to make the connection between
    gene variants and disease conditions.'' He added that, ``Twenty years
    ago we could do little to prevent or treat AMD. Today, because of new
    treatments and procedures based on NIH/NEI research, 1.3 million
    Americans at risk for severe vision loss from AMD over the next 5 years
    can receive potentially sight-saving therapies.''
        With increased ``regular'' fiscal year 2009/2010 appropriations and
    ARRA funding, NEI has been able to build upon past research in two
    important areas:
        Genetic Basis of AMD.--In 2010, NEI initiated the International AMD
    Genetics Consortium, reflecting researchers on five continents who will
    be sharing and analyzing GWAS results to further elucidate the genetic
    basis of AMD. This may lead to new diagnostics and treatments for this
    leading blinding eye disease, growing in incidence with the aging of
    the population and with potential significant costs to the Medicare
    program.
        Treatment of Diabetic Macular Edema.--In May 2010, the NEI's
    Diabetic Retinopathy Clinical Research (DRCR) Network--a multi-center
    network dedicated to facilitating clinical research into diabetic
    retinopathy, diabetic macular edema, and associated conditions--
    reported results of a comparative effectiveness trial. The study
    confirmed that laser treatment for diabetic macular edema, when
    combined with injections of the Food and Drug Administration (FDA)-
    approved anti-angiogenic drug Lucentis, is more effective than laser
    treatment alone, the latter of which has been the standard of care for
    the past 25 years. With NIH's recent announcement of a new strategic
    plan to combat diabetes, led by the National Institute of Diabetes and
    Digestive and Kidney Diseases (NIDDK), this research is more important
    than ever within the larger context of NIH priorities. The current DRCR
    Network is a successor to several previous networks, all of which
    involved NEI-NIDDK collaboration. NEI's emphasis on diabetic
    retinopathy reflects the fact that it is the leading cause of vision
    loss in the working-age population and occurs with disproportionately
    greater incidence in the Hispanic population.
     if congress does not increase fiscal year 2012 nih funding above the
    president's request, it is even more vital to improve upon the proposed
                          1.8 percent increase for nei
        The NIH budget proposed by the administration and finalized by
    Congress during the second year of the congressionally designated
    Decade of Vision should not contain a less-than-inflationary increase
    for the NEI due to the enormous challenges it faces in terms of the
    aging population, the disproportionate incidence of eye disease in
    fast-growing minority populations, and the visual impact of chronic
    disease (e.g., diabetes). If Congress is unable to fund NIH at $35
    billion in fiscal year 2012 (NEI level of $794.5 million) and adopts
    the President's proposal, the 1.8 percent increase in funding must be
    increased to at least an inflationary level of 2.4 percent to prevent
    any further erosion in NEI's purchasing power. NEI funding is an
    especially vital investment in the overall health, as well as the
    vision health, of our Nation. It can ultimately delay, save, and
    prevent health expenditures, especially those associated with the
    Medicare and Medicaid programs, and is, therefore, a cost-effective
    investment.
      vision loss is a major public health problem: increasing healthcare
             costs, reducing productivity, diminishing life quality
        The NEI estimates that more than 38 million Americans age 40 and
    older experience blindness, low vision, or an age-related eye disease
    such as AMD, glaucoma, diabetic retinopathy, or cataracts. This is
    expected to grow to more than 50 million Americans by year 2020. The
    economic and societal impact of eye disease is increasing not only due
    to the aging population, but to its disproportionate incidence in
    minority populations and as a co-morbid condition of chronic disease,
    such as diabetes.
        Although the NEI estimates that the current annual cost of vision
    impairment and eye disease to the United States is $68 billion, this
    number does not fully quantify the impact of indirect healthcare costs,
    lost productivity, reduced independence, diminished quality of life,
    increased depression, and accelerated mortality. NEI's fiscal year 2010
    baseline funding of $707 million reflects just a little more than 1
    percent of this annual costs of eye disease. The continuum of vision
    loss presents a major public health problem, as well as a significant
    financial challenge to the public and private sectors.
    naevr urges congress to fund the nih at $35 billion in fiscal year 2012
       which will ensure the momentum of breakthrough nei-funded vision
                research and the retention of trained personnel
                                  about naevr
        The National Alliance for Eye and Vision Research (NAEVR) is a
    501(c)4 nonprofit advocacy coalition comprised of 55 professional
    (ophthalmology and optometry), patient and consumer, and industry
    organizations involved in eye and vision research. Visit NAEVR's Web
    site at www.eyeresearch.org.
                                     ______

    Prepared Statement of the National Alliance of State & Territorial AIDS
                                   Directors
        The National Alliance of State & Territorial AIDS Directors
    (NASTAD) represents the Nation's chief State health agency staff who
    have programmatic responsibility for administering HIV/AIDS and viral
    hepatitis healthcare, prevention, education, and supportive service
    programs funded by State and Federal governments. On behalf of NASTAD,
    we urge your support for increased funding for Federal HIV/AIDS and
    viral hepatitis programs in the fiscal year 2012 Labor-HHS-Education
    Appropriations bill, and thank you for your consideration of the
    following critical funding needs for HIV/AIDS, viral hepatitis and STD
    programs in fiscal year 2012. These funding needs support activities
    aligned with the goals set forth in the National HIV/AIDS Strategy
    (NHAS)--a game-changing blueprint for tackling the Nation's HIV/AIDS
    epidemic.
        As we approach 30 years into the HIV/AIDS epidemic, we must be
    mindful that HIV/AIDS is still a crisis in the United States, not just
    a global issue. HIV/AIDS is an emergency and while there are life-
    saving medications that did not exist 20 years ago, there is still no
    cure, and we still see new infections--about 56,000 annually. The
    Nation's prevention efforts must match our commitment to the care and
    treatment of infected individuals. First and foremost we must address
    the devastating impact on racial and ethnic minority communities,
    particularly African Americans and Latinos, as well as gay men and
    other men who have sex with men (MSM) of all races and ethnicities,
    substance users, women and youth. To be successful, we must expand
    outreach, scale-up and consider new and innovative approaches to arrest
    the epidemic here at home.
        The President's fiscal year 2012 budget proposal provides increases
    to HIV/AIDS prevention, care and the Ryan White Program in support of
    the National HIV/AIDS Strategy for a total investment of $3.5 billion.
    The Budget prioritizes HIV/AIDS resources within high burden
    communities and among high-risk groups, including MSM, African
    Americans and Hispanics, and realigns resources within CDC, HRSA,
    SAMHSA, and the Office of the Secretary to support the National HIV/
    AIDS Federal Implementation Plan. Additionally, the budget allows CDC
    and States to transfer up to 5 percent across HIV/AIDS, tuberculosis,
    STD and viral hepatitis programs to improve coordination and
    integration.
    HIV/AIDS Care and Treatment Programs
        The Health Resources and Services Administration (HRSA) administers
    the $2.2 billion Ryan White Program that provides health and support
    services to more than 500,000 persons living with HIV/AIDS (PLWHA). The
    President's budget includes an increase of $63 million for a total of
    $2.4 billion for the entire Ryan White Program. The Budget also
    includes $940 million for AIDS Drug Assistance Programs (ADAPs), an
    increase of $55 million.
        NASTAD requests a minimum increase of $183 million in fiscal year
    2012 for State Ryan White Part B grants compared to the President's
    budget of flat funding Part B at its fiscal year 2010 level of $418.8
    million and requesting a $55 million increase or a total of $940
    million for ADAPs. We are requesting an increase of $77 million for the
    Part B Base and $106 million or a total of $991 million for ADAPs.
    ADAPs truly need an increase of $360 million in fiscal year 2012 to
    maintain their programs and fill the structural deficits that have
    built up during the last several years. With these funds States and
    territories provide care, treatment and support services to PLWHA, who
    need access to HIV clinicians, life-saving and life-extending
    therapies, and a full range of support services to ensure adherence to
    complex treatment regimens. All States have reported to NASTAD a
    significant increase in the number of individuals seeking Part B Base
    and ADAP services.
        State ADAPs provide medications to low-income uninsured or
    underinsured PLWHA. In fiscal year 2009, over 213,000 clients were
    enrolled in ADAPs nationwide. Due to many factors such as unemployment,
    economic challenges, increased HIV testing and linkages to care, and
    new HIV treatment guidelines calling for earlier therapeutic
    treatments, program demand has increased dramatically, and thus ADAPs
    are ever more in crisis. As of May 19, 2011, there 8,310 individuals
    are on waiting lists in 13 States to receive their life-sustaining
    medications through ADAP:
      --Alabama: 15 individuals
      --Arkansas: 59 individuals
      --Florida: 3,938 individuals
      --Georgia: 1,520 individuals
      --Idaho: 14 individuals
      --Louisiana: 696 individuals
      --Montana: 26 individuals
      --North Carolina: 242 individuals
      --Ohio: 413 individuals
      --South Carolina: 693individuals
      --Utah: 6 individuals
      --Virginia: 684 individuals
      --Wyoming: 4 individuals
        Last year, as of April 2010, there were 10 States with less than
    900 individuals on waiting lists. Thus, we have seen an over 900
    percent increase in individuals on waiting lists in the last year.
    HIV/AIDS Prevention and Surveillance Programs
        One of the major goals of the NHAS is to lower the annual number of
    new infections from 56,300 to 42,225 by 2015. In order to meet this
    ambitious goal, NASTAD requests an increase of $90 million above fiscal
    year 2011 funding levels for a total of $555 million compared to the
    President's request of a $4 million increase for State and local health
    department HIV prevention and surveillance cooperative agreements in
    order to provide comprehensive prevention programs. By providing
    adequate resources to State and local health departments to scale up
    HIV prevention and surveillance programs, we will be closer to meeting
    the NHAS goal of reducing new HIV infections by 25 percent by 2015. In
    addition, NASTAD fully supports the President's request to allocate
    $30.4 million from the Prevention and Public Health Fund for HIV
    prevention activities consistent with the allocation of these resources
    in fiscal year 2010.
        Of the total increase requested, NASTAD supports an increase of $60
    million above fiscal year 2011 levels compared to the President's
    request of a $6.4 million increase for the HIV prevention cooperative
    agreements with health departments in order to scale up effective
    prevention programs and enable CDC to implement a new funding formula
    that would provide equitable funding to all jurisdictions based on
    disease burden without dismantling existing prevention efforts in some
    jurisdictions. Moreover, these additional resources will allow health
    departments to increase their efforts in a variety of areas such as:
    expanding the reach of activities targeting men who have sex with men
    (MSM). According to the September 2010 CDC Fact Sheet HIV/AIDS Among
    Gay and Bisexual Men, MSM account for nearly half (48 percent) of the
    more than 1 million people living with HIV/AIDS and account for 53
    percent of new infections. Young men from racial and ethnic minority
    communities bear a disproportionate burden of the disease and there are
    more new HIV infections among young Black MSM (aged 13-29) than among
    any other age and racial group of MSM. Additional funding will allow
    heath departments to continue developing and implementing innovative,
    cost effective and evidence-based prevention programming. Increased
    funding will also allow health departments to expand services to other
    disproportionately impacted populations including Black women, persons
    who inject drugs and youth. With additional funding, health departments
    will expand outreach, targeted and routine HIV testing, partner
    services and linkage to care and other evidence-based prevention
    interventions. Increased funding will also allow for the expansion of
    additional core prevention services such as partner services (the
    identification, notification and counseling of partners of persons whom
    have tested HIV positive), capacity building and technical assistance
    to implement routine HIV testing and highly targeted behavior change
    interventions to community-based organizations and healthcare providers
    as well as public education campaigns to reinforce accurate, evidence-
    based information and begin to reduce the stigma associated with the
    disease.
        In addition, NASTAD believes increased funding should be directed
    toward critical HIV surveillance efforts and requests an increase of
    $30 million above fiscal year 2011 levels compared to the President's
    request of a decrease of nearly $2 million. Additional resources will
    allow improvements in core surveillance and expand surveillance for HIV
    incidence, behavioral risk, and receipt of care information including
    CD4 and viral load reporting. HIV surveillance data are the mechanism
    through which the success at achieving the goals of the NHAS will be
    measured. The completeness of national HIV surveillance activities is
    critical to monitor the HIV/AIDS epidemic and to provide data for
    targeting with greater precision the delivery of HIV prevention, care,
    and treatment services.
        The funding increase will also allow for the continuation of the
    Expanded Testing Program, Enhanced Comprehensive HIV Prevention
    Planning (ECHPP) and Program Collaboration and Service Integration
    (PCSI) activities. NASTAD supports maintaining funding at $70 million
    to health departments to continue the highly successful Expanded
    Testing Program (ETP), which targets African Americans, Latinos, gay
    and bisexual men of all races and ethnicities, and persons who inject
    drugs. For the 30 jurisdictions currently funded for ETP, the program
    has been an effective way to implement routine HIV testing in clinical
    settings--increasing the number of people who know their HIV status and
    linking those with HIV to care and treatment. During the first 3 years
    of the program approximately 2.6 million tests were conducted with an
    estimated 28,000 being confirmed HIV positive. Reducing new HIV
    infections relies heavily on ``knowing your status.'' This program
    should be preserved with adequate funding to ensure that more
    individuals learn their HIV status and are linked to care.
        The first step in the NHAS is to ``intensify HIV prevention efforts
    in communities where HIV is most heavily concentrated.'' In response,
    in August 2010, the CDC funded ECHPP. Eligible jurisdictions were
    awarded on September 30, 2010 with an average award of $960,000.
    Through ECHPP, these highly impacted urban areas were awarded resources
    to test and evaluate new approaches to integrate planning, monitoring
    and delivering HIV prevention and care services in their specific
    localities. NASTAD supports continuing ECHPP funding at $12 million in
    order to fund the next round of State health departments for this
    important activity.
        NASTAD also requests continued support for Program Collaboration
    and Service Integration (PCSI) to enable health departments to
    integrate prevention services for HIV, STD, viral hepatitis, and TB at
    the client level. Currently six jurisdictions are funded by CDC for
    PCSI activities.
    HIV School-based Prevention for Youth
        NASTAD also supports an increase for evidence-based programs for
    youth funded through the CDC. An increase of $10 million above the
    President's fiscal year 2012 level of $40 million should be supported
    for HIV school health for a total of $50 million. CDC currently funds
    HIV school health programs through the Division of Adolescent and
    School Health (DASH). The President's budget proposal moves HIV-
    specific DASH funding to the National Center for HIV/AIDS, Viral
    Hepatitis, STD and TB Prevention to ensure closer coordination with
    other HIV prevention programs, which NASTAD supports. One-third of all
    new infections are among young people under the age of 29, the largest
    share of any age group of new infections.
    Viral Hepatitis Prevention Programs
        NASTAD requests an increase of $40 million for a total of $59.8
    million in fiscal year 2012 compared to the President's request of $5.2
    million for a total of $25 million. Funding increases would go to the
    CDC's Division of Viral Hepatitis (DVH) to support the HHS Action Plan
    on Viral Hepatitis for a national testing, education and surveillance
    initiative as outlined in the Division's professional judgment budget
    submitted to Congress last year. While we are hopeful about the first-
    ever HHS Viral Hepatitis Action Plan, funding is needed to support
    increased capacity at the HHS Office of the Assistant Secretary for
    Health (ASH) for supporting the implementation of this plan.
        We believe that testing to identify over 3 million people or 65-75
    percent of chronic hepatitis B and C patients who do not know they are
    infected is the highest priority for reducing illness and death related
    to viral hepatitis. Testing must accompany education efforts to reach
    those already infected and at high risk of death and of spreading the
    disease. Surveillance is needed to monitor disease trends and evaluate
    evidence-based interventions. Unlike other infectious diseases, viral
    hepatitis lacks a national surveillance system. Further this funding
    would enhance the role of Adult Viral Hepatitis Prevention Coordinators
    (AVHPCs) based in State health departments to implement and integrate
    testing, education and surveillance into the existing public health
    infrastructure. States and cities receive an average funding award from
    DVH of $90,000, which supports a single staff position and is not
    sufficient for the provision of core prevention services. Therefore,
    NASTAD requests funding to State adult viral hepatitis prevention
    coordinators be increased from $5 to $10 million.
        In addition, we encourage Congress to work with CDC to provide
    adequate hepatitis B vaccination through the Section 317 program as
    proposed in CDC's fiscal year 2012 budget. In years past, cost-savings
    from the Section 317 program supported an at-risk adult hepatitis B
    vaccine initiative with a funding high of $20 million. While this
    funding went to vaccine-purchase only and not staff capacity or
    infrastructure, it was a highly successful initiative at administering
    nearly 1 million doses of vaccine. Unfortunately cost-savings for the
    program were expended in fiscal year 2011.
        Further we encourage the utilization of health reform's Prevention
    and Public Health Fund to support a broad testing and screening
    initiative that would include neglected diseases such as viral
    hepatitis in order to capture patients before they progress in their
    liver disease and increase costs to public healthcare systems.
    STD Prevention Programs
        NASTAD supports an increase of $212.7 million for a total of $367.4
    million in fiscal year 2012 compared to the President's request of a $7
    million increase for STD prevention, treatment and surveillance
    activities undertaken by State and local health departments. CDC's
    Division of STD Prevention has prioritized four disease prevention
    goals--Prevention of STD-related infertility, STD-related adverse
    pregnancy outcomes, STD-related cancers and STD-related HIV
    transmission. CDC estimates that 19 million new infections occur each
    year, almost half of them among young people ages 15 to 24. In one
    year, the United States may spend over $8 billion to treat the symptoms
    and consequences of STDs. Untreated STDs contribute to infant
    mortality, infertility, and cervical cancer. Additional Federal
    resources are needed to reverse these alarming trends and reduce the
    Nation's health spending. The teen pregnancy prevention initiative
    should be expanded to include prevention of HIV and STDs and funded at
    $20 million above the President's 2012 request of $114.5 million. Such
    an increase would allow providers to serve an additional 100,000 youth.
        As you contemplate the fiscal year 2012 Labor, HHS and Education
    Appropriations bill, we ask that you consider all of these critical
    funding needs. We thank the Chairman, Ranking Member and members of the
    Subcommittee, for their thoughtful consideration of our
    recommendations. Our response to the HIV, viral hepatitis and STD
    epidemics in the United States defines us as a society, as public
    health agencies, and as individuals living in this country. There is no
    time to waste in our Nation's fight against these infectious and often
    chronic diseases. The Nation's prevention efforts must match our
    commitment to the care and treatment of infected individuals.
                                     ______

       Prepared Statement of the National Association for Public Health
                       Statistics and Information Systems
        The National Association for Public Health Statistics and
    Information Systems (NAPHSIS) welcomes the opportunity to provide this
    written statement for the public record as the Labor, Health and Human
    Services (HHS), Education and Related Agencies Appropriations
    Subcommittee prepares its fiscal year 2012 appropriations legislation.
    NAPHSIS represents the 57 vital records jurisdictions that collect,
    process, and issue birth and death records in the United States and its
    territories, including the 50 States, New York City, the District of
    Columbia and the five territories. NAPHSIS coordinates and enhances the
    activities of the vital records jurisdictions by developing standards,
    promoting consistent policies, working with Federal partners, and
    providing technical assistance.
        NAPHSIS respectfully requests that the Subcommittee provide the
    National Center for Health Statistics (NCHS) $162 million, consistent
    with the President's budget request. This funding will enable the
    National Vital Statistics System to support States and territories as
    they implement the 2003 Standard Certificates of Birth, Death, and
    Fetal Deaths and move toward electronic collection of vital events
    data. This infrastructure investment will address the Healthy People
    2020 goal of increasing the number of States that record vital events
    using the latest U.S. standard certificates (PHI-10.1-10.3).
    Ultimately, this investment will lead to timelier, richer data that
    will facilitate public health planning, surveillance, service delivery,
    and evaluation. Specifically, such data will facilitate tracking of
    other Healthy People 2020 objectives in maternal, infant, and child
    health, cancer, diabetes, heart disease, respiratory disease, injury
    and prevention, and substance abuse, among others.
        Collection of birth and death data through vital records is a State
    function and thus governed under State laws. NCHS purchases birth and
    death data from the States to compile national data on vital events--
    births, deaths, marriages, divorces, and fetal deaths. These data are
    used to monitor disease prevalence and our Nation's overall health
    status, develop programs to improve public health, and evaluate the
    effectiveness of those interventions. For example, birth data have been
    used to:
      --Establish the relationship of smoking and adverse pregnancy
            outcomes;
      --Link the incidence of major birth defects to environmental factors;
      --Establish trends in teenage births;
      --Determine the risks of low birth weight; and
      --Measure racial disparities in pregnancy outcomes.
        Just as fundamentally, death data are used to:
      --Monitor the infant mortality rate as a leading international
            indicator of the Nation's health status;
      --Track progress and regress in reducing mortality from the leading
            causes of death, such as heart disease, cancer, stroke, and
            diabetes;
      --Document racial disparities; and
      --Otherwise provide sound information for programmatic interventions.
        Years of chronic underfunding at NCHS have threatened the
    collection of these important data on the national level, to the extent
    that in fiscal year 2007 NCHS would have been unable to collect a full
    12 months of vital statistics data from States. Had the Subcommittee
    not intervened with a small but critical budget increase to continue
    vital statistics collection, the United States would have been the
    first nation in the industrialized world to be without a complete
    year's worth of vital data. Countless national programs and businesses
    that depend on vital events information would have been immeasurably
    affected.
        Since that time, the Subcommittee has continually supported NCHS's
    vital statistics cooperative with the States. NAPHSIS and the broader
    public health community deeply appreciate these efforts. We are pleased
    that the President has once again followed the Subcommittee's lead in
    seeking to build a 21st century national statistical agency, requesting
    a $23 million increase for NCHS in fiscal year 2012, and directing NCHS
    to support the modernization of the National Vital Statistics System.
    This funding increase will support States as they upgrade their
    outdated and vulnerable paper-based vital statistics systems,
    addressing critical needs for activities that have been on hold or
    curtailed because of budget constraints.
        As we make significant strides in implementing and meaningfully
    using health information technology, it is imperative that we similarly
    invest in building a modern vital statistics system that monitors our
    citizens' health, from birth until death. The requested funding will
    move us toward a timelier and more comprehensive vital statistics
    infrastructure where all States collect the same data and all States
    collect these data electronically. Two forms of birth and death
    certificates are in use by States--the older 1989 standard certificate
    and the newer 2003 standard certificate This more recent birth
    certificate revision includes data on insurance and access to prenatal
    care, labor and delivery complications, delivery methods, congenital
    anomalies of the newborn, maternal morbidity, mother's weight and
    height, breast feeding status, maternal infections, and smoking during
    pregnancy, among other factors. The 2003 death certificate includes
    data on smoking-related, pregnancy-related, and job-related deaths.
        Currently, only 75 percent of the States and territories use the
    2003 standard birth certificate and 65 percent have adopted the 2003
    standard death certificate (see Table 1). Many States continue to rely
    on paper-based records, a practice which compromises the timeliness and
    interoperability of these data. Jurisdictions that had planned and
    budgeted to upgrade their certificates and systems have seen funding
    for these projects erode as States face severe budget shortfalls. These
    jurisdictions need the Federal Government's help to complete building a
    21st century vital statistics system. The President's requested down
    payment will help in this regard, allowing all jurisdictions to
    implement the 2003 birth certificate and electronic birth record
    systems. Approximately $30 million is needed to modernize the death
    statistics system; but the President's budget request is nonetheless an
    important first step.

                                                             TABLE 1.--JURISDICTIONS REQUIRING SUPPORT TO MODERNIZE VITAL STATISTICS SYSTEM
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                        Incomplete Electronic Birth                                                                     Incomplete Electronic Death
       No 2003 Birth Certificate       No Electronic Birth Records              Records \1\              No 2003 Death Certificate      No Electronic Death Records             Records \2\
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    Total = 20                       Total = 17                       Total = 4                       Total = 19                      Total = 24                      Total = 27

    Alabama                          Alaska                           Alabama                         Alabama                         Alaska                          Alabama
    Alaska                           American Samoa                   Hawaii                          Alaska                          American Samoa                  Arizona
    American Samoa                   Arizona                          Mississippi                     American Samoa                  Arkansas                        Delaware
    Arizona                          Arkansas                         Rhode Island                    Colorado                        Colorado                        Washington, DC
    Arkansas                         Connecticut                                                      Guam                            Connecticut                     Georgia
    Connecticut                      Guam                                                             Iowa                            Florida                         Hawaii
    Guam                             Louisiana                                                        Louisiana                       Iowa                            Idaho
    Louisiana                        Maine                                                            Maryland                        Kentucky                        Illinois
    Maine                            Massachusetts                                                    Massachusetts                   Louisiana                       Indiana
    Massachusetts                    Minnesota                                                        Mississippi                     Maine                           Michigan
    Minnesota                        New Jersey                                                       North Carolina                  Maryland                        Minnesota
    Mississippi                      Northern Mariana                                                 Northern Mariana                Massachusetts                   Montana
    New Jersey                       North Carolina                                                   Pennsylvania                    Mississippi                     Nebraska
    Northern Mariana                 Puerto Rico                                                      Puerto Rico                     Missouri                        Nevada
    North Carolina                   Virgin Islands                                                   Tennessee                       New York                        New Hampshire
    Rhode Island                     West Virginia                                                    Virgin Islands                  North Carolina                  New Jersey
    Virgin Islands                   Wisconsin                                                        Virginia                        Oklahoma                        New Mexico
    Virginia                                                                                          West Virginia                   Pennsylvania                    New York City
    West Virginia                                                                                     Wisconsin                       Rhode Island                    North Dakota
    Wisconsin                                                                                                                         Tennessee                       Ohio
                                                                                                                                      Virginia                        Oregon
                                                                                                                                      Washington                      South Carolina
                                                                                                                                      West Virginia                   South Dakota
                                                                                                                                      Wisconsin                       Texas
                                                                                                                                                                      Utah
                                                                                                                                                                      Vermont
                                                                                                                                                                      Wyoming
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    \1\ Has an electronic birth record but does not collect all 2003 data items; requires funding to modify the electronic birth record to collect the 2003 data items.
    \2\ Has an electronic death record but requires funding to finish enrolling physicians and funeral directors in the system.

    Source: NAPHSIS Survey of Vital Statistics Jurisdictions.

        The data NCHS collects are needed to track Americans' health and
    evaluate our progress improving it. The President's requested increase
    of $23 million for NCHS and the National Vital Statistics System will
    move us toward a timelier and more comprehensive system where all
    States collect the same data and all States collect these data
    electronically, enabling us to better compare critical information on a
    local, State, regional, and national basis. Without additional funding,
    a potential erosion of State data infrastructure and lack of
    standardized data will undeniably create enormous gaps in critical
    public health information and may have severe and lasting consequences
    on our ability to appropriately assess and address critical health
    needs.
        NAPHSIS appreciates the opportunity to submit this statement for
    the record and looks forward to working with the Subcommittee. If you
    have questions about this statement, please do not hesitate to contact
    NAPHSIS Executive Director, Patricia W. Potrzebowski, Ph.D., at
    ppotrzebowski@naphsis.org or (301) 563-6001. You may also contact our
    Washington representative, Emily Holubowich, at eholubowich@dc-crd.com
    or (202) 484-1100.
                                     ______

      Prepared Statement of the National Association of Community Health
                                    Centers
    Introduction
        Chairman Harkin, Ranking Member Shelby, and Distinguished Members
    of the Subcommittee: My name is Dan Hawkins, and I am the Senior Vice
    President for Public Policy and Research at the National Association of
    Community Health Centers. On behalf of the 23 million patients served
    nationwide by health centers; 150,000 full-time health center staff;
    and countless volunteer board members; I would like to express my
    heartfelt appreciation to the Subcommittee for your support of
    America's healthcare safety net, and specifically of our mission to
    deliver affordable and accessible care to all Americans. I am pleased
    to have an opportunity to submit testimony for your consideration as
    you prepare the fiscal year 2012 Labor-Health and Human Services-
    Education and Related Agencies Appropriations bill.
    About Community Health Centers
        Health centers offer cost-effective, high-quality, and patient-
    directed primary and preventive care in 8,000 rural and urban
    underserved communities across the United States. In Iowa and Alabama,
    respectively, health centers deliver care to 154,020 patients in 108
    communities and 315,670 patients in 140 communities.\1\ By statute,
    health centers must be located in a medically underserved area (MUA) or
    serve a medically underserved population (MUP) and provide
    comprehensive primary care services to all community residents
    regardless of insurance status--offering care on a sliding fee scale.
    Because of this, health centers serve as the ``healthcare home'' for
    America's most vulnerable populations, including one-third of
    individuals living below poverty, one in seven Medicaid beneficiaries,
    and one in seven of America's uninsured. And nearly half of health
    center organizations are located in our Nation's rural areas.
    ---------------------------------------------------------------------------
        \1\ See http://www.nachc.com/state-healthcare-data-list.cfm for
    State Fact Sheets on Health Centers.
    ---------------------------------------------------------------------------
        Presidents of both parties and Senators on both sides of the
    aisle--including many members of this Subcommittee--have long-
    recognized the value of health centers. As a result and with bipartisan
    support, health centers have been on an expansion path for over a
    decade. Within the past 2 years, and as a result of investments this
    Subcommittee made through the American Recovery and Reinvestment Act,
    127 new health centers opened and over 4.3 million new patients
    received access to care at virtually every health center in the
    country. I'd like to elaborate on why the Health Centers program is
    such a worthwhile investment that produces documented savings to the
    entire health system--a primary reason this program has been able to
    count on the Subcommittee's support for several decades.
        Health centers save the country money by keeping patients out of
    costlier healthcare settings (like emergency departments and
    hospitals), coordinating care amongst providers of many health
    disciplines, and effectively managing chronic conditions. Medicaid
    beneficiaries who rely on health centers for routine care are 19
    percent less likely to use the emergency department (ED) and 11 percent
    less likely to be hospitalized for ambulatory care-sensitive (ACS)
    conditions when compared to beneficiaries who see other providers.\2\
    Additionally, counties with at least one health center have 25 percent
    fewer ED visits for ACS conditions than counties without a health
    center presence.\3\ By providing timely and appropriate care, health
    centers save over $1,200 per person per year, lowering costs across the
    healthcare system--from ambulatory care settings to hospital stays.\4\
    All told, health centers currently generate $24 billion in savings each
    year. This is all possible through an investment of just $1.67 per
    patient per day.\5\
    ---------------------------------------------------------------------------
        \2\ Falik M, et al. ``Comparative Effectiveness of Health Centers
    as Regular Source of Care.'' January-March 2006 Journal of Ambulatory
    Care Management 29(1):24-35.
        \3\ Rust G, et al. ``Presence of a Community Health Center and
    Uninsured Emergency Department Visit Rates in Rural Counties.'' Winter
    2009 Journal of Rural Health 25(1):8-16.
        \4\ Ku L, et al. Strengthening Primary Care to Bend the Cost Curve:
    The Expansion of Community Health Centers Through Health Reform. Geiger
    Gibson/RCHN Community Health Foundation Collaborative at the George
    Washington University. June 30 2010. Policy Research Brief No. 19.
        \5\ Bureau of Primary Health Care, Health Resources and Services
    Administration, DHHS. 2009 Uniform Data System.
    ---------------------------------------------------------------------------
        Health centers meet or exceed national practice standards for
    chronic condition treatment and ensure that their patients receive more
    recommended screening and health promotion services than patients of
    other providers--despite serving underserved and traditionally at-risk
    populations.\6\ The Institute of Medicine (IOM) and the U.S. Government
    Accountability Office (GAO) have recognized health centers as models
    for screening, diagnosing, and managing a wide array of relatively
    common and costly chronic conditions such as diabetes, cardiovascular
    disease, asthma, depression, cancer, and HIV.\7\ Specifically related
    to diabetes, a leading cause of death and disability, health centers
    significantly reduce the expected lifetime incidence of diabetes
    complications, including blindness, kidney failure, and certain forms
    of heart disease.\8\ America's health centers also play an important
    role in improving access to prenatal care and improving birth outcomes.
    Health centers have demonstrated their ability to reduce the disparity
    of low birth weight by at least 50 percent compared to the national
    average.\9\
    ---------------------------------------------------------------------------
        \6\ Shi L, Tsai J, Higgins PC, Lebrun La. (2009). Racial/ethnic and
    socioeconomic disparities in access to care and quality of care for
    U.S. health center patients compared with non-health center patients.
    Journal of Ambulatory Care Management 32(4): 342-50. Hing E, Hooker RS,
    Ashman JJ. (2010). Primary Health Care in Community Health Centers and
    Comparison with Office-Based Practice. Journal of Community Health.
    2010 Nov 3 epublished.
        \7\ U.S. General Accounting Office. (2003). Healthcare: Approaches
    to address racial and ethnic disparities. Publication No. GAO-03-862R.
    Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic
    Disparities in Healthcare. Washington, DC: National Academy of Sciences
    Press; 2003.
        \8\ Huang E, et al. ``The Cost-effectiveness of Improving Diabetes
    Care in U.S. Federally Qualified Community Health Centers.'' 2007
    Health Services Research, 42(6): 2174-93.
        \9\ Politzer R, Yoon J, Shi L, Hughes R, Regan J, and Gaston M.
    ``Inequality in America: The Contribution of Health Centers in Reducing
    and Eliminating Disparities in Access to Care.'' 2001 Medical Care
    Research and Review 58(2):234-248.
    ---------------------------------------------------------------------------
        A key driver of the success of the health center model is that each
    non-profit entity is locally-owned and directed by a patient majority
    board that ensures the health center is accountable and responsive to
    the needs of the community it serves. Research has demonstrated that
    this type of consumer participation on governing boards ensures higher
    quality care, lower costs of services, and better results.\10\ In
    addition to tailoring their services to make healthcare delivery
    individualized to unique local circumstances, health centers also have
    a substantial and positive economic impact on their communities. In
    2009 alone, health centers generated $20 billion in total economic
    benefit and created 189,158 jobs.\11\
    ---------------------------------------------------------------------------
        \10\ Crampton P, et al. ``Does Community-Governed Nonprofit Primary
    Care Improve Access to Services?'' 2005 International Journal of Health
    Services 35(3): 465-78.
        \11\ NACHC, Capital Link. Community Health Centers as Leaders in
    the Primary Care Revolution. August 2010. www.nachc.com/research-
    data.cfm.
    ---------------------------------------------------------------------------
    Funding Background
        The Health Resources and Services Administration (HRSA) fiscal year
    2011 spending or operating plan, pursuant to Section 1863 of Public Law
    112-10, provides $1.581 billion in discretionary funding for the Health
    Centers program--a reduction of $604.4 million relative to the fiscal
    year 2010-enacted level of $2.185 billion. Together with the $1.0
    billion in fiscal year 2011 funding available for health centers
    through the Affordable Care Act (ACA), health centers have a net
    increase of $395.6 million in total programmatic funding for fiscal
    year 2011.
        While we await word from HRSA about how available fiscal year 2011
    programmatic funding will be allocated between existing and new health
    center efforts, we are heartened that there should be no interruption
    of existing health center activities, including the new centers and
    patients added in the past 2 years. We strongly support prioritizing
    fiscal year 2011 funding to maintain existing health center activities.
    It is worth noting, however, that most of the nearly $400 million
    programmatic increase in the fiscal year 2011 CR is needed to continue
    ongoing operations--leaving very limited funding to support expansion
    efforts that would otherwise have been possible if the $1.0 billion in
    new ACA resources were not being redirected to continue existing
    operations.
        Currently, 60 million Americans lack access to a routine source of
    care.\12\ And even with implementation of ACA, it is imperative that as
    more Americans become insured, they have access to care through a
    healthcare home in their community. Prior to the completion of fiscal
    year 2011 appropriations, health centers were on track to double their
    capacity and serve 40 million patients over the next 5 years, reaching
    a sizeable portion of the medically underserved individuals who would
    otherwise be forced to seek care in EDs, or delay care until
    hospitalization is the only option.
    ---------------------------------------------------------------------------
        \12\ NACHC, the Robert Graham Center, and Capital Link. Access
    Granted: The Primary Care Payoff. August 2007. www.nachc.com/
    accessreports.cfm.
    ---------------------------------------------------------------------------
        HRSA previously announced several fiscal year 2011 funding
    opportunities, including grants for new health centers and support for
    expanded capacity at virtually every existing health center nationwide.
    These opportunities produced: (1) over 800 applications submitted for
    350 New Access Point (new health center) awards in communities not
    currently served by existing health centers, demonstrating the great
    need across the country for new centers to serve patients who most need
    access to primary care; and (2) nearly 1,100 health center grantee
    applications submitted to expand health center services to reach
    additional individuals in need in their current communities, adding new
    medical, oral, behavioral, pharmacy, and vision capacity. The reduction
    to the Health Center program's fiscal year 2011 discretionary funding
    leaves HRSA far short of the funding needed to make their previously-
    announced awards at this time.
    Fiscal Year 2012 Funding Request
        Health centers stand ready to continue working to ensure that
    everyone has access to primary and preventive healthcare services. In
    fiscal year 2012, we respectfully ask that the Subcommittee provide a
    discretionary funding level of no less than $1.79 billion for the
    Health Centers program. This funding level, together with ACA funding
    available in fiscal year 2012, will allow health centers to extend
    cost-effective primary care over 3 million Americans this year alone.
    It will also allow HRSA to fund remaining and worthwhile applications
    that will go unfunded in fiscal year 2011, including over 200 new
    health center applications and funding for expanded medical, oral,
    behavioral, pharmacy, and vision health services at existing health
    centers.
    Conclusion
        As the Congress works to tackle our Nation's deficit, I understand
    Members of this Subcommittee are faced with incredibly difficult
    decisions about funding levels for the programs within the fiscal year
    2012 Labor-Health and Human Services-Education and Related Agencies
    Appropriations bill. However, health centers have proven time and time
    again that the Federal investment in the Health Centers program is
    prudent--translating to improved health outcomes for our most
    vulnerable Americans and reduced healthcare expenditures for this
    Nation. I'd ask for this Subcommittee's support in continuing the
    bipartisan expansion of health centers in fiscal year 2012 to ensure
    that our shared goal of improved access to high-quality and cost-
    effective care is realized.
                                     ______

       Prepared Statement of the National Association of County and City
                                Health Officials
    Summary
        The National Association of County and City Health Officials
    (NACCHO) represents the Nation's 2,800 local health departments (LHDs).
    These governmental agencies work every day in their communities to
    protect people, prevent disease, and promote wellness. Local health
    departments have a unique and distinctive role and set of
    responsibilities in the larger health system and within every
    community. The Nation depends upon the capacity of local health
    departments to play this role well.
        The Nation's current financial challenges are compounded by those
    in State and local government further diminishing the ability of local
    health departments to measure population-wide illness, take steps to
    prevent disease and prolong quality of life, and to serve the public in
    ways others don't. Repeated rounds of budget cuts and lay-offs continue
    to erode local health department capacity. NACCHO surveys have found
    that from 2008 to 2010, local health departments have lost 29,000 jobs
    due to budget reductions. This represents a nearly 20 percent reduction
    in local public workforce. These are jobs in local communities
    nationwide.
        On a fraying shoestring, local health departments continue to
    respond to an ever changing set of challenges, including ongoing public
    health emergency threats like floods, hurricanes, oil spills,
    infectious and chronic disease epidemics. The protection offered by
    local health departments can't be taken for granted. To help maintain
    the stability of LHDs, the Federal Government should invest in the
    following programs in fiscal year 2012 appropriations: National Public
    Health Improvement Initiative, Public Health Emergency Preparedness
    cooperative agreements, Advanced Practice Centers, Public Health
    Workforce Development, Chronic Disease Prevention and Health Promotion
    Grants, and Community Transformation Grants.
    Public Health Recommendations
                National Public Health Improvement Initiative
    NACCHO request: $50 million
    Fiscal Year 2012 President's Budget: $40.2 million
    Fiscal Year 2010: $50 million
        The National Public Health Improvement Initiative (NPHII) increases
    local health departments' capability to meet national public health
    standards and conduct effective performance management. This initiative
    promotes the effective and efficient use of resources in local health
    departments across the country while strengthening our public health
    infrastructure. In addition, these funds improve public health policies
    and decisionmaking crucial to protecting our communities from public
    health threats. NPHII boosts the ability of local health departments to
    reengineer their systems to meet 21st century challenges including
    implementation of the full range of science-based approaches to
    improving community health. As local health departments prepare to meet
    newly established national accreditation standards, NACCHO recommends
    $50 million in funding for fiscal year 2012 to continue to improve
    efficiency and effectiveness at local health departments.
                Public Health Workforce Development
    NACCHO request: $73 million
    Fiscal Year 2012 President's Budget: $73 million
    Fiscal Year 2010: $38 million
        The Nation suffers an acute shortage of trained public health
    professionals, including epidemiologists, laboratorians, public health
    nurses, and public health informaticians. This investment in public
    health education and training is essential to maintain a prepared and
    sustainable public health workforce. With the increasing variety and
    magnitude of public health threats, it is vital to train new public
    health staff and provide continuous education for existing staff in
    order to maintain and upgrade the skills needed to protect our
    communities. This funding also supports the Centers for Disease Control
    and Prevention (CDC) Prevention Corps, a workforce program to recruit
    and train new talent for assignments in State and local health
    departments. This new program will also address retention by requiring
    professionals to commit to a designated timeframe in State and local
    health departments as a condition of the fellowship. NACCHO recommends
    $73 million in funding for fiscal year 2012 to bolster the public
    health workforce.
    Emergency Preparedness Recommendations
                Public Health Emergency Preparedness Cooperative Agreements
    NACCHO request: $730 million
    Fiscal Year 2012 President's Budget: $643 million
    Fiscal Year 2010: $715 million
        Constant readiness for both new and emerging public health threats
    requires an established local public health team that can plan, train,
    and practice on a regular basis. Emergency response capabilities and
    tasks, such as distributing medical countermeasures, addressing the
    needs of at-risk individuals, conducting drills, and organizing
    collaboration among staff in public health departments, schools,
    businesses and with volunteers, requires continuous attention and
    ongoing preparation. These are not supplies purchased once and stored
    until needed. If a community is not prepared to respond to multiple
    hazards, capacity to respond will not be immediately available when
    disasters happen. Valuable time will be lost and people will suffer,
    particularly the elderly, disabled and disenfranchised, low-income
    residents, vulnerable populations. The only way to ensure that local
    health departments and their community partners are ready to respond to
    emergencies is to maintain consistent funding. With this funding, local
    health departments can sustain their level of readiness to meet
    benchmarks that align with the Pandemic and All Hazards Preparedness
    Act.
        With recent progress in nationwide preparedness, now is not the
    time to reduce Federal funding that helps health departments continue
    their progress and address new, emerging threats. Especially when local
    health departments are under great stress from the loss of over 29,000
    jobs in the last few years, the Nation cannot afford to lose the gains
    made by recent Federal investment in public health. Continuous training
    and exercising of all health department staff so that they are all
    ready for the next emergency must continue. A loss of readiness is
    inevitable if the level of Federal investment is reduced.
        The safety and well-being of America's communities is dependent on
    the capacity of their health departments to respond in any emergency
    that threatens human health, including bioterrorism, infectious disease
    outbreaks, nuclear emergencies and natural disasters. The CDC has
    explicitly adopted an ``all-hazards'' approach to preparedness,
    recognizing that the capabilities necessary to respond to differing
    public health threats have many common elements. Through the Public
    Health Emergency Preparedness cooperative agreements CDC supports State
    and local health departments so that they can adequately prepare for
    and respond to such emergencies. NACCHO recommends $730 million in
    funding for fiscal year 2012 to continue to support emergency
    preparedness in our communities.
                Advanced Practice Centers
    NACCHO request: $5.4 million
    Fiscal Year 2012 President's Budget: 0
    Fiscal Year 2010: $5.4 million
        The Advanced Practice Center program started as a CDC pilot project
    in 1999, and has since expanded to a national program. The APC program
    funds exemplary local health departments to be innovative leaders in
    public health preparedness to develop, evaluate, and promote products
    and resources that other local health department practitioners can use
    to meet the preparedness requirements expected for their organization
    or community. Since its inception, the APC program has created over 150
    products and hosted numerous workshops, webinars, and other
    presentations to local health departments. NACCHO recommends level
    funding in fiscal year 2012 of $5.4 million for the Advanced Practice
    Center program administered by CDC's Office of Public Health
    Preparedness and Response.
    Disease Prevention Recommendations
                Chronic Disease Prevention and Health Promotion Grants
    NACCHO request: $705 million
    Fiscal Year 2012 President's Budget: $705 million
        Chronic diseases such as heart disease, cancer, stroke and diabetes
    are responsible for 7 of 10 deaths among Americans each year and
    account for 75 percent of healthcare spending. The President's budget
    consolidates several previously existing grants for disease prevention
    and health promotion to provide State and local health departments with
    greater flexibility to target funds to those diseases that most burden
    their jurisdictions, using the most effective strategies for the
    populations they serve. The program recognizes that many chronic
    diseases have common risk factors such as obesity and physical
    inactivity.
        Supporting effective approaches to reducing contributing factors
    and therefore rates of chronic disease will not only make our
    communities healthier, but save money for taxpayers and the Government
    in the long run. NACCHO recommends $705 million in funding for fiscal
    year 2012 to reduce chronic disease in our communities and looks
    forward to working with Congress on the array of details that will
    ensure successful, efficient, accountable implementation of a
    consolidated grant program that enables communities to address their
    chronic disease burden.
                Community Transformation Grants
    NACCHO request: $221 million
    Fiscal Year 2012 President's Budget: $221 million
        This program builds on the success of its predecessors: Healthy
    Communities, Racial and Ethnic Approaches to Community Health, and
    Communities Putting Prevention to Work. These funds are awarded on a
    competitive basis to State or local government agencies, territories,
    national networks of community based organizations, State or local
    nonprofit organizations and Indian tribes or tribal organizations to
    reduce health disparities and leading causes of death. Communities will
    use these resources to invest in evidence-based approaches to creating
    a healthy population by promoting smoking cessation, active living,
    healthy eating, and prevention of injuries. NACCHO recommends an
    allocation process which makes these funds available to communities of
    all sizes. NACCHO recommends $221 million in funding for fiscal year
    2012 to continue proven approaches to protecting public health in our
    communities.
        As the Subcommittee drafts the fiscal year 2012 Labor-Health and
    Human Services-Education Appropriations bill, we ask for consideration
    of NACCHO's recommendations for these programs that are critical to
    protecting people and improving the public's health. We are fully aware
    of the budgetary challenges facing Congress and the need to reduce
    deficit spending. Budgetary cuts must be made carefully to cause the
    least disruption to critical public health functions and protect the
    health of the U.S. population.
        NACCHO thanks the Subcommittee members for their previous support
    of public health initiatives that support work in local communities and
    welcomes the opportunity to discuss these requests further.
                                     ______

     Prepared Statement of the National Association of Nutrition and Aging
                               Services Programs
        On behalf of NANASP, the National Association of Nutrition and
    Aging Services Programs, I thank you for providing an opportunity to
    submit testimony as you consider an fiscal year 2012 Labor-HHS and
    Education Appropriations bill. NANASP is a national membership
    organization for persons across the country working to provide older
    adults healthful food and nutrition through community-based services.
    NANASP has 14 members in Iowa and 17 members in Alabama.
        I am writing today to urge you to provide a much needed increase to
    President Obama's fiscal year 2012 funding proposal for two major
    programs in the Older Americans Act: the senior nutrition programs and
    Community Service Employment for Older Adults.
        The congregate and home-delivered (Meals on Wheels) nutrition
    programs and the Nutrition Services Incentive Program (NSIP) are the
    largest and most visible component of the Older Americans Act. Next
    year, the senior nutrition program celebrates its 40th anniversary of
    helping to keep millions of the vulnerable elderly healthy and
    independent in their homes and communities. This is a much more
    fiscally sound solution than having our seniors institutionalized
    because of the detrimental effects of hunger and malnutrition.
        The President's budget proposes no increase for the senior
    nutrition programs in fiscal year 2012. This is extremely alarming as
    these same programs were deemed worthy of increases for the past 5
    fiscal years. The need for an increase in funding for meals for our
    seniors remains today. According to the Administration on Aging (AoA),
    flat funding for the nutrition programs means that 36 million fewer
    home-delivered and congregate meals will be served in fiscal year 2012
    compared to fiscal year 2010. These meals are especially critical for
    the health of the 58 percent of congregate and 60 percent of home-
    delivered meal participants who report that they receive the majority
    of their daily food intake from the nutrition program.
        The second major program we ask you to consider for increased
    funding is the Community Service Employment for Older Adults, also
    known as the Senior Community Service Employment Program or SCSEP.
    Administered by the Labor Department, SCSEP provides part-time jobs to
    thousands of low-income seniors, about one-fourth of them working in
    senior nutrition and other programs serving the elderly. These
    disadvantaged and previously unemployed seniors earn the minimum wage
    as they re-enter the job market.
        In fiscal year 2012, the President's budget proposes to reduce the
    number of SCSEP participants by 25 percent below the fiscal year 2008
    level. SCSEP is the only Federal job training program targeted for
    older workers, who continue to suffer in today's economy. While the
    current unemployment rate among older adults is lower than among
    younger workers, older workers are less likely to find new employment,
    and when they do find new jobs, their job search has taken longer. For
    example, nearly 30 percent of unemployed people aged 55+ were jobless
    for an entire year or more, a rate that exceeds that of all other age
    groups. Such a drastic cut in funding would not only eliminate over
    22,000 job opportunities for older workers, but also take away 12
    million hours of staffing for senior nutrition and other programs
    serving the community.
        At NANASP we always say, ``It is more than just a meal.'' Our
    programs provide much needed socialization for older adults and the
    link between nutrition and health is irrefutable. The senior nutrition
    and community service employment programs play a key role in health
    promotion and disease prevention. Our programs keep the very vulnerable
    elderly healthy, engaged, and independent and out of expensive long-
    term care institutions that are very costly to the Medicaid program. We
    hope you will strongly consider an increase in funding for the
    nutrition and community service employment programs in your Labor-HHS,
    Education Appropriations bill for fiscal year 2012.
                                     ______

     Prepared Statement of the National Association of State Comprehensive
                             Health Insurance Plans
        The National Association of State Comprehensive Health Insurance
    Plans (NASCHIP) appreciates the opportunity to submit testimony as you
    consider an fiscal year 2012 Labor-HHS and Education Appropriations
    bill. NASCHIP represents the State high risk pools which were
    established by statute initially passed 10 years before the Federal
    high risk pool program (PCIP) was created by the ACA, the Affordable
    Care Act. Our programs operate in 35 States including your States, Mr.
    Chairman and Mr. Shelby. We serve more than 200,000 people providing
    them with insurance notwithstanding their preexisting conditions. This
    number reflects a 7 percent increase from 2009 levels which we consider
    a significant indicator of the value and necessity of our programs.
        We are here to urge that you support a level of $75 million for the
    Federal grant program for State high risk pool programs for fiscal year
    2012. This was the authorization level contained in our statute the
    State High-Risk Pool Funding Extension Act of 2006. This funding allows
    many States to provide means based premium subsidies to their citizens
    who might otherwise not be able to afford coverage.
        We consider this level of funding the essential minimum for us to
    continue to do our work of providing a vital safety net to individuals
    who might otherwise be uninsured. For the current fiscal year, the
    Federal grant program for State high risk pool programs has $55 million
    in available funding which represents only a fraction of the total
    costs of care for State high risk pools. In fact, total State pool
    expenses in 2009 were approximately $2.2 billion.
        We were disappointed that the President only requested $44 million
    in funding for the Federal grant program for State high risk pools in
    his fiscal year 2012 budget proposal. It was based in part on an
    incorrect premise that as enrollments grow in the PCIP program it would
    lessen enrollment in our programs. The request also ignores the reality
    of increased enrollment into our programs in 2010. Only by receiving
    $75 million in funding for fiscal year 2012 would we stand a chance of
    serving the individuals we need to serve.
        The issues related to the PCIP program and either lower or higher
    than expected enrollments should have no bearing on the funding level
    we request. We have and will continue to work with administration
    officials to improve enrollments in PCIP as we want to see this program
    succeed. However, the State high risk pools serve a growing population
    and are in need of continued funding. We urge you to include $75
    million in your Labor-HHS and Education appropriations bill for fiscal
    year 2012.
                                     ______

      Prepared Statement of the National Association of State Head Injury
                                 Administrators
        Thank you for this opportunity to submit testimony regarding the
    fiscal year 2012 budget as it pertains to funding for programs
    authorized by the Traumatic Brain Injury (TBI) Act of 1996, as amended
    in 2008. The TBI Act authorizes funding to the U.S. Department of
    Health and Human Services (HHS) to carry out the intent of the Act
    through the (1) Centers for Disease Control and Prevention (CDC) for
    purposes of brain injury surveillance, prevention and education; and
    the (2) Health Resources and Services Administration (HRSA) for grants
    to State governmental agencies and to Protection and Advocacy Systems
    to improve and increase access to rehabilitation services and community
    services and supports for individuals with TBI and their families.
        NASHIA is a nonprofit organization representing State governmental
    officials who administer an array of short-term and long-term
    rehabilitation and community services and supports for individuals with
    TBI and their families. These services are generally financed through
    an array of Federal, State and dedicated funds (State trust funds) with
    the HRSA Federal TBI grants used to support and improve the necessary
    infrastructure to support these service systems. While NASHIA is well
    aware that Federal funds are becoming increasingly difficult to obtain,
    NASHIA is recommending increased funding for the Federal TBI Act
    programs because:
      --The number of Americans who sustain a TBI is increasing, especially
            among the elderly and young children, and among our men and
            women in uniform as a result of the wars in Iraq and
            Afghanistan, while at the same time,
      --States are experiencing significant budget cuts impacting
            rehabilitation and community services and supports for
            individuals with TBI, yet
      --The number of States receiving grants has been reduced from 49 to
            21 due to recent changes in HRSA policy and the level of
            appropriations to support State grant activities.
        These factors, as well as the overall economy, are creating a
    strain on State TBI systems. As the TBI Act program is the only Federal
    funding to help States to better serve individuals with TBI, NASHIA
    recommends:
      --$10 million for the CDC programs to support TBI registries and
            surveillance; to develop Brain Injury Acute Care Guidelines,
            and to expand prevention and public education regarding injury
            prevention, including sports-related concussions (mild TBI);
      --$ 8 million for the HRSA Federal TBI State Grant Program to
            increase the number of grants to States; and
      --$ 4 million for the HRSA Federal TBI Protection & Advocacy (P&A)
            Systems Grant Program to increase the amount of grant awards.
                      hrsa federal tbi state grant program
        Since 1997, HRSA has awarded grants to 48 States, District of
    Columbia and one Territory to develop and improve services and systems
    to address the short-term and long-term needs. These grants have been
    time limited and are relatively small. Two years ago, HRSA increased
    the amount of the award from approximately $100,000 to $250,000 to make
    it more feasible for States to carry out their grant goals and the
    legislative intent. While this increased amount is more attractive to
    States, this change reduced the number of grantees from 49 to 21--less
    than half of the States and Territories. As a result, States that do
    not have Federal funding are finding it increasingly more difficult to
    sustain their previous efforts, let alone expand and improve, due to
    other budget constraints in their States.
        Over the course of the grant program, States, depending on
    individual State needs, have developed State plans for improving
    service delivery; information and referral systems; service
    coordination systems; outreach and screening among unidentified
    populations such as children, victims of domestic violence, and
    veterans; and training programs for direct care workers and other
    staff. States have also conducted public awareness and educational
    activities that have helped States to leverage and coordinate funding
    in order to maximize resources to the benefit of individuals with TBI.
        In keeping with the HRSA Federal TBI State Grant Program most
    States have identified a lead State agency responsible for providing
    and coordinating services and an advisory board to plan and coordinate
    public policies to better serve individuals who frequently needs
    assistance from multiple agencies and funding streams in order to
    address the complexity of their needs.
          state collaborative efforts to address the needs of veterans
        The HRSA grant funding has been used to address the needs of
    returning service members and veterans with TBI and their families.
    Since service members and veterans first began to return from Iraq and
    Afghanistan, States have been contacted by families and returning
    servicemembers, especially those who served in the National Guard and
    Reserves, to obtain community resources in order to return to work,
    home and community.
        NASHIA and some individual States have reached out to U.S.
    Department of Veterans Affairs (VA), particularly staff from individual
    Polytrauma Centers, to promote collaboration in order to better
    understand VA benefits for veterans that may be seeking State services,
    and for VA to understand what is available in the communities. In
    addition, some States have added representatives from VA, National
    Guard and Reserves, State Veterans Affairs, and/or veterans
    organizations to serve on their State advisory board in order to
    improve communications and policies across these programs.
               the incidence and prevalence of tbi is on the rise
        CDC released new data last year showing that the incidence and
    prevalence of TBI in the United States is on the rise. CDC reported
    that each year, an estimated 1.7 million people sustain a TBI. Of that
    amount: 52,000 die; 275,000 are hospitalized; and 1.365 million (nearly
    80 percent) are treated and released from an emergency department. TBI
    is a contributing factor to a third (30.5 percent) of all injury-
    related deaths in the United States. About 75 percent of TBIs that
    occur each year are concussions or other forms of mild TBI. The number
    of people with TBI who are not seen in an emergency department or who
    receive no care is unknown.'' (www.cdc.gov/TraumaticBrainInjury/
    statistics.hml)
        The data collected by CDC relies heavily on State data, gathered
    through State registries and hospital discharge data. These numbers do
    not include the veterans who sustained TBIs in Iraq or Afghanistan and
    now use private or State funded resources for care, or undiagnosed
    TBIs.
                       about state resources and services
        Since the 1980s, States have developed services and supports
    largely in response to families who often seek help in crisis
    situations, such as loss of job due to TBI; or out of control behaviors
    or substance abuse that may result in family violence or dangerous
    situations to self and others; and the need for overall help in
    providing care to their family members who have extensive medical,
    behavioral and cognitive problems. A critical service that States
    provide is service coordination to help coordinate and maximize
    resources and supports for individuals with TBI and their families.
        Over the past 25 years, States have developed service delivery
    systems that generally offer information and referral, service
    coordination, rehabilitation, in-home support, personal care,
    counseling, transportation, housing, vocational and other support
    services for persons with TBI and their families. These services are
    funded by State appropriations, designated funding (trust funds),
    Medicaid and Rehabilitation Act programs and are administered by
    programs located in the State public health, Vocational Rehabilitation,
    mental health, Medicaid, developmental disabilities, education or
    social services agencies.
        Approximately half of all States have a dedicated funding
    mechanism, mainly through traffic related fines, and about half of all
    States also administer a Medicaid Home and Community-Based Services
    (HCBS) Waiver for individuals with brain injury who are Medicaid
    eligible. Individuals with TBI are also served in other State waiver
    programs designed for physical disabilities, developmental
    disabilities, elderly and other populations. Some States have the
    advantage of both waiver and trust fund programs, in addition to other
    State and Federal resources.
        As private insurance generally does not provide for extended
    rehabilitation and long-term care, supports and services, most long-
    term services and supports for persons with TBI are administered by the
    States. These programs are funded mainly through the shared Federal/
    State Medicaid Home and Community-based Services Waivers (HCBS) program
    and Medicaid State Plan services, such as personal assistance, nursing
    homes and in-home care.
        Medicaid HCBS Waivers for Individuals with TBI have grown
    significantly in recent years, doubling from 5,400 individuals served
    in 2002 to 11,214 in 2006, at a cost of $155 million in 2002 to $327
    million in 2006 (Kaiser Commission on Medicaid and the Uninsured (2007,
    December); Medicaid Home and Community-Based Service Programs: Data
    Update, The Henry J. Kaiser Family Foundation, Washington, DC).
        Without appropriate services and supports, individuals with TBI may
    become homeless, or inappropriately placed in institutional settings or
    end up in State or local Correctional facilities due to their cognitive
    and behavioral disabilities. A recent report issued by the Centers for
    Disease Control and Prevention (CDC) cited other jail and prison
    studies indicating that 25-87 percent of inmates report having
    experienced a TBI as compared to 8.5 percent in a general population
    reporting a history of TBI.
                                  about nashia
        The mission of NASHIA is to assist State government in promoting
    partnerships and building systems to meet the needs of individuals with
    brain injury and their families. Since 1990, NASHIA has held an annual
    State-of-the-States conference, and has served as a resource to State
    TBI program managers. NASHIA also maintains a website (www.nashia.org)
    containing State program contacts and other resources. NASHIA members
    include State officials administering public TBI programs and services,
    and associate members who are professionals, provider agencies, State
    affiliates of the Brain Injury Association of America (BIAA), family
    members and individuals with brain injury.
        Should you wish additional information on State services and
    resources, or other information, please do not hesitate to contact
    Rebeccah Wolfkiel, Governmental Consultant at 202-480-8901 (office) or
    rwolfkiel@ridgepolicygroup.com. You may also contact Susan L. Vaughn,
    Director of Public Policy, at 573-636-6946 or publicpolicy@nashia.org
    or William A.B. Ditto, Chair of the Public Policy Committee, at
    williamabditto@aol.com.
        Thank you.
                                     ______

       Prepared Statement of the National Association of Workforce Boards
        Thank you for the opportunity to comment on the Administration's
    proposed 2012 budget for the Department of Labor. The National
    Association of Workforce Boards (NAWB) is a member association, which
    represents a majority of the 575 local employer-led Workforce
    Investment Boards and their nearly 13,000 employer member volunteers.
        We write in support of the Administration's fiscal year 2012
    overall appropriations request for the Training and Employment Services
    account under the Department of Labor. Adequate funding for the public
    workforce system has never been more critical. While the worst of the
    economic downturn seems behind us, one-stop centers across the Nation
    continue to deal with large numbers of unemployed individuals who seek
    advice about career options and whose skills need upgraded. In short,
    our employment crisis is not expected to ease in the foreseeable
    future.
        The annual Economic Report of the President indicated that
    unemployment would remain above 8 percent through 2012. In April of
    this year the rate stood at 9 percent. Federal Reserve Chairman Ben S.
    Bernanke said the unemployment rate is likely to remain high ``for some
    time'' even after the biggest 2-month drop in the jobless rate since
    1958.
        Mr. Bernanke appearing before the House Budget Committee in
    February 2011, said that while the declines in the jobless rate in
    December and January ``do provide some grounds for optimism,'' he
    cautioned that ``with output growth likely to be moderate for a while
    and with employers reportedly still reluctant to add to their payrolls,
    it will be several years before the unemployment rate has returned to a
    more normal level.''
        Workforce Investment Act programs have been on the front lines of
    assisting job seekers impacted by the recession. Over the past year,
    Title I of the Workforce Investment Act (WIA) system has seen over 8
    million American workers turn to it for help in navigating the labor
    market in search of jobs and/or the training individuals need to be
    competitive in their labor market. This continues the trend of an over
    234 percent increase in the numbers of people who have sought
    assistance over the last two reporting years.
        Despite a ratio of four/five job seekers nationally for every
    available job, over 4 million were helped back into the labor force. In
    short, those who received WIA services were likely to find jobs with
    the likelihood increasing the higher the service level. Information for
    the quarter ending September 30, 2010 shows the following results:
    Performance Results
        Workforce Investment Act Adult Program
      --Entered Employment Rate 53.1 percent
      --Employment Retention Rate 75.3 percent
      --Average 6 months Earnings $13,482
        Workforce Investment Act Dislocated Worker Program
      --Entered Employment Rate 50.3 percent
      --Employment Retention Rate 79 percent
      --Average 6 months Earnings $17,227
        Workforce Investment Act Youth Program
      --Placement in Employment or Education rate 59.5 percent
      --Attainment of Literacy and Numeracy gains 49.5 percent
        The ability of the pubic workforce system to maintain this level of
    success on behalf of job seekers and employers seeking skilled workers
    is incumbent upon the continuation of adequate funding. We encourage
    the Subcommittee to fund WIA formula programs at a minimum at the
    administration's request levels, as we expect to continue to face the
    challenges brought about by high unemployment for the foreseeable
    future.
    Program Funding
        We applaud the Administration's proposal for a Workforce Innovation
    Fund. We believe that the State and local workforce boards have
    developed a host of promising practices since WIA was enacted in 1998,
    particularly in helping address the large numbers of persons dislocated
    during this recession or shut-out of the labor market due to a lack of
    appropriate skills. The Workforce Innovation Fund will allow local
    areas to engage with community partners and quickly scale effective
    practices on behalf of jobseekers in need.
        However, we strongly urge the Subcommittee to fully fund the
    administration's request for WIA formula programs before allocating
    funding for the Workforce Innovation Fund, as these formula funds are
    essential to our ability to provide services to job seekers at the
    local level around the Nation.
        The protection of the WIA formula programs to support the locally
    delivered services is critical as the system continues to deal with
    large numbers of individuals seeking work. The Continuing Resolution
    passed in April contained budget reductions that are already having the
    impact of local areas having to close and consolidate local career one-
    stop centers.
    Policy Riders
        NAWB would strongly encourage the committee to continue the policy
    riders that prohibit the re-designation of local areas or changes to
    the definition of administrative costs until WIA is reauthorized. There
    have been instances where there has been arbitrary action to
    reconfigure local areas and NAWB believes these riders will prevent any
    State v. local conflict until reauthorization.
        We urge the Subcommittee to continue to provide the support
    necessary for the workforce system to help our jobseekers retool for
    employment in high demand sectors and maintain our global
    competitiveness.
    Summer Youth employment
        While our testimony is focused on fiscal year 2012 funding, we
    would be remiss if we did not express our support for summer youth
    funding. Youth unemployment remains at all-time highs. The unemployment
    rate in April 2011 was listed as 9 percent for the total civilian labor
    force, but for youth the rate is over 24 percent for 16-19 year olds.
    In summer 2009 utilizing ARRA funding for WIA Youth programs, 313,000
    young people had a summer job. Youth reported to us that their wages
    provided much needed income to the household for basic needs of their
    family and for the expenses in returning to school. Lack of youth funds
    imperils business finding job-ready youth to fill their employment
    needs as the ``boomer'' generation begins to retire. Serving youth that
    are at-risk and/or school drop-outs with the level of service needed
    requires intense intervention that combines academic, as well as,
    experiential learning techniques. The summer youth employment project
    allowed the system to provide youth practical work experience that
    reinforced classroom academics. Without it, employers in the private
    sector become the work-ready trainers; training that we have reason to
    believe employers are ill-prepared and/or unwilling to provide.
        We understand these budget times, but would hope that at some point
    the Congress would take-up the issue of youth unemployment and we are
    prepared to assure Congress that any additional funding for WIA Youth
    programs would allow us to better address the crisis we are facing in
    youth employment.
        Thank you for the opportunity to testify.
                                     ______

      Prepared Statement of the National Coalition for Cancer Survivorship
        It is my pleasure to submit this statement regarding fiscal year
    2012 funding for the National Institutes of Health (NIH) and the
    Centers for Disease Control and Prevention (CDC) on behalf of the
    National Coalition for Cancer Survivorship (NCCS) and the 12 million
    cancer survivors living in the United States. NCCS advocates for
    quality healthcare for survivors of all forms of cancer, and we believe
    the Federal Government should play a strong leadership role, through
    basic and clinical cancer research and delivery of survivorship
    services, to boost the quality of cancer care from diagnosis and for
    the balance of life. These research and survivorship programs should be
    conducted in partnership with private sector organizations.
        In this statement, NCCS will focus on the need for a balanced
    program of basic, translational, and clinical research at the National
    Institutes of Health (NIH) and the National Cancer Institute (NCI) as
    well as the urgent need for Centers for Disease Control and Prevention
    (CDC) leadership to strengthen educational and informational services
    for survivors and improve access to cancer screening for the medically
    underserved.
        Two recent reports--the Annual Report to the Nation on the Status
    of Cancer, 1975-2007, Featuring Tumors of the Brain and Other Nervous
    System and the Morbidity and Mortality Weekly Report of March 11, 2011,
    reporting on the number of cancer survivors in 2007--provide a
    compelling portrait of the progress the Nation has made in the fight
    against cancer, the work still to be done, and the pressing needs of
    millions of cancer survivors who are still in active treatment or
    living as long-term survivors.
        The Annual Report notes that the incidence of cancer is decreasing;
    the decrease is statistically significant for women although not for
    men, because of a recent increase in prostate cancer incidence. The
    cancer death rates are decreasing for both sexes. The decreases in
    incidence and mortality are attributed to progress in cancer
    prevention, early detection, and treatment. Despite the overall
    progress, there are increasing incidence rates for some cancers and low
    survival for certain forms of cancer. For example, pediatric cancer
    incidence is increasing, although death rates are down. The survival
    from melanoma, pancreatic cancer, liver cancer, and many forms of
    malignant brain tumors remains much too short.
        Those who do survive cancer experience a myriad of late and long-
    term effects. In the editorial note accompanying the Morbidity and
    Mortality Weekly Report that found almost 12 million American cancer
    survivors, CDC stressed the need for more research to identify those
    cancer survivors at risk of recurrence, second cancers, and the late
    effects of cancer and its treatment. CDC also recommended that special
    attention be paid to the burden of survivorship for the medically
    underserved and the older cancer survivor.
    Recommendations for Fiscal Year 2012 Funding
        NCCS recommends smart, effective, and aggressive Federal
    investments in initiatives to improve the quality of care and quality
    of life for cancer survivors. We recommend:
      --A strong and sustained investment in NIH and NCI in fiscal year
            2012 to support basic, translational, and clinical research
            aimed at answering fundamental questions about cancer,
            advancing new and improved cancer treatments, identifying the
            side effects of cancer treatments, and strengthening
            interventions for the late and long term effects of cancer and
            treatment. No reductions should be made in NIH funding in
            fiscal year 2012, in order to prevent interruption of both
            basic and clinical studies and to sustain the progress in
            cancer treatment that we are making through research.
      --Steady progress in the overhaul of the NCI clinical trials system.
            The Institute of Medicine (IOM) has outlined a plan for
            modernizing the clinical trials system and eliminating
            inefficiencies, and NCI leaders have taken steps to implement
            the IOM recommendations. We urge completion of this reform
            effort, to guarantee that patients are willing to enroll in
            clinical research studies because they know they will be
            studies of high quality investigating important issues and
            treatments. An improved system will also ensure that research
            studies are efficiently completed and questions related to new
            treatments are answered without delay.
      --A strong investment in survivorship research that will discover
            those at risk of late and long-term effects from cancer and
            treatment and appropriate interventions for those individuals.
      --A sustained commitment to basic research aimed at detecting
            subtypes of cancer and contributing to the development of
            targeted, or personalized, cancer therapies.
      --Maintenance of the Federal cancer screening programs--including the
            breast and cervical cancer screening program and the colorectal
            cancer screening program--in a manner that will support
            services to medically underserved individuals and ensure early
            detection and diagnosis. The proposal to create a block grant
            of chronic disease programs should not include the screening
            programs, which do not lend themselves to effective
            administration through a block grant.
      --A strong program of education and information regarding
            survivorship services for the 12 million cancer survivors
            living in the United States. CDC has provided grant funding to
            support a survivorship resource center, and we urge that steps
            be taken to ensure that the services offered through the center
            reflect the latest knowledge about the problems of survivors
            and the most appropriate interventions. Morever, special
            populations, including the medically underserved and the
            elderly, should be provided adequate and appropriate
            information and services.
        Federal research and survivorship programs have yielded better
    treatments and enhanced quality of life for millions of American cancer
    patients. These programs should be sustained through continued Federal
    support so that the needs of a growing population of cancer survivors
    can be met.
                                     ______

       Prepared Statement of the National Coalition for Osteoporosis and
                             Related Bone Diseases
        The National Coalition for Osteoporosis and Related Bone Diseases
    (Bone Coalition) would like to take this opportunity to thank you all
    for your continued visionary support of the National Institutes of
    Health--the Nation's biomedical research agency. Because of your past
    efforts and your appreciation of the potential and value of medical
    research, new scientific opportunities are being pursued that hold
    potential for better diagnosis, treatment, prevention and eventually
    cures for diseases such as osteoporosis, osteogenesis imperfecta,
    Paget's disease of bone, and a wide range of rare bone diseases.
        Recommendation.--The National Coalition for Osteoporosis and
    Related Bone Diseases joins with hundreds of health and medical
    organizations of the Ad Hoc Group for Medical Research Funding in
    urging the Committee to provide an appropriation of $35 billion in
    fiscal year 2012 for the National Institutes of Health. This increase
    will create substantial opportunities for scientific and health
    advances, while also providing key economic scientific support in
    communities across the Nation.
        Organized in the early 1990s, the Bone Coalition is dedicated to
    increasing Federal research funding for bone diseases through advocacy
    and education. Five leading national bone disease groups comprise the
    Bone Coalition: two professional societies, the American Academy of
    Orthopaedic Surgeons and the American Society for Bone and Mineral
    Research; and three voluntary health organizations, the National
    Osteoporosis Foundation, the Osteogenesis Imperfecta Foundation, and
    the Paget Foundation for Paget's Disease of Bone and Related Disorders.
        Osteoporosis and related bone diseases are omnipresent--affecting
    people of all ages, ethnicities, and gender. These diseases profoundly
    alter the quality of life and constitute a tremendous burden to
    patients, society and the economy--causing loss of independence,
    disability, pain and death. The annual direct and indirect costs for
    bone and joint healthcare are $849 billion--7.7 percent of the U.S.
    gross domestic product.
      --Osteoporosis is a bone-thinning disease in which the skeleton can
            become so fragile that the slightest movement, even a cough or
            a sneeze can cause a bone to fracture. About 10 million
            Americans already have the disease, and another 34 million
            people have low bone density, which puts them at risk for
            osteoporosis and bone fractures. According to estimated
            figures, osteoporosis was responsible for more than 2 million
            fractures in 2005, including hip, spine, wrist, and other
            fractures. The number of fractures due to osteoporosis is
            expected to rise to more than 3 million by 2025. Approximately
            1 in 2 women and up to 1 in 4 men over age 50 will break a bone
            because of osteoporosis, and an average of 24 percent of hip
            fracture patients age 50 and older will die in the year
            following their fracture. Individuals with certain diseases are
            at higher risk of developing osteoporosis. For example:
            diabetes patients are at increased risk for developing an
            osteoporosis-related fracture; cancer patients are at increased
            risk because many cancer therapies, such as chemotherapy and
            corticosteroids, have direct negative effects on bone; and
            certain cancers, including prostate and breast cancer, may be
            treated with hormonal therapy, which can cause bone loss.
      --Osteogenesis imperfecta, or ``brittle bone disease,'' is an
            inherited genetic disorder characterized by fragile bones which
            fracture easily, often from no apparent cause. A severely
            affected child begins fracturing before birth. Hundreds of
            fractures can be experienced in a lifetime, as well as hearing
            loss, short stature, skeletal deformities, weak muscles and
            respiratory difficulties. As many as 50,000 Americans may be
            affected by this disease.
      --Paget's disease of bone is a geriatric disorder that results in
            enlarged and deformed bones in one or more parts of the body.
            Excessive bone breakdown and formation can result in bone which
            is structurally disorganized, resulting in an overall decrease
            in bone strength and an increase in susceptibility to bowing of
            limbs and fractures. Pain is the most common symptom. Other
            complications include arthritis and hearing loss if Paget's
            disease affects the skull. Paget's disease of bone affects 1\1/
            2\ to 8 percent of older adults depending on a person's age and
            where he or she lives. Approximately 700,000 Americans over the
            age of 60 are affected.
        Past investments in NIH by your Committee have paid dividends for
    patients in the many advances in the bone research field, and these
    investments have had significant impact on public health. In just one
    example, researchers have recently discovered that bisphosphonate drugs
    commonly prescribed for osteoporosis and Paget's disease significantly
    reduce death rates by preventing fractures among older adults,
    producing mortality rates five times lower than those over 60 taking no
    bone medications. Years of basic research by NIH established the
    scientific foundation for development of this type of medication now
    producing significant results.
        And while progress to date has clearly been impressive, there is
    still no cure for osteoporosis, osteogenesis imperfecta, Paget's
    disease or numerous other diseases and conditions that affect the
    skeleton. Depending on the disease, the opportunity to build on recent
    discoveries for new treatments, cures and preventive measures has never
    been greater. With that in mind, the Coalition has identified the
    following areas where further intensive investigation is warranted:
        Office of the NIH Director.--The Coalition urges the Director to
    work with all relevant Institutes to enhance interdisciplinary research
    leading to targeted therapies for improving the density, quality and
    strength of bone for all Americans. More scientific knowledge is needed
    in a number of key areas involving bone and muscle, fat, and the
    central nervous system. Research is also urgently needed to improve the
    identification of populations who might require earlier treatment
    because they are at risk of rapid bone loss due to a wide range of
    conditions or diseases: obesity, diabetes, chronic renal failure,
    cancer, HIV, conditions that affect absorption of nutrients or
    medications, or addiction to tobacco, alcohol or other opiates. The
    Coalition encourages NIH to develop a plan to expand genetics and other
    research on rare bone diseases, including: osteogenesis imperfecta,
    Paget's disease of bone, fibrous dysplasia, osteopetrosis, fibrous
    ossificans progressiva, melorheostosis, X-linked hypophosphatemic
    rickets, multiple hereditary exostoses, multiple osteochondroma,
    Gorham's disease, and lymphangiomatosis.
        National Institute of Arthritis and Musculoskeletal and Skin
    Diseases (NIAMS).--The Coalition urges support for research into the
    pathophysiology of bone loss in diverse populations. The information
    gained will be critical in developing targeted therapies to reduce
    fractures and improve bone density, quality and strength. Efforts are
    needed to determine appropriate levels of calcium and vitamin D for
    bone health at different life stages. Research is also needed in
    assessing bone microarchitecture and remodeling rates for determining
    fracture risk, anabolic approaches to increase bone mass, novel
    molecular and cell-based therapies for bone and cartilage regeneration,
    and discerning the clinical utility of new, non-invasive bone imaging
    techniques to measure bone architecture and fragility. Support for
    studies on the molecular basis of bone diseases such as Paget's
    disease, osteogenesis imperfecta and other rare bone diseases should
    also be a priority.
        National Cancer Institute (NCI).--The Coalition urges
    investigations on how to repair bone defects caused by cancer cells.
    Translational research is also needed to understand the impact of
    metastasis on the biomechanical properties of bone and the mechanisms
    by which bone marrow and tumor derived cells can influence metastatic
    growth, survival and therapeutic resistance.
        National Institute on Aging (NIA).--The Coalition encourages
    research to better define the causes of age-related bone loss and
    fractures, reduced physical performance and frailty, including
    identifying epigenetic changes, with the aim of translating basic and
    animal studies into new therapeutic approaches. Critical research is
    also needed on changes in bone structure and strength with aging, and
    the relationship of age-related changes in other organ systems. The
    prevention and treatment of other metabolic bone diseases, including
    osteogenesis imperfecta, glucocorticoid-induced osteoporosis, and bone
    loss due to kidney disease should also be priority research areas.
        National Institute of Child Health and Human Development (NICHD).--
    The Coalition urges research in the new, emerging field of metabolic
    disease and bone in children and adolescents, especially childhood
    obesity, anorexia nervosa and other eating disorders. Research is also
    needed on what the optimal Vitamin D levels should be in children to
    achieve bone health, and the implications of chronic or seasonal
    Vitamin D deficiency to the growing skeleton. Development and testing
    of therapies and bone building drugs for pediatric patients are also a
    pressing clinical need. The committee is encouraged by results thus far
    from the Bone Mineral Density in Childhood Study (BMDCS) that will
    serve as a valuable resource for clinicians and investigators to assess
    bone deficits in children and risk factors for impaired bone health.
    However the committee is concerned that without further funding to
    continue the study, there will be inadequate data on bone development
    in adolescents and different ethnic groups. Therefore the committee
    encourages NIH to extend the study and to explore research that will
    lead to better understanding and prevention of osteopenia and
    osteoporosis.
        National Institute of Dental and Craniofacial Research (NIDCR).--
    The Coalition urges continued research support on the effects of
    systemic bone active therapeutics on the craniofacial skeleton,
    including factors predisposing individuals to osteonecrosis of the jaw,
    as well as new approaches to facilitate bone regeneration. The
    Coalition commends NIDCR for its longstanding intramural program on
    fibrous dysplasia.
        National Institute of Diabetes and Digestive and Kidney Diseases
    (NIDDK).--The Coalition encourages support for research on the
    relationship between Vitamin D and morbidity and mortality in chronic
    kidney disease. Research is also needed on the value of anti-resorptive
    therapies, the link between renal insufficiency and diabetic bone
    disease, the differences in calcification of blood vessels, the
    mechanisms of metastasis of renal cell carcinoma, and diseases that
    occurs in patients with end stage chronic renal disease on
    hemodialysis.
        National Institute of Neurological Disorders and Stroke (NINDS).--
    The Coalition encourages research support into the pathophysiology of
    spinal cord, brachial plexus, and peripheral nerve injuries in order to
    develop targeted therapies to improve neural regeneration and
    functional recovery.
        National Institute of Biomedical Imaging and Bioengineering
    (NIBIB).--The Coalition encourages critical research to advance our
    ability to treat bone diseases and disorders through bone imaging, as
    well as managing the loss of bone and soft tissue associated with
    trauma by advancing tissue engineering strategies to replace and
    regenerate bone and soft tissue.
    Centers for Disease Control and Prevention
        On another front, prevention is of major concern to the Coalition.
    As the population ages and the ranks of senior citizen Baby Boomers
    expand, the annual cost of acute and long-term care for osteoporosis,
    alone, is projected to increase dramatically from $19 billion annually
    to more than $25 billion by 2025. Without significant intervention now,
    chronic diseases such as osteoporosis will overwhelm efforts to contain
    healthcare costs. Thanks to medical research better diagnosis,
    prevention and screening strategies and treatment therapeutics are now
    available to address the growing problem of osteoporosis.
        The recent HHS report, ``Enhancing Use of Clinical Preventive
    Services Among Older Adults: Closing the Gap,'' calls attention to the
    potential of preventive measures for osteoporosis. The report shows new
    data outlining critical gaps with a high percentage of women on
    Medicare reporting never having received osteoporosis screenings. Yet,
    as the report states, studies have proven that osteoporosis screening
    using hip scans and follow-up management can reduce hip fractures by 36
    percent. In 1999 alone, Medicare spent more than $8 billion to treat
    injuries to seniors, with fractures accounting for two-thirds of the
    spending.
        The Coalition, therefore, urges the Director of the Centers for
    Disease Control to develop an education and outreach plan in
    consultation with the patient and medical community to begin laying the
    ground work to address osteoporosis on a public health basis.
                                     ______

             Prepared Statement of the National Consumer Law Center
        The Federal Low Income Home Energy Assistance Program (LIHEAP) \1\
    is the cornerstone of Government efforts to help needy seniors and
    families stay warm and avoid hypothermia in the winter, as well as stay
    cool and avoid heat stress (even death) in the summer. LIHEAP is an
    important safety net program for low-income, unemployed and
    underemployed families struggling in this economy. The demand for
    LIHEAP assistance remains at record high levels for a third year in a
    row. In fiscal year 2011, the program is expected to help an estimated
    9 million low-income households afford their energy bills. The
    unemployment and poverty forecasts for fiscal year 2012 indicate that
    the number of struggling households will also remain at these high
    levels. In light of the crucial safety net function of this program in
    protecting the health and well-being of low-income seniors, the
    disabled, and families with very young children, we respectfully
    request that LIHEAP be fully funded at its authorized level of $5.1
    billion for fiscal year 2012 and that advance funding of $5.1 billion
    be provided for the program in fiscal year 2013.
    ---------------------------------------------------------------------------
        \1\ 42 U.S.C. Sec. Sec. 8621 et seq.
    ---------------------------------------------------------------------------
    LIHEAP Provides Critical Help With Home Energy Bills for The Large
            Number of Low-Income Households Struggling to Move Forward in
            These Difficult Economic Times
        Funding LIHEAP at $5.1 billion for the regular program in fiscal
    year 2011 is essential in light of the sharp increase in poverty and
    unemployment and the steady climb in home energy prices in recent
    years.\2\ One indicator of the growing need for energy assistance is
    the growing number of disconnections. In States like Ohio that track
    utility disconnections, the disconnection numbers for gas and electric
    residential customers have increased by 23.9 percent over 5 years. For
    the year ending December 2010, there were 452,221 disconnections. For
    the year ending December 2006, there were 364,912 gas and electric
    disconnections. For the years ending December 2009, 2008, and 2007,
    there were 476,490, 424,952, and 424,411 gas and electric
    disconnections respectively. LIHEAP helps bring the cost of essential
    heating and cooling within reach for an estimated 9 million low-income
    households and helps keep these struggling households connected to
    essential utility service.
    ---------------------------------------------------------------------------
        \2\ See, Chad Stone, Arloc Sherman and Hannah Shaw,
    Administration's Rational For Severe Cut in Low-Income Home Energy
    Assistance is Weak, Figure 2 (CBPP calculation of winter fuel price
    index from EIA) Center on Budget and Policy Priorities, February 18,
    2011.
    ---------------------------------------------------------------------------
        The demand for LIHEAP increases when residential home energy prices
    increase, such as the fly up in home heating oil and propane in the
    winter of fiscal year 2011.\3\ Since the winter of 2005-2006, energy
    costs have increased from $1,337 to $2,291 for households heating with
    home heating oil; $1,275 to $2,040 for households heating with propane,
    and $723 to $947 for households heating with electricity. Households
    heating with natural gas have experience more moderate increases from
    $813 to $990. Home energy is also more expensive during prolonged
    periods of extreme temperatures because households use more fuel to
    keep the home at safe temperatures. For example, a colder than normal
    winter can result in higher heating bills than in years past. The third
    variable that drives up the demand for LIHEAP is the number of
    households that are struggling with unemployment, underemployment and
    the number of households in poverty.
    ---------------------------------------------------------------------------
        \3\ Id.
    ---------------------------------------------------------------------------
        Unfortunately, the number of households that are struggling to make
    ends meet remains very high. According a Pew Fiscal Analysis Initiative
    report, as of December 2010, 30 percent of the 14 million unemployed
    have been unemployed for a year or longer.\4\ While long-term
    unemployment has affected all age groups, older workers have been hit
    particularly hard by this downturn.\5\ CBO's budget and economic
    outlook report projects that unemployment will be 8.2 percent by the
    fourth quarter in fiscal year 2012, far from the 5.3 percent that CBO
    estimates is the natural rate of unemployment.\6\ A recent Brookings
    Center on Children & Families analysis looks at the correlation between
    unemployment rates and poverty rates and estimates that the poverty
    rate will increase to over 15 percent in 2012.\7\ Thus indications are
    that the demand for LIHEAP in fiscal year 2012 will remain very strong
    as this program helps struggling households in a number of ways. LIHEAP
    protects the health and safety of the frail elderly, the very young and
    those with chronic health conditions, such as diabetes, that increase
    susceptibility to temperature extremes. LIHEAP assistance also helps
    keep families together by keeping homes habitable during the bitter
    cold winter and sweltering summers.
    ---------------------------------------------------------------------------
        \4\ Pew Economic Policy Group Fiscal Analysis Initiative, Addendum:
    A Year or More: The High Cost of Long-Term Unemployment, January 27,
    2011.
        \5\ Id. (``More than 40 percent of unemployed workers older than 55
    have been out of work for at least a year'').
        \6\ CBO, The Budget and Economic Outlook: Fiscal Years 2011 to
    2021, Summary (January 2011 at Summary Table 2).
        \7\ Emily Monea and Isabel Sawhill, An Update to ``Simulating the
    Effect of the `Great Recession' on Poverty'', Brookings Center on
    Children and Families (September 16, 2010).
    ---------------------------------------------------------------------------
    LIHEAP Is a Critical Safety Net Program for the Elderly, the Disabled
            and Households With Young Children
        Dire Choices and Dire Consequences.--Recent national studies have
    documented the dire choices low-income households face when energy
    bills are unaffordable. Because adequate heating and cooling are tied
    to the habitability of the home, low-income families will go to great
    lengths to pay their energy bills. Low-income households faced with
    unaffordable energy bills cut back on necessities such as food,
    medicine and medical care.\8\ The U.S. Department of Agriculture has
    released a study that shows the connection between low-income
    households, especially those with elderly persons, experiencing very
    low food security and heating and cooling seasons when energy bills are
    high.\9\ A pediatric study in Boston documented an increase in the
    number of extremely low weight children, age 6 to 24 months, in the 3
    months following the coldest months, when compared to the rest of the
    year.\10\ Clearly, families are going without food during the winter to
    pay their heating bills, and their children fail to thrive and grow. A
    2007 Colorado study found that the second leading cause of homelessness
    for families with children is the inability to pay for home energy.\11\
    ---------------------------------------------------------------------------
        \8\ See e.g., National Energy Assistance Directors' Association,
    2008 National Energy Assistance Survey, Tables in section IV, G and H
    (April 2009) (to pay their energy bills, 32 percent of LIHEAP
    recipients went without food, 42 percent went without medical or dental
    care, 38 percent did not fill or took less than the full dose of a
    prescribed medicine, 15 percent got a payday loan). Available at http:/
    /www.neada.org/communications/press/2009-04-28.htm.
        \9\ Mark Nord and Linda S. Kantor, Seasonal Variation in Food
    Insecurity Is Associated with Heating and Cooling Costs Among Low-
    Income Elderly Americans, The Journal of Nutrition, 136 (Nov. 2006)
    2939-2944.
        \10\ Deborah A. Frank, MD et al., Heat or Eat: The Low Income Home
    Energy Assistance Program and Nutritional and Health Risks Among
    Children Less Than 3 years of Age, AAP Pediatrics v.118, no.5 (Nov.
    2006) e1293-e1302. See also, Child Health Impact Working Group,
    Unhealthy Consequences: Energy Costs and Child Health: A Child Health
    Impact Assessment Of Energy Costs And The Low Income Home Energy
    Assistance Program (Boston: Nov. 2006) and the Testimony of Dr. Frank
    Before the Senate Committee on Health, Education, Labor and Pensions
    Subcommittee on Children and Families (March 5, 2008).
        \11\ Colorado Interagency Council on Homelessness, Colorado
    Statewide Homeless Count Summer, 2006, research conducted by University
    of Colorado at Denver and Health Sciences Center (Feb. 2007).
    ---------------------------------------------------------------------------
        When people are unable to afford paying their home energy bills,
    dangerous and even fatal results occur. In the winter, families resort
    to using unsafe heating sources, such as space heaters, ovens and
    burners, all of which are fire hazards. Space heaters pose 3 to 4 times
    more risk for fire and 18 to 25 times more risk for death than central
    heating. In 2007, space heaters accounted for 17 percent of home fires
    and 20 percent of home fire deaths.\12\ In the summer, the inability to
    keep the home cool can be lethal, especially to seniors. According to
    the CDC, older adults, young children and persons with chronic medical
    conditions are particularly susceptible to heat-related illness and are
    at a high risk of heat-related death. The CDC reports that 3,442 deaths
    resulted from exposure to extreme heat during 1999-2003.\13\ The CDC
    also notes that air-conditioning is the number one protective factor
    against heat-related illness and death.\14\ LIHEAP assistance helps
    these vulnerable seniors, young children and medically vulnerable
    persons keep their homes at safe temperatures during the winter and
    summer and also funds low-income weatherization work to make homes more
    energy efficient.
    ---------------------------------------------------------------------------
        \12\ John R. Hall, Jr., Home Fires Involving Heating Equipment
    (Jan. 2010) at ix and 33. Also, 40 percent of home space heater fires
    involve devices coded as stoves.
        \13\ CDC, ``Heat-Related Deaths--United States, 1999-2003'' MMWR
    Weekly, July 28, 2006.
        \14\ CDC, ``Extreme Heat: A Prevention Guide to Promote Your
    Personal Health and Safety'' available at http://emergency.cdc.gov/
    disasters/extremeheat/heat_guide.asp.
    ---------------------------------------------------------------------------
        LIHEAP is an administratively efficient and effective targeted
    health and safety program that works to bring fuel costs within a
    manageable range for vulnerable low-income seniors, the disabled and
    families with young children. LIHEAP must be fully funded at its
    authorized level of $5.1 billion in fiscal year 2012 in light of
    unaffordable, but essential heating and cooling needs of millions of
    struggling households due to the record high unemployment levels.
        In addition, fiscal year 2013 advance funding would facilitate the
    efficient administration of the State LIHEAP programs. Advance funding
    provides certainty of funding levels to States to set income guidelines
    and benefit levels before the start of the heating season. States can
    also better plan the components of their program year (e.g., amounts
    set aside for heating, cooling and emergency assistance,
    weatherization, self-sufficiency and leveraging activities) if there is
    forward funding. Forward funding is critical to LIHEAP running
    smoothly.
                                     ______

         Prepared Statement of the National Council of Social Security
                            Management Associations
        On behalf of the National Council of Social Security Management
    Associations (NCSSMA), thank you for the opportunity to submit our
    written testimony on the fiscal year 2012 funding for the Social
    Security Administration (SSA) to the Subcommittee. I am the President
    of NCSSMA and have been the District Manager of the Social Security
    office in Newburgh, New York for 10 years. I have worked for the Social
    Security Administration for 31 years, with 27 years in management.
        NCSSMA is a membership organization of nearly 3,400 SSA managers
    and supervisors who provide leadership in 1,299 community based Field
    Offices and Teleservice Centers throughout the country. We are the
    front-line service providers for SSA in communities all over the
    Nation. We are also the Federal employees with whom many of your staff
    members work to resolve problems and issues for your constituents who
    receive Social Security retirement, survivors and disability benefits,
    and Supplemental Security Income. Since the founding of our
    organization over 41 years ago, NCSSMA has considered our top priority
    to be a strong and stable Social Security Administration, one that
    delivers quality and prompt locally delivered service to the American
    public. We also consider it a top priority to be good stewards of the
    taxpayers' moneys.
        Appropriations to the Social Security Administration are an
    excellent investment and return on taxpayer dollars. We are very
    appreciative of the support for SSA funding the Subcommittee has
    provided in recent years. The additional funding SSA received in fiscal
    years 2008-2010 helped significantly to prevent workloads from
    spiraling out of control and assisted with improving service to the
    American public.
        NCSSMA strongly supports the President's fiscal year 2012 budget
    request for SSA. The total SSA budget request is $12.667 billion, which
    includes $12.522 billion in administrative funding through the
    Limitation on Administrative Expenses (LAE) account. We respectfully
    request that the Subcommittee provides at the least the President's
    full budget request for SSA in fiscal year 2012. Full funding of this
    request is critical to maintain staffing in SSA's front-line
    components, cover inflationary increases, continue efforts to reduce
    hearing and disability backlogs, and increase deficit-reducing program
    integrity work.
    Current State of SSA Operations
        NCSSMA has critical concerns about the dramatic growth in SSA
    workloads, and the need to receive necessary funding to maintain
    service levels vital to 60 million Americans. Despite agency strategic
    planning, expansion of online services, significant productivity gains,
    and the best efforts of management and employees, SSA is still faced
    with many challenges to providing the service that the American public
    has earned and deserves.
        Over the last 7 years, SSA has experienced a dramatic increase in
    Retirement, Survivor, Dependent, Disability, and Supplementary Security
    Income (SSI) claims. The additional claims receipts are driven by the
    initial wave of the nearly 80 million baby boomers who will be filing
    for Social Security benefits by 2030--an average of 10,000 per day!
    Concurrently, there has been a surge in claims filed due to poor
    economic conditions and rising unemployment levels.
        The need for resources in SSA Field Offices is critical to process
    these additional claims and provide other vital services to the
    American public. Field Offices are responsible for processing 2.4
    million SSI redeterminations in fiscal year 2011, a 100 percent
    increase compared to fiscal year 2008. Nationally, visitors to Field
    Offices increased from 41.9 million in fiscal year 2007 to 45.4 million
    in fiscal year 2010. SSA is also experiencing unprecedented telephone
    call volumes, and in fiscal year 2010, SSA completed 67 million
    transactions over the 800 number network--the most ever. In addition to
    the transactions over the 800 number network, NCSSMA estimates that
    Field Offices receive 32 million public telephone contacts annually.
    SSA Funding for Fiscal Year 2011
        NCSSMA strongly supported the President's fiscal year 2011 budget
    request of $12.379 billion for SSA's administrative expenses. Much of
    this increase was needed to cover inflationary costs for fixed
    expenses. Funding at this level would have assured that SSA could meet
    its public service obligations. Despite SSA's enormous challenges, with
    the Federal deficit concerns, attaining this level of funding was not
    possible. SSA's fiscal year 2011 appropriation for administrative
    funding through the LAE account was $10.7755 billion, which is $25
    million below the fiscal year 2010 enacted level and $275 million was
    rescinded from SSA's Carryover Information Technology funds.
        Inadequate funding of SSA in fiscal year 2011 and additional
    rescissions will have major repercussions for SSA including a hiring
    freeze, reduction of overtime, and postponements of initiatives to
    improve efficiency. Reducing resources at the same time SSA workloads
    are increasing is a prescription for making a very productive agency
    that efficiently uses the taxpayers' moneys into one with significant
    service delays and backlogs. Service deterioration and backlogs
    resulting from inadequate fiscal year 2011 funding levels will have a
    collateral negative impact on fiscal year 2012.
    Field Office Service Delivery Challenges
        SSA Field Offices are experiencing tremendous stress because of
    increased workloads and additional visitors. The effect of funding SSA
    in fiscal year 2011 below fiscal year 2010 levels exacerbates the
    situation and has already had a significant impact on local Field
    Offices around the country.
      --Frontline feedback from our busiest urban offices indicates that
            some have seen their visitor traffic explode with overflowing
            reception areas and increased waiting times.
      --Most of SSA has been under a hiring freeze because of the current
            funding situation. A hiring freeze for all of fiscal year 2011
            could result in a loss of over 2,500 SSA Federal employees.
      --A November 2010, Office of the Inspector General (OIG) Report,
            ``Threats against SSA employees or Property,'' indicates, ``SSA
            has experienced a dramatic increase in the number of reported
            threats against its employees or property. The number of
            threats . . . increased by more than 50 percent in fiscal year
            2009 and by more than 60 percent in fiscal year 2010.''
      --SSA projects 50 percent of its employees, including 66 percent of
            supervisors, will be eligible to retire by fiscal year 2018.
            Serious concerns exist about SSA's ability to sustain service
            levels with the tremendous loss of institutional knowledge from
            front-line personnel.
      --Geographical staffing disparities will occur with attrition leaving
            some offices significantly understaffed. This is problematic
            for rural SSA Field Offices, whose customers often live vast
            distances away, may have no Internet service, and lack access
            to public transportation.
    SSA Online eServices to Assist with Service Delivery Challenges
        The expansion of services available to the American public via the
    Internet has helped to alleviate the number of visitors and telephone
    calls to SSA. However, the Internet is not keeping pace with the
    increasing demand for service. High-volume transactions, such as Social
    Security cards and benefit verifications are not available on the
    Internet, or are only being used to a limited degree. This represents
    over 40 percent of the 45.4 million visitors to SSA Field Offices.
        NCSSMA believes that SSA must be properly funded in fiscal year
    2012 and beyond so that it may continue to invest in improved user-
    friendly online services to allow more online transactions. If
    individuals were able to successfully transact their request for
    services online, this would result in fewer contacts with Field
    Offices, improved efficiencies, and better public service.
    Disability Workload Processes
        Nationwide, over 3.2 million new disability claims were filed and
    sent to State Disability Determination Services in fiscal year 2010.
    This surge of increased claims has created backlogs. At the end of
    fiscal year 2010, the number of pending initial disability claims was
    at an all-time high of 824,192 cases--a 46 percent increase from the
    end of fiscal year 2008. SSA's largest backlogs are hearings, appealing
    initial disability decisions processed by the Office of Disability
    Adjudication and Review. Hearing receipts continue to rise, and through
    April 2011, 734,666 hearings were pending which is over 29,000 more
    hearings than at the end of fiscal year 2010.
        Despite these unprecedented challenges, SSA continues to make
    progress. In March 2011, the average processing time for a hearing was
    359 days, the lowest level since December 2003. Unfortunately, the
    number of claims and hearings pending is still not acceptable to
    Americans who need Social Security to support their families. Progress
    was undermined by the fiscal year 2011 budget impasse, resulting in the
    suspension of opening eight planned Hearing Offices in Alabama,
    California, Indiana, Michigan, Minnesota, Montana, New York, and Texas.
    This significantly threatens to prevent SSA from eliminating the
    hearings backlog by fiscal year 2013.
        It is important to understand that annual appropriated funding
    levels for SSA have a critical impact on the hearings backlog. One of
    the most significant reasons for the increase in the hearings backlog
    was the significant underfunding of SSA from fiscal year 2004 through
    fiscal year 2007.
    President's Proposed Fiscal Year 2012 SSA Budget
        NCSSMA strongly supports the President's fiscal year 2012 budget
    request for SSA and requests that Congress provide full funding to
    sustain the momentum achieved to allow the agency to:
      --Reduce the initial disability claims backlog to 632,000 by
            processing over 3 million claims;
      --Conduct disability hearings for 822,500 cases and reduce the
            waiting time for a hearing decision below a year for the first
            time in a decade;
      --Reduce pending hearings to 597,000 from the fiscal year 2010 level
            of 705,367; and
      --Complete additional program integrity workloads yielding nearly
            $9.3 billion in savings over 10 years, including Medicare and
            Medicaid savings--process 592,000 medical Continuing Disability
            Reviews (CDRs) and 2.6 million SSI redeterminations.
        SSA issues $800 billion in benefit payments annually to 60 million
    people and the agency takes its stewardship responsibilities seriously.
    The fiscal year 2012 budget request includes $938 million dedicated to
    program integrity. Investment in program integrity reviews saves
    taxpayer dollars and is fiscally prudent in reducing the Federal budget
    and deficit.
      --CDRs determine whether an individual is still disabled, or if
            benefits should be ceased because of medical improvement. SSA
            has accumulated a backlog of nearly 1.5 million CDRs. Medical
            CDRs yield $10 in lifetime program savings for every $1 spent.
      --SSI redeterminations review nonmedical factors of eligibility, such
            as income and resources, to identify payment errors. SSI
            redeterminations yield a return on investment of $7 in program
            savings over 10 years for each $1 spent, including Medicaid
            savings accruals.
        NCSSMA recommends consideration of legislative proposals included
    in the fiscal year 2012 budget request, which can improve the effective
    administration of the Social Security program, with minimal effect on
    program dollars. We believe these proposals have the potential to
    reduce operational costs and increase administrative efficiency. This
    includes enacting the Work Incentives Simplification Pilot, requiring
    quarterly reporting of wages, workers compensation automatic reporting,
    and developing an automated system to report state and local pensions.
    Conclusion
        NCSSMA recognizes in the current budget environment that it will be
    difficult to provide adequate funding for SSA. However, Social Security
    is one of the most successful Government programs in the world and
    touches the lives of nearly every American family. We are a very
    productive agency and a key component of the Nation's economic safety
    net for the aged and disabled, but sufficient resources are necessary.
    A strong Social Security program equates to a strong America and it
    must be maintained as such for future generations.
        NCSSMA sincerely appreciates the Subcommittee's interest in the
    vital services Social Security provides, and your ongoing support to
    ensure SSA has the resources necessary to serve the American public. We
    respectfully request your support of full funding of the President's
    fiscal year 2012 budget request on behalf of our agency and the
    American public we serve. We remain confident increased investments in
    SSA will benefit our entire Nation.
        On behalf of NCSSMA members nationwide, thank you for the
    opportunity to submit this written testimony. We respectfully ask that
    you consider our comments, and would appreciate any assistance you can
    provide in ensuring the American public receives the critical and
    necessary service they deserve from the Social Security Administration.
                                     ______

           Prepared Statement of the National Head Start Association
        Chairman Harkin, Ranking Member Shelby, and Members of the
    Subcommittee, thank you for allowing the National Head Start
    Association (NHSA) to submit written testimony in support of funding
    for Head Start and Early Head Start. As the Head Start community's
    voice, NHSA believes that Head Start centers nationwide need the
    resources necessary to provide quality school readiness opportunities
    for young children and their families. The essence of Head Start is a
    national commitment to provide critical early education, health,
    nutrition, child care, parent involvement and family support services
    in return for a lifelong measurable impact on the low-income children
    and families enrolled in Head Start. Today, as our Nation's children
    face greater obstacles than ever before, there is a significant need to
    prepare the next generation for success in school and later in life,
    and Head Start has a proven track record of accomplishing this. The
    Head Start community is pleased to offer the following recommendation
    to Congress as it begins its consideration of fiscal year 2012 funding
    levels.
        NHSA is grateful that the President and Congress made a solid
    commitment to quality early childhood education in the fiscal year 2011
    Continuing Resolution by providing the funds necessary to at least
    maintain services for children currently served by Head Start and Early
    Head Start programs across the country. Quality early education
    prepares the Nation's youngest children for a lifetime of learning. In
    fact, studies show that for every $1 invested in a Head Start child,
    society earns at least $7 back through increased earnings, employment,
    and family stability; and decreased welfare dependency, crime costs,
    grade repetition, and special education. NHSA supports President
    Obama's fiscal year 2012 budget request for $8.1 billion for Head Start
    and Early Head Start. These funds will enable Head Start and Early Head
    Start centers to continue to serve the entire, increasingly vulnerable
    Head Start community for an additional school year, and complete some
    necessary program improvements both to ensure accountability and
    quality, as well as meet the requirements of the 2007 Head Start
    Reauthorization Act.
    Increased Needs of an Increased At-Risk Population
        One of Head Start's greatest challenges is an increasingly needy
    population--both among those served and those eligible for service.
    Today more than one in five children are born into poverty--less than
    $22,050 per year for a family of four. In many areas, Head Start
    directors are seeing a rapid increase of homeless families/children
    enrolled. The Administration's request aims to address some of this
    growing need by allocating a significant portion of the additional
    funds to increasing the number of available Migrant and Seasonal, and
    American Indian and Alaskan Native spaces.
        Though funding for Head Start has increased in recent budget years,
    the cost of serving families has risen at a much faster pace. When
    surveyed, a full 83 percent of Head Start centers reported that their
    costs have increased just over the past year--in fact, 25 percent of
    those who responded report that their fixed costs, including
    maintenance, transportation, and insurance, have increased by more than
    11 percent over the last 12 months. This puts many local centers in the
    awkward position of choosing between serving fewer children and
    families better and according to the statutory quality standards, or
    serving as many as possible with perhaps lesser quality.
        Additionally, Head Start and Early Head Start centers often do not
    have adequate resources during the enrollment process to perform a
    comprehensive needs assessment on all potential enrollees.
    Specifically, targeted funds would enable center directors to
    coordinate more fully with families before enrollment to determine
    their needs and match those needs with the capacity of the center, and
    work with partner organizations that may be better equipped to handle
    special issues. In Kansas City, Kansas, the Project EAGLE Community
    Programs has implemented a sort of ``community triage'' system, whereby
    families are assessed more fully, and dollars are spent much more
    wisely. This approach may also enable many more at-risk families that
    were previously on Head Start waiting lists to receive assistance from
    a multitude of partnering organizations--placing perhaps a higher
    income, yet still impoverished family to a more fitting type of service
    provider and providing a waiting list slot for a needier family.
        Though Head Start and Early Head Start centers are able to accept a
    limited number of children from families with incomes slightly above
    the poverty threshold (up to 130 percent, or $29,055 for a family of
    four) and are required to accept children with special needs, the Head
    Start community shares a commitment to identifying and targeting
    resources, especially in these economic circumstances, to the absolute
    neediest of families. Additional program funds to enable better
    monitoring, needs-assessments, and collaboration will assist Head Start
    providers in meeting this goal.
    Necessary Accountability Improvements
        Head Start and Early Head Start directors are also eager for the
    Administration on Children and Families to fully implement the quality
    improvement provisions included in the 2007 Head Start Reauthorization.
    The law put in place new minimum education requirements for Head Start
    and Early Head Start teachers and caretakers. Though employing highly
    qualified individuals is a goal shared by the National Head Start
    Association, the education requirements necessitate a higher salary
    range in many areas to attract and keep these highly educated
    professionals, putting a strain on the administrative budgets of Head
    Start and Early Head Start Centers. Head Start directors, when
    surveyed, report that they are having difficulty competing with other
    educational entities in their services areas; in many cases, they
    cannot match the salaries provided to qualified individuals in the K-12
    system or in other private pre-schools.
        One of the most anticipated provisions yet to be implemented will
    require Head Start grantees designated as low-performing to compete for
    continuation of their grant. This competition is an enormous
    undertaking for the Office of Head Start and will certainly require
    additional funds to design, fully staff, and execute.
        However, the law also enables the creation of rigorous performance
    standards for each Head Start and Early Head Start center. These have
    not yet been publicly drafted or finalized, though the Head Start
    community is eager to work with Office of Head Start to inform the
    effective design and implementation of these performance standards.
    Further, we hope that the centers can be evaluated against these new
    standards, particularly as they relate to the impending recompetition/
    redesignation. We very much hope that Congress includes report language
    directing the Administration to ensure that Head Start and Early Head
    Start grantees are given the opportunity to realign and monitor
    themselves against the full set of new performance standards before
    being judged as to whether they will be subject to a recompetition/
    redesignation. This will ensure that all grantees, in all areas, are
    judged on consistent standards in competitions going forward.
    Maintenance of Quality
        Lastly, the National Head Start Association supports the
    Administration's proposal to provide $202 million for Training and
    Technical Assistance Activities. Within those funds, we suggest that
    Congress direct the Administration to continue supporting the 10
    Centers of Excellence in Early Childhood that were named last year--in
    the following localities: Greensburg, Pennsylvania; Baltimore,
    Maryland; Mount Vernon, Ohio; Houghton, Michigan; Owensboro, Kentucky;
    Morganton, North Carolina; Birmingham, Alabama; Denver, Colorado;
    Albuquerque, New Mexico; and Dunkirk, New York. Head Start directors
    very much value the advice of fellow practitioners, and the resources
    and tools these Centers have designed and provided to the Head Start
    community are considered effective, well-designed, and serve as models
    for other Head Start and Early Head Start programs to emulate. Their
    innovative practices and collaborative community approaches will be in
    more demand as practitioners adjust to the requirements of the 2007
    law.
    Head Start Works
        Since 1965, Head Start (and now Early Head Start as well) has been
    providing a proven, evidence-based comprehensive program to prepare at-
    risk children and families for a stable, successful life. Head Start
    improves the odds and the options for at-risk kids for a lifetime. Kids
    that have been through Head Start and Early Head Start are healthier,
    more academically accomplished, more likely to be employed, commit
    fewer crimes, and contribute more to society. Head Start is a smart
    investment--one of the smartest and most effective we make. Study after
    study has demonstrated that Head Start has yielded a benefit-cost ratio
    as large as $7 to $1.\1\
    ---------------------------------------------------------------------------
        \1\ Ludwig, J. and Phillips, D. (2007). The Benefits and Costs of
    Head Start. Social Policy Report. 21 (3: 4); Meier, J. (2003, June 20).
    Interim Report. Kindergarten Readiness Study: Head Start Success.
    Preschool Service Department, San Bernardino County, California.
    ---------------------------------------------------------------------------
        Head Start saves our hard-earned tax dollars by decreasing the need
    for children to receive special education services in elementary
    schools.\2\ For example, data analysis of a recent Montgomery County
    Public Schools evaluation found that a MCPS child receiving full-day
    Head Start services requires 62 percent fewer special education
    services and saves taxpayers $10,100 per child annually.\3\ States can
    save $29,000 per year for each prisoner that they incarcerate because
    Head Start children are 12 percent less likely to have been charged
    with a crime.\4\
    ---------------------------------------------------------------------------
        \2\ Barnett, W. (2002, September 13). The Battle Over Head Start:
    What the Research Shows. Presentation at a Science and Public Policy
    Briefing Sponsored by the Federation of Behavioral, Psychological, and
    Cognitive Sciences.
        \3\ NHSA Public Policy and Research Department analysis of data
    from a Montgomery County Public Schools evaluation. See Zhao, H. &
    Modarresi, S. (2010, April). Evaluating lasting effects of full-day
    prekindergarten program on school readiness, academic performance, and
    special education services. Office of Shared Accountability, Montgomery
    County Public Schools.
        \4\ Reuters. (2009, March). Cost of locking up Americans too high:
    Pew study; Garces, E., Thomas, D. and Currie, J. (2002, September).
    Longer-term effects of Head Start. American Economic Review, 92 (4):
    999-1012.
    ---------------------------------------------------------------------------
        Head Start families with increased health literacy experience
    immediate healthcare benefits, including lower Medicaid costs--on
    average $232 lower per family. The program has also reduced mortality
    rates for 5- to 9-year olds by as much as 50 percent.\5\ Studies have
    shown that the program reduces healthcare costs for employers and
    individuals because Head Start children are less obese, \6\ 8 percent
    more likely to be immunized, \7\ and 19 to 25 percent less likely to
    smoke as an adult.\8\
    ---------------------------------------------------------------------------
        \5\ Ludwig, J. and Phillips, D. (2007) Does Head Start improve
    children's life chances? Evidence from a regression discontinuity
    design. The Quarterly Journal of Economics, 122 (1): 159-208.
        \6\ Frisvold, D. (2006, February). Head Start participation and
    childhood obesity. Vanderbilt University Working Paper No. 06-WG01.
        \7\ Currie, J. and Thomas, D. (1995, June). Does Head Start Make a
    Difference? The American Economic Review, 85 (3): 360.
        \8\ Anderson, K.H., Foster, J.E., & Frisvold, D.E. (2009).
    Investing in health: The long-term impact of Head Start on smoking.
    Economic Inquiry, 48 (3), 587-602.
    ---------------------------------------------------------------------------
        And these benefits last a lifetime. Head Start produces measurable,
    long-term results such as school-readiness, increased high school
    graduation rates, and reduced needs for special education. And the more
    than 27 million Head Start graduates are working every day in our
    communities to make our country and our economy strong.
        The Head Start community understands the budgetary pressures the
    Federal Government is facing and while reductions in early childhood
    education may produce short-term savings, as a Nation we cannot afford
    the lasting impact such cuts would impose on our most vulnerable
    children today and on our children's futures. The research shows that
    the ``achievement gap'' is apparent as early as the age of 18 months--
    we will spend substantially more downstream if these same young people
    are not prepared to graduate high-school, attend college and lead
    prosperous lives. We urge the Subcommittee to fully fund the
    President's budget request of $8.1 billion for Head Start and Early
    Head Start in fiscal year 2012.
        Thank you for your time and consideration.
                                     ______

               Prepared Statement of the National Health Council
        The National Health Council (NHC) is the only organization of its
    kind that brings together all segments of the healthcare community to
    provide a united voice for the more than 133 million people with
    chronic diseases and disabilities and their family caregivers. Made up
    of more than 100 national health-related organizations and businesses,
    its core membership includes approximately 50 of the Nation's leading
    patient advocacy groups, which control its governance. Other members
    include professional societies and membership associations, nonprofit
    organizations with an interest in health, and major pharmaceutical,
    medical device, biotechnology, and insurance companies.
        The NHC is well aware of the challenging fiscal environment facing
    the Subcommittee--indeed the entire country. We recognize that Federal
    resources must be carefully targeted to ensure that such investments
    produce the greatest good for the American people. This will involve
    very tough decisions on healthcare priorities by the Subcommittee.
        As work begins on the fiscal year 2012 Labor-HHS appropriations
    bill, the NHC urges the Subcommittee to take a ``global'' view of the
    healthcare system as it identifies funding priorities for the coming
    year. The NHC and its membership, particularly those groups
    representing the patient community, stress that no one aspect of the
    healthcare system--research, public health, healthcare delivery--can be
    considered as a separate, stand-alone component. For a true benefit and
    service to the American people, especially those living with chronic
    conditions, the healthcare system must function through the effective
    and productive interaction of its many parts.
        NHC's members have specific interests that span the entire
    healthcare system. However, a recent survey of our members demonstrated
    that they share a common concern for the entire continuum of the
    healthcare system.
        One aspect of the healthcare system that is of concern to the NHC
    is patient access to care. With healthcare costs rising and a growing
    number of uninsured Americans, far too many people living with chronic
    conditions are not able to access the care needed to maintain their
    health and productivity. This is a concern not just for each individual
    patient but the health system as a whole, which will face greater costs
    due to declining public health. While the NHC views the entire
    healthcare system as important, we recognize that the most vitally
    important piece is for patients to be able to obtain high quality,
    patient-focused care. Without this, the various components are unable
    to serve their intended function and the system as a whole falters.
        Another large concern of the patient community is the lack of
    effective cures and treatments. Too many people who are facing serious
    and life-threatening conditions are doing so without the hope of a cure
    or even a treatment for their symptoms. Funding for biomedical research
    at the National Institutes of Health (NIH) offers this hope. But the
    drug development pipeline does not end with the NIH. Many therapeutics
    are taking longer to reach patients due to a backlog at the Food and
    Drug Administration (FDA). While the scope of FDA regulation has grown
    to the point that it is now regulating one-third of the U.S. economy,
    the agency's funding has remained relatively consistent. This fact is
    troubling to the patient advocacy organizations that represent people
    who lack effective cures and treatments. Both NIH and FDA must be
    adequately funded to increase the likelihood that these patients will
    live longer, healthier, and more productive lives.
        The NHC appreciates the opportunity to submit this written
    testimony to the Subcommittee. We understand that you face many hard
    decisions and again urge that you focus on the healthcare system as
    continuum that patients must be able to access in order to best serve
    the needs of Americans living with chronic conditions.

                                     ______

       Prepared Statement of the National Healthy Mothers Healthy Babies
                                   Coalition
        Highlighting the urgent need to address the startling infant
    mortality rates in the United States by strengthening programs at
    HRSA's Maternal and Child Health Bureau.
        Mr. Chairman and Members of the Subcommittee, thank you for giving
    the National Healthy Mothers, Healthy Babies Coalition (HMHB) the
    opportunity to provide testimony as the Subcommittee begins to consider
    funding priorities for fiscal year 2012. My name is Judy Meehan and I
    am the Chief Executive Officer of HMHB, an organization founded in
    1981, prompted by the U.S. Surgeon General's conference on infant
    mortality. Since its founding, HMHB has become a recognized leader and
    resource in maternal and child health, reaching an estimated 10 million
    healthcare professionals, parents, and policymakers annually through
    its membership of over 100 local, State and national organizations.
        Mr. Chairman, I would like to limit my testimony today to discuss
    an exciting program of HMHB, referred to as the text4baby program. This
    program is focused on improving the health outcomes of mothers and
    babies and demonstrating the potential of mobile health technology to
    reach underserved populations with critical health information. Of the
    33 countries that the International Monetary Fund describes as
    ``advanced economies'' the United States now has the highest infant
    mortality rate according to data from the World Bank. In 1980, we were
    13th and in 2000 we were 2d. In the United States approximately 28,000
    babies die before their first birthday, despite a volume of science
    around behaviors that improve a baby's chances for a healthy birth and
    opportunity to thrive. The text4baby program was launched to help
    address this problem.
        Though the text4baby program has been financed by generous funding
    from Founding Sponsor Johnson & Johnson, with technical and in-kind
    support from Voxiva and CTIA--The Wireless Foundation, we are hopeful
    that with your leadership, the Health Resources and Services Maternal
    and Child Health Bureau can commit to helping us expand this program in
    two States where there is demonstrated and significant need. The
    Maternal and Child Health Block Grant program provides a flexible
    source of funding that allows States to target their most urgent
    maternal and child health needs. The program supports a broad range of
    activities including reducing infant mortality. HMHB recommends that
    funding from within the base of the block grant's Special Projects of
    Regional and National Significance (SPRANS) be provided to text4baby so
    that enrollment in this program could be expanded to targeted and
    special populations in Louisiana and Mississippi, the two States that
    have the worst infant mortality outcomes. Mr. Chairman, HMHB also
    recommends fiscal year 2012 funding for the Maternal and Child Health
    Block Grant program of $695 million, an increase of $33 million or 5
    percent above the level provided in the fiscal year 2011 continuing
    resolution.
    Text4baby Program
        Text4baby, a free mobile information service designed to promote
    maternal and child health, was developed to deliver evidence-based
    health information to the women who need it most: the 1.5 million women
    on Medicaid who give birth each year. While many of these women may
    lack access to the Internet and other sources of health information,
    the vast majority of them do have a cell phone, and a reported 80
    percent of Medicaid beneficiaries are active texters. Text4baby
    provides pregnant women and new moms with information they need to take
    care of their health and give their babies the best possible start in
    life. Women who sign up for the service receive free SMS text messages
    each week, timed to their due date or baby's date of birth. Since its
    launch in February 2010, text4baby has enrolled over 157,000 users and
    delivered over 12 million evidence-based tips to help them women keep
    themselves and their babies healthy. That's a great start but it's not
    enough. Thanks to the grassroots efforts of more than 500 text4baby
    partners across the country, we are on track to achieve our goal of
    bringing the service to 1 million moms by 2012 and delivering over 100
    million timely and relevant health messages.
        The text4baby program was developed in collaboration with the
    Centers for Disease Control and Prevention (CDC), Health Resources and
    Services, Administration (HRSA), American Academy of Pediatrics (AAP),
    and other experts. Text4baby messages cover topics like immunization,
    nutrition, smoking cessation, safe sleep, and the importance of early
    prenatal care. The content also connects women to services such as
    health insurance, childcare, and toll-free ``quitlines'' for assistance
    in becoming smoke- and drug-free. Text4baby has also delivered urgent
    infant product alerts at the request of the Food and Drug
    Administration and outbreak and immunization alerts at the request of
    CDC. Just last month, text4baby moms saw: ``Breaking news! The American
    Academy of Pediatrics announced new car seat guidelines. Kids should
    now ride in rear facing-car safety seats until age 2.''
    Evaluation of the Program
        Mr. Chairman, we know that the program is effective. Over 96
    percent of those enrolled in the program say they would refer a friend
    to the service. Also, preliminary data analysis indicates that
    text4baby is reaching the target audience: for example, analysis of
    enrollment data in Virginia in October, 2010 showed that text4baby
    utilization is highest in zip codes with lower income levels and higher
    incidence rates of low birth weight babies. However, we also want to
    understand if and how text4baby is improving knowledge and changing
    behavior. There are currently six formal evaluations underway to
    examine text4baby's impact. The largest study, funded by the Department
    of Health and Human Services (HHS) and conducted by Mathematica Policy
    Research, is a mixed mode study and includes a mobile survey of
    text4baby users, focus groups, a community survey, electronic health
    record review, and interviews with key partners. This study will assess
    utilization of recommended care during prenatal and postpartum periods
    (considering things such as prenatal visits, postpartum visit, well-
    child visits, dental visits, and immunization); adherence to
    recommended health practices (such as breastfeeding and infant sleep
    position); and adoption of healthy behaviors (such as smoking
    cessation, healthy eating and exercise).
        Even before the formal study results are in, we know that
    delivering over 12 million important evidence-based health tips to over
    160,000 individuals (and, by the end of next year, 100 million messages
    to 1 million moms) is an important national service.
    Expanding the Program
        Glaring disparities in infant mortality exist within certain
    populations in the United States suggesting the need for a targeted
    expansion of the program. For example, babies born to African American
    mothers are most at risk with a rate of 13.5 deaths per 1,000 births.
    The States with the highest rates of infant mortality are Louisiana (10
    babies per 1,000 died before their first birthday) and Mississippi
    (10.5 babies per 1,000 died before their first birthday). In order to
    demonstrate the full impact of text4baby, HMHB proposes a targeted
    outreach and support initiative in those two States. Specifically, HMHB
    proposes to leverage its great array of activities at the national,
    regional, State, and local level to meet the ultimate goal of seeing
    that every woman in Louisiana and Mississippi who is pregnant or a
    mother of a child less than 1 year enrolls in the service and receives
    the valuable health information she needs. This targeted outreach will
    include the development of state-wide implementation teams, technical
    assistance in the way of event planning and media relations,
    fulfillment of requests for information, speakers and promotional
    materials, and support for local data and assessment activities. It
    will also include targeted outreach for African-American and Hispanic
    communities. HMHB's zip-code based analysis will allow tracking of the
    impact of targeted outreach activities with enrollment in real time.
    Mississippi and Louisiana Statistics
        Since its launch in February 2010, text4baby has enlisted 1,276
    users in Mississippi and over 2,768 users in Louisiana; however, in
    2007, 46,491 babies were born in Mississippi and 66,301 babies were
    born in Louisiana. So, clearly, there is work to be done to increase
    enrollment in these States. Unfortunately, these two States are among
    the bottom in the Nation in terms of preterm births, low birth weight,
    and rates of death among children before their first birthday. They are
    also among the top in terms of smoking and obesity rates (see table
    below). These are two States in desperate need of a new way to receive
    information to help them care for their health and give their babies
    the best possible start in life.

                                                      [In percent]
    ----------------------------------------------------------------------------------------------------------------
                                                                        Mississippi      Louisiana       National
    ----------------------------------------------------------------------------------------------------------------
    Preterm.........................................................            18.3            16.6            12.7
    Low birth weight................................................            12.3            11.2             8.2
    IMR.............................................................            10.5            10.0             6.7
    Women smokers...................................................            21.9            22.1            19.6
    Men smokers.....................................................            27.2            25.1            19.6
    Obesity in women................................................            37.1            31.5            24.4
    ----------------------------------------------------------------------------------------------------------------

    Summary and Conclusion
        Mr. Chairman, again we wish to thank the Subcommittee for the
    opportunity to submit testimony and for your leadership in these
    difficult times. While HMHB recognizes the demands on our Nation's
    resources, we believe the continuing decline of our Nation's health and
    the increase in infant mortality justifies a targeted and specific
    effort. In conclusion, we specifically urge that funding from within
    the Maternal and Child Health Bureau's SPRANS program be made available
    for a targeted effort to increase program enrollment among
    disproportionately impacted populations in Louisiana and Mississippi,
    the two States with the worst overall outcomes. We also recommend that
    $695 million be provided in fiscal year 2012 for the Maternal and Child
    Health Block Grant Program, an increase of $33 million or 5 percent
    over the fiscal year 2011 continuing resolution.
                                     ______

      Prepared Statement of the National Hispanic Council on Aging (NHCOA)
        Thank you for the opportunity to submit written testimony. The
    National Hispanic Council on Aging (NHCOA) is the leading organization
    working to improve the lives of Hispanic older adults, their families,
    and caregivers--the fastest growing segment of the U.S.'s rapidly
    expanding aging population. For more than 30 years, NHCOA has been a
    strong voice dedicated to ensuring our Nation's Hispanic seniors enjoy
    healthy and happy golden years. Alongside its nearly 40 local
    affiliates across the country, NHCOA reaches ten million Hispanics each
    year.
        Hispanic older adults experience myriad challenges as they seek to
    obtain a good quality of life in their later years, including health
    inequities and economic insecurity. They are disproportionately
    affected by several health afflictions--among them diabetes,
    hypertension, obesity, and Alzheimer's disease. Exacerbating these
    problems is the low rate of access to preventative care. Hispanics are
    disproportionately employed in low-paying jobs that require low levels
    of formal education or skills and often depend on Social Security as
    their sole source of income later in life.
        NHCOA writes to you today to urge an increase in the funding for
    the Corporation for National and Community Service's Senior Corps and
    the Administration on Aging's Older Americans Act Programs. Senior
    Corps' three programs, the Retired Senior Volunteer Program (RSVP), the
    Foster Grandparent Program, and the Senior Companion Program, keep the
    elderly active and allow the community to benefit from their years of
    wisdom and experience. RSVP connects seniors to volunteer opportunities
    available in their communities. Foster Grandparents tutor and mentor
    at-risk children. The Senior Companion Program provides support to
    volunteers ages 55+ who provide care and friendship to frail elderly.
    Increasing funding to Senior Corps would provide valuable services to
    communities while saving Federal funds. According to Pamela Carre of
    Senior Volunteer Services in Broward County, Florida, during fiscal
    year 2009, the volunteer work provided by Senior Volunteer Services
    valued $6.3 million. All of this work came from Senior Corps
    volunteers. The Older Americans Act provides a wide variety of
    nutrition, caretaking, and training programs to thousands of service
    providers across the country.
        The Older Americans Act's National Family Caregiver Support Program
    and Senior Corps' Senior Companion Program are particularly effective
    and beneficial for Hispanic older adults. Additional funding to these
    programs will help meet the needs of Hispanic older adults in a
    culturally sensitive and effective manner while also easing the
    financial burden on Medicare and Medicaid.
        The Senior Companion program reduces the isolation that can easily
    trap an elderly person. The Program trains volunteers ages 55+ to
    assist vulnerable elderly people. In addition to training and
    placement, the Program also provides a stipend of $2.65 an hour,
    reimbursed travel expenses, and accident and liability insurance.
    Senior Companions assist the elderly, whether by accompanying them on
    visits to the doctor or running their errands. Administrators of the
    Senior Companion Program, like Ms. Carre, highlight the importance of
    the flexible and individualized service these companions provide to
    other older adults. The main service that all Senior Companions provide
    is friendship.
        The Senior Companion Program benefits the elderly and the economy.
    Senior Companions provide assistance that allows elderly people to
    remain independent and out of institutionalized care. Keeping the
    elderly out of nursing homes and assisted living facilities reduces the
    cost of healthcare and keeps people from using Medicaid funds.
    According to Ms. Carre, it costs $4,800 to support one Senior Companion
    annually, while one year in a nursing home costs over $70,000.
    Additionally, Senior Companions can act as home health aides, providing
    assistance in the basic activities of daily living. Senior Companions
    are able to cook for elders, remind them to take their medication,
    perform housekeeping, and keep family aware of their loved one's needs
    and condition. This service, also offered by Medicaid and Medicare, can
    be fulfilled in a cost-effective manner through the Senior Companion
    Program. In a conversation about the value of senior volunteer
    programs, Becky Snider, of Pacific Retirement Services in Medford,
    Oregon, explained that State and local governments recognize the great
    value these programs provide.
        The Senior Companion program has the potential to effectively serve
    Hispanic older adults in a way that other programs cannot. Many in this
    group view formal service providers as impersonal and lacking in
    cultural sensitivity. A dearth of services able to adequately provide
    assistance to Hispanic older adults further exacerbates this problem.
    The Senior Companion program can effectively serve Hispanic older
    adults by offering them friendly and linguistically and culturally
    sensitive services in their own homes. Senior Companions can help
    Hispanic older adults manage their health while also providing
    attention and friendship in a way that home health aides and doctors do
    not. Ms. Leticia Martinez, the administrator of Senior Companion
    Volunteer Service of Los Angeles, states that she has heard from many
    older adults that Senior Companions are often the only people they see
    on a regular basis and that, ``they wouldn't be around without their
    Senior Companion.'' Instead of receiving treatment from a home health
    aide, Senior Companions provide a daily visit from a good friend.
        Like a good friend, Senior Companions advocate for, and protect,
    the older adults with whom they interact. Ms. Martinez stressed that
    many Senior Companions helped their clients identify and avoid
    financial abuse. The Senior Companion Program saves money for our
    seniors.
        Although the Senior Companion program can improve the health of
    seniors and our economy, it is underfunded. The Edward M. Kennedy Serve
    America Act authorized $55 million to be appropriated in fiscal year
    2010, however, only $46.9 million was appropriated that year. In fact,
    the Senior Companion program has not received a substantial increase in
    funding in at least 10 years. The Senior Companion program deserves an
    appropriation of at least $55 million in order to carry out its
    important duties.
        Similar to the Senior Companion Program, the Administration on
    Aging's National Family Caregiver Support Program (NFCSP) plays a vital
    role in protecting older adults. The NFCSP provides grants to States to
    create programs to assist people who care for elderly relatives. These
    programs support family members in providing the best care possible.
    The Administration on Aging grants funds for five broad categories: (1)
    providing information to caregivers about effective caretaking methods
    and available services; (2) assistance in accessing services; (3)
    creation of caregiver support groups and training sessions; (4) funds
    for home health aides to give respite to family caregivers; and (5) on
    a limited basis, supplemental services.
        The NFCSP reduces the financial strain on Medicare and Medicaid. By
    focusing on maintenance of health and prevention of serious problems,
    the NFCSP can keep Hispanic older adults out of nursing homes and off
    Medicaid. Additionally, the ability of NFCSP to provide funding for
    home health aides and training and respite for family caregivers makes
    it less likely for older adults to require a Medicare-financed home
    health aide.
        The NFCSP is perfectly suited to help Hispanic older adults, their
    families, and caregivers. There are valuable, effective programs
    available to help older adults afford healthcare and nursing home
    treatment, but many Hispanics feel that traditional healthcare and
    nursing home programs are too impersonal. The NFCSP addresses this
    problem by providing respite care and training for effective caregiving
    and by improving access to caregiving services. Delivering effective,
    personalized care for older adults in their homes can help manage
    health issues in a comfortable setting. Furthermore, home health aide
    services can provide enough respite care for a family caregiver to take
    on a part-time job, reducing the likelihood that the family will have
    to turn to Medicaid or other forms of public assistance.
        The NFCSP provides support to people who are unexpectedly drawn
    into helping an older family member. While cleaning and errands may be
    the first help given to an elderly loved one, these tasks can quickly
    multiply. The NFCSP teaches family members how to effectively care for
    their elderly relatives and cope with the stress of such care.
    Regarding the value of caregiver training and support groups, Mr. Jose
    Perez, Executive Director of Senior Community Outreach Services in
    Alamo, Texas says, ``I have seen people break down into tears because
    the stress of caring for their father and how close it brought them to
    physically abusing their loved one. Training and support groups help
    them ease this burden.''
        President Obama's fiscal year 2012 budget request recognizes the
    importance of the NFCSP and requests a substantial funding increase. In
    the last several years, the program has received between $153 million
    and $155 million. For fiscal year 2012, President Obama has requested
    over $192 million for the NFCSP. This increased funding will help to
    reduce healthcare costs for seniors while also allowing them to
    maintain their independence and receive effective treatment from those
    who know them best. Hispanic older adults will benefit from increased
    NFCSP funding due to the program's ability to deliver culturally
    sensitive care to a group that traditional healthcare providers have
    thus far struggled to adequately serve.
        Mr. Perez describes the effectiveness of these two programs with a
    simple phrase: ``Everybody wins.'' Senior Companions win the
    satisfaction of helping their fellow citizens and the pride of earning
    wages for productive work. The elderly win by receiving the care and
    attention that they deserve. Families win when they learn how to care
    for their loved ones. The government wins because these programs keep
    the elderly healthy, independent, and off Medicaid.
        NHCOA urges you to appropriate at least $55 million for the
    Corporation for National and Community Service's Senior Companion
    Program. Additionally, we request that you follow President Obama's
    recommendation and appropriate at least $192 million for the
    Administration on Aging's National Family Caregiver Support Program.
    These two programs will not only effectively serve Hispanic older
    adults in a way other programs do not, but they will also ease the
    financial strain on Medicare and Medicaid. Thank you for your
    consideration, and please feel free to contact NHCOA with any questions
    or concerns.
                                     ______

              Prepared Statement of the National Kidney Foundation
        In 2008, the number of Americans with End Stage Renal Disease
    (ESRD), which requires dialysis or a kidney transplant to survive,
    reached 535,000. In that year alone, 110,000 progressed to ESRD.
    Medicare covers dialysis or transplantation regardless of age or other
    disability, the only disease-specific coverage under the program.
    Despite this social and economic impact, no national public health
    program focusing on early detection and treatment existed until fiscal
    year 2006, when Congress provided $1.8 million for the first of 5 years
    of support to initiate a Chronic Kidney Disease Program at the Centers
    for Disease Control and Prevention (CDC). Congressional concern
    regarding kidney disease education and awareness also is found in Sec.
    152 of the Medicare Improvements for Patients and Providers Act of 2008
    (MIPPA, Public Law 110-275), in which it directed the Secretary to
    establish pilot projects to increase screening for Chronic Kidney
    Disease (CKD) and enhance surveillance systems to better assess the
    prevalence and incidence of CKD. Treatments exist to potentially slow
    progression of kidney disease and prevent its complications, but only
    if individuals are diagnosed before the latter stages of CKD.
        The CDC program is designed to identify members of populations at
    high risk for CKD, develop community-based approaches for improving
    detection and control, and educate health professionals about best
    practices for early detection and treatment. The National Kidney
    Foundation respectfully urges the Committee to maintain line-item
    funding in the amount of $2.1 million for the Chronic Kidney Disease
    Program in the CDC's Division of Diabetes Translation. We are
    encouraged by the fiscal year 2011 Operating Plan for CDC, which
    recommends only a $39,000 reduction from the fiscal year 2010
    appropriation for the CKD program. Continued support will benefit
    kidney patients and Americans who are at risk for kidney disease,
    advance the objectives of Healthy People 2020 and the National Strategy
    for Quality Improvement in Health Care, and fulfill the mandate created
    by Sec. 152 of MIPPA.
        The prevalence of CKD in the United States, when last measured, was
    higher than a decade earlier. This is partly explained by the
    increasing prevalence of the related diseases of diabetes and
    hypertension. It is estimated that CKD affects 26 million adult
    Americans \1\ and that the number of individuals in this country with
    CKD who will have progressed to kidney failure, requiring chronic
    dialysis treatments or a kidney transplant to survive, will grow to
    712,290 by 2015 \2\. Furthermore, a task force of the American Heart
    Association noted that decreased kidney function has consistently been
    found to be an independent risk factor for cardiovascular disease (CVD)
    outcomes and all-cause mortality and that the increased risk is present
    with even mild reduction in kidney function.\3\ Therefore addressing
    CKD is a way to achieve one of the priorities in the National Strategy
    for Quality Improvement in Health Care: Promoting the Most Effective
    Prevention and Treatment of the Leading Causes of Mortality, Starting
    with Cardiovascular Disease.
    ---------------------------------------------------------------------------
        \1\ Josef Coresh, et al. ``Prevalence of Chronic Kidney Disease in
    the United States,'' JAMA, November 7, 2007.
        \2\ D.T. Gilbertson, et al., Projecting the Number of Patients with
    End-Stage Renal Disease in the United States to the Year 2015. J Am Soc
    Nephrol 16: 3736-3741, 2005.
        \3\ Mark J. Sarnak, et al. Kidney Disease as a Risk Factor for the
    Development of Cardiovascular Disease: A Statement from the American
    Heart Association Councils on Kidney in Cardiovascular Disease, High
    Blood Pressure Research, Clinical Cardiology, and Epidemiology and
    Prevention. Circulation 2003: 108: 2154-69.
    ---------------------------------------------------------------------------
        Despite the extent of the problem, CKD is an under-recognized and
    under-treated public health challenge in the United States.
    Accordingly, Healthy People 2020 Objective CKD-2 is to ``increase the
    proportion of persons with chronic kidney disease (CKD) who know they
    have impaired renal function.'' One reason CKD is neglected is that it
    is often asymptomatic, especially in the early stages, and, therefore,
    laboratory testing is required to detect it. Increasing the proportion
    of persons with CKD who know they are affected requires expanded public
    and professional education programs and screening initiatives targeted
    at populations who are at high risk for CKD. Thanks to the interest
    that this Committee has expressed in CKD in the past, through directed
    appropriations, the National Center for Chronic Disease Prevention and
    Health Promotion at CDC has instituted a series of projects that could
    assist in attaining the Healthy People 2020 objective. However, this
    forward momentum will be stifled and CDC's investment in CKD to date
    jeopardized if line-item funding is not continued.
        As noted in CDC's Preventing Chronic Disease: April 2006, Chronic
    Kidney Disease meets the criteria to be considered a public health
    issue: (1) the condition places a large burden on society; (2) the
    burden is distributed unfairly among the overall population; (3)
    evidence exists that preventive strategies that target economic,
    political, and environmental factors could reduce the burden; and (4)
    evidence shows such preventive strategies are not yet in place.
    Furthermore, CDC convened an expert panel in March 2007 to outline
    recommendations for a comprehensive public health strategy to prevent
    the development, progression, and complications of CKD in the United
    States.
        The CDC Chronic Kidney Disease program consists of three projects
    to promote kidney health by identifying and controlling risk factors,
    raising awareness, and promoting early diagnosis and improved outcomes
    and quality of life for those living with CKD. These projects include
    the following:
      -- Establishing a surveillance system for Chronic Kidney Disease in
            the United States.
      --Demonstrating effective approaches for identifying individuals at
            high risk for chronic kidney disease through State-based
            screening (CKD Health Evaluation and Risk Information Sharing,
            or CHERISH).
      --Conducting an economic analysis by the Research Triangle Institute,
            under contract with the CDC, on the economic burden of CKD and
            the cost-effectiveness of CKD interventions.
        Pursuant to CHERISH, individuals at high risk for CKD have been
    screened in eight locations in four States. The goals of the
    demonstration project have been:
      --To educate providers and the public that simple tests can be used
            to identify CKD in the target population and to assess risk
            factors for intervention (obesity, hypertension, cardiovascular
            disease, lipid disorders, diabetes, and glycemic control).
      --Evaluate whether providers change practice patterns after being
            consulted by a person who went through the detection program.
        The demonstration project should be replicated at eight sites in
    four additional States in order to confirm initial findings. If we fail
    to do so, we could be forfeiting the valuable insight that has been
    gained thus far.
        We believe it is possible to distinguish between the CKD program
    and other categorical chronic disease initiatives at CDC, because the
    CKD program does not provide funds to State health departments.
    Instead, CDC has been making available seed money for feasibility
    studies in the areas of epidemiological research and health services
    investigation. Because the CKD program does not provide funds to State
    health departments, we maintain it should be exempted from the changes
    in the structure and budget of the National Center for Chronic Disease
    Prevention and Health Promotion, at least until surveillance planning,
    and studies of detection feasibility and economic impact are completed.
        Thank you for your consideration of our testimony.
                                     ______

             Prepared Statement of the National League for Nursing
        The National League for Nursing (NLN) is the premiere organization
    dedicated to promoting excellence in nursing education to build a
    strong and diverse nursing workforce to advance the Nation's health.
    With leaders in nursing education and nurse faculty across all types of
    nursing programs in the United States--doctorate, master's,
    baccalaureate, associate degree, diploma, and licensed practical--the
    NLN has more than 1,200 nursing school and healthcare agency members,
    34,000 individual members, and 24 regional constituent leagues.
        The NLN urges the subcommittee to fund the following Health
    Resources and Services Administration (HRSA) nursing programs:
      --The Nursing Workforce Development Programs, as authorized under
            Title VIII of the Public Health Service Act, at $313.075
            million in fiscal year 2012; and
      --The Nurse Managed Health Clinics, as authorized under Title III of
            the Public Health Service Act, at $20 million in fiscal year
            2012.
    Nursing Education is a Jobs Program
        According to the U.S. Bureau of Labor Statistics (BLS), the
    registered nurse (RN) workforce will grow by 22 percent from 2008 to
    2018, resulting in 581,500 new jobs. This growth will be much faster
    than the average for all occupations. The April 1, 2011 BLS Employment
    Situation Summary--March 2011 likewise reinforces the strength of the
    nursing workforce to the Nation's job growth. While the Nation's
    overall unemployment rate was little changed at 8.8 percent for March
    2011, the employment in healthcare increased in March with the addition
    of 37,000 jobs (i.e., a 36.6 percent rise from February 2011) at
    ambulatory healthcare services, hospitals, and nursing and residential
    care facilities.
        Nursing is the predominant occupation in the healthcare industry,
    with more than 3.78 million active, licensed RNs in the United States
    in 2009. BLS notes that healthcare is a critically important industrial
    complex in the Nation. Growing steadily even during the depths of the
    recession, healthcare is virtually the only sector that added jobs to
    the economy on a net basis since 2001. Over the last 12 months,
    healthcare added 283,000 jobs, or an average of 24,000 jobs per month.
        The Nursing Workforce Development Programs provide training for
    entry-level and advanced degree nurses to improve the access to, and
    quality of, healthcare in underserved areas. These Title VIII nursing
    education programs are fundamental to the infrastructure delivering
    quality, cost-effective healthcare. The NLN applauds the subcommittee's
    bipartisan efforts to recognize that a strong nursing workforce is
    essential to a health policy that provides high-value care for every
    dollar invested in capacity building for a 21st century nurse
    workforce.
        Yet, the current $243.872 million in fiscal year 2010 for the Title
    VIII programs falls short of the healthcare inequities facing our
    Nation. Absent consistent support, recent boosts to Title VIII will not
    fulfill the expectation of paying down on asset investments to generate
    quality health outcomes; nor will episodic increases in funding fill
    the gap generated by a 13-year nurse shortage felt throughout the
    entire U.S. health system.
    The Nurse Pipeline and Education Capacity
        Although the recession resulted in some stability in the short-term
    for the nurse workforce, policy makers must not lose sight of the long-
    term growing demand for nurses in their own districts and States. For
    the complete perspective, the NLN's findings from the Annual Survey of
    Schools of Nursing--Academic Year 2009-2010 cast a wide net on all
    types of nursing programs, from doctoral through diploma, to determine
    rates of application, enrollment, and graduation. The survey creates a
    true picture of nursing education. Key findings include:
      --Expansion of nursing education programs impeded by shortage of
            faculty and clinical placements. The overall systemic capacity
            of prelicensure nursing education continues to fall well short
            of demand. Fully 42 percent of all qualified applications to
            basic RN programs were met with rejection in 2010. Associate
            degree in nursing (ADN) programs rejected 46 percent of
            qualified applications, compared with 37 percent of
            baccalaureate of science in nursing (BSN) programs. Notably,
            the Nation's practical nursing (PN) programs turned away 40
            percent of qualified applications.
      --Yield rates continued to grow. Yield rates--a classic indicator of
            the competitiveness of college admissions--remain
            extraordinarily high among both pre- and post-licensure nursing
            programs. A stunning 94 percent of all applicants accepted into
            ADN programs, and 93 percent of those accepted in PN programs,
            went on to enroll in 2010. Yield rates among the other program
            types were nearly as high, averaging 89 percent for RN-to-BSN
            programs; 86 percent for RN diploma programs, master's in
            nursing (MSN) programs, and doctoral programs; and 84 percent
            for BSN programs.
    Nurse Shortage Affected by Faculty Shortage
        A strong correlation exists between the shortage of nurse faculty
    and the inability of nursing programs to keep pace with the demand for
    new RNs. Increasing the productivity of education programs is a high
    priority in most States, but faculty recruitment is a glaring problem
    that likely will grow more severe. Without faculty to educate our
    future nurses, the shortage cannot be resolved.
        The NLN's findings from the 2009 Faculty Census show that:
      --Shortages of faculty and clinical placements impeded expansion. A
            shortage of faculty continues to be cited most frequently as
            the main obstacle to expansion by RN-to-BSN and doctoral
            programs--indicated by 47 and 53 percent, respectively. By
            contrast, prelicensure programs are more likely to point to a
            lack of available clinical placement settings as the primary
            obstacle to expanding admissions.
      --Inequities in faculty salaries added to shortage difficulties.
            Despite a national shortage of nurse educators, in 2009 the
            salaries of nurse educators remained notably below those earned
            by similarly ranked faculty across higher education. At the
            professor rank nurse educators suffer the largest deficit with
            salaries averaging 45 percent lower than those of their non-
            nurse colleagues. Associate and assistant nursing professors
            were also at a disadvantage, earning 19 and 15 percent less
            than similarly ranked faculty in other fields, respectively.
    Title VIII Federal Funding Reality
        Today's undersized supply of appropriately prepared nurses and
    nurse faculty does not bode well for our Nation. The Title VIII Nursing
    Workforce Development Programs are a comprehensive system of capacity-
    building strategies that provide students and schools of nursing with
    grants to strengthen education programs, including faculty recruitment
    and retention efforts, facility and equipment acquisition, clinical lab
    enhancements, and loans, scholarships, and services that enable
    students to overcome obstacles to completing their nursing education
    programs. HRSA's Title VIII data below provide perspective on a few of
    the current Federal investments.
        Nurse Education, Practice, Quality, and Retention Grants (NEPQR).--
    NEPQR funds projects addressing the critical nursing shortage via
    initiatives designed to expand the nursing pipeline, promote career
    mobility, provide continuing education, and support retention. In
    fiscal year 2010, NEPQR funded 108 infrastructure grants, including the
    launching of 22 nurse-managed health centers, four nurse internships,
    and five new accelerated baccalaureate programs. Also in fiscal year
    2010, the program expanded with the Nursing Assistant (NA) and Home
    Health Aide (HHA) program awarding grants to 10 colleges or community-
    based training programs.
        Comprehensive Geriatric Education Program (CGEP).--CGEP funds
    training, curriculum development, faculty development, and continuing
    education for nursing personnel who care for older citizens. In
    academic year 2009-2010, 27 CGEP grantees provided education and
    training to 3,030 RNs/RN students; 260 advanced practice registered
    nurses (APRNs); 221 faculty; 110 HHSs; 483 LPNs/LPN students; 730 NAs;
    810 allied health professionals; and 929 laypersons, guardians,
    activity directors.
        Advanced Nursing Education (ANE) Program.--ANE supports
    infrastructure grants to schools of nursing for advanced practice
    programs preparing nurse-midwives, nurse anesthetists, clinical nurse
    specialists, nurse administrators, nurse educators, public health
    nurses, or other advanced level nurses. In addition, the Advanced
    Nursing Education Expansion (ANEE) program provides grants to schools
    of nursing to accelerate the production of primary care advanced
    practice nurses. In fiscal year 2009, 151 schools of nursing received
    grants through the ANE Program and enrolled 7,518 advanced nursing
    education students. In fiscal year 2010, 26 schools of nursing received
    grants under ANEE to support the production of over 600 primary care
    APRNs.
    Nurse Managed Health Clinics (NMHC)
        Most leading authorities recognize that there will be a shortage of
    primary care providers over the next decade. With the recent growth of
    NMHCs, APRNs have demonstrated their flexibility as they practice
    independently or collaborate with physicians in both primary care and
    specialty areas. This shift suggests that professionals' practice can
    be directed to changing workforce and population needs as the increased
    use of APRNs holds the potential for improving access, reducing costs
    for high-value care, and changing patterns of care.
        NMHCs deliver comprehensive primary healthcare services, disease
    prevention, and health promotion in medically underserved areas for
    vulnerable populations. Approximately 58 percent of NMHC patients
    either are uninsured, Medicaid recipients, or self-pay. The complexity
    of care for these patients presents significant financial barriers,
    heavily affecting the sustainability of these clinics.
        In fiscal year 2010, HRSA awarded $15,268,000 for 10 3-year
    infrastructure grants to community-based NMHCs. While providing access
    points in areas where primary care providers are in short supply, the
    expansion of the NMHCs also increased the number of structured clinical
    teaching sites available to train nurses and other primary care
    providers. These clinics funded by HRSA in fiscal year 2010 expect to
    train 900 primary care nurse practitioners during their 3-year grants.
    Appropriating $20 million in fiscal year 2012 to NMHCs would increase
    access to primary care for thousands of uninsured people in rural and
    underserved urban communities. The funding of additional NMHCs likewise
    will enable schools of nursing to increase innovative clinical teaching
    site opportunities for nursing students, which will directly expand the
    capacity of nursing school enrollments.
        The NLN can state with authority that the deepening health
    inequities, inflated costs, and poor quality of healthcare outcomes in
    this country will not be reversed until the concurrent shortages of
    nurses and qualified nurse educators are addressed. Your support will
    help ensure that nurses exist in the future who are prepared and
    qualified to take care of you, your family, and all those who will need
    our care. Without national efforts of some magnitude to match the
    healthcare reality facing our Nation today, a calamity in nurse
    education and in healthcare generally may not be avoided.
        The NLN urges the subcommittee to strengthen the Title VIII Nursing
    Workforce Development Programs by funding them at a level of $313.075
    million in fiscal year 2012. We also recommend that the Nurse Managed
    Health Clinics, as authorized under Title III of the Public Health
    Service Act, be funded at $20 million in fiscal year 2012.
                                     ______

              Prepared Statement of the National Marfan Foundation
        Mr. Chairman, thank you for the opportunity to submit testimony
    regarding the fiscal year 2012 budget for the National Heart, Lung and
    Blood Institute, the National Institute of Arthritis, Musculoskeletal
    and Skin Diseases, and the Centers for Disease Control and Prevention.
    The National Marfan Foundation is grateful for the subcommittee's
    strong support of the NIH and CDC, particularly as it relates to life-
    threatening genetic disorders such as Marfan syndrome. Thanks in part
    to your leadership we are at a time of unprecedented hope for our
    patients.
        It is estimated that 200,000 people in the United States are
    affected by Marfan syndrome or a related condition. Marfan syndrome is
    a genetic disorder of the connective tissue that can affect many areas
    of the body, including the heart, eyes, skeleton, lungs and blood
    vessels. It is progressive condition and can cause deterioration in
    each of these body systems. The most serious and life-threatening
    aspect of the syndrome is a weakening of the aorta. The aorta is the
    largest artery carrying oxygenated blood from the heart. Over time,
    many Marfan syndrome patients experience a dramatic weakening of the
    aorta which can cause the vessel to dissect and tear.
        Early surgical intervention can prevent a dissection and strengthen
    the aorta and the aortic valves. If preventive surgery is performed
    before a dissection occurs, the success rate of the procedure is over
    95 percent. If surgery is initiated after a dissection has occurred,
    the success rate drops below 50 percent. Aortic dissection is a leading
    killer in the United States, and 20 percent of the people it affects
    have a genetic predisposition, like Marfan syndrome, to developing the
    complication.
        Fortunately, new research offers hope that a commonly prescribed
    blood pressure medication might be effective in preventing this
    frequent and devastating event.
                fiscal year 2012 appropriations recommendations
    National Institutes of Health
        Mr. Chairman, hope for a better quality of life for patients with
    Marfan syndrome and related connective tissue disorders lies in NIH-
    sponsored biomedical research. With that in mind, NMF joins with other
    voluntary patient and medical organizations in recommending an
    appropriation of $35 billion for the National Institutes of Health in
    fiscal year 2012. , This level of funding will ensure continued
    expansion of research on rare diseases like Marfan syndrome and build
    upon the significant investment provided to the NIH in the American
    Recovery and Reinvestment Act.
    National Heart, Lung, and Blood Institute
                Pediatric Heart Network Clinical Trial
        NMF applauds the National Heart, Lung and Blood Institute for its
    leadership in advancing a landmark clinical trial on Marfan syndrome.
    Under the direction of Dr. Lynn Mahoney and Dr. Gail Pearson, the
    institute's Pediatric Heart Network (PHN) has spearheaded a multicenter
    study focused on the potential benefits of a commonly prescribed blood
    pressure medication (losartan) on aortic growth in Marfan syndrome
    patients.
        Dr. Hal Dietz, the Victor A. McKusick Professor of Genetics in the
    McKusick-Nathans Institute of Genetic Medicine at the Johns Hopkins
    University School of Medicine, and the director of the William S.
    Smilow Center for Marfan Syndrome Research, is the driving force behind
    this groundbreaking research. Dr. Dietz uncovered the role that the
    growth factor TGF-beta plays in aortic enlargement, and demonstrated
    the benefits of losartan in halting aortic growth in mice. He is the
    reason we have reached this time of such promise and NMF is proud to
    have supported Dr. Dietz's cutting-edge research for many years.
        After 4 years of recruitment and patient screening, the PHN trial
    reached its enrollment target of 604 subjects on February 2, 2011.
    Marfan syndrome patients (age 6 months to 25 years) are enrolled in the
    study. Patients are randomized onto either losartan or atenolol (a beta
    blocker that is the current standard of care for Marfan patients with
    an enlarged aortic root).
        We anxiously await the results of this first-ever clinical trial
    for our patient population. It is our hope that losartan will emerge as
    the new standard-of-care and greatly reduce the need for surgery in at-
    risk patients.
        Mr. Chairman, NMF is proud to actively support the losartan
    clinical trial in partnership with the Pediatric Heart Network.
    Throughout the life of the trial we have provided support for patient
    travel costs, coverage of select echocardiogram examinations, and
    funding for ancillary studies. These ancillary studies will explore the
    impact that losartan has on other manifestations of Marfan syndrome.
                Evaluation of Surgical Options for Marfan Syndrome Patients
        Mr. Chairman, we are grateful for the subcommittee's previous
    recommendations encouraging NHLBI to support research on surgical
    options for Marfan syndrome patients.
        For the past several years, the NMF has supported an innovative
    study looking at outcomes in Marfan syndrome patients who undergo
    valve-sparing surgery compared with valve replacement. Initial findings
    were published last year in the Journal of Thoracic and Cardiovascular
    Surgery. Some short term questions have been answered, most importantly
    that valve-sparing can be done safely on Marfan patients by an
    experienced surgeon. The consensus among the investigators however is
    that long-term durability questions will not be answered until patients
    are followed for at least 10 years.
        Confirming the utility and durability of valve sparing procedures
    will save our patients a host of potential complications associated
    with valve replacement surgery. We hope to partner with the NIH on this
    important work moving forward.
                NHLBI ``Working Group on Research in Marfan Syndrome and
                        Related Conditions''
        In 2007, NHLBI convened a ``Working Group on Research in Marfan
    Syndrome and Related Conditions.'' Chaired by Dr. Dietz, this panel was
    comprised of experts in all aspects of basic and clinical science
    related to the disorder. The panel was charged with identifying key
    recommendations for advancing the field of research in the coming
    decade. The recommendations of the Working Group are as follows:

        Scientific opportunities to advance this field are conferred by
    technological advances in gene discovery, the ability to dissect
    cellular processes at the molecular level and imaging, and the
    establishment of multi-disciplinary teams. The barriers to progress are
    addressed through the following recommendations, which are also
    consistent with Goals and Challenges in the NHLBI Strategic Plan.
      --Existing registries should be expanded or new registries developed
            to define the presentation, natural history, and clinical
            history of aneurysm syndromes.
      --Biological and aortic tissue sample collection should be
            incorporated into every clinical research program on Marfan
            syndrome and related disorders and funds should be provided to
            ensure that this occurs. Such resources, once established,
            should be widely shared among investigators.
      --An Aortic Aneurysm Clinical Trials Network (ACTnet) should be
            developed to test both surgical and medical therapies in
            patients with thoracic aortic aneurysms.
      --The identification of novel therapeutic targets and biomarkers
            should be facilitated by the development of genetically defined
            animal models and the expanded use of genomic, proteomic and
            functional analyses. There is a specific need to understand
            cellular pathways that are altered leading to aneurysms and
            dissections, and to develop robust in vivo reporter assays to
            monitor TGFb and other cellular signaling cascades.
      --The developmental underpinnings of apparently acquired phenotypes
            should be explored. This effort will be facilitated by the
            dedicated analysis of both prenatal and early postnatal tissues
            in genetically defined animal models and through the expanded
            availability to researchers of surgical specimens from affected
            children and young adults.
        We look forward to working closely with NHLBI to pursue these
    important research goals and ask the Subcommittee to support the
    recommendations of the Working Group.
    National Institute of Arthritis and Musckuloskeletal and Skin Diseases
        NMF is proud of its longstanding partnership with the National
    Institute of Arthritis and Musculoskeletal and Skin Diseases, which is
    celebrating its 25th anniversary this year. Dr. Steven Katz has been a
    strong proponent of basic research on Marfan syndrome during his tenure
    as NIAMS director and has generously supported several ``Conferences on
    Heritable Disorders of Connective Tissue.'' Moreover, the Institute has
    provided invaluable support for Dr. Dietz's mouse model studies. The
    discoveries of fibrillin-1, TGF-beta, and their role in muscle
    regeneration and connective tissue function were made possible in part
    through collaboration with NIAMS.
        As the losartan trial continues to move forward, we hope to expand
    our partnership with NIAMS to support related studies that fall under
    the mission and jurisdiction of the Institute. One of the areas of
    great interest to researchers and patients is the role that losartan
    may play in strengthening muscle tissue in Marfan patients. We would
    welcome an opportunity to partner with NIAMS on this and other
    research.
    Centers for Disease Control and Prevention
        Mr. Chairman, one of the most important things we can do to prevent
    untimely deaths from aortic aneurysms is to increase awareness of
    Marfan syndrome and related connective tissue disorders.
        Last year, the American College of Cardiology and the American
    Heart Association issued landmark practice guidelines for the treatment
    of thoracic aortic aneurysms and dissections. The NMF is promoting
    awareness of the new guidelines in collaboration with other
    organizations through a new Coalition known as TAD; the Thoracic Aortic
    Disease Coalition. We hope to partner with the CDC in fiscal year 2012
    to increase awareness of the guidelines so all patients will be
    adequately diagnosed and treated. For fiscal year 2012, NMF joins with
    the CDC Coalition in recommending an appropriation of $7.7 billion for
    CDC's core-programs.
                                     ______

            Prepared Statement of the National Minority AIDS Council
        The National Minority AIDS Council (NMAC) represents a coalition of
    over 3,000 community based organizations and AIDS service organizations
    delivering HIV/AIDS services in communities of color nationwide. Our
    constituents are on the front lines of the HIV epidemic and are the
    most affected when funding for HIV/AIDS programs are reduced or
    eliminated.
        Our Nation is facing difficult decisions on how to stabilize the
    economy and pass a sensible Federal budget. Although we support
    efficient, cost-effective spending, we cannot support reducing
    healthcare funding which would adversely affect the health and well
    being of the most vulnerable: minority communities, with higher rates
    of poverty where poor health outcomes are often linked to poor access
    to care. While budget negotiations often focus on cold numbers, it is
    easy to lose sight of the fact that human lives are at stake.
        Cost-effective research and prevention programs that prevent life-
    threatening diseases such as HIV/AIDS, as well as life-saving access to
    care and medications for those already infected are critical in
    preventing avoidable infections, serious illness, and deaths. Although
    funding has failed to keep up with demand, it is impossible to deny the
    strides in prevention, research, and treatment of HIV/AIDS that has
    been supported by previous appropriations.
        We now have a National HIV/AIDS Strategy which sets attainable
    goals in reducing the devastation caused by this epidemic. The Strategy
    calls for a reduction of new infections by 25 percent in the next 5
    years as well as improved access to care for those already infected. As
    we continue to move forward in trying to reduce new infections and
    saving precious lives through the Strategy, it is imperative that the
    existing public health and safety net infrastructure be adequately
    funded.
    Health Care Reform
        In addition to the Strategy, implementation of healthcare reform
    offers a monumental opportunity to make progress in reducing the impact
    of the domestic HIV epidemic by greatly increasing the number of
    Americans eligible for healthcare access. As such, we request full
    funding of the President's fiscal year 2012 budget request for
    healthcare reform programs aimed at reducing health disparities. Many
    of the programs under the Patient Protection and Affordable Care Act
    (ACA) are funded through discretionary budgets. Increased access to
    medical care through venues such as Community Health Centers are
    welcomed as they provide care in cost effective settings when compared
    to the emergency room, which are too often the primary source of
    medical care for communities of color.
    Minority AIDS Initiative (MAI)
        MAI programs seek to improve HIV-related health outcomes for racial
    and ethnic minority communities that are disproportionately affected by
    HIV/AIDS. Central to these goals is the MAI's focus on efforts to
    strengthen the organizational capacity of community-based providers, in
    particular minority providers; improve the quality of HIV services; and
    expand the pool of HIV service providers. NMAC strongly recommends this
    Committee fund MAI programs at $610 million for fiscal year 2012 as
    minority communities continue to carry a disproportionate burden of the
    epidemic. NMAC does appreciate the President's fiscal year 2012 budget
    request of $430.7 million as a minimum budget for MAI.
    HIV/AIDS Bureau of the Health Resources and Services Administration
            (HRSA)
        The number of people living with HIV in the United States has grown
    to over 1.1 million people. That fact coupled with the skyrocketing
    costs of medical care creates a dire need for substantial increases in
    funding for care and treatment. We urge you to increase funding for the
    Ryan White program by $350 million in fiscal year 2012. At minimum, we
    strongly urge you to support the President's proposed fiscal year 2012
    increase of $69.3 million for the Ryan White program over fiscal year
    2010.
        As a payer of last resort, Ryan White provides critical access to
    treatment and medications to under-insured and uninsured people. Part A
    funds are used to provide a continuum of care for people living with
    HIV disease. To support this critical component, we request an increase
    of $74.2 million when compared to fiscal year 2010. Part B funds are
    provided to States to improve their capacity to provide medical care.
    It also funds the AIDS Drug Assistance program (ADAP), which currently
    has a wait list of over 8,100 people with no other means to access
    medications. Eleven States have implemented waiting lists and many
    others have implemented cost containment strategies since funding is
    not keeping up with demand. We request an increase of $76.8 million in
    funding to States as compared to fiscal year 2010 and an increase of
    $106 million for ADAP.
    Centers for Disease Control and Prevention's (CDC) National Center for
            HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP)
        With over 56,000 new infections annually, a renewed emphasis on
    prevention and early HIV screening is critical at this juncture. NMAC
    urges total fiscal year 2012 funding of $1,983.9 million for the CDC's
    NCHHSTP. This includes funding of $1,325.7 million for HIV prevention
    and surveillance, $59.8 million for viral hepatitis and $231 million
    for tuberculosis prevention. We appreciate that the President proposed
    a $1,178.5 million budget for HIV prevention at the CDC, and at a bare
    minimum we urge the Committee to meet this request.
    National Institutes of Health (NIH)--Office of AIDS Research
        HIV/AIDS research has made great strides in understanding and
    improving HIV treatment, viral suppression, and various prevention
    tools. Continued commitment to a thorough AIDS research portfolio is
    necessary to build on past innovation. In order to build on this
    research and continue to see how these interventions affect communities
    of color, NMAC requests $3.5 billion to support the Office of AIDS
    Research. Additionally, NMAC believes that $35 billion to fund NIH's
    overall programs and infrastructure.
        Investments in prevention, treatment and research for HIV, as well
    as co-morbidities, must keep pace with the epidemic if we are to see
    real progress in reducing new infections, disease burden, and untimely
    deaths due to this devastating disease.
                                     ______

             Prepared Statement of the National Minority Consortia
        The National Minority Consortia (NMC) submits this statement on the
    fiscal year 2014 Advance appropriation for the Corporation for Public
    Broadcasting (CPB). The NMC is a coalition of five national
    organizations dedicated to bringing the unique voices and perspectives
    from America's diverse communities into all aspects of public
    broadcasting and to other media, including content transmitted
    digitally over the Internet. The role we fulfill in this regard has
    been crucial to public broadcasting's mission for over 30 years. We are
    unique as organizations and as a coalition of organizations in the
    services we provide in access, training and support for important and
    timely public interest content to our communities and to public
    broadcasting. We ask the Committee to:
      --Direct CPB to increase its efforts for diverse programming with
            commensurate increases for minority programming and for
            organizations and stations located within underserved
            communities;
      --Direct CPB to establish a percentage basis for biennial funding of
            the National Minority Consortia to permit long range financial
            and strategic planning;
      --Direct CPB to establish an annual ``report card'' on diversity to
            track efforts to better represent the full breadth of the
            American people and their experiences through public
            television, public radio and non-profit media online;
      --Direct CPB to publish on the Internet clear and enforced guidelines
            for all CPB-directed funding, including funds jointly
            administered by PBS and NPR, and end the closed-door funding
            processes historically in place, especially as the current
            practices favor existing relationships and can be seen as
            biased against minority applicants, in particular.
        Report Language.--We ask for report language, which recognizes the
    contribution of the NMC and directs that the CPB partnership with us be
    expanded. Specifically:

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

        Fiscal Year 2014 Appropriation.--We support a fiscal year 2014
    advance appropriation for CPB of $495 million, which recognizes the
    need to develop content that reaches across traditional media
    boundaries, such as those separating television and radio. However, we
    feel strongly that should CPB receive this appropriation, CPB should be
    directed to engage in transparent and fair funding practices that
    guarantee all applicants equal access to these public resources. In
    particular, we urge Congress to direct CPB to insert language in all of
    its funding guidelines that encourages and rewards public media that
    fully represents and reaches a diverse American public.\1\
    ---------------------------------------------------------------------------
        \1\ According to the 2008 Public Radio Tech Survey, 90 percent of
    public radio listeners are white. Of those, 84 percent are college-
    educated, with 48 percent having graduate degrees. This compares to
    just 9 percent of Americans who have postgraduate degrees. It is
    therefore mandatory that we prioritize actually ``reaching'' a diverse
    audience of Americans and not simply reflecting diverse and often
    misleading staffing numbers to measure public media's effectiveness in
    serving all of the American taxpayers that fund CPB.
    ---------------------------------------------------------------------------
        While public broadcasting continues to uphold strong ethics of
    responsible journalism and thoughtful examination of American history,
    life and culture, including the ways we are a part of a global society,
    it has not kept pace with our rapidly changing public as far as
    diversity is concerned. Members of minority groups continue to be
    underrepresented on both the programming and oversight levels within
    public broadcasting as well as on the content production side. There
    are fewer than five executives of diverse background at the highest
    levels in the three leading organizations within public broadcasting.
    This is unacceptable in America today, where minorities comprise over
    35 percent of the population.
        Public broadcasting has the potential to be particularly important
    for our Nation's growing minority and ethnic communities, especially as
    we transition to a broadband-enabled, 21st century workforce that
    relies on the skills and talent of all of our citizens. While there is
    a niche in the commercial broadcast and cable world for quality
    programming about our communities and our concerns, it is in the public
    broadcasting sphere where minority communities and producers should
    have more access and capacity to produce diverse high-quality
    programming for national audiences. We therefore, urge Congress to
    insert strong language in this act to ensure that this is the case and
    that these opportunities are made available to minorities and other
    underserved communities.
        About the National Minority Consortia.--With primary funding from
    the CPB, the NMC serves as an important component of American public
    television as well as content delivered over the Internet. By training
    and mentoring the next generation of minority producers and program
    managers as well as brokering relationships between content makers and
    distributors (such as PBS, APT and NETA), we are in a perfect position
    to ensure the future strength and relevance of public television and
    radio television programming from and to our communities. However,
    these efforts are vulnerable because of chronic underfunding and lack
    of meaningful and ongoing representation within CPB's decisionmaking
    processes. This instability, coupled with what is essentially a
    decrease in our funding over time, are the primary reasons that have
    led to a public media that has become less diverse over the past 5
    years.\2\
    ---------------------------------------------------------------------------
        \2\ CPB funding for the NMC remained flat for 13 years until fiscal
    year 2008, at approximately $1 million per year per consortia. At that
    time, we received a one-time increase of $150,000 per organization. In
    fiscal year 2009, we received another one-time increase of
    approximately $500,000 each, but have been told that does not reflect a
    permanent increase. Over this same 13-year period, CPB's budget nearly
    doubled.
    ---------------------------------------------------------------------------
        This is obviously not the case in the rest of America. With
    minority populations already estimated at over 35 percent of the U.S.
    population, it is more important that our public institutions reflect
    this reality.
        Individually, each Consortia organization is engaged in cultivating
    ongoing relationships with the independent producer community by
    providing technical assistance and program funding, support and
    distribution. Often the funding we provide is the initial seed money
    for a project, thus allowing it to develop. We also provide numerous
    hours of programming to individual public television and radio
    stations, programming that is beyond the production reach of most local
    stations. To have a real impact, we need funding that recognizes and
    values the full extent of minority participation in public life.
        While the Consortia organizations work on projects specific to
    their communities, the five organizations also work collaboratively. An
    example of a joint production in which the NMC provided the initial
    seed money is ``Unnatural Causes: Is Inequality Making Us Sick?'', a
    multi-part series that uncovers the roots of racial and socio-economic
    disparities in health and spotlights community initiatives to achieve
    health equality. Our seed money enabled the project to go forward and
    to attract additional funding. We are also co-producers of and
    presenters in this series. Additionally, we jointly funded an online
    initiative around the Presidential Election in 2008 and continue to
    explore as a group other topics of national importance.
        CPB Funds for the National Minority Consortia.--The NMC receives
    funds from two portions of the CPB budget: organizational support funds
    from the Systems Support and programming funds from the Television
    Programming funds. The organizational support funds we receive are used
    for operations requirements and also for programming support activities
    and for outreach to our communities and system-wide within public
    broadcasting. The programming funds are re-granted to producers, used
    for purchase of broadcast rights and other related programming
    activities. Each organization solicits applications from our
    communities for these funds. A brief description of our organizations
    follows:
        Center for Asian American Media (CAAM).--CAAM's mission is to
    present stories that convey the richness and diversity of Asian
    American experiences to the broadest audience possible. We do this by
    funding, producing, distributing and exhibiting works in film,
    television and digital media. Over our 25-year history we have provided
    funding for more than 200 projects, many of which have gone on to win
    Academy, Emmy and Sundance awards, examples of which are Daughter from
    Danang; Of Civil Rights and Wrongs: The Fred Korematsu Story; and Maya
    Lin: A Strong Clear Vision. CAAM presents the annual San Francisco
    International Asian American Film Festival and distributes Asian
    American media to schools, libraries and colleges. CAAM's newest
    department, Digital Media is becoming a respected leader in bringing
    innovative content and audience engagement to public media. CAAM is
    partnering with Pacific Islanders in Communications on a documentary
    about YouTube ukulele sensation Jake Shimabukuro.
        Latino Public Broadcasting (LPB).--LPB supports the development,
    production and distribution of public media content that is
    representative of Latino people, or addresses issues of particular
    interest to Latino Americans. Since 1998, LPB has awarded over $6
    million to Latino Independent Producers, provided over 120 hours to
    public television, funded over 200 projects and conducted over 150
    professional development workshops. LPB also produces Voces, the only
    Latino anthology series on public television, which showcases the
    impact of Latino culture on American life through music, sports,
    education and public service. In addition, LPB had several high profile
    programs on PBS including the concert special, In Performance at the
    White House: Fiesta Latina, that was re-broadcast on Telemundo and V-me
    and Latin Music USA, a four part series about the history and impact of
    Latino music on American culture which reached 14.7 million viewers, 16
    percent of whom were Hispanic households (well above the PBS average).
    This past year, LPB launched the Equal Voice Community Engagement
    Campaign using the documentary film Raising Hope: The Equal Voice
    Story, a film about strategies to overcome poverty. The community
    engagement campaign helped PBS stations demonstrate how they too can
    become advocates for their communities. Currently, LPB is working on a
    6 hour series titled The Latino Americans, about the history of Latinos
    in the United States.
        The National Black Programming Consortium (NBPC).--NBPC develops,
    produces and funds television and more recently audio and online
    programming about the black experience for American public media
    outlets. Since its founding in 1979, NBPC has provided hundreds of
    broadcast hours documenting African American history, culture and
    experience to public television and launched major initiatives that
    have brought important public media content to diverse audiences. In
    2010, the National Black Programming Consortium launched an ambitious
    new project designed to re-engineer public media to better involve and
    inform diverse users in the digital era: The Public Media Corps (PMC).
    The PMC is a new national public media service that helps local
    stations to forge relationships with underserved communities through
    content production, local events, and digital media training. By
    recruiting, training and supporting the work of young, tech savvy
    ``fellows'' from these communities the PMC provides both stations and
    community partner organizations with a blueprint for not only
    connecting with audiences who have traditionally not found public
    broadcasting relevant to their lives, but also by providing them with
    access to emerging participatory platforms.
        Native American Public Telecommunications (NAPT).--NAPT shares
    Native stories with the world through support of the creation,
    promotion and distribution of Native media. Founded in 1977, through
    various media--public television and radio, and the Internet--NAPT
    brings awareness of Indian and Alaska Native issues.
        In 2010 NAPT presented eight Native American documentaries to PBS
    stations nationwide and launched a search capable educational micro-
    site featuring educational guides, post-viewer discussion guides,
    digital media clips, and interactive time lines. NAPT offered producers
    numerous workshops related to media maker topics such as preparation
    for broadcast, marketing your film on a budget, station carriage,
    online promotional tools, podcasting and more through nationwide media
    maker training offerings and conference attendance opportunities. In
    addition NAPT launched the Multimedia Fellowship Program, where two
    full-time Native American journalists wrote and produced multimedia
    projects about national Native American issues. Through our location at
    the University of Nebraska-Lincoln, we offer student employment,
    internships and fellowships. Reaching the general public and the global
    market is the ultimate goal for the dissemination of Native-produced
    media.
        Pacific Islanders in Communications (PIC).--Since 1991, PIC has
    delivered programs and training that bring voice and visibility to
    Pacific Islander Americans. PIC produced the award winning film One
    Voice which tells the story of the Kamehameha Schools Song Contest.
    Other PBS broadcasts include There Once Was an Island, about the
    devastating effects of global warming on the Pacific Islands and
    Polynesian Power: Islanders in Pro Football. Currently PIC is
    developing a multi-part series, Expedition: Wisdom, in partnership with
    the National Geographic Society. PIC offers a wide range of development
    opportunities for Pacific Island producers through travel grants,
    seminars and media training. Producer training programs are held in the
    U.S. territories of Guam and American Samoa, as well as in Hawai`i, on
    a regular basis.
        Thank you for your consideration of our recommendations. We see new
    opportunities to increase diversity in programming, production,
    audience, and employment in the new media environment, and we thank
    Congress for support of our work on behalf of our communities.
                                     ______

         Prepared Statement of the National Multiple Sclerosis Society
        Multiple sclerosis (MS), an unpredictable, often disabling disease
    of the central nervous system, interrupts the flow of information
    within the brain, and between the brain and body. Symptoms range from
    numbness and tingling to blindness and paralysis. The progress,
    severity, and specific symptoms of MS in any one person cannot yet be
    predicted, but advances in research and treatment are moving us closer
    to a world free of MS. Most people with MS are diagnosed between the
    ages of 20 and 50, with at least two to three times more women than men
    being diagnosed with the disease. MS affects more than 400,000 people
    in the United States.
        The National MS Society recommends the following funding levels for
    agencies and programs that are of vital importance to Americans living
    with MS in fiscal year 2012.
    Lifespan Respite Care Program
        Respite care services are a critical part of ensuring quality home-
    based care for people living with MS. Because of the importance of
    these services, the National MS Society requests the inclusion of $50
    million in the fiscal year 2012 Labor-HHS-Education appropriations bill
    to fund lifespan respite programs. The Lifespan Respite Care Program,
    enacted in 2006, provides competitive grants to states to establish or
    enhance statewide lifespan respite programs, improve coordination, and
    improve respite access and quality. States provide planned and
    emergency respite services, train and recruit workers and volunteers,
    and assist caregivers in gaining access to services. Perhaps the most
    critical aspect of the program for people living with MS is that
    Lifespan Respite serves families regardless of special need or age--
    literally across the lifespan. Much existing respite care has age
    eligibility requirements and since MS is typically diagnosed between
    the ages of 20 and 50, Lifespan Respite Programs are often the only
    open door to needed respite services.
        Up to one-quarter of individuals living with MS require long-term
    care services at some point during the course of the disease. Often, a
    family member steps into the role of primary caregiver to be closer to
    the individual with MS and to be involved in care decisions.
    Approximately 65 million family caregivers in the Nation are
    responsible for 80 percent of long-term care. The value of
    uncompensated family care giving services keeps growing and is
    currently estimated at $375 billion per year--more than total Medicaid
    spending and almost as high as Medicare spending. Family caregiving,
    while essential, can be draining and stressful, with caregivers often
    reporting difficulty managing emotional and physical stress, finding
    time for themselves, and balancing work and family responsibilities.
    The impact is so great, in fact, that American businesses lose an
    estimated $17.1 to $33.36 billion each year due to lost productivity
    costs related to caregiving responsibilities. Providing $50 million for
    Lifespan Respite in fiscal year 2012 would provide the critical
    infrastructure to states to improve access to respite services,
    allowing family caregivers to take a break from the daily routine and
    stress of providing care, improve overall family health, and help
    alleviate the monstrous financial impact that caregiver strain
    currently has on American businesses.
    National Institutes of Health
        We urge Congress to continue its investment in innovative medical
    research that can help prevent, treat, and cure diseases such as MS by
    providing $35 billion for the National Institutes of Health (NIH) in
    fiscal year 2012.
        The NIH conducts and sponsors a majority of the MS related research
    carried out in the United States. Approximately $151 million of fiscal
    year 2010 and Recovery Act appropriations were directed to MS-related
    research. An invaluable partner, the NIH has helped make significant
    progress in understanding MS. NIH scientists were among the first to
    report the value of MRI in detecting early signs of MS, before symptoms
    even develop. Advancements in MRI technology allow doctors to monitor
    the progression of the disease and the impact of treatment.
        Research during the past decade has enhanced knowledge about how
    the immune system works, and major gains have been made in recognizing
    and defining the role of this system in the development of MS lesions.
    These NIH discoveries are helping find the cause, alter the immune
    response, and develop new MS therapies that are now available to modify
    the disease course, treat exacerbations, and manage symptoms. The NIH
    also directly supports jobs in all 50 States and 17 of the 30 fastest
    growing occupations in the United States are related to medical
    research or healthcare. More than 83 percent of the NIH's funding is
    awarded through almost 50,000 competitive grants to more than 325,000
    researchers at over 3,000 universities, medical schools, and other
    research institutions in every State. To continue the forward momentum
    in the ability to aggressively combat, treat, and one day cure diseases
    like MS, the National MS Society requests Congress provide $35 billion
    for the NIH in fiscal year 2012.
    Centers for Medicare & Medicaid Services
                Medicare
        Medicare programs are a lifeline for people living with MS, as
    approximately one-quarter of people living with MS rely on Medicare for
    access to essential medical care. These programs ensure that
    individuals living with MS have access to doctors, diagnostic
    equipment, durable medical devices, MRIs, and prescription drugs among
    other lifesaving treatments. Medicare also ensures full access to home
    healthcare, which is vital for keeping individuals with disabilities,
    like MS, in their communities and in their homes. Without Medicare,
    people living with MS may not have access to some forms of medical care
    and their quality of life may decrease.
        The National MS Society is concerned about recent budget proposals
    that would essentially convert Medicare from an entitlement program to
    a voucher-type program. While proponents of these proposals believe
    that they will cut costs of the program, in reality the voucher system
    would primarily shift costs from the Medicare program to patients and
    consumers. In fact, the Congressional Budget Office has estimated that
    by 2030, the typical Medicare beneficiary would be required to pay more
    than two-thirds of their medical costs. Additionally, according the
    Kaiser Family Foundation, a typical 65-year-old retiring in 2022 would
    be expected to devote nearly half their monthly Social Security checks
    toward healthcare costs, more than double what they would spend under
    current Medicare law.
        Beginning in 2022, the proposed system would give new beneficiaries
    money to purchase insurance from the private market, under the
    assumption that beneficiaries can make better and more cost-effective
    decisions about healthcare than the government and that this open
    market will create competition that will help keep costs down. However,
    the size of Medicare allows the program to impose lower rates on
    medical services and thus, private plans on average are more expensive.
    Therefore, the proposed voucher system may reduce costs within the
    Medicare program but not within the overall healthcare system because
    it will shift more cost to some of the most vulnerable patients in the
    healthcare system. In order to continue to provide the adequate and
    necessary care individuals with MS and other disabilities require,
    Medicare must maintain its status as an entitlement program.
                Medicaid
        The National MS Society urges Congress to maintain funding for
    Medicaid and reject proposals to cap or block grant the program.
        Approximately 10 percent of people living with MS rely on Medicaid.
    The program has a strong track record of providing services that grant
    individuals with disabilities access to employment, cost-effective
    health services, home- and community-based services, and long-term
    care.
        Capping or block-granting Medicaid will merely shift costs to
    states, forcing states to shoulder a seemingly insurmountable financial
    burden or cut services on which our most vulnerable rely. Capping and
    block-granting could result in many more individuals becoming
    uninsured, compounding the current problems of lack of coverage, over
    flowing emergency rooms, limited access to long term services, and
    increased healthcare costs in an overburdened system. By capping funds
    that support home- and community-based care, such proposals would also
    likely lead to an increased reliance on costlier institutional care
    that contradicts the principles laid forth in the 1999 U.S. Supreme
    Court Olmstead decision of integrating and keeping people with
    disabilities in their communities.
        While the economic situation demands leadership and thoughtful
    action, the National MS Society urges Congress to remember people with
    MS and all disabilities, their complex health needs, and the important
    strides Medicaid has made for persons living with disabilities,
    particularly in the area of community-based care and not modify the
    program to their detriment.
    Social Security Administration
        The National MS Society urges Congress to provide $12.522 billion
    for the Social Security Administration's (SSA) Limitations on
    Administrative (LAE) Expenses to fund SSA's day-to-day operational
    responsibilities and make key investments in addressing increasing
    disability and retirement workloads, in program integrity, and in SSA's
    Information Technology (IT) infrastructure.
        Because of the unpredictable nature and sometimes serious
    impairment caused by the disease, SSA recognizes MS as a chronic
    illness or ``impairment'' that can cause disability severe enough to
    prevent an individual from working. During such periods, people living
    with MS are entitled to and rely on Social Security Disability
    Insurance (SSDI) or Supplemental Security Income (SSI) benefits to
    survive. People living with MS, along with millions of others with
    disabilities, depend on SSA to promptly and fairly adjudicate their
    applications for disability benefits and to handle many other actions
    critical to their well-being including: timely payment of their monthly
    benefits; accurate withholding of Medicare Parts B and D premiums; and
    timely determinations on post-entitlement issues, e.g., overpayments,
    income issues, prompt recording of earnings.
        With an expected increase in disability claims of nearly 29 percent
    between fiscal year 2008 and fiscal year 2010, SSA faces an
    unprecedented backlog in unprocessed disability claims. The average
    processing time is fortunately improving due to recent investments in
    and appropriations to SSA and as of March 2010, was approximately 437
    days or a little more than 14 months. This progress must continue.
        Providing at least $12.522 billion for the SSA is necessary to
    continue these programs and advancements, which are integral parts of
    efficiently and effectively getting benefits to individuals with
    disabilities, including those with MS.
    Food and Drug Administration
        Because of the tremendous impact the FDA has on the development and
    availability of drugs and devices for individuals with disabilities,
    the National MS Society requests that Congress provide a 15 percent
    increase over the fiscal year 2011 budget.
        Advancements in medical technology and medical breakthroughs play a
    pivotal role in decreasing the societal costs of disease and
    disability. The FDA is responsible for approving drugs for the market
    and in this capacity has the ability to keep healthcare costs down.
    Each dollar invested in the life-science research regulated by the FDA
    has the potential to save upwards of $10 in health gains. Breakthroughs
    in medication and devices can reduce the potential costs of disease and
    disability in Medicare and Medicaid and can help support the healthier,
    more productive lives of people living with chronic diseases and
    disabilities, like MS. The approval of low-cost generic drugs saved the
    healthcare system $140 billion last year and nearly $1 trillion over
    the past decade. However, recent funding constraints have resulted in a
    2 year backlog of generic drug approval applications and could
    potentially cost the Federal Government and patients billions of
    dollars in the coming years. The potential for these cost-saving
    medical breakthroughs and overall healthcare savings relies on a
    vibrant industry and an adequately funded FDA. Therefore, Congress is
    urged to provide the FDA with a 15 percent increase to address this
    backlog.
    Conclusion
        The National MS Society thanks the Committee for the opportunity to
    provide written testimony and our recommendations for fiscal year 2012
    appropriations. The agencies and programs we have discussed are of
    vital importance to people living with MS and we look forward to
    continuing to working with the Committee to help move us closer to a
    world free of MS.
                                     ______

      Prepared Statement of the National Network to End Domestic Violence
    Introduction
        I am submitting testimony to request a targeted investment of $196
    million in the Family Violence Prevention and Services Act (FVPSA) and
    the Violence Against Women Act (VAWA) programs administered by the U.S.
    Department of Health and Human Services fiscal year 2012 budget
    (specific requests detailed below).
        Labor, Health and Human Services Chairman Harkin, Ranking Member
    Shelby, Chairman Inouye, Ranking Member Cochran and distinguished
    members of the Appropriations Committee, thank you for this opportunity
    to submit testimony to the Committee on the importance of investing in
    FVPSA and VAWA programs. I sincerely thank the Committee for its
    ongoing support and investment in these lifesaving programs. These
    investments help to bridge the gap created by an increased demand and a
    lack of available resources.
        I am the President of the National Network to End Domestic Violence
    (NNEDV), the Nation's leading voice on domestic violence. We represent
    the 56 State and territorial domestic violence coalitions, including
    those in Iowa, Alabama, Hawaii and Mississippi, their 2,000 member
    domestic violence and sexual assault programs, as well as the millions
    of victims they serve. Our direct connection with victims and victim
    service providers gives us a unique understanding of their needs and
    the vital importance of continued Federal investments.
    Incidence, Prevalence, Severity and Consequences of Domestic and Sexual
            Violence
        The crimes of domestic and sexual violence are pervasive, insidious
    and life-threatening. Nearly one in four women are beaten or raped by a
    partner during adulthood \1\ and 2.3 million people are raped and/or
    physically assaulted by a current or former spouse or partner each
    year.\2\ One in six women and 1 in 33 men have experienced an attempted
    or completed rape.\3\ Of course the most heinous of these crimes is
    murder. Every day in the United States, an average of three women are
    killed by a current or former intimate partner.\4\In 2005 alone, 1,181
    women were murdered by an intimate partner in the United States \5\ and
    approximately one-third of all female murder victims are killed by an
    intimate partner.\6\
    ---------------------------------------------------------------------------
        \1\ AU.S. Department of Justice, National Institute of Justice and
    Centers for Disease Control and Prevention. (July 2000). Extent,
    Nature, and Consequences of Intimate Partner Violence: Finding from the
    National Violence Against Women Survey. Washington, DC. Tjaden, Pl., &
    Thoennes., N.
        \2\ Ibid.
        \3\ U.S. Department of Justice, Prevalence, Incidence, and
    Consequences of Violence Against Women: Findings from the National
    Violence Against Women Survey (1998).
        \4\ Bureau of Justice Statistics (2008). Homicide Trends in the
    U.S. from 1976-2005. Dept. of Justice.
        \5\ Ibid.
        \6\ Bureau of Justice Statistics, Homicide Trends from 1976-1999.
    (2001)
    ---------------------------------------------------------------------------
        The cycle of intergenerational violence is perpetuated as children
    are exposed to violence. Approximately 15.5 million children are
    exposed to domestic violence every year.\7\ One study found that men
    exposed to physical abuse, sexual abuse and adult domestic violence as
    children were almost 4 times more likely than other men to have
    perpetrated domestic violence as adults.\8\
    ---------------------------------------------------------------------------
        \7\ McDonald, R., et al. (2006). ``Estimating the Number of
    American Children Living in Partner-Violence Families.'' Journal of
    Family Psychology, 30(1), 137-142.
        \8\ Greenfield, L. A. (1997). Sex Offences and Offenders: An
    Analysis of Date on Rape and Sexual Assault. Washington, DC. Bureau of
    Justice Statistics, U.S. Department of Justice.
    ---------------------------------------------------------------------------
        In addition to the terrible cost domestic and sexual violence have
    on the lives of individual victims and their families, these crimes
    cost taxpayers and communities. In fact, the cost of intimate partner
    violence exceeds $5.8 billion each year, of which $4.1 billion is for
    direct medical and mental healthcare services.\9\ Research shows that
    intimate partner violence costs a health insurance plan $19.3 million
    each year for every 100,000 women between the ages of 18 and 64 who are
    enrolled.\10\ Domestic violence costs U.S. employers an estimated $3 to
    $13 billion annually.\11\ Between one-quarter and one-half of domestic
    violence victims report that they lost a job, at least in part, due to
    domestic violence.
    ---------------------------------------------------------------------------
        \9\ National Center for Injury Prevention and Control. Costs of
    Intimate Partner Violence Against Women in the United States. Atlanta
    (GA): Centers for Disease Control and Prevention; 2003.
        \10\ Ibid.
        \11\ Bureau of National Affairs Special Rep. No. 32, Violence and
    Stress: The Work/Family Connection 2 (1990); Joan Zorza, Women
    Battering: High Costs and the State of the Law, Clearinghouse Rev.,
    Vol. 28, No. 4, 383, 385; Supra, see endnote 10.
    ---------------------------------------------------------------------------
        Despite this grim reality, we know that when a coordinated response
    is developed and immediate, essential services are available, victims
    can escape from life-threatening violence and begin to rebuild their
    shattered lives. Funding these programs is fiscally sound, as they save
    lives, prevent future violence, keep families and communities safe, and
    save our Nation money. While Federal funding cannot meet all the needs
    of victims, it leverages State, private and local dollars to provide
    consistent funding streams to lifesaving services. To address unmet
    needs and build upon its successes, VAWA/FVPSA should receive targeted
    investments in fiscal year 2012.
        Family Violence Prevention and Services Act (FVPSA) (Administration
    for Children and Families)--$140 million request. Since its passage in
    1984 as the first national legislation to address domestic violence,
    FVPSA has remained the only funding directly for shelter programs. For
    more than 25 years, FVPSA has made substantial progress toward ending
    domestic violence. Despite the progress and success brought by FVPSA, a
    strong need remains for FVPSA-funded services for victims.
        Domestic violence is more than a crime--it is a public health
    issue. To address this issue, there are more than 2,000 community-based
    domestic violence programs for victims and their children
    (approximately 1,500 of which are FVPSA-funded through State formula
    grants). These programs offer services such as emergency shelter,
    counseling, legal assistance, and preventative education to millions of
    women, men and children annually and are at the heart of our Nation's
    response to domestic violence.\12\ These effective programs save and
    rebuild lives. A recently released multi-state study conclusively shows
    that the Nation's domestic violence shelters are addressing victims'
    urgent and long-term needs and are helping victims protect themselves
    and their children. This same study indicated that, if shelters did not
    exist, the consequences for victims would be dire, including
    ``homelessness, serious losses including children [or] continued abuse
    or death.''
    ---------------------------------------------------------------------------
        \12\ National Coalition Against Domestic Violence, Detailed Shelter
    Surveys (2001).
    ---------------------------------------------------------------------------
        According to a report by the National Network to End Domestic
    Violence, in one day in 2010, more than 70,000 victims of domestic
    violence received services, of which 50 percent found refuge in
    emergency shelters and transitional housing. Of the 23,743 victims in
    emergency shelter that day, more than 50 percent were children.
    However, on that same day, more than 9,500 requests for services by
    adults and children were unmet due to lack of funding.
    Addressing the Needs of Children and Breaking the Intergenerational
            Cycle of Violence
        In addition to providing crisis services to adults fleeing
    violence, FVPSA helps to break the intergenerational cycle of violence.
    Approximately one-half to two-thirds of residents in domestic violence
    shelters are children. In 2010, Congress reauthorized FVPSA that
    included a newly authorized program, Specialized Services for Abused
    Parents and Their Children. In fiscal year 2010, Congress appropriated
    nearly $131 million for FVPSA, which for the first time triggered
    spending dedicated to specialized service for children who witness
    domestic violence.
        The newly authorized Children's program is an important step in the
    Federal Government's response to domestic violence. It will build an
    evidence base for services, strategies, advocacy and interventions for
    children and youth exposed to domestic violence. Although many domestic
    violence programs currently serve children, this program will expand
    the capacity of domestic violence programs to address the needs of
    children and adolescents coming into emergency shelters. To ensure that
    children's needs are met in the community, the program will create
    statewide and local improvements in systems and responses to children
    and youth exposed to domestic violence. Finally, the program will
    eventually lead to nationwide dissemination of lessons learned and
    strategies for implementation in communities across the country.
        Currently, four States have received modest funding grants to build
    upon their work and lay groundwork for the national project. The New
    Jersey Coalition for Battered Women will expand an established model
    program, Peace: A Learned Solution (PALS), which provides children ages
    3 through 17 with creative arts therapy to help them heal from exposure
    to domestic violence. The Wisconsin Coalition Against Domestic Violence
    will launch the Safe Together Project, which will increase the capacity
    of Wisconsin domestic violence programs, particularly those serving
    under-represented or culturally specific populations, to support non-
    abusing parents and mitigate the impact of exposure to domestic
    violence on their children. The Alaska Network on Domestic Violence and
    Sexual Assault will improve services and responses to Alaska's families
    by addressing the lack of coordination between domestic violence
    agencies and child welfare systems. Together, grantees will serve as
    leaders for expanding a broader network for support; developing
    evidence-based interventions for children, youth and parents exposed to
    domestic violence; and building national implementation strategies that
    will lead to local improvements in domestic violence program and
    community systems interventions.
        Unfortunately, the rescission in the final fiscal year 2011 budget
    cut all funding for the new children's program. If the funding is not
    restored to at least $140 million in fiscal year 2012, these innovative
    and cost-saving projects will be in jeopardy.
    The Increased Need for Funding
        Many programs across the country use their FVPSA funding to keep
    the lights on and their doors open. We cannot overstate how important
    this is: victims must have a place to flee to when they are escaping
    life-threatening violence. Countless shelters across the country would
    not be able to operate without FVPSA funding. As increased training for
    law enforcement, prosecutors and court officials has greatly improved
    the criminal justice system's response to victims of domestic violence,
    there is a corresponding increase in demand for emergency shelter,
    hotlines and supportive services. Additionally, demand has increased as
    a result of the economic downturn and victims with fewer personal
    resources become increasingly vulnerable. Since the economic crisis
    began, three out of four domestic violence shelters have reported an
    increase in women seeking assistance from abuse.\13\ As a result,
    shelters overwhelmingly report that they cannot fulfill the growing
    need for these services.
    ---------------------------------------------------------------------------
        \13\ Mary Kay's Truth About Abuse. Mary Kay Inc. (May 12, 2009).
    ---------------------------------------------------------------------------
        In the current economic climate, the demand for domestic violence
    services has increased precisely at the time when programs are
    struggling to maintain State and private funding to meet the demand. In
    fact, the National Domestic Violence Census found that in 2010, 1,441
    (82 percent) domestic violence programs reported a rise in demand for
    services, while at the same time, 1,351 (77 percent) programs reported
    a decrease in funding.\14\ Between 2009 and 2010, domestic violence
    programs laid off or did not replace nearly 2,000 staff positions
    including counselors, advocates and children's advocates, and a number
    of shelters around the country closed. In 2009, although FVPSA-funded
    domestic violence programs provided shelter and nonresidential services
    to more than 1 million victims, an additional 167,069 requests for
    lifesaving shelter went unmet due to lack of capacity. In Alabama, the
    problem reflects the rest of the Nation. More than 30 percent of
    Alabama programs reported that they did not have enough funding for
    needed programs and services and 17 percent reported no available beds
    or funding for hotels. In Iowa, nine programs statewide have already
    closed their doors due to funding shortages and many other programs
    have been forced to reduce the types of services provided, including
    eliminating child advocate positions and prevention programs dedicated
    to breaking the cycle of violence.
    ---------------------------------------------------------------------------
        \14\ Domestic Violence Counts 2010: A 24-Hour census of domestic
    violence shelters and services across the United States. The National
    Network to End Domestic Violence. (Jan. 2011).
    ---------------------------------------------------------------------------
        We cannot allow the gap between available resources and the
    desperate need of victims to widen. For those individuals who are not
    able to find safety, the consequences can be extremely dire, including
    continued exposure to life-threatening violence or homelessness. It is
    absolutely unconscionable that victims cannot find safety for
    themselves and their children due to a lack of adequate investment in
    these services. In order to meet the immediate needs of victims in
    danger and to continue to break the intergenerational cycle of
    violence, FVPSA funding must be increased to at least $140 million in
    fiscal year 2012.
    Additional Requests
                National Domestic Violence Hotline (Administration for
                        Children and Families)--$5 million request
        For the past 15 years the Hotline has provided 24-hour, toll-free
    and confidential services, immediately connecting callers to local
    service providers. During this economic downturn, crisis calls to the
    Hotline have increased. Additionally, to address the specific needs of
    dating violence victims, the Hotline launched the National Dating Abuse
    Helpline, which has seen increased traffic recently.
                DELTA Prevention Program (Centers for Disease Control and
                        Injury Prevention)--$6 million request
        DELTA is one of the only sources of funding for domestic violence
    prevention work. The program supports statewide projects that integrate
    primary prevention principles and practices into local coordinated
    community responses that address and reduce the incidence of domestic
    violence. Currently, DELTA funds 56 Coordinated Community Response
    Coalitions nationwide. In the first 3 years that DELTA funded these
    projects, the primary prevention activities in communities increased
    ten-fold. Nineteen States, including Alabama and Iowa, are currently
    funded as DELTA Prep states by the Robert Wood Johnson Foundation.
    Without additional DELTA funding, these States, ready in 2012 to fully
    participate, may not be able to access CDC funding.
                Rape Prevention and Education (RPE) (Centers for Disease
                        Control and Injury Prevention)--$42.6 million
                        request
        This VAWA program administered through CDC strengthens national,
    State and local sexual violence prevention efforts and the operation of
    rape crisis hotlines. RPE funding provides formula grants to States and
    territories to support rape prevention and education programs conducted
    by rape crisis centers, State sexual assault coalitions and other
    public and private nonprofit entities. Funding also supports the
    National Sexual Violence Resource Center, which provides up-to-date
    information regarding sexual violence to policymakers, Federal and
    State agencies, college campuses, sexual assault and domestic violence
    coalitions, local programs, the media, and the general public. Despite
    its critical work, RPE has faced funding decreases since fiscal year
    2006.
                Violence Against Women Health Initiative (Office of Women's
                        Health)--$2.3 million request
        This eight State and two tribe initiative promotes public health
    programs that integrate domestic and sexual violence assessment and
    intervention into basic care. Congress has included the program in the
    last 3 fiscal years, but after the first year, the funding has not been
    on top of the agency's overall budget. As a result, HHS has been forced
    to cut other violence prevention activities to fund the program.
    Funding is needed to identify best practices, conduct general
    evaluation and disseminate the results to the field so that victims
    nationwide can benefit.
    Conclusion
        Together, these LHHS programs work to prevent and end domestic and
    sexual violence. While our country has made continued investments in
    the criminal justice response to these heinous crimes, we need an equal
    investment in the human service, public health and prevention response
    in order to holistically address and end violence against women. We
    know that our Nation is facing a difficult financial time and that
    there is pressure to reduce spending. Investments in these vital, cost-
    effective programs, however, help break the cycle of violence, reduce
    related social ills and will save our Nation money now and in the
    future.
                                     ______

          Prepared Statement of the National Postdoctoral Association
        Thank you for this opportunity to testify in regard to the fiscal
    year 2012 funding for the National Institutes of Health (NIH). We are
    writing today in regard to support for postdoctoral scholars,
    specifically in support of the 4-percent increase in the NIH Ruth L.
    Kirschstein National Research Service Awards (NRSA) training stipends,
    as requested in the President's budget.
    Background: Postdocs are the Backbone of U.S. Science and Technology
        According to estimates by The National Science Foundation (NSF)
    Division of Science Resource Statistics, there are approximately 89,000
    postdoctoral scholars in the United States\1\. The NIH and the NSF
    define a ``postdoc'' as: An individual who has received a doctoral
    degree (or equivalent) and is engaged in a temporary and defined period
    of mentored advanced training to enhance the professional skills and
    research independence needed to pursue his or her chosen career path.
    The number of postdocs has been steadily increasing. The incidence of
    individuals taking postdoc positions during their careers has risen,
    from about 25 percent of those with a pre-1972 doctorate to 46 percent
    of those receiving their doctorate in 2002-05 \2\. Moreover, the number
    of science and engineering doctorates awarded each year is steadily
    rising with doctorates awarded in the medical/life sciences almost
    tripling between 2003 and 2007 \3\.
    ---------------------------------------------------------------------------
        \1\ National Science Foundation Division of Science Resource
    Statistics. (January 2010). Science and engineering indicators 2010.
    Arlington, VA: National Science Board.
        \2\ Ibid.
        \3\ Ibid.
    ---------------------------------------------------------------------------
        Postdocs are critical to the research enterprise in the United
    States and are responsible for the bulk of the cutting edge research
    performed in this country. Consider the following:
      --According to the National Academies, postdoctoral researchers
            ``have become indispensable to the science and engineering
            enterprise, performing a substantial portion of the Nation's
            research in every setting.'' \4\
    ---------------------------------------------------------------------------
        \4\ COSEPUP. (June 2001). Enhancing the postdoctoral experience for
    scientists and engineers. Washington, D.C.: National Academy Press. p.
    10.
    ---------------------------------------------------------------------------
      --Postdoctoral training has become a prerequisite for many long-term
            research projects.\5\ In fact, the postdoc position has become
            the de facto next career step following the receipt of a
            doctoral degree in many disciplines.
    ---------------------------------------------------------------------------
        \5\ COSEPUP. (June 2001). Enhancing the postdoctoral experience for
    scientists and engineers. Washington, D.C.: National Academy Press. p.
    11.
    ---------------------------------------------------------------------------
      --The retention of women and under-represented groups in biomedical
            research depends upon their successful and appropriate
            completion of the postdoctoral experience.
      --Postdoctoral scholars carry the potential to solve many of the
            world's most pressing problems; they are the principal
            investigators of tomorrow.
        Unfortunately, postdocs are routinely exploited. They are paid a
    low wage relative to their years of training and are often ineligible
    for workman's compensation, disability insurance, paid maternity or
    paternity leave, employer-sponsored medical benefits, and retirement
    accounts.
        The National Postdoctoral Association (NPA) advocates for policies
    that support and enhance postdoctoral training. NPA members advocate
    for policy change on the national level and also within the research
    institutions that host postdoctoral scholars. To date, more than 150
    institutions have adopted portions of the NPA's recommended practices,
    but low compensation remains one of the serious issues faced by the
    postdoctoral community.
    Problem: NRSA Stipends are Low and Don't Meet Cost-of-Living Standards;
            For Better or Worse, Postdoc Compensation is Based on NRSA
            Stipends
        The NIH leadership has been aware that the NRSA training stipends
    are too low since 2001, after the publication of the results of the
    National Academy of Sciences (NAS) study, Addressing the Nation's
    Changing Needs for Biomedical and Behavioral Scientists. In response,
    the NIH pledged (1) to increase entry-level stipends to $45,000 by
    raising the stipends at least 10 percent each year and (2) to provide
    automatic cost-of-living increases each year thereafter to keep pace
    with inflation. Most recently, the 2011 NAS study, Research Training in
    the Biomedical, Behavioral, and Clinical Research Sciences, called for,
    among other recommendations, increased funding to support more NRSA
    positions and to fulfill the NIH's 2001 commitment to increase pre-
    doctoral and postdoctoral stipends.
        Without sufficient appropriations from Congress, the NIH has not
    been able to fulfill its pledge. In 2007, the stipends were frozen at
    2006 levels and since then have not been significantly increased. The
    stipends were increased by 1 percent each year in 2009 and 2010 and by
    2 percent in 2011. The 2011 entry-level training stipend remains low,
    at $38,496, the equivalent of a GS-8 position in the Federal Government
    (NIH Statement NOT-OD-10-047), despite the postdocs' advanced degrees
    and specialized technical skills. Furthermore, this stipend remains far
    short of the promised $45,000. Certainly, it is not reflective of any
    cost-of-living increases (please see Figure 1).

                                    Figure 1

        It is not only the NRSA fellows who remain undercompensated; the
    impact of the low stipends extends beyond the NRSA-supported postdocs.
    The NPA's research has shown that the NIH training stipends are used as
    a benchmark by research institutions across the country for
    establishing compensation for postdoctoral scholars. Thus, an
    unintended consequence is that institutions undercompensate all of
    their postdocs, who must then struggle to make ends meet, which in turn
    affects their productivity and undermines their efforts to solve the
    world's most critical problems. Additionally, many are leaving their
    research careers behind because of the low compensation. In order to
    keep the ``best and the brightest'' scientists in the U.S. research
    enterprise, the NPA believes that it is crucial that Congress
    appropriate funding for the 4-percent increase in training stipends, as
    a moderate yet substantial step toward reaching the recommended entry-
    level stipend of $45,000.
    Solution: Keep the NIH's Original Promise to Raise the Minimum Stipends
        We ask the Subcommittee to appropriate $794 million for the 4-
    percent stipend increase, as requested in the President's proposed
    budget (http://www.nih.gov/about/director/budgetrequest/
    NIH_BIB_020911.pdf): As part of the President's initiative in fiscal
    year 2012 to emphasize support for science, technology, engineering,
    and mathematics (STEM) education programs, the budget proposes a 4
    percent stipend increase for predoctoral and postdoctoral research
    trainees supported by NIH's Ruth L. Kirschstein National Research
    Service Awards program. A total of $794 million is requested in fiscal
    year 2012 for this training program. The proposed increase in stipends
    will allow NIH to continue to attract high quality research trainees
    that will be available to address the Nation's future biomedical,
    behavioral, and clinical research needs.
        The NPA believes it is fair, just, and necessary to increase the
    compensation provided to these new scientists, who make significant
    contributions to the bulk of the research discovering cures for disease
    and developing new technologies to improve the quality of life for
    millions of people in the United States. Please do not hesitate to
    contact us for more information. Thank you for your consideration.
                                     ______

          Prepared Statement of the National Primate Research Centers
        The Directors of the eight National Primate Research Centers
    (NPRCs) respectfully submit this written testimony for the record to
    the Senate Appropriations Subcommittee on Labor, Health and Human
    Services, Education and Related Agencies. The NPRCs appreciate the
    commitment that the Members of this Subcommittee have made to
    biomedical research through your support for the National Institutes of
    Health (NIH) and recommend that you provide $31.987 billion for NIH in
    fiscal year 2012, which represents a 3.4 percent increase above the
    fiscal year 2011 level. Within this proposed increase the NPRCs also
    respectfully request that the Subcommittee provide strong support for
    the NPRC P51 (base grant) program, which is essential for the
    operational costs of the eight NPRCs. This support would help to ensure
    that the NPRCs and other animal research resource programs continue to
    serve effectively in their role as a vital national resource.
        The mission of the National Primate Research Centers is to use
    scientific discovery and nonhuman primate models to accelerate progress
    in understanding human diseases, leading to better health. The NPRCs
    collaborate as a transformative and innovative network to support the
    best science and act as a resource to the biomedical research community
    as efficiently as possible. There is an exceptional return on
    investment in the NPRC program; $10 is leveraged for every $1 of
    research support for the NPRCs. It is important to sustain funding for
    the NPRC program and the NIH as a whole to continue to grow and develop
    the innovative plan for the future of NIH.
    NPRCs Contributions to NIH Priorities
        The NPRCs activities are closely aligned with NIH's priorities. In
    fact, NPRC investigators conduct much of the Nation's basic and
    translational nonhuman primate research, facilitate additional vital
    nonhuman primate research that is conducted by hundreds of
    investigators from around the country, provide critical scientific
    expertise, train the next generation of scientists, and advance
    cutting-edge technologies. The NPRCs currently are engaged with NIH
    staff in a comprehensive strategic planning process to further enhance
    the capabilities of the NPRCs to serve as a resource across all NIH
    institutes and centers. The NPRC consortium strategic plan has as its
    center and driving force the scientific priorities that drive
    translational work into better interventions and diagnostics for
    improved human health. Outlined below are a few of the overarching
    goals of the plan, including specifics of how the NPRCs are striving to
    achieve these through programs and activities across the centers.
        Advance Translational Research Using Animal Models.--Nonhuman
    primate models bridge the divide between basic biomedical research and
    implementation in a clinical setting. Currently, seven of the eight
    NPRCs are affiliated and collaborate with NIH Clinical and
    Translational Science Awards (CTSA) program through their host
    institution. Specifically, the nonhuman primate models at the NPRCs
    often provide the critical link between research with small laboratory
    animals and studies involving humans. As the closest genetic model to
    humans, nonhuman primates serve in the development process of new
    drugs, treatments, and vaccines to ensure safe and effective use for
    the Nation's public.
        Strengthen the Research Workforce.--The success of the Federal
    Government's efforts in enhancing public health is contingent upon the
    quality of research resources that enable scientific research ranging
    from the most basic and fundamental to the most highly applied.
    Biomedical researchers have relied on one such resource--the NPRCs--for
    nearly 50 years for research models and expertise with nonhuman
    primates. The NPRCs are highly specialized facilities that foster the
    development of nonhuman primate animal models and provide expertise in
    all aspects of nonhuman primate biology. NPRC facilities and resources
    are currently used by over 2,000 NIH funded investigators around the
    country.
        The NPRCs are also supportive of getting students interested in the
    biomedical research workforce pipeline at an early age. For example,
    the Yerkes NPRC supports a program that connects with local high
    schools and colleges in Atlanta, Georgia, and invites students to
    participate in research projects taking place at their field station
    location.
        Offer Technologies to Advance Translational Research and Expand
    Informatics Approaches to Support Research.--The NPRCs have been
    leading the development of a new Biomedical Informatics Research
    Network (BIRN) for linking brain imaging, behavior, and molecular
    informatics in nonhuman primate preclinical models of neurodegenerative
    diseases. Using the cyberinfrastructure of BIRN for data-sharing, this
    project will link research and information to other primate centers, as
    well as other geographically distributed research groups.
    Translational Science at the NPRCs
        Animal models are an essential tool for translating basic
    biomedical research to treatments and cures for patients, and the NPRCs
    are a national resource instrumental to this effort. The network of the
    eight NPRCs collaborates across many disciplines and institutions, with
    the goal of advancing biomedical knowledge to understand disease and
    improve human and animal health. Below are specific examples of
    translational research conducted at each of the eight NPRCs.
        In work conducted at the California National Primate Research
    Center, Immunoglobulin G (IgG) antibodies purified from mothers of
    children with autism and mothers of typically developing children were
    injected into pregnant rhesus monkeys. The offspring were then
    evaluated both neurologically and behaviorally. Offspring of mothers
    who received IgG from mothers of children with autism demonstrated
    significantly higher levels of repetitive behaviors than the offspring
    who received control antibodies. There are currently no diagnostic
    tests for autism. This research identifies one potential autoimmune
    cause of autism. Moreover, detection of the maternal autoantibodies may
    become an early diagnostic test for increased risk of having a child
    with autism. This research, which relied on treating pregnant rhesus
    monkeys, could not have been conducted without the facilities provided
    by the national primate center.
        Rhesus monkeys are widely used as animal models across many fields
    of biomedical research because of their genetic, physiological,
    behavioral, and anatomical similarities to humans. Scientists at the
    New England National Primate Research Center are taking advantage of
    the genetic similarity between rhesus monkeys and humans to create the
    first monkey model of alcoholism genetics. Recent studies in human
    alcoholics who are treated with naltrexone, a leading medication for
    alcohol dependence, have shown that the medication works better in
    people who have a specific genetic variant in the OPRM1 gene.
    Scientists at the New England NPRC identified a similar genetic change
    in the rhesus monkey OPRM1 gene, and have shown that monkeys with the
    genetic change not only drink more alcohol but also have a comparable
    genetically determined response to naltrexone to that seen in some
    human alcoholics. This animal model gives scientists a new way to
    create personalized medications for the treatment of alcoholism.
        A new technique developed by a research team at the Oregon National
    Primate Research Center offers a way for women with mitochondrial
    diseases to have their own children without passing on defective
    genetic material. According to the scientists, defective genes in
    mitochondria can be passed to children at a frequency of 1 in 4,000
    births and can lead to a variety of diseases. Symptoms of these
    potentially fatal illnesses include dementia, movement disorders,
    blindness, hearing loss, and problems of the heart, muscle, and kidney.
    Following this successful study in a nonhuman primate model, scientists
    believe that the technique could be applied quickly to humans to
    prevent devastating diseases.
        In 2005, researchers were looking for an animal model in which to
    test a prototype device which might ameliorate degenerative disc
    disease, a major cause of disability in working-age adults. The baboon
    was chosen as an appropriate animal model for safety testing of the new
    device because of its upright posture and the high magnitude of forces
    placed on the vertebral column during the baboon's natural movement.
    After a small pilot study, two subsequent pre-clinical studies were
    performed at the Southwest National Primate Research Center. This was
    an international effort in which specialists from Denmark, Canada, and
    the United Kingdom visited the Primate Center on numerous occasions to
    participate in the studies. The data from these studies along with data
    from human clinical trials are now being assembled for submission to
    the U.S. Food and Drug Administration for approval to use the
    artificial disc in the United States as an alternative for the
    treatment of degenerative lumbar spinal disease.
        Testing the safety and efficacy of potential compounds in nonhuman
    primates is virtually essential to advancing microbicide candidates to
    clinical trials to prevent HIV transmission. There are far too many
    microbicide candidates in development for all of them to be tested in
    human trials. Over the years, the Tulane National Primate Research
    Center has facilitated microbicide studies in nonhuman primates that
    have led to human clinical trials, and have been the only successful
    predictor of success or failure of compounds in these trials.
    Furthermore, candidates that were not sufficiently tested in nonhuman
    primates prior to human trials were shown to fail, and later studies,
    once performed in macaques, confirmed they would have been predictive
    of failure.
        Studies completed at the Tulane NPRC have resulted in Merck
    releasing one of these compounds to the International Partnership for
    Microbicides (IPM) for microbicide development and human clinical
    testing. Based on the positive results in macaque studies, the IPM also
    has been granted license to pursue topical development of Pfizer's
    Maraviroc as a microbicide. Nonhuman primate testing has resulted in a
    wealth of information that has prevented expensive clinical trials in
    humans that would have otherwise been fruitless.
        Recovery of function after stroke, traumatic brain injury or spinal
    cord injury is a significant medical challenge for millions of patients
    in the United States. A promising new treatment for many of these
    disabled survivors is an implantable recurrent brain-computer interface
    (R-BCI). The Washington National Primate Research Center developed R-
    BCI, a ``neurochip'' that records neural activity from the brain and
    transforms that activity into stimuli delivered to the brain, spinal
    cord, or muscles during free behavior. R-BCI technology has the
    clinical potential to aid patients paralyzed by ALS or spinal cord
    injury to regain some motor control directly from cortical cells and
    may also be used to strengthen weak connections impaired by stroke.
        Researchers and physicians are getter closer to a novel diagnostic
    test for polycystic ovary syndrome (PCOS), which has staggering adverse
    physiological, psychological, and financial consequences for women's
    reproductive health. Scientists at the Wisconsin National Primate
    Research Center are studying the profile of metabolites in both monkey
    and patient samples of blood, urine, sweat, and breath molecules to
    identify signals in the body's internal chemistry that are consistent
    with the syndrome. From the vast pool of metabolites in their samples,
    they have found a handful that rise to the surface as indicators of
    PCOS. These telltale molecules could become the basis for the first-
    ever diagnostic test for the syndrome.
        A recent study based on work conducted at the Yerkes National
    Primate Research Center with nonhuman primates illustrates the promise
    of the Visual Paired Comparison (VPC) task for the detection of mild
    memory impairment associated with Alzheimer's disease (AD). To
    investigate this possibility, the Yerkes NPRC recently extended their
    collaborations to include the Department of Computer Sciences at Emory
    University. The results show that eye movement characteristics
    including fixation duration, saccade length and direction, and re-
    fixation patterns can be used to automatically distinguish impaired and
    normal subjects. Accordingly, this generalized approach has proven
    useful for improving early detection of AD, and may be applied, in
    combination with other behavioral tasks, to examine cognitive
    impairments associated with other neurodegenerative diseases.
    Researchers at the Yerkes NPRC have developed two patents based on this
    work.
    The Need for Facilities Support
        The NPRC program is a vital resource for enhancing public health
    and spurring innovative discovery. In an effort to address many of the
    concerns within the scientific community regarding the need for funding
    for infrastructure improvements, the NPRCs support the continuation of
    a robust construction and instrumentation grant program at NIH.
        Animal facilities, especially primate facilities, are expensive to
    maintain and are subject to abundant ``wear and tear.'' In prior years,
    funding was set aside that fulfilled the infrastructure needs of the
    NPRCs and other animal research facilities. The NPRCs ask the
    Subcommittee to provide strong support for construction and renovation
    of animal facilities through C06 and G20 programs. Without proper
    infrastructure, the ability for animal facilities, including the NPRCs,
    to continue to meet the high demand of the biomedical research
    community will be unattainable.
        Thank you for the opportunity to submit this written testimony and
    for your attention to the critical need for primate research and the
    continuation of infrastructure support, as well as our recommendations
    concerning funding for NIH in the fiscal year 2012 appropriations bill.
                                     ______

            Prepared Statement of the National Psoriasis Foundation
                           introduction and overview
        The National Psoriasis Foundation (the Foundation) appreciates the
    opportunity to submit written public witness testimony regarding fiscal
    year 2012 Federal funding for psoriasis and psoriatic arthritis data
    collection and research. The Foundation is the largest psoriasis
    patient advocacy organization and charitable funder of psoriatic
    disease research worldwide, and has a primary mission of finding a cure
    for psoriasis and psoriatic arthritis. Psoriasis, the Nation's most
    prevalent autoimmune disease, affecting as many as 7.5 million
    Americans, is a noncontagious, chronic, inflammatory, painful and
    disabling disease for which there is no cure. It appears on the skin,
    most often as red, scaly patches that itch, can bleed and require
    sophisticated medical intervention. Up to 30 percent of people with
    psoriasis also develop potentially disabling psoriatic arthritis that
    causes pain, stiffness and swelling in and around the joints. There are
    other serious risks associated with psoriasis--for example, diabetes,
    cardiovascular disease, stroke and some cancers. Of serious concern is
    that, beyond its terrible physical and psychosocial toll on
    individuals, psoriasis also costs the Nation $11.25 billion annually.
        The Foundation works with the research community and policymakers
    at all levels of government to advance policies and programs that will
    reduce and prevent suffering from psoriasis and psoriatic arthritis. In
    2009, after examining existing scientific literature, clinical practice
    and other components of psoriasis and psoriatic arthritis research and
    care, the Foundation's medical and scientific advisors recommended the
    creation of a federally organized, public health research program for
    psoriasis and psoriatic arthritis to collect the information necessary
    to address the key scientific questions in the study and treatment of
    psoriatic disease. Responding to this recommendation, recognizing the
    significant economic and social costs of psoriasis and psoriatic
    arthritis and acknowledging the sizeable gap in the understanding of
    these devastating conditions, in fiscal year 2010, Congress provided
    $1.5 million to the Centers for Disease Control and Prevention (CDC) to
    commence the first-ever Government effort to collect data on psoriasis
    and psoriatic arthritis. Following this initial investment, in its
    fiscal year 2011 Labor, Health and Human Services, Education (LHHS)
    funding bill, the Senate provided a second allocation of $1.5 million
    to continue these critical public health efforts. While that measure
    was not enacted, we want to thank you and your colleagues for
    recognizing the importance of psoriasis data collection and ask for
    your support again in fiscal year 2012.
        Since the initial appropriation, considerable progress has been
    made in developing this data collection program in a thoughtful and
    deliberate manner, and we commend CDC for its excellent methodology and
    undertaking of this important effort. Thus far, Federal investment in
    this effort has allowed the CDC, along with other Federal stakeholders,
    to identify the key gaps in psoriatic disease data, including:
    prevalence, age of onset, health-related quality of life, healthcare
    utilization, burden of disease (employment, work, etc.), direct and
    indirect costs, health disparities (age, gender, racial and ethnic),
    comorbidities and an understanding of the course of the disease over
    time. To uncover these important public health issues, in 2010, CDC
    researchers collaborated with the Foundation's scientific and medical
    advisors to establish a process by which a common basis for defining
    and diagnosing psoriasis will be created and validated. This work, in
    turn, will provide the insight, information and tools CDC researchers
    need to determine the key psoriasis and psoriatic arthritis public
    health questions to be pursued.
        While the Foundation acknowledges the fiscal realities currently
    facing Congress and this Nation, scientific discovery, at this moment,
    is poised to advance the understanding and treatment of psoriasis and
    psoriatic arthritis. As such, we respectfully request that Congress
    continue to support this important initiative by appropriating level
    funding, $1.5 million, in fiscal year 2012, to enable CDC to refine and
    implement the psoriasis and psoriatic data collection process that has
    been defined with previous funding. With fiscal year 2012 funding, CDC
    researchers will be able to build upon the initial investment and
    integrate psoriasis and psoriatic arthritis questions into existing
    federally funded public health surveys, allowing economies of scale and
    leveraging scarce resources to maximum their utility. The information
    gleaned from this effort will help improve treatments and disease
    management, identify new pathways for future research and drug
    development and inform efforts to reduce the burden of disease on
    patients, their families and society in general.
        In addition, the Foundation urges the Subcommittee to support
    robust fiscal year 2012 funding for the National Institutes of Health
    (NIH). Sustaining Federal investment in biomedical research will help
    support new investigator-initiated research grants for genetic,
    clinical and basic research related to the understanding of the
    cellular and molecular mechanisms of psoriasis and psoriatic arthritis.
    Epidemiologic research at CDC, coupled with biomedical investigations
    through NIH, will help further the Nation's understanding of psoriasis
    and psoriatic arthritis and contribute to the development of better
    therapies, improved treatments and disease management and
    identification of ways in which comorbid conditions (e.g., heart
    attack, cancer and diabetes) can be prevented or mitigated, in turn,
    helping to save money and lives.
         the impact of psoriasis and psoriatic arthritis on the nation
        Psoriasis requires steadfast treatment and lifelong attention,
    especially since it most often strikes between ages 15 and 25. People
    with psoriasis also have significantly higher healthcare resource
    utilization, which costs more than that for the general population. Of
    serious and increasing concern is mounting evidence that people with
    psoriasis are at elevated risk for myriad other serious, chronic and
    life-threatening conditions, including cardiovascular disease,
    diabetes, stroke and some cancers. A higher prevalence of
    atherosclerosis, chronic obstructive pulmonary disease, Crohn's
    disease, lymphoma, metabolic syndrome and liver disease are found in
    people with psoriasis, as compared to the general population. In
    addition, people with psoriasis experience higher rates of depression
    and anxiety, and people with severe psoriasis die 4 years younger, on
    average, than people without the disease.
        Despite some recent breakthroughs, many people with psoriasis and
    psoriatic arthritis remain in need of effective, safe, long-term and
    affordable therapies to allow them to function normally without both
    physical and emotional pain. Due to the nature of the disease, patients
    often have to cycle through available treatments, and while there are
    an increasing number of methods to control the disease, there is no
    cure. Many of the existing treatments can have serious side effects and
    can pose long-term risks for patients (e.g., suppress the immune
    system, deteriorate organ function, etc.). The lack of viable, long-
    term methods of control for psoriasis can be addressed through Federal
    commitment to epidemiological, genetic, clinical and basic research.
    NIH and CDC research, taken together, hold the key to improved
    treatment of these diseases, better diagnosis of psoriatic arthritis
    and eventually a cure.
         the role of cdc in psoriasis and psoriatic arthritis research
        Despite our increased understanding of the autoimmune underpinnings
    of psoriasis and its treatments, there is a dearth of population-based
    epidemiology data on psoriatic disease. The majority of existing
    studies of psoriasis are based on case reports, case series and cross-
    sectional studies, which are likely biased toward more severe disease.
    Several analytical studies have been performed to identify potentially
    modifiable risk factors (e.g., smoking, diet, etc.) and some have
    yielded conflicting, or inconsistent, results. Most case-control
    studies looking for risk factors have been hospital-based, or specialty
    clinic-based, and again may be biased toward more severe disease,
    limiting their value for the larger population with psoriasis. Broadly
    representative population-based studies of psoriasis reflecting the
    full spectrum of disease are lacking and needed because there are still
    wide gaps in our knowledge and understanding of psoriatic disease.
        The CDC's psoriatic data collection effort will help to provide
    scientists and clinicians with critical information to further their
    understanding of: (a) how early intervention can prevent or delay the
    development of comorbid conditions; (b) what can trigger relapses and
    remissions; (c) some of the underlying causes of disease; (d) how
    differentiating lifestyle and other environmental triggers might lead
    to approaches that minimize exposure to these factors, thus reducing
    the incidence and severity of disease; and (e) best practice
    treatments, which in turn, would assist in streamlining appropriate
    patient care and help reduce the use of ineffective, unnecessary and
    costly treatments with challenging side effects.
               psoriasis and psoriatic arthritis research at nih
        It has taken nearly 30 years to understand that psoriasis is, in
    fact, not solely a disease of the skin, but also of the immune system.
    In recent years, scientists finally have identified some of the immune
    cells involved in psoriasis. The last decade has seen a surge in our
    understanding of these diseases, accompanied by new drug development.
    Scientists are poised, as never before, to make major breakthroughs.
        Within the NIH, the National Institute of Arthritis and
    Musculoskeletal and Skin Diseases (NIAMS) is the principal Federal
    Government agency that currently supports psoriasis research. We
    commend NIAMS for its leadership role and very much appreciate its
    steadfast commitment to supporting psoriasis research. Additionally, we
    are pleased that research activities that relate to psoriasis or
    psoriatic arthritis also have been undertaken at the National Institute
    of Allergy and Infectious Diseases (NIAID), the National Cancer
    Institute (NCI), the National Center for Research Resources (NCRR) and
    the National Human Genome Research Institute (NHGRI); however, the
    Foundation maintains that many more NIH institutes and centers--such as
    the National Heart, Lung, and Blood Institute (NHLBI) and the National
    Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)--have a
    role to play, especially with respect to the myriad comorbidities of
    psoriasis, as noted earlier. Although overall NIH funding levels
    improved for psoriasis research in fiscal year 2010, and funding was
    boosted through stimulus funding awards of $3 million in fiscal year
    2009 and (an estimated) $2 million in fiscal year 2010, the Foundation
    remains concerned that total NIH funding generally is not keeping pace
    with psoriasis and psoriatic arthritis research needs. Our scientific
    advisors believe a strong Federal investment in genetic, immunological
    and clinical studies focused on understanding the mechanisms of
    psoriasis and psoriatic arthritis is needed.
        Given the myriad factors involved in psoriatic disease and its
    comorbid conditions, the Foundation advocates increasing overall NIH
    funding, with a focus on the aforementioned institutes. We recognize
    and appreciate that the Nation faces significant budgetary challenges;
    however, we maintain that an increased investment in the Nation's
    biomedical research enterprise will help strengthen both the economy
    and our understanding of psoriasis and psoriatic arthritis.
                               conclusion/summary
        On behalf of the more than 7.5 million people with psoriasis and
    psoriatic arthritis, I want to thank the Committee for affording us the
    opportunity to submit written testimony regarding the fiscal year 2012
    investments we believe are necessary to ensure that our Nation
    adequately addresses the needs of individuals and families affected by
    psoriatic disease. By sustaining the Nation's biomedical research
    efforts at NIH, coupled with a specific allocation of $1.5 million for
    the CDC's psoriasis data collection efforts, Congress will help ensure
    that the Nation makes progress in understanding the connection between
    psoriasis and its comorbid conditions; uncovering the biologic aspects
    of psoriasis and other risk factors that lead to higher rates of
    comorbid conditions; and identifying ways to prevent and reduce the
    onset of comorbid conditions associated with psoriasis.
        Please feel free to contact the Foundation at any time; we are
    happy to be a resource to Subcommittee members and your staff. Again,
    we very much appreciate the Committee's attention to, and consideration
    of, our fiscal year 2012 requests.
                                     ______

               Prepared Statement of the National REACH Coalition
        The National REACH Coalition represents more than 40 communities
    and coalitions in 22 States working to eliminate racial and ethnic
    health disparities and improve the health of Native American/Native
    Hawaiian, African American, Latino, and Asian/Pacific Islander
    populations and communities. The coalition is an outgrowth of the
    Racial and Ethnic Approaches to Community Health (REACH U.S.) 2010
    initiative, launched in 1999 by the Centers for Disease Control and
    Prevention (CDC). REACH programs are embedded in communities with
    disproportionately higher rates of chronic disease, hospitalization,
    and premature death than other cities and counties across the country.
    They provide coordination and leadership for the advancement and
    translation of community-based participatory research into evidence-
    based practices, policies, and community engagement.
        For the fiscal year 2012 funding cycle, the National REACH
    Coalition requests the Labor, Health and Human Services, Education and
    Related Agencies (Labor-HHS) Subcommittee to fully fund, at current
    levels, the CDC's REACH program as a discrete line item in CDC's
    National Center for Chronic Disease Prevention and Health Promotion or
    as a specific initiative within the Public Health and Prevention Trust.
        The NRC gratefully acknowledges the strong bipartisan support that
    the Senate Labor-HHS Subcommittee has provided to the REACH U.S.
    program over the years. Working in communities that are among the
    hardest hit by the recession, REACH programs provide a cost effective
    strategy to improve health outcomes and close the health gap. We
    understand the purpose of the newly established Community
    Transformation Grants (CTG) program to address health disparities in
    addition to chronic disease. However, the severity of discrepancy in
    health conditions among REACH-serving populations requires specific and
    intentional interventions and it is not sufficient for this to occur
    only through the CTG program. The generalized approach offered by CTG
    has been used over the last several decades and has resulted in no
    significant reduction in health disparities. Research data support the
    conclusion that to effectively close the gap in health outcomes in our
    country, there remains a definitive need for a program committed solely
    to the elimination of racial and ethnic health disparities.
        REACH programs have been successful in mobilizing community
    resources, addressing policy, systems, and environmental change, and
    creating a shared vision to achieve healthy communities for racial and
    ethnic minorities. REACH programs focus on a variety of health issues,
    most notably chronic diseases such as cardiovascular disease, diabetes,
    HIV/AIDS, and cancer, as well as the contributors to these diseases,
    which include smoking, low physical activity, obesity, poor screening
    rates, and lack of prevention and disease management activities.
    Chronic diseases account for the largest health gap among racial and
    ethnic minority populations and are the Nation's leading cause of
    morbidity and mortality, accounting for 70 percent of all deaths.
    Collectively, chronic diseases are responsible for 75 cents of every
    dollar spent on healthcare in the United States.
        REACH U.S. programs are working hard to eliminate these health
    disparities and many have seen successful outcomes in their
    communities. REACH programs nationwide have engaged hundreds of local
    coalition members and improved the lives of thousands of program
    participants. As a result, REACH communities are testing, evaluating,
    and implementing practice and evidence-based interventions that reduce
    the human and financial cost of these preventable diseases and
    associated risk factors. REACH has achieved significant policy and/or
    systems change in public policy, healthcare and preventative services,
    and health education.
        Some of our recent successes in program intervention and policy
    change include:
      --In South Carolina, the REACH Charleston and Georgetown Diabetes
            Coalition reports that a 21 percent gap in blood sugar testing
            between African Americans and the general population has been
            virtually eliminated. Amputations among African-American males
            with diabetes have been reduced by over 33 percent.
      --In Macon County, Alabama, the REACH Alabama Breast and Cervical
            Cancer Coalition reports that disparities in mammography
            screening between the general population and African American
            women decreased from 15 percent to 2 percent within 5 years.
      --In Lawrence, Massachusetts, Latino CEED: REACH New England improved
            14 healthcare indicators and outcomes for over 3200 Latinos
            with diabetes over the past decade, including four indicators
            now on par with the U.S. general population. One significant
            improvement was the percentage of Latino patients whose blood
            sugar was controlled, increasing from 15 percent to 45 percent
            as a result of REACH interventions.
      --In New York City, Bronx Health REACH led local partners in the ``1
            percent Or Less'' campaign to eliminate whole milk and reduce
            the availability of sweetened milk in NYC public schools, where
            25 percent of children in elementary schools are obese. By
            eliminating whole milk, the NYC Department of Health and Mental
            Hygiene calculated that per student per year almost 5,960
            calories and 619 grams of fat were eliminated, or more than one
            pound of weight per child per year.
      --In South Los Angeles, Community Health Councils, a REACH grantee,
            addressed the lack of healthy food options in a predominantly
            African American community by advocating for local policy
            changes. These included an incentive package to attract 3 new
            grocery stores and sit-down restaurants into vulnerable
            communities and the adoption of an ordinance by the city to
            prohibit new stand-alone fast food restaurants within one half
            mile of an existing fast food chain.
        In addition to the individual community improvements, data from the
    REACH national behavioral risk factor survey show that the REACH
    program is having a significant impact in risk reduction and disease
    management across communities and program wide. In 11 REACH communities
    evaluated between 2003 and 2009, there was meaningful improvement for
    all races in 34 out of 48 health risk factors, which include smoking
    prevalence, diabetes management, vaccination, and physical activity.
    REACH has demonstrated for the first time at a significant level that
    the elimination of health disparities is a ``winnable battle''.
        The success of REACH communities in reducing health risk and
    improving patient compliance and disease management is particularly
    striking when compared to overall U.S. trends. Some recent data trends
    include:
      --From 2001 to 2009, the smoking prevalence in REACH communities for
            Asian men decreased from 30.5 percent to 13.8 percent in
            contrast to the 16.9 percent of Asian men that smoke in the
            U.S. overall. Smoking prevalence in Hispanic men decreased from
            28.8 percent to 17.6 percent in contrast to the 19 percent of
            Hispanic men that smoke in the U.S. overall.
      --From 2001 to 2004, African Americans transitioned from being less
            likely to more likely than the general population to have their
            cholesterol checked.
      --Health education interventions in REACH communities resulted in
            larger rates (as much as 66 percent) of improvement across
            racial and ethnic populations for smoking, physical activity,
            consumption of fruits and vegetables, etc., than national
            trends between 2001 and 2009.
        In addition to improving health outcomes, REACH programs also build
    capacity in the communities in which they operate. REACH programs train
    community and coalition members to work at the grassroots level on
    health issues, which can lead to employment opportunities at local
    health centers or community outreach programs. REACH also builds the
    capacity of local organizations and institutions to better serve their
    communities by addressing disparities and distributing resources where
    they are most needed. REACH is broadening the field of public health by
    engaging the food retail industry, local parks and recreation
    departments, city and regional land use, planning, housing, and
    transportation agencies, as well as healthcare providers.
        REACH communities across the United States have spent the last
    decade leveraging CDC funding with public private partnerships in order
    to effectively address health disparities. We have demonstrated through
    our research and our community programs that health disparities in
    racial and ethnic populations, once considered expected, are not
    intractable. Though we have made significant progress since REACH's
    inception, we could do a lot more. To move forward and eliminate health
    disparities, we must continue our work within underserved communities
    across the United States and build upon the successes achieved to date.
    Without continued funding for REACH programs, communities with high
    minority populations will continue to bear a disproportionate share of
    the national chronic disease burden. This not only keeps vulnerable
    communities at an increased disadvantage, but drives up healthcare
    costs by requiring long-term and costly medical intervention to treat
    chronic diseases that may have been prevented or better managed.
        The success and cost effectiveness of the REACH program would
    suggest it both practical and fiscally prudent to increase funding for
    the program to expand into additional communities across the country.
    However, given the current budget constraints we strongly urge the
    Committee to fully fund, at current levels, the CDC's REACH program in
    a discrete line item in CDC's National Center for Chronic Disease
    Prevention and Health Promotion or as a specific initiative within the
    Public Health and Prevention Trust. By doing so, we can continue our
    work in underserved communities and achieve marked improvements in the
    health of all Americans. We believe that our efforts will help to
    decrease the approximately 83,000 deaths that occur each year as a
    result of racial and ethnic health disparities, decrease the estimated
    $60 billion a year we spend in direct healthcare expenditures as a
    result of these disparities, and improve health access, quality, and
    outcomes for many people.
        We thank you for this opportunity to present our views to this
    Subcommittee. We look forward to working with you to improve the health
    and safety of all Americans.
                                     ______

              Prepared Statement of the National Respite Coalition
        Mr. Chairman, I am Jill Kagan, Chair of the ARCH National Respite
    Coalition, a network of respite providers, family caregivers, State and
    local agencies and organizations across the United States who support
    respite. Thirty State respite coalitions are also affiliated with the
    NRC. This statement is presented on behalf of the these organizations,
    as well as the members of the Lifespan Respite Task Force, a coalition
    of over 80 national and 100 State and local groups who supported the
    passage of the Lifespan Respite Care Act (Public Law 109-442).
    Together, we are requesting that the Subcommittee include funding for
    the Lifespan Respite Care Program administered by the U.S.
    Administration on Aging in the fiscal year 2011 Labor, HHS, and
    Education Appropriations bill at $50 million. Given the serious fiscal
    constraints facing the Nation, this request has been reduced by one-
    half below the previous fiscal year's authorized and requested amount.
    This will enable:
      --State replication of best practices in Lifespan Respite to allow
            all family caregivers, regardless of the care recipient's age
            or disability, to have access to affordable respite, and to be
            able to continue to play the significant role in long-term care
            that they are fulfilling today;
      --Improvement in the quality of respite services currently available;
      --Expansion of respite capacity to serve more families by building
            new and enhancing current respite options, including
            recruitment and training of respite workers and volunteers; and
      --Greater consumer direction by providing family caregivers with
            training and information on how to find, use and pay for
            respite services.
    Who Needs Respite?
        In 2009, a national survey found that over 65 million family
    caregivers are providing care to individuals of any age with
    disabilities or chronic conditions (Caregiving in the U.S. 2009.
    Bethesda, MD: National Alliance for Caregiving (NAC) and Washington,
    DC: AARP, 2009). Family caregivers provide an estimated $375 billion in
    uncompensated care, an amount almost as high as Medicare spending ($432
    billion in 2007) and more than total spending for Medicaid, including
    both Federal and State contributions and both medical and long-term
    care ($311 billion in 2005) (Gibson and Hauser, 2008).
        Family caregiving is not just an aging issue, but a lifespan one
    for the majority of the Nation's families. While the aging population
    is growing rapidly, the majority of family caregivers are caring for
    someone under age 75 (56 percent); 28 percent of family caregivers care
    for someone between the ages of 50-75, and 28 percent are caring for
    someone under age 50, including children (NAC and AARP, 2009). Many
    family caregivers are in the sandwich generation--46 percent of women
    who are caregivers of an aging family member and 40 percent of men also
    have children under the age of 18 at home (Aumann, Kerstin and Ellen
    Galinsky, et al. 2008). And 6.7 million children, are in the primary
    custody of an aging grandparent or other relative.
        Families of the wounded warriors--those military personnel
    returning from Iraq and Afghanistan with traumatic brain injuries and
    other serious chronic and debilitating conditions--are at risk for
    limited access to respite. Even with enactment of the new VA Family
    Caregiver Support Program, the need for respite will remain high among
    all veterans and their family caregivers. Among family caregivers of
    veterans whose illness, injury or condition is in some way related to
    military service surveyed in 2010, only 15 percent had received respite
    services from the VA or other community organization within the past 12
    months. Caregivers whose veterans have PTSD are only about half as
    likely as other caregivers to have received respite services (11
    percent vs. 20 percent) (NAC, Caregivers Of Veterans--Serving On The
    Homefront, November 2010). Sixty-eight percent of veterans' caregivers
    reported their situation as highly stressful compared to 31 percent of
    caregivers nationally who feel the same and three times as many say
    there is a high degree of physical strain (40 percent vs. 14 percent)
    (NAC, 2010). Veterans' caregivers specifically asked for up-to-date
    resource lists of respite providers in their local communities and help
    to find services--the very thing Lifespan Respite is charged to provide
    (NAC, 2010).
        National, State and local surveys have shown respite to be the most
    frequently requested service of the Nation's family caregivers
    (Evercare and NAC, 2006). Other than financial assistance for
    caregiving through direct vouchers payments or tax credits, respite is
    the number one national policy related to service delivery that family
    caregivers prefer (NAC and AARP, 2009). Yet respite is unused, in short
    supply, inaccessible, or unaffordable to a majority of the Nation's
    family caregivers. The NAC 2009 survey found that despite the fact that
    among the most frequently reported unmet needs of family caregivers
    were ``finding time for myself'' (32 percent), ``managing emotional and
    physical stress'' (34 percent), and ``balancing work and family
    responsibilities'' (27 percent), nearly 90 percent of family caregivers
    across the lifespan are not receiving respite services at all.
        Together, these family caregivers provide an estimated 80 percent
    of all long-term care in the United States. This percentage will only
    rise in the coming decades with an expected increase in the number of
    chronically ill veterans returning from war, greater life expectancies
    of individuals with Down's Syndrome and other disabling and chronic
    conditions, the aging of the baby boom generation, and the decline in
    the percentage of the frail elderly who are entering nursing homes.
    Respite Barriers and the Effect on Family Caregivers
        Barriers to accessing respite include reluctance to ask for help,
    fragmented and narrowly targeted services, cost, and the lack of
    information about how to find or choose a provider. Even when respite
    is an allowable funded service, a critically short supply of well-
    trained respite providers may prohibit a family from making use of a
    service they so desperately need. Lifespan Respite is designed to help
    States eliminate these barriers through improved coordination and
    capacity building.
        While most families take great joy in helping their family members
    to live at home, however, it has been well documented that family
    caregivers experience physical and emotional problems directly related
    to their caregiving responsibilities. A majority of family caregivers
    (51 percent) caring for someone over the age of 18 have medium or high
    levels of burden of care, measured by the number of activities of daily
    living with which they provide assistance, and 31 percent of all family
    caregivers were identified as ``highly stressed'' ((NAC and AARP,
    2009). While family caregivers of children with special healthcare
    needs are younger than caregivers of adults, they give lower ratings to
    their health. Only 4 out of 10 consider their health to be excellent or
    very good (44 percent) compared to 6 in 10 (59 percent) caregivers of
    adults; 26 percent say their health is fair or poor, compared to 16
    percent of those caring for adults. Caregivers of children are twice as
    likely as the general adult population to say they are in fair/poor
    health (26 percent vs 13 percent) (Provisional summary Health
    Statistics for US Adults, National Health Interview Survey, 2008, dated
    August 2009).
        The decline of family caregiver health is one of the major risk
    factors for institutionalization of a care recipient, and there is
    evidence that care recipients whose caregivers lack effective coping
    styles or have problems with depression are at risk for falling,
    developing preventable secondary complications such as pressure sores
    and experiencing declines in functional abilities (Elliott & Pezent,
    2008). Care recipients may also be at risk for encountering abuse from
    caregivers when the recipients have pronounced need for assistance and
    when caregivers have pronounced levels of depression, ill health, and
    distress (Beach et al., 2005; Williamson et al., 2001).
        Supports that would ease their burden, most importantly respite,
    are too often out of reach or completely unavailable. Even the simple
    things we take for granted, like getting enough rest or going shopping,
    become rare and precious events. Restrictive eligibility criteria also
    preclude many families from receiving services or continuing to receive
    services for which they once were eligible. A mother of a 12-year-old
    with autism was denied respite by her State DD (Developmental
    Disability) agency because she was not a single mother, was not at
    poverty level, was not exhibiting any emotional or physical conditions
    herself, and had only one child with a disability. As she told us, ``Do
    I have to endure a failed marriage or serious health consequences for
    myself or my family before I can qualify for respite? Respite is
    supposed to be a preventive service.''
        For the millions of families of children with disabilities, respite
    has been an actual lifesaver. However, for many of these families,
    their children will age out of the system when they turn 21 and they
    will lose many of the services, such as respite, that they currently
    receive. In fact, 46 percent of U.S. State units on aging identified
    respite as the greatest unmet need of older families caring for adults
    with lifelong disabilities.
        Respite may not exist at all in some States for adult children with
    disabilities still living at home, or individuals under age 60 with
    conditions such as ALS, MS, spinal cord or traumatic brain injuries, or
    children with serious emotional conditions. In Tennessee, a young woman
    in her twenties gave up school, career and a relationship to move in
    and take care of her 53 year-old mom with MS when her dad left because
    of the strain of caregiving. Fortunately, she lives in Tennessee with a
    State Lifespan Respite Program. Now 31, she wrote, ``And I was young--I
    still am--and I have the energy, but--it starts to weigh. Because we've
    been able to have respite care, it has made all the difference.''
    Respite Benefits Families and is Cost Saving
        Respite has been shown to be a most effective way to improve the
    health and well-being of family caregivers that in turn helps avoid or
    delay out-of-home placements, such as nursing homes or foster care,
    minimizes the precursors that can lead to abuse and neglect, and
    strengthens marriages and family stability. A U.S. Department of Health
    and Human Services report prepared by the Urban Institute found that
    higher caregiver stress among those caring for the aging increases the
    likelihood of nursing home entry. Reducing key stresses on caregivers,
    such as physical strain and financial hardship, through services such
    as respite would reduce nursing home entry (Spillman and Long, USDHHS,
    2007). The budgetary benefits that accrue because of respite are just
    as compelling. Delaying a nursing home placement for just one
    individual with Alzheimer's or other chronic condition for several
    months can save thousands of dollars. In an Iowa survey of parents of
    children with disabilities, a significant relationship was demonstrated
    between the severity of a child's disability and their parents missing
    more work hours than other employees. It was also found that the lack
    of available respite appeared to interfere with parents accepting job
    opportunities. (Abelson, A.G., 1999)
        Moreover, data from an ongoing research project of the Oklahoma
    State University on the effects of respite care found that the number
    of hospitalizations, as well as the number of medical care claims
    decreased as the number of respite care days increased (Fiscal Year
    1998 Oklahoma Maternal and Child Health Block Grant Annual Report, July
    1999). A Massachusetts social services program designed to provide
    cost-effective family centered respite care for children with complex
    medical needs found that for families participating for more than 1
    year, the number of hospitalizations decreased by 75 percent, physician
    visits decreased by 64 percent, and antibiotics use decreased by 71
    percent (Mausner, S., 1995).
        In the private sector, the Metropolitan Life Insurance Company and
    the National Alliance for Caregivers found that U.S. businesses lose
    from $17.1 billion to $33.6 billion per year in lost productivity of
    family caregivers. (MetLife and National Alliance for Caregiving,
    2006). A more recent study from the National Alliance on Caregiving and
    Evercare demonstrated that the economic downturn has had a particularly
    harsh effect on family caregivers. Of the 6 in 10 caregivers who are
    employed, 50 percent of them are less comfortable during the economic
    downturn with taking time off from work to care for a family member or
    friend. A similar percentage (51 percent) says the economic downturn
    has increased the amount of stress they feel about being able to care
    for their relative or friend. Respite for working family caregivers
    could help improve job performance and employers could potentially save
    billions.
    Lifespan Respite Care Program Will Help
        The Lifespan Respite Care Program is based on the success of
    statewide Lifespan Respite programs in Oregon, Nebraska, Wisconsin and
    Oklahoma. The Federal Lifespan Respite program is administered by the
    U.S. Administration on Aging, Department of Health and Human Services
    (HHS). AoA provides competitive grants to State agencies in concert
    with Aging and Disability Resource Centers working in collaboration
    with State respite coalitions or other State respite organizations. The
    program was authorized at $53.3 million in fiscal year 2009 rising to
    $95 million in fiscal year 2011. Congress appropriated $2.5 million in
    fiscal year 2009 and again in fiscal year 2010 and fiscal year 2011.
    Twenty-four States have received 3-year $200,000 Lifespan Respite
    Grants from AoA since 2009. Another 9 or 10 States are expected to
    receive grants by August 2011.
        The purpose of the law is to expand and enhance respite services,
    improve coordination, and improve respite access and quality. States
    are required to establish State and local coordinated Lifespan Respite
    care systems to serve families regardless of age or special need,
    provide new planned and emergency respite services, train and recruit
    respite workers and volunteers and assist caregivers in gaining access
    to services. Those eligible would include family members, foster
    parents or other adults providing unpaid care to adults who require
    care to meet basic needs or prevent injury and to children who require
    care beyond that required by children generally to meet basic needs.
        Lifespan Respite, which is a coordinated system of community-based
    respite services, helps States use limited resources across age and
    disability groups more effectively, instead of each separate State
    agency or community-based organization being forced to reinvent the
    wheel or beg for small pots of money. Pools of providers can be
    recruited, trained and shared, administrative burdens can be reduced by
    coordinating resources, and savings used to fund new respite services
    for families who may not qualify for existing Federal or State
    programs. For the growing number of veterans returning home with TBI or
    other polytrauma, the shortage of staff qualified to provide respite to
    this population is especially critical. Lifespan Respite systems can
    make all the difference by ameliorating special barriers for this
    population. The Government Accountability Office summarized the
    innovative activities being taken by the 24 States to implement these
    State Lifespan Respite Systems in its report to Congress, Respite Care:
    Grants and Cooperative Agreements Awarded to Implement the Lifespan
    Respite Care Act. GAO-11-28R, October 22, 2010.
        The Administration recommended $10 million for Lifespan Respite in
    fiscal year 2012. This is a doubling of the Administration's previous
    request in fiscal year 2011 of $5 million as part of their Middle Class
    Initiative. We are heartened to see that support for family caregiving
    is recognized as a critical component of a typical family's economic
    and social well-being and extremely grateful for the Administration's
    support. Still, we must not neglect that fact that 90 percent of the
    Nation's family caregivers are not receiving respite at all. More than
    half of them are caring for someone under age 75 with MS, ALS,
    traumatic brain or spinal cord injury, mental health conditions,
    developmental disabilities or cancer. $10 million will not address the
    need for respite. Based on expenditures by State funded Lifespan
    Respite programs in the original best practice States, we estimate that
    an average sized State will need at least $1 million to build a
    Lifespan Respite System that can better coordinate its services and
    funding streams, maximize use of existing resources, and leverage new
    dollars in both the public and private sectors to build respite
    capacity and serve the unserved.
        No other Federal program mandates respite as its sole focus. No
    other Federal program would help ensure respite quality or choice, and
    no current Federal program allows funds for respite start-up, training
    or coordination or to address basic accessibility and affordability
    issues for families. We urge you to include $50 million in the fiscal
    year 2012 Labor, HHS, Education appropriations bill so that Lifespan
    Respite Programs can be replicated in the States and more families,
    with access to respite, will be able to continue to play the
    significant role in long-term care that they are fulfilling today.
                                     ______

          Prepared Statement of the National Rural Health Association
        The National Rural Health Association (NRHA) is pleased to provide
    the Labor, Health and Human Services, Education and Related Agencies
    Appropriations Subcommittee with a statement for the record on fiscal
    year 2012 funding levels for programs with a significant impact on the
    health of rural America.
        The NRHA is a national nonprofit membership organization with more
    than 20,000 members that provides leadership on rural health issues.
    The Association's mission is to improve the health of rural Americans
    and to provide leadership on rural health issues through advocacy,
    communications, education and research. The NRHA membership consists of
    a diverse collection of individuals and organizations, all of whom
    share the common bond of an interest in rural health.
        The NRHA is advocating for continued full funding for a group of
    rural health programs that assist many rural communities in maintaining
    and building a strong healthcare delivery system into the future. Most
    importantly, these programs help increase the capacity of the rural
    healthcare delivery system. Additional capacity that will be absolutely
    necessary with the addition of many newly insured Americans under the
    Patient Protection and Affordable Care Act. These programs have been
    successful in increasing access to healthcare in rural areas, helping
    communities create new health programs for those in need and training
    the future health professionals that will give care to rural America.
    With modest investments, these programs are able to evaluate, study,
    and implement quality improvement programs and health information
    technology systems.
        While recognizing the constraints of the current economic and
    budgetary climate, we would like to remind you of the critical
    importance of these rural health programs and request modest increases
    to ensure that these programs do not lose any ground. Even small
    investments in these ``rural health safety net'' programs go a long way
    and generate big returns in rural communities. Cuts to these programs
    do more hard than good and in the long run the Federal government will
    pay a much higher cost should these rural programs go away.
        Some important rural health programs supported by the NRHA are
    outlined below.
        Rural Health Outreach and Network Grants provide capital investment
    for planning and launching innovative projects in rural communities
    that later become self-sufficient. These grants are unique in the
    Federal system as they allow the community to choose what is most
    important for their own situation and then build a program around that.
    These grants have led to projects dealing with obesity and diabetes,
    information technology networks, oral screenings, preventive services,
    and many other health concerns. Due to the community nature of the
    grants and a focus on self-sustainability after the terms of the grant
    have run out--85 percent of the Outreach Grantees continue to deliver
    services even 5 full years after Federal funding had ended. Request:
    $59.8 million
        Rural Health Research and Policy forms the Federal infrastructure
    for rural health policy. Without these funds, rural America has no
    coordinated voice in the Department of Health and Human Services (HHS).
    In addition to the expertise provided to agencies such as the Centers
    for Medicare and Medicaid Services, this line item also funds rural
    health research centers across the country. These research centers
    provide the knowledge and the evidence needed for good policy making,
    both in the Federal Government and across the Nation. Additionally, we
    urge the Subcommittee to include in report language instructions to the
    Office of Rural Health Policy to direct additional funding to the State
    rural health associations. The State associations serve to coordinate
    rural health activities at the State level and have a strong record of
    positive outcomes. Request: $10.76 million
        State Offices of Rural Health are the State counterparts to the
    Federal rural health research and policy efforts, and form the State
    infrastructure for rural health policy. They assist States in
    strengthening rural healthcare delivery systems by maintaining a focal
    point for rural health within each State and by linking small rural
    communities with State and Federal resources to develop long term
    solutions to rural health problems. Without these funds, States would
    have diminished capacity to administer many of the rural health
    programs that are so critical to access to care. Request: $10 million
        Rural Hospital Flexibility Grants fund quality improvement and
    emergency medical service projects for Critical Access Hospitals across
    the country. This funding is essential. CAHs are by definition small
    hospitals with fewer than 25 beds; they do not have the size, volume or
    the expertise to do the types of quality improvement or information
    technology activities that they need to do. These grants allow
    statewide coordination and provide expertise to CAHs. Also funded in
    this line is the Small Hospital Improvement Program (SHIP), which
    provides grants to more than 1,500 small rural hospitals (50 beds or
    less) across the country to help improve their business operations,
    focus on quality improvement and to ensure compliance provisions
    related to health information privacy. Request: $43.46 million
        Rural and Community Access to Emergency Devices assists communities
    in purchasing emergency devices and training potential first responders
    in their use. Defibrillators double a victim's chance of survival after
    sudden cardiac arrest, which an estimated 163,221 Americans experience
    every year. Request: $3.49 million
        The Office for the Advancement of Telehealth supports distance-
    provided clinical services and is designed to reduce the isolation of
    rural providers, foster integrated delivery systems through network
    development and test a range of telehealth applications. Long-term,
    telehealth promises to improve the health of millions of Americans,
    provide constant education to isolated rural providers and save money
    through reduced office visits and expensive hospital care. These
    approaches are still new and unfolding and continued investment in the
    infrastructure and development is needed. Request: $12.3 million
        National Health Service Corps (NHSC) plays a critical role in
    providing primary healthcare services to rural underserved populations
    by placing healthcare providers in our Nation's most underserved
    communities. Invesment in our healthcare workforce is absolutely vital
    to support the newly insured population resulting from health reform.
    Programs like the NHSC help to maximize the capacity of our health
    system to care for patients. The Patient Protection and Affordable Care
    Act provided additional funding to the NHSC through the HHS Secretary's
    Community Health Center fund. The NRHA is supporting the President's
    request, which will ensure that the NHSC has access to the additional
    dedicated funding through the CHC Fund. Request: $173.2 million
        Title VII Health Professions Training Programs (with a significant
    rural focus):
      --Rural Physician Pipeline Grants will help medical colleges to
            develop special rural training programs and recruit students
            from rural communities, who are more likely to return to their
            home regions to practice. Newly created under the Patient
            Protection and Affordable Care Act, this ``grow-your-own''
            approach is one of the best and most cost-effective ways to
            ensure a robust rural workforce into the future. Request: $
      --Area Health Education and Centers (AHECs) financially support and
            encourage those training to become healthcare professionals to
            choose to practice in rural areas. Without this experience and
            support while in medical school, far fewer professionals would
            make the commitment to rural areas and facilities including
            Community Health Centers, Rural Health Clinics and rural
            hospitals. It has been estimated that nearly half of AHECs
            would shut down without Federal funding. The success of this
            program was recognized through increased authorized levels in
            the Patient Protection and Affordable Care Act. Request: $75
            million
      --Geriatric Programs train health professionals in geriatrics,
            including funding for Geriatric Education Centers (GEC). There
            are currently 47 GECs nationwide that ensure access to
            appropriate and quality healthcare for seniors. Rural America
            has a disproportionate share of the elderly and could see a
            shortage of health providers without this program. Request: $
            35.6 million
        The NRHA appreciates the support throughout the fiscal year 2011
    continuing resolution process and the opportunity to provide our
    recommendations for your fiscal year 2012 appropriations bill. Our
    request for continued funding for the rural health safety net is
    critical to maintaining access to high quality care in rural
    communities. We greatly appreciate the support of the Subcommittee and
    look forward to working with Members of Congress to continue making
    these important investments in rural health in fiscal year 2012 and
    into the future.
                                     ______

          Prepared Statement of the National Senior Corps Association
        Mr. Chairman, Members of the Committee, I testify today on behalf
    of the National Senior Corps Association, representing the interests
    and ideals of 500,000 senior volunteers and the directors, staff, and
    friends of local Foster Grandparent, Senior Companion, and RSVP
    programs throughout the country.
        The recent agreement for fiscal year 2011 appropriations included a
    20 percent cut in funding for RSVP--a devastating setback that
    threatens to deny 100,000 seniors the opportunity to serve their
    communities. We urge that this funding be restored, first and foremost,
    and that the Corporation for National and Community Service (CNCS) take
    particular care to do so in protecting opportunities for senior
    volunteers without interruption.
        For fiscal year 2012, NSCA requests $111,100,000 for the Foster
    Grandparent Program (FGP), $63,000,000 for RSVP, and $47,000,000 for
    the Senior Companion Program (SCP). This is an aggregate increase of
    $200,000 over the fiscal year 2010 enacted level. In addition, we
    support an appropriation of $5 million for demonstration projects to
    increase high school graduation rates through the Foster Grandparent
    Program and to support independent living for veterans through the
    Senior Companion Program.
        SENIOR CORPS is a federally authorized and funded network of
    national service programs that provides older Americans with the
    opportunity to apply their life experiences to volunteer service.
    Senior Corps is comprised of the Foster Grandparent Program, RSVP, and
    the Senior Companion Program, through which Americans age 55 and older
    provide essential services to cost-effectively address critical
    community needs.
        Foster Grandparent Program.--29,000 Foster Grandparents in 328
    projects provide a cost-effective means to reach and support more than
    280,000 at-risk children with special or exceptional needs annually who
    otherwise may not have the opportunity to receive individual assistance
    and attention from a caring adult. In 2009, Foster Grandparents
    volunteered 24.3 million hours.
      --81 percent of children served demonstrated improvements in academic
            performance. Mentored children have reduced truancy resulting
            in reduced school costs and, ultimately, reduced high school
            dropout rates and increased lifetime earnings.
      --90 percent demonstrated increased self-image. This includes
            improved health outcomes such as reductions in teen pregnancy
            and reduced or delayed use of tobacco, alcohol, or illicit
            drugs.
      --56 percent reported improved school attendance leading to increased
            graduation rates, increased post-secondary education, and
            higher lifetime earnings.
      --59 percent reported reduction in risky behavior, including reduced
            juvenile violence and property crimes, saving victim and court
            expenses, costly treatment of juvenile offenders, costs of
            adult crime, crime losses of victims and the societal costs of
            prosecuting and incarcerating adult offenders.
      --In 2009, FGP volunteers mentored 41,767 children and youth, of
            which 5,400 were children of prisoners at high risk of
            repeating their parent's path.
      --FGP intervention reduced need for social services, both short-term
            costs of counseling and long-term costs of public assistance.
      --Based on conservative assumptions about outcomes and valuations,
            studies indicate a return benefit of $2.72 for every dollar of
            resources used for mentoring programs. (Analyzing the Social
            Return on Investment in Youth Mentoring Programs, prepared by:
            Paul A. Anton, Wilder Research; and Prof. Judy Temple,
            University of Minnesota).
        Foster Grandparent Program Profiles.--Foster Grandparent Birda
    Dillon completed the ninth grade, worked doing factory assembly for 25
    years, raised 20+ children--14 of her own as well as grandchildren. She
    is a remarkable Foster Grandparent as the following remarks from her
    teacher in Benton Harbor, Michigan begin to illustrate: ``Grandma is so
    good with these students. She knows just how to work with them to get
    them to read the words themselves. She is positive and knows how to get
    the students to sound the words out. George is reading so much better.
    I was surprised when he told me recently, 'I need another book!''' I
    can't spend one-on-one time with them, and she can. Birda is one of the
    best reading tutors I've encountered in my many years of teaching. She
    knows all of the tricks and tools to help the students help themselves.
    She said much of what she knows she has learned through her training as
    a Foster Grandparent. I appreciate her giftedness very much. We hope we
    can be together for a long, long time.'' From Professional Volunteer
    who assists with site visits (a retired veteran teacher): ``I
    complimented her on her teaching of reading and told her I was a
    reading teacher, too. I told her she was a natural! She said she hadn't
    had any formal training; she wished she'd been a teacher, and I told
    her she was.'' Three of the children Birda tutors have incarcerated
    parents.
        Foster Grandparent Leila Williams: Leila serves in a first grade
    classroom at Washington Elementary School in Coloma, Michigan. ``I had
    no idea how rewarding it would be. And I feel so much better. I love
    having a schedule, being busy, and I sleep so good at night. Thank you,
    for making my life better. I'm 91 years old, and getting younger.''
    Leila is matched with two children with parents in active military
    service. Leila's teacher reports that as a result of Leila's one-on-one
    attention, her two assigned students have developed positive
    relationships with Leila, improved socialization skills and have both
    improved reading skills, especially sight word recognition and fluency.
        RSVP.--405,000 RSVP volunteers contributed 62 million hours of
    service in 2009 through 741 projects nationwide working with more than
    65,000 community organizations. The average cost to support one RSVP
    volunteer is approximately $145 a year, whereas the average annual
    value per volunteer is more than $3,000. RSVP volunteers saved local
    communities $1.25 billion in 2009.
      --RSVP is continually strengthening its leadership role in engaging
            volunteers 55+ by providing nonprofit agencies with volunteers
            trained to recruit and coordinate other community members in
            support of the nonprofits mission and goals. In 2009, RSVP
            volunteers recruited 38,000 additional community volunteers.
      --RSVP projects demonstrate that their volunteer services increase
            literacy scores for the 74,326 children they mentor--the
            National Education Association states the lowest hourly rate
            for teacher aides is $10.31 reflecting a savings of $16,858,623
            in remedial reading assistance.
      --24,370 RSVP volunteers increased the capacity of the organizations
            where they serve by enhancing both the quality and quantity of
            services.
      --In 2009, RSVP volunteers mentored 6,400 children of prisoners at
            high risk of repeating their parent's path.
      --RSVP volunteers provided 23,300 caregivers with respite services. A
            recent AARP survey of working caregivers reports that 30
            percent of family caregivers either quit their jobs or reduce
            their work hours to take on more care giving responsibilities.
      --RSVP volunteers supported 509,000 with Independent Living Services.
      --30 percent of RSVP volunteers provided at least one service in the
            area of Health/Nutrition which includes in-home and congregate
            meals, food distribution/collection, immunization, etc. valued
            at more than $27 million.
        RSVP Program Profile.--The Beginning Alcohol and Addictions Basic
    Education Studies (BABES) program has been operating successfully for
    many years in districts throughout the Portage County, Wisconsin RSVP
    service area. Each year, hundreds of second graders in the various
    districts learn from their puppet friends (via the RSVP volunteers)
    about complex issues like peer pressure, good decisionmaking, and
    asking for help.
        In 2009, over 600 second graders participated in the program. The
    intermediate outcome states that teachers in the second grade classes
    will observe children using phrases from the presentations and
    reminding others about the lessons they have learned. In 2009, the
    target was exceeded as 21 teachers returned surveys and 90 percent (19)
    reported they observed children using phrases from the BABES
    presentations. Teacher comments included: (1) ``They have brought up
    coping, decisionmaking, peer pressure and self image when we are
    reading other stories. They have made a connection from these lessons
    to what is going on in their world.'' (2) ``One student came in from
    recess and said someone was peer pressuring her to do something on the
    playground. It was great hearing the term used!''
        The end outcome states that students in second grade classes who
    complete the BABES program will show an increase in knowledge about
    alcohol and drug use and abuse and seeking help as measured on a pre/
    post test. In 2009, the target was exceeded as 74 percent (20 of 27
    classes participating in BABES in 2009) of classes improved their
    scores on the post test by at least 10 percent.
        While the program is successful because volunteers are willing to
    present the lessons, the coordination of the program is also an
    important piece. The RSVP Intergenerational Coordinator provides annual
    volunteer training, ensures volunteers have all the materials they
    need, works with the schools to schedule the program, ensures the pre
    and post tests are completed and returned and analyzes and reports the
    date collected to all the stakeholders.
        Senior Companion Program.--15,200 Senior Companions serving in 194
    projects provided 12.2 million hours of service helping 68,200 frail,
    homebound clients in need of assistance in order to remain living
    independently. Senior Companion Program services prevented premature
    and costly institutionalization at an annual savings well over $200
    million. The national average cost for 1 year in a nursing home is
    $72,270; the assisted living facility yearly average cost is $37,572.
    One Senior Companion volunteer assists 2-6 homebound clients for the
    annual investment of $4,800.
      --Senior Companions offered essential respite to nearly 9,000 primary
            caregivers who struggle to remain in the regular workforce
            while caring for their loved one.
      --The Family Caregiver Alliance reports that families with long-term
            care responsibilities miss an average of 7.5 workdays each
            year.
      --The MetLife Caregiving Cost Study of July 2006 reports the
            estimated cost to employers of full-time employed intense
            caregivers at a total of $17.1 billion in lost productivity
            annually as well as absenteeism, workday interruptions, costs
            due to crisis in care, supervision costs associated with
            caregiver employees, costs with unpaid leave and reducing hours
            from full-time to part-time.
      --Clients have significant, long-term mental health benefits and
            reduced rates of depression saving $50-$75 a month in
            medication.
      --Cost of stress management therapy for one caregiver ($125 per
            session) vs. respite provided by volunteer (4 hours of respite
            care = $10.60 plus mileage average cost of $3).
      --Cost for a home health aide after a client's release from the
            hospital is $21 per hour as compared to $2.65 per hour for a
            Senior Companion volunteer (at no cost to clients).
        Senior Companion Program Profile.--Julia, an 80 year old woman who
    is blind was faced with having to leave her home in Rochester, NY due
    to her inability to see and complete the tasks of daily living needed
    to stay independent. While she had home health aide service to help her
    bathe, dress and clean her apartment, her family wasn't able to be with
    her during the day and evening due to their work schedules and their
    own family commitments.
        Julia was given two Senior Companion (SC) volunteers. One came each
    day mid-morning after the home health aide left and stayed until early
    afternoon. The SC kept Julia company, escorted her to the bathroom when
    needed, fixed lunch and ensured she was okay daily. The second SC came
    about 5 p.m. each evening. She fixed dinner, visited, cleaned up after
    dinner and helped Julia get ready and into bed each evening.
        Between these two volunteers Julia was able to stay living at home
    an additional 5+ years. At an average cost of $70,000 annually for long
    term care compared to the cost of her SC services at approximately
    $4,800 annually per companion, a savings of over $300,000 was saved.
        It has been stated that baby boomer and senior volunteers represent
    our Nation's single and fastest growing resource. During this
    unprecedented economic crisis facing our Nation, the number of baby
    boomer and senior volunteers should be greatly expanded and mobilized
    as solutions to the problems facing our local communities. NSCA's 2012
    budget request will provide the opportunity for thousands more older
    adults to serve in their communities and enhance the lives of those
    most in need, including children with special needs, the frail and
    isolated elderly striving to maintain independence, and expanding the
    services of local non-profit agencies.
        The 2010 national value of one hour of volunteer service was
    estimated at $21.36.
        Senior Corps volunteers' 98.2 million service hours in 2010 = $2.1
    billion savings.
                                     ______

      Prepared Statement of the National Technical Institute for the Deaf
        Mr. Chairman and Members of the Committee: I am pleased to present
    the fiscal year 2012 budget request for NTID, one of eight colleges of
    RIT, in Rochester, New York. Created by Congress by Public Law 89-36 in
    1965, we provide university technical and professional education for
    students who are deaf and hard-of-hearing, leading to successful
    careers in high-demand fields for a sub-population of individuals
    historically facing high rates of unemployment and under-employment. We
    also provide baccalaureate and graduate level education for hearing
    students in professions serving deaf and hard-of-hearing individuals.
    As of fall 2010, NTID served a total of 1,521 students from across the
    Nation, including 1,263 deaf and hard-of-hearing undergraduate students
    and 147 hearing undergraduate students. NTID students live, study and
    socialize with more than 15,000 hearing students on the RIT campus.
        NTID has fulfilled its mission with distinction for 43 years.
    Budget Request
        As shown below, NTID's fiscal year 2012 budget request was
    $64,677,000 in Operations and $2,000,000 in Construction, as part of a
    plan that would provide NTID with a total of $10,000,000 in
    Construction over the next 5 years to fund needed capital projects. The
    NTID request is a total of $66,677,000; the President's request is
    $63,037,000 in Operations and $2,000,000 in Construction, for a total
    of $65,037,000.

                                         FISCAL YEAR 2012 BUDGET REQUEST STATUS
    ----------------------------------------------------------------------------------------------------------------
                                                                        Operations     Construction        Total
    ----------------------------------------------------------------------------------------------------------------
    NTID Request....................................................     $64,677,000      $2,000,000     $66,677,000
    President's Request \1\.........................................      63,037,000       2,000,000      65,037,000
                                                                     -----------------------------------------------
          Difference................................................       1,640,000  ..............       1,640,000
    ----------------------------------------------------------------------------------------------------------------
    \1\ For fiscal years 2009, 2010 and most likely, 2011, NTID's Operations budget has been funded at $63,037,000;
      the President's recommended Operations budget for fiscal year 2012 would mark four consecutive years of
      funding at the same amount.

        For the past 3 years, NTID has been able to absorb the same level
    of funding in Operations primarily due to two factors: (1) a self-
    initiated budget-reduction/revenue enhancement campaign from fiscal
    year 2003 through fiscal year 2007; and (2) limited RIT-mandated salary
    increases in recent years. However, realized savings from the campaign
    now have been reallocated and are no longer available. Furthermore, the
    limited increases from fiscal year 2009 through fiscal year 2011 mean
    that NTID has fallen significantly behind its salary benchmarks. RIT
    has mandated a 3 percent salary increase for all faculty and staff in
    the coming fiscal year.
        While NTID certainly would benefit from a budget increase to
    support upcoming strategic initiatives (see below), we understand the
    resource challenges facing the Committee this year. While an additional
    $1,640,000 beyond the President's recommended Operations funding for
    fiscal year 2012 is needed, we are amenable to meeting this need by
    shifting funds designated in the President's 2012 budget from
    Construction to Operations. This would ensure NTID stays within the
    total allocation proposed in the President's 2012 budget of
    $65,037,000, and will allow us to better meet our Operations needs. In
    the meantime, we will continue to seek non-Federal funding to support
    immediate construction/renovation needs while continuing to communicate
    about critical long-term construction needs.
    Enrollment
        In fiscal year 2011 (fall 2010), we attracted the largest
    enrollment in our 43-year history. Truly a national program, NTID has
    enrolled students from all 50 States. Our current enrollment is 1,521.
    Over the last 5 years our enrollment has increased 22 percent (271
    students). For fiscal year 2012, NTID anticipates maintaining this
    record high enrollment level. Our enrollment history over the last 5
    years is shown below:

                                                               NTID ENROLLMENTS: FIVE-YEAR HISTORY
    --------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                Deaf/Hard-of-Hearing Students                       Hearing Students
                                                    --------------------------------------------------------------------------------------------
                      Fiscal Year                                                                        Interpreting                            Grand total
                                                      Undergrad     Grad RIT       MSSE       Subtotal      Program        MSSE       Subtotal
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    2007...........................................        1,017           47           31        1,095           130           25          155        1,250
    2008...........................................        1,103           51           31        1,185           130           28          158        1,353
    2009...........................................        1,212           48           24        1,284           135           31          166        1,450
    2010...........................................        1,237           38           32        1,307           138           29          167        1,474
    2011...........................................        1,263           40           29        1,332           147           42          189        1,521
    --------------------------------------------------------------------------------------------------------------------------------------------------------

    Student Accomplishments
        For our graduates, over the past 5 years, an average of 93 percent
    have been placed in jobs commensurate with the level of their education
    (using the Bureau of Labor Statistics methodology). Of our fiscal year
    2009 graduates (the most recent class for which numbers are available),
    59 percent were employed in business and industry, 21 percent in
    education/nonprofits, and 20 percent in Government.
        Graduation from NTID has a demonstrably positive effect on
    students' earnings over a lifetime, and results in a noteworthy
    reduction in dependence on Supplemental Security Income (SSI), Social
    Security Disability Insurance (SSDI) and public assistance programs. In
    fiscal year 2007, NTID, the Social Security Administration, and Cornell
    University examined approximately 13,000 deaf and hard-of-hearing
    individuals who applied and attended NTID over our entire history. We
    learned that graduating from NTID has significant economic benefits. By
    age 50, deaf and hard-of-hearing baccalaureate graduates earned on
    average $6,021 more per year than those with associate degrees, who in
    turn earned $3,996 more per year on average than those who withdrew
    before graduation. Students who withdrew earned $4,329 more than those
    not admitted. Students who withdrew experienced twice the rate of
    unemployment as graduates.
        The same studies showed 78 percent of these individuals were
    receiving SSI benefits at age 19, but when they were 50 years old, only
    1 percent of graduates drew these benefits, while on average 19 percent
    of individuals who withdrew or were not admitted continued to
    participate in the SSI program. Graduates also accessed SSDI, an
    unemployment benefit, at far lesser rates than students who withdrew;
    by age 50, 34 percent of non-graduates were receiving SSDI, while 22
    percent of baccalaureate graduates and 27 percent of associate
    graduates were receiving them. Considering the reduced dependency on
    these Federal income support programs, the Federal investment in NTID
    returns significant societal dividends.
        NTID clearly makes a significant, positive difference in earnings,
    and in lives.
    Strategic Initiatives Beginning Fiscal Year 2011
        In 2010, NTID completed Strategic Decisions 2020, a strategic plan
    based on our founding mission statement. This statement sets forth our
    institutional responsibility to work with students to develop their
    academic, career and life-long learning skills as future contributors
    in a rapidly changing world. It also recognizes our role as a special
    resource for preparing individuals who are deaf and hard-of-hearing,
    for conducting applied research in areas critical to the advancement of
    individuals who are deaf and hard-of-hearing, and for disseminating our
    collective and cumulative expertise.
        Strategic Decisions 2020 establishes key initiatives responding to
    future challenges and shaping future opportunities. These initiatives,
    which began implementation in fiscal year 2011, include:
      --Pursuing enrollment targets and admissions and programming
            strategies that will result in increasing numbers of our
            graduates achieving baccalaureate degrees and higher, while
            maintaining focus and commitment to quality associate-level
            degree programs leading directly to the workplace;
      --Improving services to under-prepared students through working with
            regional partners to implement intensive summer academic
            preparation programs in selected high-growth, ethnically
            diverse areas of the country. Through this initiative, NTID
            will identify those students demonstrating promise for success
            in career-focused degree-level programs and beyond, and provide
            consultation to others regarding postsecondary educational
            alternatives;
      --Expanding NTID's role as a National Resource Center of Excellence
            regarding the education of deaf and hard-of-hearing students in
            senior high school (grades 10, 11 and 12) and at the
            postsecondary level. Components of this role as a National
            Resource Center of Excellence will include:
        --Center for Excellence in STEM Education.--NTID currently is
                working to develop an externally funded Center of
                Excellence on STEM Education for Deaf and Hard-of-Hearing
                Students. This is an example of making our expertise
                available nationally and enhancing deaf and hard-of-hearing
                students' access to STEM fields.
        --NTID Research Centers.--NTID will organize research resources
                into Research Centers focused on the following strategic
                areas of research: Teaching and Learning; Communication;
                Technology, Access, and Support Services; and Employment
                and Adaptability to Social Changes and the Global
                Workplace.
        --Outreach Programs.--Extending outreach activities to junior and
                senior high school students who are deaf and hard-of-
                hearing, many of who represent AALANA populations, to
                expand their horizons regarding a college education. We
                also support other colleges and universities serving
                students who are deaf and hard-of-hearing, as well as post-
                college adults who are deaf and hard-of-hearing.
      --Enhancing efforts to become a recognized national leader in the
            exploration, adaptation, testing, and implementation of new
            technologies to enhance access to, and support of, learning by
            deaf and hard-of-hearing individuals.
    NTID Academic Programs
        NTID offers high quality, career-focused associate degree programs
    preparing students for specific well-paying technical careers. NTID
    also is expanding the number of its transfer associate degree programs,
    currently numbering seven, to better serve the higher achieving segment
    of our student population seeking bachelor's and master's degrees in an
    increasingly demanding marketplace. These transfer programs provide
    seamless transition to baccalaureate studies in the other colleges of
    RIT. In support of those deaf and hard-of-hearing students enrolled in
    the other RIT colleges, NTID provides a range of access services
    (including interpreting, real-time speech-to-text captioning, and note-
    taking) as well as tutoring services. One of NTID's greatest strengths
    is our outstanding track record of assisting high-potential students to
    gain admission to, and graduate from, the other colleges of RIT at
    rates comparable to their hearing peers.
        A cooperative education (co-op) component is an integral part of
    academic programming at NTID and prepares students for success in the
    job market. A co-op gives students the opportunity to experience a
    real-life job situation and focus their career choice. Students develop
    technical skills and enhance vital personal skills such as teamwork and
    communication, which will make them better candidates for full-time
    employment after graduation. Over 250 students each year participate in
    10-week co-op experiences that augment their academic studies, refine
    their social skills, and prepare them for the competitive working
    world.
    Summary
        It is extremely important that our funding be provided at the full
    level requested by the President as we continue our mission to prepare
    deaf and hard-of-hearing people to enter the workplace and society. We
    ask only that the funds provided by the President for Construction be
    moved into Operations.
        Our alumni have demonstrated that they can achieve independence,
    contribute to society, and find sustainable employment as a result of
    NTID. Research shows that NTID graduates over their lifetimes are
    employed at much higher rates, earn substantially more (therefore
    paying significantly more in taxes), and participate at a much lower
    rate in SSI, SSDI, and public assistance programs than those who
    withdraw or who apply but do not attend NTID.
        We are hopeful that the members of the Committee will agree that
    NTID, with its long history of successful stewardship of Federal funds
    and outstanding educational record of service with people who are deaf
    and hard-of-hearing, remains deserving of your support and confidence.
                      fiscal year 2012 ntid budget request

                                           FISCAL YEAR 2012 NTID BUDGET STATUS
    ----------------------------------------------------------------------------------------------------------------
                                                                        Operations     Construction        Total
    ----------------------------------------------------------------------------------------------------------------
    NTID fiscal year 2011 funding...................................     $65,437,000        $240,000     $65,677,000
    NTID original request...........................................      64,677,000       2,000,000      66,677,000
    NTID updated request \1\........................................      65,437,000       1,240,000      66,677,000
    ----------------------------------------------------------------------------------------------------------------
    \1\ Note: Our updated request keeps within the limits of our original request; however, it moves money from our
      Construction request to maintain our Operations funding at the 2011 level.

    Context
        Enrollment is the highest in NTID history with 1,521 students, a 22
    percent increase over the past 5 years.
        In an effort to maximize non-Federal revenues, NTID increased
    tuition by 5 percent for fiscal year 2012. From fiscal year 2006-fiscal
    year 2012, student tuition has increased by 40 percent.
        Support for NTID is an investment with significant returns in the
    form of increased employment and reduced dependence on Federal SSI and
    SSDI payments for our students. NTID's employment rate in 2010 was 89
    percent in spite of a challenging job market and averages to be 93
    percent over the past 5 years.
        Prior to fiscal year 2011, NTID had received $63,037,000 in
    Operations for 2009 and 2010 and was slated to receive that sum again
    in 2011. NTID was able to accommodate level funding in the past through
    a combination of additional non-Federal revenues and targeted fiscal
    control strategies with minimal impact on services and programs for
    students. However, the $65,437,000 that NTID received in Operations for
    fiscal year 2011 was crucial in order to offset record student
    enrollment and use of access services, prevent enrollment caps, and
    avoid the elimination of outreach programs, equipment purchases, and
    matching endowments.
        NTID's updated budget request for fiscal year 2012 maintains
    Operations funding at the fiscal year 2011 level, to support our
    increased enrollment, increased provision of services, and upcoming
    strategic initiatives. It contains $1,240,000 requested for
    Construction to begin major renovations to a building designed 30 years
    ago that houses 3 major NTID programs.
    Possible actions if less than fiscal year 2011 operations funding
            received
        Limit admission of new students for Fall 2012.--NTID has never
    limited the number of qualified students who can enroll--to do so would
    mean denying deaf and hard-of-hearing students the opportunity to
    receive a state-of-the-art technical education with the unparalleled
    access services found at NTID.
        Hiring freeze and possible staff furloughs.--83 percent of NTID's
    resources support salaries/wages--NTID would have to reduce
    expenditures with a hiring freeze and possible furlough of staff,
    leaving positions vacant while serving more students than ever before.
        Substantial reduction or elimination of summer outreach programs.--
    This would affect deaf and hard-of-hearing pre-college youth,
    especially young women and African-American and Latino-American youth,
    by eliminating programs that encourage them to continue on to college,
    especially in the STEM fields.
        Substantial reduction or elimination of equipment purchases.--
    NTID's mission is to prepare deaf and hard-of-hearing students for
    technical and professional careers in fields characterized by cutting-
    edge technologies. Without the most technologically updated equipment
    available, the education of our students will be impaired
    significantly.
        Substantial reduction or elimination of matching endowment funds.--
    NTID would be unable to fulfill its commitment to match endowment
    donations to the Institute, decreasing the level of scholarship support
    for students.
                                     ______

                         Prepared Statement of Nemours
        Nemours thanks Chairman Harkin, Ranking Member Shelby and members
    of the Subcommittee for the opportunity to submit written testimony on
    the fiscal year 2012 Labor, Health and Human Services, Education and
    Related Agencies Appropriations bill. Nemours, one of the Nation's
    leading child health systems, is dedicated to improving children's
    health and well-being by offering a spectrum of clinical treatment,
    research, advocacy, educational health, and prevention services
    extending to families in the communities it serves.
    About Nemours
        Nemours has developed a model of care that integrates clinical
    preventive and treatment services for children with population-based
    prevention initiatives. No other health system in the Nation has made
    the same level of investment in community-based prevention programs,
    policies and practices to reach all children in the community, not just
    those who cross our doors. Nemours Health and Prevention Services
    (NHPS) has developed a comprehensive, multi-sector obesity prevention
    initiative to reach all children in Delaware. To achieve the greatest
    impact, NHPS considers the many places where children and families
    spend their time: schools, child care, healthcare settings, community
    centers and neighborhoods. The goal is to reinforce consistent messages
    through policy and practice changes in each setting to help children
    make healthy food and lifestyle choices and to stay physically active.
        In school settings, NHPS works with district-level teams of
    administrators, teachers, counselors, school nurses, parents and
    students to encourage wellness policies and provide training and
    educational tools that support policy and environmental changes to
    encourage healthier eating and more physical activity on school
    campuses. In the child care setting, Nemours worked with government
    leaders to help Delaware become a frontrunner for policies that support
    healthy eating and physical activity. NHPS provides training and
    educational tools to help child care providers promote healthy
    behaviors for young children.
        In the primary care setting, Nemours convened pediatric primary
    care providers from across the State to participate in a learning
    collaborative focused on improving office-based weight management and
    health promotion skills. Practitioners learned about new interventions
    and received tools for use in the office setting, as well as take-home
    materials for families. In the community, NHPS works with youth-serving
    organizations to promote healthy eating and physical activity and to
    develop champions who will model the behavior and help spread the
    message. We also work to create an environment that promotes healthy
    lifestyles.
    Community-based Prevention
        As an integrated health system that is very engaged with the
    community, Nemours sees first-hand the impact of chronic disease on our
    Nation's children. We treat obese young children at our clinics, and we
    know that unhealthy habits that contribute to obesity are starting at a
    very young age. In fact, nationally, over 24 percent of children ages
    2-5 are already overweight or obese. Much of what influences their
    health is outside the realm of the healthcare system, which is why we
    have made and will continue to make significant investments in
    community-based prevention. We believe that investing in clinical and
    community-based prevention is an important way to ensure that children
    grow up to be healthy adults. We are supportive of the Prevention and
    Public Health Fund and urge the Committee to utilize the resources
    provided from this Fund to support the integration of clinical and
    community-based prevention and to evaluate the outcomes associated with
    those investments. In particular, we are supportive of Community
    Transformation Grants.
        Community Transformation Grants draw upon the best of what we know
    works: strong coalitions, multi-sector, public-private partnerships,
    evidence-based approaches, and evaluation. In Delaware, Nemours has
    successfully used this combination of approaches to stem the rising
    childhood obesity curve between 2006 and 2008. These grants allow us to
    build upon this foundation and spread what works to other communities.
    The purpose of the grants is to support the implementation, evaluation,
    and dissemination of evidence-based community preventive health
    activities in order to reduce chronic disease rates, prevent the
    development of secondary conditions, address health disparities, and
    develop a stronger evidence-base of effective prevention programming.
    In short, these grants would help us in our efforts to help children
    grow up healthy. If we are serious about the commitment to improving
    health, then we need to transform the places where children live, learn
    and play, which is exactly what these grants are designed to
    accomplish. We urge the Committee to provide $221.06 million for
    Community Transformation Grants in fiscal year 2012, which is the level
    requested by the President.
    Children's Hospital Graduate Medical Education
        Another important priority for Nemours is the healthcare workforce,
    particularly the pediatric workforce. Children's hospitals care for
    large numbers of children with complex health conditions. In order to
    achieve high quality clinical care and outcomes, these specialty
    hospitals need to have well-trained residents and physicians. The
    Children's Hospital Graduate Medical Education program (CHGME) provides
    support for graduate medical education to freestanding children's
    hospitals that train resident physicians. The CHGME program was created
    to correct an unintended inequity in the GME financing system, which is
    tied to the number of Medicare beneficiaries being treated at a
    hospital. Freestanding children's hospitals generally do not provide
    care to Medicare-eligible patients, and were therefore largely left out
    of the GME financing system. The CHGME program has addressed this
    issue.
        CHGME supports 55 freestanding children's hospitals that train
    approximately 40 percent of all pediatricians, 43 percent of all
    pediatric specialists, and many pediatric researchers and physicians
    who require pediatric training. In 2009, CHGME supported the training
    of 5,439 pediatric resident physicians. This is a very important
    contribution to training our pediatric workforce, which continues to
    experience shortages, particularly in pediatric specialty care. A 2009
    survey by the National Association of Children's Hospitals and Related
    Institutions (NACHRI) found that national shortages contribute to
    vacancies in children's hospitals that commonly last 12 months or
    longer for a number of pediatric specialties. These vacancies often
    result in longer wait times for children to see pediatric specialists.
        At the Alfred I. duPont Hospital for Children, over 300 residents
    are trained each year. Under the supervision of physicians, these
    residents provide care for inpatients and also provide primary and
    specialty care in outpatient settings, including clinics. In 2010,
    CHGME covered approximately 54 percent of the cost of the Nemours
    residency program.
        Unfortunately, the President's budget proposes to eliminate funding
    for this critical program. We urge Congress to reject this short-
    sighted cut and to continue to provide support for training the next
    generation of pediatricians, pediatric specialists and pediatric
    researchers. Nemours urges the Subcommittee to provide $317.5 million
    for CHGME in fiscal year 2012, the same amount that was provided in
    fiscal year 2010.
    Conclusion
        Nemours appreciates the opportunity to submit written testimony. As
    an integrated child health system, we have prioritized investments in
    clinical and community-based prevention and our workforce because we
    believe that in the long-run these investments will bend the health
    curve and the cost curve. We recognize that the Nation's fiscal
    situation requires a close examination of the programs and priorities
    that the Federal Government funds. As you make these critical funding
    decisions, we hope that prevention and the healthcare workforce will
    remain priorities of the Subcommittee in fiscal year 2012.
                                     ______

                 Prepared Statement of the Nephcure Foundation
        Nephrotic syndrome (NS) is a collection of signs and symptoms
    caused by diseases that attack the kidney's filtering system. These
    diseases include focal segmental glomerulosclerosis (FSGS), Minimal
    Change Disease (MCD) and Membranous Nephropathy (MN). When affected,
    the kidney filters leak protein from the blood into the urine and often
    cause kidney failure which requires dialysis or kidney transplantation.
    According to a Harvard University report, 73,000 people in the United
    States have lost their kidneys as a result of FSGS. Unfortunately, the
    causes of FSGS and other filter diseases are very poorly understood.
        FSGS is the second leading cause of NS and is especially difficult
    to treat. There is no known cure for FSGS and current treatments are
    difficult for patients to endure. These treatments include the use of
    steroids and other dangerous substances which lower the immune system
    and contribute to severe bacterial infections, high blood pressure and
    other problems in patients, particularly child patients. In addition,
    children with NS often experience growth retardation and heart disease.
    Finally, NS caused by FSGS, MCD or MN is idiopathic and can often
    reoccur, even after a kidney transplant.
        FSGS disproportionately affects minority populations and is five
    times more prevalent in the African American community. In a
    groundbreaking study funded by NIH, researchers found that FSGS is
    associated with two APOL1 gene variants. These variants are common in
    African Americans but not in European Americans, and it is thought that
    these variants developed as an evolutionary response to African
    sleeping sickness.
        FSGS also has a large social impact on the United States. FSGS
    leads to end-stage renal disease (ESRD) which is one of the most costly
    chronic diseases to manage. In 2007, the Medicare program alone spent
    $24 billion, 6 percent of its entire budget, on ESRD. In 2005, FSGS
    accounted for 12 percent of ESRD cases in the United States, at an
    annual cost of $3 billion. It is estimated that there are currently
    approximately 20,000 Americans living with ESRD due to FSGS.
        Research on FSGS could achieve tremendous savings in Federal
    healthcare costs and reduce health status disparities--both critical
    and appropriate themes of the current administration. For this reason,
    and on behalf of the thousands of families that are significantly
    affected by this disease, we recommend the following:
      --$35 billion for the National Institutes of Health (NIH) and a
            corresponding increase to the National Institute of Diabetes
            and Digestive and Kidney Diseases (NIDDK).
      --Continue to support the Nephrotic Syndrome Rare Disease Clinical
            Research Network at the Office of Rare Diseases Research
            (ORDR).
      --Support continued expansion of the FSGS/NS research portfolio at
            NIDDK and the National Institute on Minority Health and Health
            Disparities (NIMHD) by funding more research proposals for
            glomerular disease.
      --Support awareness activities through the Centers for Disease
            Control and Prevention Chronic Kidney Disease Program.
    Encourage FSGS/NS Research at NIH
        There is no known cause or cure for FSGS and scientists tell us
    that much more research needs to be done on the basic science behind
    FSGS/NS. More research could lead to fewer patients undergoing ESRD and
    tremendous savings in healthcare costs in the United States.
        With collaboration from other Institutes and Centers, ORDR
    established the Rare Disease Clinical Research Network. This network
    provided an opportunity for the NephCure Foundation, the University of
    Michigan, and other university research health centers to come together
    to form the Nephrotic Syndrome Study Network (NEPTUNE). NEPTUNE is a
    relatively new collaboration and has tremendous potential to make
    significant advancements in NS and FSGS research because it pools
    resources and develops a database of NS patients who are interested in
    participating in clinical trials. The addition of Federal resources, as
    well as NIH coordination of this important initiative, is crucial to
    ensuring the best possible outcomes for RDCRN and NEPTUNE.
        The NephCure Foundation is also grateful to the NIDDK for issuing a
    program announcement (PA) that serves to initiate grant proposals on
    glomerular disease. This PA was issued in March of 2007 and utilizes
    utilize the R01 mechanism to award funding to glomerular disease
    researchers. In February, 2010 the PA was re-released and is now
    scheduled to expire in 2013. We ask the subcommittee to encourage NIDDK
    to continue to issue glomerular disease PAs.
        Due to the disproportionate burden of FSGS on minority populations,
    the NephCure Foundation feels that it is appropriate for NIMHD to
    develop an interest in this research. However, NIMHD has not supported
    any research on FSGS. We ask the Subcommittee to encourage ORDR, NIDDK,
    and NIMHD to collaborate on research that studies the incidence and
    cause of this disease among minority populations. We also ask the
    Subcommittee to urge NIDDK and the NIMHD undertake culturally
    appropriate efforts aimed at educating minority populations about
    glomerular disease.
    Raise Glomerular Disease Awareness at CDC
        When glomerular disease strikes, the resulting NS causes a loss of
    protein in the urine and edema. The edema often manifests itself as
    puffy eyelids, a symptom that many parents and physicians mistake as
    allergies. With experts projecting a substantial increase in nephrotic
    syndrome in the coming years, there is a clear need to educate
    pediatricians and family physicians about glomerular disease and its
    symptoms.
        It would be of great benefit for CDC to begin raising public
    awareness of the glomerular diseases in an attempt to diagnose patients
    earlier.
        We ask the Subcommittee to encourage CDC to establish a glomerular
    disease education and awareness program aimed at both the general
    public and healthcare providers.
                                     ______

                 Prepared Statement of Neurofibromatosis, Inc.
        Thank you for the opportunity to submit testimony to the
    Subcommittee on the importance of continued funding at the National
    Institutes of Health (NIH) for Neurofibromatosis (NF), a terrible
    genetic disorder closely linked to many common diseases widespread
    among the American population.
        On behalf of Neurofibromatosis, Inc., a national coalition of NF
    advocacy groups, I speak on behalf of the 100,000 Americans who suffer
    from NF as well as approximately 175 million Americans who suffer from
    diseases and conditions linked to NF such as cancer, brain tumors,
    heart disease, memory loss and learning disabilities. Thanks in large
    measure to this Subcommittee's strong and enduring support, scientists
    have made enormous progress since the discovery of the NF1 gene in 1990
    resulting in clinical trials now being undertaken at NIH with broad
    implications for the general population.
    What is Neurofibromatosis (NF)?
        NF is a genetic disorder involving the uncontrolled growth of
    tumors along the nervous system which can result in terrible
    disfigurement, deformity, deafness, blindness, brain tumors, cancer,
    and even death. NF can also cause other abnormalities such as unsightly
    benign tumors across the entire body and bone deformities. In addition,
    approximately one-half of children with NF suffer from learning
    disabilities. While not all NF patients suffer from the most severe
    symptoms, all NF patients and their families live with the uncertainty
    of not knowing whether they will be seriously affected because NF is a
    highly variable and progressive disease.
        NF is not rare. It is the most common neurological disorder caused
    by a single gene and three times more common than Muscular Dystrophy
    and Cystic Fibrosis combined, but it is not widely known because it has
    been poorly diagnosed for many years. Approximately 100,000 Americans
    have NF, and it appears in approximately 1 in every 2,500 births. It
    strikes worldwide, without regard to gender, race or ethnicity.
    Approximately 50 percent of new NF cases result from a spontaneous
    mutation in an individual's genes and 50 percent are inherited. There
    are three types of NF: NF1, which is more common, NF2, which primarily
    involves tumors causing deafness and balance problems, and
    schwannomatosis, the hallmark of which is severe pain. In addition,
    advances in NF research stand to benefit over 175 million Americans in
    this generation alone because NF is directly linked to many of the most
    common diseases affecting the general population.
        When a child is diagnosed with NF it means tumors can grow anytime,
    anywhere on his/her nervous system, from the day he/she is born until
    the day he/she dies with no way to predict when or how severely the
    tumors will affect his/her body--and no viable way to treat the disease
    outside of surgery--which often results in more tumors that grow twice
    as fast. That same child then has a 50 percent chance to pass the gene
    to his/her children. That is an overwhelming diagnosis and it bears
    repeating: NF is one of the most common genetic disorders in our
    country and has no cure and no viable treatment. But that is changing.
    The immediate future holds real promise.
    Link to Other Illnesses
        Researchers have determined that NF is closely linked to cancer,
    heart disease, learning disabilities, memory loss, brain tumors, and
    other disorders including deafness, blindness and orthopedic disorders,
    primarily because NF regulates important pathways common to these
    disorders such as the RAS, cAMP and PAK pathways. Research on NF
    therefore stands to benefit millions of Americans:
        Cancer.--NF is closely linked to many of the most common forms of
    human cancer, affecting approximately 65 million Americans. In fact, NF
    shares these pathways with 70 percent of human cancers. Research has
    demonstrated that NF's tumor suppressor protein, neurofibromin,
    inhibits RAS, one of the major malignancy causing growth proteins
    involved in 30 percent of all cancer. Accordingly, advances in NF
    research may well lead to treatments and cures not only for NF
    patients, but for all those who suffer from cancer and tumor-related
    disorders. Similar studies have also linked epidermal growth factor
    receptor (EGF-R) to malignant peripheral nerve sheath tumors (MPNSTs),
    a form of cancer which disproportionately strikes NF patients.
        Heart disease.--Researchers have demonstrated that mice completely
    lacking in NF1 have congenital heart disease that involves the
    endocardial cushions which form in the valves of the heart. This is
    because the same ras involved in cancer also causes heart valves to
    close. Neurofibromin, the protein produced by a normal NF1 gene,
    suppresses ras, thus opening up the heart valve. Promising new research
    has also connected NF1 to cells lining the blood vessels of the heart,
    with implications for other vascular disorders including hypertension,
    which affects approximately 50 million Americans. Researchers believe
    that further understanding of how an NF1 deficiency leads to heart
    disease may help to unravel molecular pathways involved in genetic and
    environmental causes of heart disease.
        Learning disabilities.--Learning disabilities are the most common
    neurological complication in children with NF1. Research aimed at
    rescuing learning deficits in children with NF could open the door to
    treatments affecting 35 million Americans and 5 percent of the world's
    population who also suffer from learning disabilities. In NF1 the
    neurocognitive disabilities range includes behavior, memory and
    planning. Recent research has shown there are clear molecular links
    between autism spectrum disorder and NF1; as well as with many other
    cognitive disabilities. Tremendous research advances have recently led
    to the first clinical trials of drugs in children with NF1 learning
    disabilities. These trials are showing promise. In addition because of
    the connection with other types of cognitive disorders such as autism,
    researchers and clinicians are actively collaborating on research and
    clinical studies, pooling knowledge and resources. It is anticipated
    that what we learn from these studies could have an enormous impact on
    the significant American population living with learning difficulties
    and could potentially save Federal, State, and local governments, as
    well as school districts, billions of dollars annually in special
    education costs resulting from a treatment for learning disabilities.
        Memory loss.--Researchers have also determined that NF is closely
    linked to memory loss and are now investigating conducting clinical
    trials with drugs that may not only cure NF's cognitive disorders but
    also result in treating memory loss as well with enormous implications
    for patients who suffer from Alzheimer's disease and other dementias.
        Deafness.--NF2 accounts for approximately 5 percent of genetic
    forms of deafness. It is also related to other types of tumors,
    including schwannomas and meningiomas, as well as being a major cause
    of balance problems.
    Scientific Advances
        Thanks in large measure to this Subcommittee's support; scientists
    have made enormous progress since the discovery of the NF1 gene in
    1990. Major advances in just the past few years have ushered in an
    exciting era of clinical and translational research in NF with broad
    implications for the general population.
        These recent advances have included:
      --Phase II and Phase III clinical trials involving new drug therapies
            for both cancer and cognitive disorders;
      --Creation of a National Clinical and Pre-Clinical Trials
            Infrastructure and NF Centers;
      --Successfully eliminating tumors in NF1 and NF2 mice with the same
            drug;
      --Developing advanced mouse models showing human symptoms;
      --Rescuing learning deficits and eliminating tumors in mice with the
            same drug;
      --Determining the biochemical, molecular function of the NF genes and
            gene products; and
      --Connecting NF to more and more diseases because of NF's impact on
            many body functions.
    Congressional support for NF research
        The enormous promise of NF research, and its potential to benefit
    over 175 million Americans who suffer from diseases and conditions
    linked to NF, has gained increased recognition from Congress and the
    NIH. This is evidenced by the fact that 12 institutes at NIH are
    currently supporting NF research (NCI, NHLBI, NINDS, NIDCD, NHGRI,
    NCRR, NIMH, NIGMS, NEI, NIA, NICHD, and OD), and NIH's total NF
    research portfolio has increased from $3 million in fiscal year 1990 to
    an estimated $24 million in fiscal year 2011. Given the potential
    offered by NF research for progress against a range of diseases, we are
    hopeful that NIH will continue to build on the successes of this
    program by funding this promising research and thereby continuing the
    enormous return on the taxpayers' investment.
        We respectfully request that you include the following report
    language on NF research at the National Institutes of Health within
    your fiscal year 2012 Labor, Health and Human Services, Education
    Appropriations bill.
        Neurofibromatosis [NF].--NF is an important research area for
    multiple NIH Institutes; therefore the Committee supports efforts to
    increase funding and resources toward NF research and treatment. As NF
    is connected to many forms of cancer in children and adults; the
    Committee encourages the NCI to substantially increase its NF research
    portfolio in pre-clinical and clinical trials by applying newly
    developed and existing drugs. The Committee also encourages the NCI to
    support NF centers, clinical trials consortia, patient databases, and
    biospecimen repositories. The Committee also urges additional focus
    from the NHLBI, given NF's involvement with hypertension and congenital
    heart disease. Because NF causes tumors to grow on the nerves
    throughout the body, the Committee urges the NINDS to continue
    aggressive research on nerve damage and repair which has strong
    implications not only for NF but for spinal cord and brain injury,
    learning disabilities and attention deficit disorders. In addition, the
    Committee continues to encourage the NICHD and NIMH to expand funding
    of clinical trials for NF patients in the area of learning
    disabilities. Children with NF1 are prone to the development of severe
    bone deformities, including scoliosis; the Committee encourages NIAMS
    to expand its NF1 research portfolio. NF2 accounts for approximately 5
    percent of genetic forms of deafness; the Committee therefore
    encourages the NIDCD to expand its NF2 research portfolio. The
    Committee encourages NEI to expand its NF research portfolio to advance
    the cause of treating Optic gliomas, vision loss and cataracts, major
    clinical problems associated with NF. The Committee encourages the
    NHGRI to expand its NF portfolio given that NF represents an ideal
    model to study the genomics of cancer predisposition, learning and
    behavior, and bone disease translatable to personalized medicine for
    affected individuals.
        We appreciate the Subcommittee's strong support for NF research and
    will continue to work with you to ensure that opportunities for major
    advances in NF research are aggressively pursued. Thank you.
                                     ______

                  Prepared Statement of the Nursing Community
        The Nursing Community is a forum for professional nursing
    organizations to collaborate on a wide spectrum of healthcare and
    nursing issues, including practice, education, and research. These 56
    organizations are committed to promoting America's health through
    nursing care. Collectively, the Nursing Community represents over
    850,000 Registered Nurses (RNs), Advanced Practice Registered Nurses
    (APRNs--including certified nurse-midwives, nurse practitioners,
    clinical nurse specialists, and certified registered nurse
    anesthetists), nurse executives, nursing students, nursing faculty, and
    nurse researchers. Together, our organizations work collaboratively to
    increase funding for the Nursing Workforce Development programs
    (authorized under Title VIII of the Public Health Service Act [42
    U.S.C. 296 et seq.]), the National Institute of Nursing Research
    (NINR), and to secure authorized funding for Nurse-Managed Health
    Clinics so that American nurses have the support needed to provide high
    quality healthcare to the Nation.
        Nurses are involved in every aspect of healthcare, and if the
    nursing workforce is not strengthened, the healthcare system will
    continue to suffer. Currently, RNs comprise the largest group of health
    professionals with approximately 3.1 million licensed providers. Nurses
    offer essential care to patients as well as our Nation's active duty
    military and veterans in a variety of settings, including hospitals,
    ambulatory care clinics, long-term care facilities, community or public
    health areas, schools, workplaces, and private homes. In addition, many
    nurses pursue graduate degrees to assume roles as advanced practice
    registered nurses who practice autonomously; become nurse faculty,
    nurse researchers, nurse administrators, and advanced public health
    nurses. Nurses also specialize in areas such as mental and women's
    health, pain management, hospice and palliative care, nephrology,
    oncology, rehabilitation, forensics, dermatology, urology, and care
    coordination. They are critical team members in all departments such as
    intensive and critical care, pediatrics, geriatrics, medical surgical,
    and operating rooms. RNs and APRNs hold a holistic view of health.
        With the Patient Protection and Affordable Care Act [Public Law
    111-148] (ACA) focus on creating a system that will increase access to
    quality care, emphasize prevention, and decrease cost, it is critical
    that a substantial investment be made in our RN and APRN workforce, in
    the scientific research that provides the basis for nursing practice,
    and in the safety-net facilities they operate.
        In an article published in the July/August 2009 issue of Health
    Affairs, Dr. Peter Buerhaus, a noted health professions workforce
    analyst, and colleagues confirmed that although the economic recession
    has led to a temporary easing of the nursing shortage in some parts of
    the country, the overall shortfall in the number of nurses needed is
    expected to grow to 260,000 by the year 2025. Three major factors
    contribute to this growing demand for nursing care. First, over 275,000
    practicing RNs are over the age of 60 according to the 2008 National
    Sample Survey of Registered Nurses. When the economy rebounds, many of
    these nurses will seek retirement. Second, America's population is
    aging. Older Americans will seek more healthcare services creating an
    influx of consumers and necessitate the need for quality nursing care.
    Finally, the ACA will expand the number of individuals seeking care by
    32 million.
        Furthermore, in a report released by the Institute of Medicine and
    Robert Wood Johnson Foundation titled, The Future of the Nursing:
    Leading Change, Advancing Health, clear and evidence based guidance was
    provided on how to shape nursing's role in healthcare delivery as the
    system undergoes considerable changes. The report's key messages
    include:
      --Nurses should practice to the full extent of their education and
            training; scope of practice limitations should be removed.
      --Nurses should achieve higher levels of education and training
            through an improved education system that promotes seamless
            academic progression.
      --Nurses should be full partners with other healthcare professionals
            in redesigning healthcare in the United States.
      --Effective workforce planning and policymaking require better data
            collection and an improved information infrastructure.
        To achieve these goals, different levels of support will be needed
    for all nurses and each of the funding requests outlined below will
    help to meet not only the goals of the IOM report, but the larger
    national goals of access to high quality, cost effective care.
         addressing the demand: nursing workforce development programs
        The Nursing Workforce Development programs, authorized under Title
    VIII of the Public Health Service Act (42 U.S.C. 296 et seq.), helped
    build the supply and distribution of qualified nurses to meet our
    Nation's healthcare needs since 1964. Over the last 47 years, these
    programs addressed all aspects of supporting the workforce--education,
    practice, retention, and recruitment. The Title VIII programs bolster
    nursing education at all levels, from entry-level preparation through
    graduate study, and provide support for institutions that educate
    nurses for practice in rural and medically underserved communities.
    Today, the Title VIII programs are essential to ensure the demand for
    nursing care is met. Between fiscal year 2006 and 2009, the Title VIII
    programs supported over 347,000 nurses and nursing students as well as
    numerous academic nursing institutions, and healthcare facilities.
        Results from the American Association of Colleges of Nursing's
    (AACN) 2010-2011 Title VIII Student Recipient Survey included responses
    from 1,459 students who noted that these programs played a critical
    role in funding their nursing education. The survey showed that 80
    percent of the students receiving Title VIII funding are attending
    school full-time. By supporting full-time students, the Title VIII
    programs are helping to ensure that students enter the workforce
    without delay. The programs also address the current demand for primary
    care providers. Nearly one-third of respondents reported that their
    career goal is to become a nurse practitioner. Approximately 80 percent
    of nurse practitioners provide primary care services throughout the
    United States. Additionally, the respondents identified working in
    rural and underserved areas as future goals, with becoming a nurse
    faculty member, a nurse practitioner, or a certified registered nurse
    anesthetist as the top three nursing positions for their career
    aspirations.
        The Nursing Community respectfully requests $313.075 million for
    the Nursing Workforce Development programs authorized under Title VIII
    of the Public Health Service Act in fiscal year 2012 as recommended in
    the President's fiscal year 2012 budget proposal.
        building the science: the national institute of nursing research
        As one of the 27 Institutes and Centers at the National Institutes
    of Health (NIH), the NINR funds research that establishes the
    scientific basis for quality patient care. Nurse researchers make
    significant advances in and contributions to health prevention and
    care. In addition, they work collaboratively as well as part of
    multidisciplinary research teams with colleagues from other fields and
    are vital in setting the national research agenda.
        The Nursing Community respectfully requests $163 million for the
    National Institute of Nursing Research in fiscal year 2012. Nursing
    research is an essential part of scientific endeavors to improve the
    Nation's health. Knowledge of care across the lifespan is critical to
    the present and future health of the Nation. Research funded at the
    NINR helps to integrate biology and behavior as well as design new
    technology and tools. At a time when healthcare needs are changing,
    nursing care must be firmly grounded in nursing science. The four
    strategic areas of emphasis for research at NINR are promoting health
    and preventing disease, eliminating health disparities, improving
    quality of life, and setting directions for end-of-life research.
        The science advanced at NINR is integral to the future of the
    Nation's healthcare system. Through grants, research training, and
    interdisciplinary collaborations, NINR addresses care management of
    patients during illness and recovery, reduction of risks for disease
    and disability, promotion of healthy lifestyles, enhancement of quality
    of life for those with chronic illness, and care for individuals at the
    end of life. NINR's research fosters advances in nursing practice,
    improves patient care, and attracts new students to the profession.
         supporting safety net facilities: nurse-managed health clinics
        The ACA amended Sec. 330 of the Public Health Service Act to
    provide grant eligibility to Nurse-Managed Health Clinics (NMHCs) to
    support operating costs and authorized up to $50 million a year for
    this purpose. NMHCs are defined as a nurse-practice arrangement,
    managed by APRNs, that provides primary care or wellness services to
    underserved or vulnerable populations and that is associated with a
    school, college, university or department of nursing, federally
    qualified health center, or independent nonprofit health or social
    services agency. Nurse-Managed Health Clinics successfully engage
    communities and address critical health needs for underserved
    populations.
        The Nursing Community respectfully requests $20 million for the
    Nurse-Managed Health Clinics authorized under Title III of the Public
    Health Service Act in fiscal year 2012 as recommended in the
    President's fiscal year 2012 budget proposal.
        NMHCs provide care to clients and patients in clinics located in
    places like public housing, on blighted urban streets, on Native
    American reservations, in rural communities, in senior citizen centers,
    in elementary schools, in storefronts, and even in churches. The
    services these clinics provide include primary care, health promotion,
    and disease prevention. Furthermore, NMHCs also act as important
    teaching and practice sites for nursing students.
        The care provided in these sites directly contributes to positive
    health outcomes and savings in the long term. In one U.S. city alone,
    nurses at an NMHC see their patients almost twice as frequently as
    other providers, and their patients are hospitalized 30 percent less
    and use the emergency room 15 percent less often than those of other
    healthcare providers. Providing funding for these centers is a direct
    investment in the specific health needs of localized communities.
        Without a workforce of well-educated nurses providing evidence-
    based care to those who need it most, including our growing aging
    population, the healthcare system is not sustainable. The Nursing
    Community's request of $313.075 million in fiscal year 2012 for the
    Title VIII Nursing Workforce Development programs, $163 million for the
    NINR, and $20 million for NMHCs will help ensure access to quality care
    provided by America's nursing workforce.
           members of the nursing community submitting this testimony
    Academy of Medical-Surgical Nurses
    American Academy of Ambulatory Care Nursing
    American Academy of Nurse Practitioners
    American Academy of Nursing
    American Assembly for Men in Nursing
    American Association of Colleges of Nursing
    American Association of Critical-Care Nurses
    American Association of Nurse Anesthetists
    American Association of Nurse Assessment Coordinators
    American College of Nurse Practitioners
    American College of Nurse-Midwives
    American Holistic Nurses Association
    American Nephrology Nurses' Association
    American Nurses Association
    American Organization of Nurse Executives
    American Psychiatric Nurses Association
    American Society for Pain Management Nursing
    American Society of PeriAnesthesia Nurses
    Association of Community Health Nursing Educators
    Association of periOperative Registered Nurses
    Association of Rehabilitation Nurses
    Association of State and Territorial Directors of Nursing
    Association of Women's Health, Obstetric and Neonatal Nurses
    Commissioned Officers Association
    Dermatology Nurses' Association
    Gerontological Advanced Practice Nurses Association
    Hospice and Palliative Nurses Association
    Infusion Nurses Society
    International Association of Forensic Nurses
    International Nurses Society on Addictions
    International Society of Psychiatric Nurses
    National Association of Clinical Nurse Specialists
    National Association of Nurse Practitioners in Women's Health
    National Association of Pediatric Nurse Practitioners
    National Black Nurses Association
    National Coalition of Ethnic Minority Nurse Associations
    National Nursing Centers Consortium
    National Organization of Nurse Practitioner Faculties
    Nurses Organization of Veterans Affairs
    Oncology Nursing Society
    Public Health Nursing Section, American Public Health Association
    Society of Urologic Nurses and Associates
                                     ______

               Prepared Statement of the Oncology Nursing Society
                                    overview
        The Oncology Nursing Society (ONS) appreciates the opportunity to
    submit written comments for the record regarding fiscal year 2012
    funding for cancer and nursing related programs. ONS, the largest
    professional oncology group in the United States, composed of more than
    35,000 nurses and other health professionals, exists to promote
    excellence in oncology nursing and the provision of quality care to
    those individuals affected by cancer. As part of its mission, the
    Society honors and maintains nursing's historical and essential
    commitment to advocacy for the public good.
        In 2010, an estimated 1.529 million Americans were diagnosed with
    cancer, and more than 569,490 lost their battle to this terrible
    disease; at the same time the national nursing shortage is expected to
    worsen. Overall, age is the number one risk factor for developing
    cancer. Approximately 77 percent of all cancers are diagnosed at age 55
    and older.\1\ Despite these grim statistics, significant gains in the
    war against cancer have been made through our Nation's investment in
    cancer research and its application. Research holds the key to improved
    cancer prevention, early detection, diagnosis, and treatment, but such
    breakthroughs are meaningless, unless we can deliver them to all
    Americans in need. Moreover, a recent survey of ONS members found that
    the nursing shortage is having an impact in oncology physician offices
    and hospital outpatient departments. Some respondents indicated that
    when a nurse leaves their practice, they are unable to hire a
    replacement due to the shortage--leaving them short-staffed and posing
    scheduling challenges for the practice and the patients. These
    vacancies in all care settings create significant barriers to ensuring
    access to quality care.
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        \1\ American Cancer Society. Cancer Facts and Figures 2010. http://
    www.cancer.org/Research/CancerFactsFigures/CancerFactsFigures/cancer-
    facts-and-figures-2010.
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        To ensure that all people with cancer have access to the
    comprehensive, quality care they need and deserve, ONS advocates
    ongoing and significant Federal funding for cancer research and
    application, as well as funding for programs that help ensure an
    adequate oncology nursing workforce to care for people with cancer. ONS
    stands ready to work with policymakers at the local, State, and Federal
    levels to advance policies and programs that will reduce and prevent
    suffering from cancer and sustain and strengthen the Nation's nursing
    workforce. We thank the Subcommittee for its consideration of our
    fiscal year 2012 funding request detailed below.
        securing and maintaining an adequate oncology nursing workforce
        Oncology nurses are on the front lines in the provision of quality
    cancer care for individuals with cancer--administering chemotherapy,
    managing patient therapies and side-effects, working with insurance
    companies to ensure that patients receive the appropriate treatment,
    providing treatment education and counseling to patients and family
    members, and engaging in myriad other activities on behalf of people
    with cancer and their families. Cancer is a complex, multifaceted
    chronic disease, and people with cancer require specialty-nursing
    interventions at every step of the cancer experience. People with
    cancer are best served by nurses specialized in oncology care, who are
    certified in that specialty.
        As the overall number of nurses is expected to decline in the
    coming years, we likely will experience a commensurate decrease in the
    number of nurses trained in the specialty of oncology. With an
    increasing number of people with cancer needing high-quality
    healthcare, coupled with an inadequate nursing workforce, our Nation
    could quickly face a cancer care crisis of serious proportion, with
    limited access to quality cancer care, particularly in traditionally
    underserved areas. A study in the New England Journal of Medicine found
    that nursing shortages in hospitals are associated with a higher risk
    of complications--such as urinary tract infections and pneumonia,
    longer hospital stays, and even patient death.\2\ Without an adequate
    supply of nurses, there will not be enough qualified oncology nurses to
    provide the quality cancer care to a growing population of people in
    need, and patient health and well-being could suffer.
    ---------------------------------------------------------------------------
        \2\ Needleman J., Buerhaus P., Mattke S., Stewart M., Zelevinsky K.
    ``Nurse-Staffing Levels and the Quality of Care in Hospitals.'' New
    England Journal of Medicine 346:, (May 30, 2002): 1715-1722.
    ---------------------------------------------------------------------------
        Of additional concern is that our Nation also will face a shortage
    of nurses available and able to conduct cancer research and clinical
    trials. With a shortage of cancer research nurses, progress against
    cancer will take longer because of scarce human resources coupled with
    the reality that some practices and cancer centers' resources could be
    funneled away from cancer research to pay for the hiring and retention
    of oncology nurses to provide direct patient care. Without a sufficient
    supply of trained, educated, and experienced oncology nurses, we are
    concerned that our Nation may falter in its delivery and application of
    the benefits from our Federal investment in research.
        ONS joins our colleagues from all nursing sectors and specialties
    to request $313.075 million for the Health Resources and Services
    Administrations (HRSA) Title VIII programs in fiscal year 2012, as
    recommended in the President's fiscal year 2012 budget. With additional
    funding in fiscal year 2012, the HRSA Workforce Development Programs
    will have much-needed resources to address the multiple factors
    contributing to the nationwide nursing shortage. Advanced nursing
    education programs play an integral role in supporting registered
    nurses interested in advancing in their practice and becoming faculty.
    As such, these programs must be adequately funded in the coming year.
        ONS strongly urges Congress to provide HRSA with this amount to
    ensure that the agency has the resources necessary to fund a higher
    rate of nursing scholarships and loan repayment applications and
    support other essential endeavors to sustain and boost our Nation's
    nursing workforce. Nurses--along with patients, family members,
    hospitals, and others--have joined together in calling upon Congress to
    provide this essential level of funding. The National Coalition for
    Cancer Research (NCCR), a nonprofit organization comprised of 23
    national cancer organizations, and One Voice Against Cancer (OVAC), a
    collaboration of 39 national nonprofit organizations, are also
    advocating $313.075 million in fiscal year 2012 for the Nurse
    Reinvestment Act. ONS and its allies have serious concerns that without
    full funding, the Nurse Reinvestment Act will prove an empty promise,
    and the current and expected nursing shortage will worsen, and people
    will not have access to the quality care they need and deserve.
                sustain and seize cancer research opportunities
        Our Nation has benefited immensely from past Federal investment in
    biomedical research at the National Institutes of Health (NIH). ONS has
    joined with the broader health community in advocating a $35 billion
    for NIH in fiscal year 2012. This level of investment will allow NIH to
    sustain and build on its research progress, while avoiding the severe
    disruption to advancement that could result from a minimal increase.
    Cancer research is producing amazing breakthroughs--leading to new
    therapies that translate into longer survival and improved quality of
    life for cancer patients. In recent years, we have seen extraordinary
    advances in cancer research, resulting from our national investment,
    which have produced effective prevention, early detection, and
    treatment methods for many cancers. To that end, ONS calls upon
    Congress to allocate $5.740 billion to the National Cancer Institute
    (NCI), as well as $231 million to the National Center for Minority
    Health and Health Disparities in fiscal year 2012 to support the battle
    against cancer.
        The National Institute of Nursing Research (NINR) supports basic
    and clinical research to establish a scientific basis for the care of
    individuals across the life span--from management of patients during
    illness and recovery, to the reduction of risks for disease and
    disability and the promotion of healthy lifestyles. These efforts are
    crucial in translating scientific advances into cost-effective
    healthcare that does not compromise quality of care for patients.
    Additionally, NINR fosters collaborations with many other disciplines
    in areas of mutual interest, such as long-term care for older people,
    the special needs of women across the life span, bioethical issues
    associated with genetic testing and counseling, and the impact of
    environmental influences on risk factors for chronic illnesses, such as
    cancer. ONS joins with others in the nursing community and NCCR in
    advocating a fiscal year 2012 allocation of $163 million for NINR.
     boost our nation's investment in cancer prevention, early detection,
                                 and awareness
        Approximately two-thirds of cancer cases are preventable through
    lifestyle and behavioral factors and improved practice of cancer
    screening. Although the potential for reducing the human, economic, and
    social costs of cancer by focusing on prevention and early detection
    efforts remains great, our Nation does not invest sufficiently in these
    strategies. The Nation must make significant and unprecedented Federal
    investments today to address the burden of cancer and other chronic
    diseases, and to reduce the demand on the healthcare system and
    diminish suffering in our Nation, both for today and tomorrow.
        As the Nation's leading prevention agency, the Centers for Disease
    Control and Prevention (CDC) plays an important role in translating and
    delivering, at the community level, what is learned from research.
    Therefore, ONS joins with our partners in the cancer community in
    calling on Congress to provide additional resources for the CDC to
    support and expand much-needed and proven effective cancer prevention,
    early detection, and risk reduction efforts. Specifically, ONS
    advocates the following fiscal year 2012 funding levels for the
    following CDC programs:
      --$275 million for the National Breast and Cervical Cancer Early
            Detection Program;
      --$65 million for the National Cancer Registries Program;
      --$70 million for the Colorectal Cancer Prevention and Control
            Initiative;
      --$50 million for the Comprehensive Cancer Control Initiative;
      --$25 million for the Prostate Cancer Control Initiative;
      --$5 million for the National Skin Cancer Prevention Education
            Program;
      --$10 million for the Gynecologic Cancer and Education and Awareness
            (Johanna's Law);
      --$10 million for the Ovarian Cancer Control Initiative; and
      --$6 million for the Geraldine Ferraro Blood Cancer Program.
                                   conclusion
        ONS maintains a strong commitment to working with Members of
    Congress, other nursing and oncology groups, patient organizations, and
    other stakeholders to ensure that the oncology nurses of today continue
    to practice tomorrow, and that we recruit and retain new oncology
    nurses to meet the unfortunate growing demand that we will face in the
    coming years. By providing the fiscal year 2012 funding levels detailed
    above, we believe the Subcommittee will be taking the steps necessary
    to ensure that our nation has a sufficient nursing workforce to care
    for the patients of today and tomorrow and that our nation continues to
    make gains in our fight against cancer.
                                     ______

           Prepared Statement of the Ovarian Cancer National Alliance
        The Ovarian Cancer National Alliance (the Alliance) appreciates the
    opportunity to submit comments for the record regarding the Alliance's
    fiscal year 2012 funding recommendations. We believe these
    recommendations are critical to ensure advances to help reduce and
    prevent suffering from ovarian cancer.
        For 14 years, the Alliance has worked to increase awareness of
    ovarian cancer and advocate for additional Federal resources to support
    research that would lead to more effective diagnostics and treatments.
    As an umbrella organization with approximately 50 national, State and
    local organizations, the Alliance unites the efforts of survivors,
    grassroots activists, women's health advocates and healthcare
    professionals to bring national attention to ovarian cancer. The
    Ovarian Cancer National Alliance is the foremost advocate for women
    with ovarian cancer in the United States. To advance the interests of
    women with ovarian cancer, the organization advocates at a national
    level for increases in research funding for the development of an early
    detection test, improved healthcare practices and life-saving treatment
    protocols. The Ovarian Cancer National Alliance educates healthcare
    professionals and raises public awareness of the risks, signs and
    symptoms of ovarian cancer.
        According to the American Cancer Society, in 2010, more than 22,000
    American women were diagnosed with ovarian cancer and approximately
    15,000 lost their lives to this terrible disease. Ovarian cancer is the
    fifth leading cause of cancer death in women. Currently, more than half
    of the women diagnosed with ovarian cancer will die within 5 years.
    While ovarian cancer has symptoms, there is no reliable early detection
    test. Most women are diagnosed in Stage III or Stage IV, when survival
    rates are low. If diagnosed early, more than 90 percent of women will
    survive for 5 years, but when diagnosed later, less than 30 percent
    will.
        Only a few treatments have been approved by the Food and Drug
    Administration (FDA) for ovarian cancer treatment. These are platinum-
    based therapies and women needing further rounds of treatment are
    frequently resistant to them. More than 70 percent of ovarian cancer
    patients will have a recurrence at some point, underlying the need for
    treatments to which patients do not grow resistant.
        For all of these reasons, we urgently call on Congress to
    appropriate funds to find solutions.
        As part of this effort, the Alliance advocates for continued
    Federal investment in the Centers for Disease Control and Prevention's
    (CDC) Ovarian Cancer Control Initiative. The Alliance respectfully
    requests that Congress provide $10 million for the program in fiscal
    year 2012.
        The Alliance also fully supports Congress in taking action on
    educating Americans about ovarian cancer through providing funding for
    The Gynecologic Cancer Education and Awareness Act (Johanna's Law)
    [Public Law 111-324]. The Alliance respectfully requests that Congress
    provide $10 million to implement The Gynecologic Cancer Education and
    Awareness Act (Johanna's Law) in fiscal year 2012.
        Further, the Alliance urges Congress to continue funding the
    Specialized Programs of Research Excellence (SPOREs), including the
    five ovarian cancer sites. These programs are administered through the
    National Cancer Institute (NCI) of the National Institutes of Health
    (NIH). The Alliance respectfully requests that Congress provide $5.74
    billion to the National Cancer Institute for fiscal year 2012.
                   centers for disease control and prevention
                     the ovarian cancer control initiative
        As the statistics indicate, late detection and, therefore, poor
    survival are among the most urgent challenges we face in the ovarian
    cancer field. The CDC's cancer program, with its strong capacity in
    epidemiology and excellent track record in public and professional
    education, is well positioned to address these problems. As the
    Nation's leading prevention agency, the CDC plays an important role in
    translating and delivering at the community level what is learned from
    research, especially ensuring that those populations disproportionately
    affected by cancer receive the benefits of our Nation's investment in
    medical research.
        Congress established the Ovarian Cancer Control Initiative at the
    CDC in November 1999 with bipartisan, bicameral support. Congress'
    directive to the agency was to develop an appropriate public health
    response to ovarian cancer and conduct several public health activities
    targeted toward reducing ovarian cancer morbidity and mortality.
        The CDC's Ovarian Cancer Control Initiative conducts research about
    early detection, treatment and survivorship nationwide to increase
    understanding of ovarian cancer. Some of the Ovarian Cancer Control
    Initiative's notable studies include: a study of women who died of
    ovarian cancer within three managed care organizations to investigate
    end-of-life care; the Ovarian Cancer Treatment Patterns and Outcomes
    study, which attempted to determined how the stage of cancer, the
    specialty of a surgeon and the success of the surgery contributed to
    the survival of ovarian cancer patients diagnosed between 1997 and
    2000; and a study to examine geographic access to subspecialists for
    treating ovarian cancer.
       the gynecologic cancer education and awareness act (johanna's law)
        It is critical for women and their healthcare providers to be aware
    of the signs, symptoms and risk factors of ovarian and other
    gynecologic cancers. Often, women and providers mistakenly confuse
    ovarian cancer signs and symptoms with those of gastrointestinal
    disorders or early menopause. While symptoms may seem vague--bloating,
    pelvic or abdominal pain, increased abdominal size and bloating and
    difficulty, eating or feeling full quickly, or urinary symptoms
    (urgency or frequency)--the underlying disease can be deadly without
    proper medical intervention.
        In recognition of the need for awareness and education, Congress
    unanimously passed Johanna's Law in 2006, enacted in early 2007. This
    law provides for an education and awareness campaign that will increase
    providers' and women's awareness of all gynecologic cancers including
    ovarian. Johanna's Law was reauthorized in 2010.
        Thanks to funding under Johanna's Law, more women are learning how
    to identify the signs and symptoms of gynecologic. From September 2010
    to January 2011, the broadcast PSAs have been played 68,630 times,
    generating 154,632,815 audience impressions (the number of times they
    have been seen or heard), worth $7,491,846 in donated placements.
    Additionally, since October 2010:
      --there have been 25,706 plays of the TV PSAS, worth $2,800,805 in
            donated airtime,
      --there have been 9,701 plays of English TV spots,
      --there have been 16,005 plays of Spanish TV spots,
      --the PSAs have aired in the top markets, including Los Angeles,
            Chicago, Philadelphia, San Francisco, Boston, Dallas/Fort
            Worth, Atlanta, Tampa/St. Petersburg, Pittsburgh, PA, Salt Lake
            City, Raleigh/Durham, Green Bay, Baltimore, Tucson, Cleveland,
            Phoenix, Tulsa, Orlando, Hartford/New Haven, Houston, Spokane,
            and Seattle/Tacoma, among others, and
      --English spots have aired during popular programs such Today, Good
            Morning America, CBS Morning News, Access Hollywood, Cold Case,
            Real Housewives of Orange County, The Bachelor, The View, Dr.
            Oz Show, Ellen DeGeneres Show, The Doctors, Entertainment
            Tonight, and Late Night with David Letterman during the hours
            of 8 a.m. to midnight.
        With continued funding, the CDC will be able to continue to print
    and distribute brochures, maintain and update the web resources,
    develop additional educational materials such as posters for physician
    offices, complete continuing education materials for healthcare
    providers, and reach out to women beyond the original 40-60 year-old
    initial target group.
                   cdc chronic disease program consolidation
        The President's budget proposal for fiscal year 2012 recommends
    consolidating all of the Centers for Disease Control and Prevention's
    (CDC) chronic disease programs that are focused on heart disease and
    stroke, diabetes, cancer, arthritis, nutrition, and other health-
    related issues into one competitive grant program. It is our
    understanding that the Gynecologic Cancer Education and Awareness Act
    (Johanna's Law) and the Ovarian Cancer Control Initiative would be
    included in this all-encompassing competitive grant program. These
    programs, with congressional support, have been able to increase
    understanding and raise awareness of ovarian and other women's cancers
    that afflict Americans.
        While we support efforts to improve the efficiency of Federal
    programs, we oppose shifting control and funding of these programs away
    from Congress. Moreover, given that ovarian cancer mortality rates have
    remained virtually unchanged for decades and currently there is no
    early detection test for the disease, we feel strongly that the CDC
    should maintain dedicated efforts focused on reducing ovarian cancer
    mortality and morbidity. As such, we recommend that Johanna's Law and
    the Ovarian Cancer Control Initiative remain standalone line items in
    the fiscal year 2012 Labor, Health and Human Services, and Education
    (LHHS) appropriations bill.
                           national cancer institute
        The National Cancer Institute is the chief funder of ovarian cancer
    research in the United States and the world. In 2009, the National
    Cancer Institute funded over 170 studies solely dedicated to bettering
    our scientific understanding of ovarian cancer. These studies
    investigated diverse topics such as the effect of Vitamin D on ovarian
    cancer prevention and treatment, whether Prolactin is a risk biomarker
    of ovarian cancer, and whether viruses can be converted into ovarian
    cancer-fighting agents. Research investigators who receive funding from
    the National Cancer Institute study cancer are located all across the
    United States. According to Families USA, every dollar in Federal
    research spending generates about $2 in economic activity in local
    economies where funded projects are located.
    specialized programs of research excellence in the national institutes
                                   of health
        The Specialized Programs of Research Excellence were created by the
    NCI in 1992 to support translational, organ site-focused cancer
    research. The ovarian cancer SPOREs began in 1999. There are five
    currently funded Ovarian Cancer SPOREs located at the MD Anderson
    Cancer Center, the Fred Hutchinson Cancer Research Center, the Fox
    Chase Cancer Center, the Dana Farber/Harvard Cancer Center and the Mayo
    Clinic Cancer Center.
        These SPORE programs have made outstanding strides in understanding
    ovarian cancer, as illustrated by their more than 300 publications as
    well as other notable achievements, including the development of an
    infrastructure between Ovarian SPORE institutions to facilitate
    collaborative studies on understanding, early detection and treatment
    of ovarian cancer.
                                clinical trials
        The National Cancer Institute supports clinical research--the only
    way to test the safety and efficacy of potential new treatments for
    ovarian cancer. An example of NCI-funded clinical research is a new 5-
    year study addressing the lack of knowledge about causes and risk
    factors for ovarian cancer in African American women conducted by
    University Hospitals Case Medical Center and Case Western Reserve
    University School of Medicine. Another study funded by the National
    Cancer Institute compared the efficacy and safety of a dose-dense
    regimen of single-agent cisplatin with a standard 3-weekly schedule in
    first-line chemotherapy for advanced epithelial ovarian cancer. The
    study found that increasing dose intensity of cisplatin does not
    improve PFS or OS compared with standard chemotherapy.
        NCI supports the Gynecology Oncology Group, a more than 50-member
    collaborative focusing on cancers of the female reproductive system.
    From 2008 until present, the GOG has published 103 articles about
    ovarian cancer. An important and recent finding from the GOG, the GOG
    218 study, was that women with advanced cancer who received
    chemotherapy followed by maintenance use of Avastin increased survival
    time without their disease worsening compared to chemotherapy alone.
                                    summary
        The Alliance maintains a long-standing commitment to work with
    Congress, the administration, and other policy makers and stakeholders
    to improve the survival rate for women with ovarian cancer through
    education, public policy, research and communication. Please know we
    appreciate and understand that our Nation faces many challenges and
    Congress has limited resources to allocate; however, we are concerned
    that without increased funding to bolster and expand ovarian cancer
    education, awareness and research efforts, the nation will continue to
    see growing numbers of women losing their battle with this terrible
    disease.
        On behalf of the entire ovarian cancer community--patients, family
    members, clinicians and researchers--we thank you for your leadership
    and support of Federal programs that seek to reduce and prevent
    suffering from ovarian cancer. We request your support for our
    appropriations requests for fiscal year 2012 that include $10 million
    for the CDC's Ovarian Cancer Control Initiative, $10 million for The
    Gynecologic Cancer Education and Awareness Act (Johanna's Law) and
    $5.74 billion to NCI.
                                     ______

           Prepared Statement of the Pancreatic Cancer Action Network
        Mr. Chairman and members of the Subcommittee: My name is Julie
    Fleshman and I am submitting this testimony on behalf of the Pancreatic
    Cancer Action Network.
        Founded in 1999, the Pancreatic Cancer Action Network is a
    nationwide network of individuals dedicated to advancing research,
    supporting patients and fostering hope for the families and loved ones
    affected by this disease.
        Pancreatic cancer continues to be one of the deadliest cancers in
    this country. In fact, it is the only cancer tracked by both the
    American Cancer Society and the National Cancer Institute (NCI) that
    still has a 5-year survival rate in the single digits. This is even
    more astounding because the overall 5-year survival rate for all
    cancers was 50 percent in the 1970s and is now 68 percent. Last year,
    pancreatic cancer struck more than 43,000 Americans and resulted in
    36,800 deaths. The similarity of these statistics underscores its
    deadliness: indeed, most patients die within months of their diagnosis.
        There is no question that we have made important progress in many
    forms of cancer. There is also no question that this progress has been
    lacking in pancreatic cancer. The fact remains that there are still no
    early detection tools or effective treatments. A patient diagnosed
    today generally hears the same words as a patient diagnosed 40 years
    ago, ``I'm sorry, but there is not much that we can do for you. Go home
    and get your affairs in order.'' The Pancreatic Cancer Action Network
    believes that the time has come for bold action and has launched a new
    mission to double the 5-year survival rate by 2020. This is an
    ambitious but achievable goal.
        Dismal as the picture is today, unless something is done soon, it
    will only get worse. A recently published study in the Journal of
    Clinical Oncology predicts that the number of new pancreatic cancer
    cases will increase by 55 percent over the next two decades.
        Why has there been so little change in the mortality rate
    associated with pancreatic--and what can be done about it?
        Progress has been slow in large part because the Federal
    Government's investment in pancreatic cancer research has been weak.
    The Pancreatic Cancer Action Network recently published a report,
    ``Pancreatic Cancer: A trickle of Federal funding for a river of
    need'', analyzing the investment made by the NCI into this disease. The
    analysis shows that pancreatic cancer is behind in nearly every
    important grant category funded by the Federal Government.
      --Currently, research dedicated to pancreatic cancer receives a mere
            2 percent of the Federal dollars distributed by the NCI. By
            contrast, the other four of the top five cancer killers in the
            United States (lung, colon, breast and prostate cancer)
            received 2.8 to 6.3 fold more NCI funding in 2009 than
            pancreatic cancer.
      --The average dollar amount of basic research (R) grants in
            pancreatic cancer was 18 to 29 percent less than R grants for
            the other four top cancer killers. The R grant mechanisms are
            the mainstay of scientific discovery in cancer research.
      --Training grant funding in pancreatic cancer decreased by 15 percent
            from 2008 to 2009, a decline larger than in any other leading
            cancer. Pancreatic cancer trainees were awarded between 2.4 and
            6.5 fold less grant money in 2009 than young researchers
            studying the other four top cancer killers.
      --American Recovery & Reinvestment Act (ARRA) funding represented a
            unique opportunity for the NCI to direct research monies toward
            the deadliest cancers, including pancreatic cancer.
            Unfortunately, this opportunity was missed, as pancreatic
            cancer research received only slightly more than 1 percent of
            the NCI ARRA budget.
        As has been noted by this Subcommittee and others in Congress in
    recent years, what is lacking is a well-defined, long-term
    comprehensive strategic plan in place to: advance the understanding of
    the biology of pancreatic cancer, examine its natural history and the
    genetic and environmental factors that contribute to its development;
    expand research on ways to screen and detect pancreatic cancer in much
    earlier stages; and launch innovative clinical trials to test targeted
    therapeutics and novel agents that will extend the survival and improve
    the quality of life of patients.
        In addition, there must be a robust and sustained commitment of
    resources by the NCI and its sister institutes and centers at the
    National Institutes of Health (NIH).
        Thanks to you and your colleagues, Mr. Chairman, and under the
    leadership of Dr. Harold Varmus, NCI has taken some encouraging steps
    in the right direction.
        In 2010 NCI convened an internal group to develop an action plan
    for pancreatic cancer research and training. NCI brought together
    pancreatic cancer researchers and program staff from within the
    Institute to form the Pancreatic Cancer Action Planning Group, charged
    with developing an Action Plan that summarizes the fiscal year 2011
    research and training portfolio and identifies research gaps and
    opportunities for collaboration within NCI and with other members of
    the National Cancer Program, including advocacy groups, academia, and
    industry. This Action Plan was developed based on discussions at a
    Planning Group meeting held in July 2010 and continued interactions
    following the meeting. While it was not the long-term comprehensive
    strategic plan that we would still like to see the NCI develop for
    pancreatic cancer, we do believe that it was a good first step.
        In addition to the initiatives and activities already included in
    the fiscal year 2011 portfolio, the Planning Group identified several
    opportunities for NCI to advance pancreatic cancer research. Emphasis
    was placed on activities with a high likelihood of improving survival
    rates, which have remained low despite improvements in many other
    cancer types. It was recognized that given the range of research
    conducted within and funded by NCI, the Institute is uniquely poised to
    support activities and provide services that other stakeholders are
    unable or unwilling to do. The Planning Group identified several
    opportunities for collaboration with advocacy organizations and the
    private sector to gain momentum in pancreatic cancer research.
        The Action Plan reviewed the research activities that were planned
    for fiscal year 2011. We look forward to hearing from the NCI about the
    outcome of these plans. It also identified a few potential new
    initiatives such as a program announcement for R01 grants focused on
    pancreatic cancer. We strongly believe that a program announcement
    would be a positive step in the right direction and would urge you to
    find ways to encourage NCI to implement this idea. We hope to have the
    opportunity to work with NCI to implement the steps outlined in the
    plan.
        Some ideas that emerged--such as promoting interaction and
    increased use of existing resources--will likely involve only modest
    financial investment, while others, like new program announcements,
    will require more resources. We therefore join with our colleagues in
    the One Voice Against Cancer (OVAC) coalition in highlighting the
    important role that NCI plays in our economy and in cancer research
    worldwide and ask this Committee to do everything in its power to safe-
    guard and expand this important resource.
        Mr. Chairman, research is the only hope. We ask that you strongly
    urge the National Cancer Institute to put in place a long-term
    comprehensive strategic plan for pancreatic cancer research and ensure
    that there is funding available to implement that plan.
        Thank you.
                                     ______

      Prepared Statement of the Physician Assistant Education Association
        On behalf of its membership, the 156 accredited physician assistant
    (PA) education programs in the United States, the Physician Assistant
    Education Association (PAEA) is pleased to submit these comments on the
    fiscal year 2012 appropriations for PA education programs that are
    authorized through Title VII of the Public Health Service Act.
        PAEA is a member of the Health Professions and Nursing Education
    Coalition (HPNEC) and we support the HPNEC recommendation for funding
    of at least $762.5 million in fiscal year 2012 for the health
    professions education programs authorized under Title VII and VIII of
    the Public Health Service Act and administered through the Health
    Resources and Services Administration (HRSA). HPNEC is an informal
    alliance of more than 60 national organizations representing schools,
    programs, health professionals, and students and dedicated to ensuring
    that the healthcare workforce is trained to meet the needs of the
    country's growing, aging, and diverse population.
    Need for Increased Federal Funding
        Faculty development is one of the profession's critical needs. In
    order to attract the best qualified to teaching, PA education programs
    must have the resources to train faculty in academic skills, such as
    curriculum development, teaching methods, and laboratory instruction.
    The challenges of teaching are broad and varied and include
    understanding different pedagogical theories, writing instructional
    objectives, and learning and applying educational technology. Most
    educators come from clinical practice and these skills are essential to
    transitioning to teaching. Educators are a critical element of meeting
    the Nation's demand for an increased supply of primary care clinicians.
        Generalist training, workforce diversity, and practice in
    underserved areas are key priorities identified by HRSA. It is
    increasingly important that the health workforce better represents
    America's changing demographics, as well as addresses the issues of
    disparities in healthcare. PA programs have been successful in
    attracting students from underrepresented minority groups and
    disadvantaged backgrounds. Studies have found that health professionals
    from underserved areas are three to five times more likely to return to
    underserved areas to provide care.
    Physician Assistant Practice
        Physician assistants (PAs) are licensed health professionals who
    practice medicine as members of a team with their supervising
    physicians. PAs exercise autonomy in medical decisionmaking and provide
    a broad range of medical and therapeutic services to diverse
    populations in rural and urban settings. In all 50 States, PAs carry
    out physician-delegated duties that are allowed by law and within the
    physician's scope of practice and the PA's training and experience.
    Additionally, PAs are delegated prescriptive privileges by their
    physician supervisors in all 50 States, the District of Columbia, and
    Guam. This allows PAs to practice in rural, medically underserved areas
    where they are often the only full-time medical provider.
    Physician Assistant Education
        There are currently 156 accredited PA education programs in the
    United States--a growth of 22 percent in less than 5 years; together
    these programs graduate nearly 6,000 PA students each year. PAs are
    educated as generalists in medicine; their flexibility allows them to
    practice in more than 60 medical and surgical specialties. More than
    one-third of PA program graduates practice in primary care.
        The average PA education program is 27 months in length. Typically,
    1 year is devoted to classroom study and approximately 15 months is
    devoted to clinical rotations. The typical curriculum includes 400
    hours of basic sciences and nearly 600 hours of clinical medicine.
        As of today, approximately 20 programs are in the pipeline at
    various stages of development, moving toward accredited status. The
    growth rate in the applicant pool is even more remarkable. In March
    2006, there were a total of 7,608 applicants to PA education programs;
    as of March 2011, there were 16,112 applicants to PA education
    programs. This represents a 112 percent increase in Centralized
    Application Service (CASPA) applicants over the past 5 years.
        The PA profession is expected to continue to grow as a result of
    the projected shortage of physicians and other healthcare
    professionals, the growing demand for professionals from an aging
    population, and the continuing strong PA applicant pool, which has
    grown by more than 10 percent each year since the year 2000. The Bureau
    of Labor Statistics projects a 39 percent increase in the number of PA
    jobs between 2008 and 2018. With its relatively short initial training
    time and the flexibility of generalist-trained PAs, the PA profession
    is well-positioned to help fill projected shortages in the numbers of
    healthcare professionals.
        The continued growth of the profession heightens the need for
    additional resources to help meet the challenges of recruiting
    qualified faculty, shortages of preceptors and clinical sites, and
    increasing the diversity of faculty and program applicants.
    Title VII Funding
        Title VII funding is the only opportunity for PA programs to apply
    for Federal funding and plays a crucial role in developing and
    supporting PA education programs.
        Title VII funding fills a critical need for curriculum development
    and faculty development. Funding enhances clinical training and
    education, assists PA programs with recruiting applicants from minority
    and disadvantaged backgrounds, and funds innovative programs that focus
    on educating a culturally competent workforce. Title VII funding
    increases the likelihood that PA students will practice in medically
    underserved communities with health professional shortages. The absence
    of this funding would result in the loss of care to patients in
    underserved areas.
        Title VII support for PA programs has been strengthened with the
    enactment of the Patient Protection and Affordable Health Care Act
    (Public Law 111-148), which provides a 15 percent carve out in the
    appropriations process for PA programs. This funding will enhance
    capabilities to train a growing PA workforce and is likely to increase
    the pool for faculty positions as a result of PA programs now being
    eligible for faculty loan repayment. Huge loan burdens serve as
    barriers for physician assistant entry into academia.
        Here we provide several examples of how PA programs have used Title
    VII funds to creatively expand care to underserved areas and
    populations, as well as to develop a diverse PA workforce.
      --One Texas program has used its PA training grant to support the
            program at a distant site in an underserved area. This grant
            provides assistance to the program for recruiting, educating,
            and training PA students in the largely Hispanic South Texas
            and mid-Texas/Mexico border areas and supports new faculty
            development.
      --A Utah program has used its PA training grant to promote
            interprofessional teams--an area of strong emphasis in the
            Patient Protection and Affordable Care Act. The grant allowed
            the program to optimize its relationship with three service-
            learning partners, develop new partnerships with three service-
            learning sites, and create a model geriatric curriculum that
            includes didactic and clinical education.
      --An Alabama program used its PA training grant to update and expand
            the current health behavior educational curriculum and HIV/STD
            training. They were also able to include PA students from other
            programs who were interested in rural, primary care medicine
            for a 4-week comprehensive educational program in HIV disease
            diagnosis and management.
      --A South Carolina program has developed a model program that offers
            a 2-year academic fellowship for recent PA graduates with at
            least one year of clinical experience. To further enhance an
            evidence-based approach to education and practice, two specific
            evidence-based practice projects were embedded in the
            fellowship experience. Fellows direct and evaluate PA students'
            involvement in the ``Towards No Tobacco'' curriculum, aimed at
            fifth graders, and the PDA Patient Data experience, aimed at
            assessing healthcare services.
    Recommendations on fiscal year 2012 Funding
        The Physician Assistant Education Association requests the
    Appropriations Committee to support funding for Title VII and VIII
    health professions programs at a minimum of $762.5 million for fiscal
    year 2012. This level of funding is crucial to support the Nation's
    demand for primary care practitioners, particularly those who will
    practice in medically underserved areas and serve vulnerable
    populations. Additionally we encourage support for the new programs and
    responsibilities contained in the Patient Protection and Affordable
    Care Act (Public Law 111-148), including a minimum of $10 million to
    support PA education programs. We thank the members of the subcommittee
    for their support of the health professions and look forward to your
    continued support of solutions to the Nation's health workforce
    shortage. We appreciate the opportunity to present the Physician
    Assistant Education Association's fiscal year 2012 funding
    recommendation.
                                     ______

    Prepared Statement of PolicyLink, The Food Trust, and The Reinvestment
                                      Fund
        Chairman and distinguished Senators of the Committee, thank you for
    the opportunity to share our support for a Healthy Food Financing
    Initiative (HFFI). PolicyLink is a national research and action
    institute advancing economic and social equity by Lifting Up What
    Works; The Food Trust is a nonprofit organization working to ensure
    that everyone has access to affordable, nutritious food; and The
    Reinvestment Fund is a Community Development Financial Institution that
    creates wealth and opportunity for low-wealth people and places through
    the promotion of socially and environmentally responsible development.
        Our three organizations, along with a diverse coalition of
    stakeholders, which includes representatives from the grocery industry,
    health, civil rights, agriculture and the community development finance
    community, support the creation of HFFI to address the problem of
    ``food deserts'' in urban and rural areas across the Nation. This
    problem can be solved in many communities using a successful model that
    is underway in the State of Pennsylvania and is now being replicated
    throughout the country.
        HFFI is a program worthy of investment as it promotes health,
    creates jobs and sparks economic development. HFFI will provide loan
    and grant financing to attract grocery stores and other fresh food
    retail to underserved urban, suburban, and rural areas, and renovate
    and expand existing stores so they can provide the healthy foods that
    communities want and need. Over time, with continued investment, HFFI
    could solve the problem of food deserts in urban and rural communities
    across the country.
        For decades, low-income communities, particularly communities of
    color, have suffered from a lack of access to healthy, fresh food. USDA
    research determined that more than 23.5 million Americans are living in
    communities without access to high-quality, fresh food. Studies
    repeatedly show that residents of many low-income neighborhoods must
    travel long distances for healthy food, or rely on corner stores and
    fast food outlets offering high fat, high sugar foods. For instance, a
    recent multistate study found that low-income census tracts had half as
    many supermarkets as wealthy tracts, and four times as many smaller
    grocery stores. Another multistate study found that 8 percent of
    African Americans live in a tract with a supermarket, compared to 31
    percent of whites. Nationally, low-income zip codes have 30 percent
    more convenience stores, which tend to lack healthy food, than middle
    income zip codes.
        And, a nationwide analysis found there are 418 rural food desert
    counties where all residents live more than 10 miles from a supermarket
    or a supercenter--this is 20 percent of rural counties. In rural
    communities, inadequate transportation can be a particular challenge.
    In Mississippi, which has the highest obesity rate of any State, over
    70 percent of food stamp eligible households travel more than 30 miles
    to reach a supermarket. Adults living in rural Mississippi food desert
    counties are 23 percent less likely to consume the recommended fruits
    and vegetables than those in counties that have supermarkets,
    controlling for age, sex, race, and education.
        Controlling for population density, rural areas have fewer food
    retailers of any types compared to urban areas, and only 14 percent the
    number of chain supermarkets. For instance, in New Mexico, rural
    residents have access to fewer grocery stores than urban residents, pay
    more for comparable items, and have less selection. The same market
    basket of groceries costs $85 for rural residents versus $55 for urban
    residents.
        The results of this lack of healthy food options are grim--these
    communities have significantly higher rates of obesity, diabetes, and
    other related health issues. Over the past decade, obesity rates have
    more than doubled in children and tripled in adolescents. In 2010,
    PolicyLink and The Food Trust conducted a review of more than 130
    studies on the issue of access to healthy food and found a direct
    correlation between diet-related diseases and access. A California
    study found that obesity and diabetes rates were 20 percent higher for
    those living in the least healthy ``food environments.'' In
    Indianapolis, a study found that BMI values corresponded with access to
    supermarkets and fast food restaurants. Researchers estimated that
    adding a new grocery store to a high poverty neighborhood translates
    into a 3 pound weight decrease.
        Fortunately, changing access changes eating habits. For every
    additional supermarket in a census tract, produce consumption increases
    32 percent for African Americans and 11 percent for whites, according
    to a multistate study. A survey of produce availability in New Orleans'
    small neighborhood stores found that for each additional meter of shelf
    space devoted to fresh vegetables, residents eat an additional .35
    servings per day. In fact, of 14 studies that examine food access and
    consumption of healthy foods, all but one of them found a correlation
    between greater access and better eating behaviors. This is also true
    for food stamp recipients. Proximity to a supermarket was found to be
    associated with increased fruit and vegetable consumption.
        The problems associated with lack of access go beyond health. Low-
    income communities are cut off from all the economic development
    benefits that come with a local grocery store: the creation of steady
    jobs at decent wages and the sparking of complementary retail stores
    and services nearby. Grocery stores operate as important economic
    anchors for communities, providing a vital service and bringing
    customers that can also support other nearby business. Securing new or
    improved local grocery stores can improve local economies and create
    jobs.
        President Barack Obama's proposed fiscal year 2012 budget includes
    a proposal to invest $330 million, including $250 million in New
    Markets Tax Credits, in a national HFFI. Specifically, the initiative
    would provide:
      --$35 million through USDA's Office of the Secretary, with additional
            ``other funds of Rural Development and the Agricultural
            Marketing Service available to support the USDA's portion of
            the Healthy Food Financing Initiative'';
      --$25 million through the Treasury Department's CDFI Fund;
      --$20 million through Health and Human Services; and
      --$250 million through the Treasury Department's New Markets Tax
            Credits Program.
        A Healthy Food Financing Initiative would attract investment in
    underserved communities by providing critical loan and grant financing.
    These one-time resources will help fresh food retailers overcome the
    higher initial barriers to entry into underserved, low-income urban and
    rural communities, and would also support renovation and expansion of
    existing stores so they can provide the healthy foods that communities
    want and need. The program would be flexible and comprehensive enough
    to support innovations in healthy food retailing and to assist
    retailers with different aspects of the store development and
    renovation process.
        Grocery industry representatives find that there are obstacles to
    grocery store development in underserved low-income communities, but
    also that those obstacles can be overcome. The development process for
    building a new grocery store is lengthy and complex, and retailers
    often find that stores in low-income communities have high start-up
    costs, appropriate sites are hard to find, and securing financing is
    difficult. Grocery operators in both urban and rural areas cite lack of
    access to flexible financing as one of the top barriers hindering the
    development of stores in underserved areas.
        HFFI is modeled after the successful Pennsylvania Fresh Food
    Financing Initiative (FFFI), a public/private partnership launched in
    2004. Using a State investment of $30 million, the program has led to:
      --projects totaling more than $190 million;
      --88 stores built or renovated in underserved communities in urban
            and rural areas across the State;
      --improved access to healthy food for more than 400,000 residents;
      --more than 5,000 jobs created or retained;
      --increased local tax revenues; and
      --much-needed additional economic development in these communities.
        Stores range from full-service 70,000 square foot supermarkets to
    900 square food shops; and from traditional grocery stores to farmers'
    markets, cooperatives, and corner stores selling healthy food.
    Approximately two-thirds of the projects were in rural areas and small
    towns with the remainder in urban areas.
        HFFI is a viable, effective, and economically sustainable solution
    to the problem of limited access to healthy foods. It can bring triple
    bottomline benefits, achieving multiple goals: reducing health
    disparities and improving the health of families and children; creating
    jobs; and, stimulating local economic development in low-income
    communities.
        HFFI would incorporate the key components that allowed the
    Pennsylvania program to be so effective at attracting private dollars,
    garnering the commitment of store operators, getting fresh food retail
    stores and markets successfully developed, and stimulating local
    economies.
        The Pennsylvania FFFI has been cited as an innovative model by the
    U.S. Centers for Disease Control and Prevention, the National
    Conference of State Legislatures, Harvard's Kennedy School of
    Government, and the National Governors Association. There is
    significant momentum in many States and cities across the country to
    address the lack of grocery access in underserved communities. Several
    States and/or cities are in the process of replicating the successful
    Pennsylvania Fresh Food Financing Initiative Program, and many others
    have begun to examine the needs and opportunities in their communities.
    For example:
      --The State of New York has launched the Healthy Food, Healthy
            Communities Initiative, a business financing program to
            encourage supermarket and other fresh food retail investment in
            underserved areas throughout the State that will provide loans
            and grants to eligible projects. New York City has launched a
            complementary FRESH program that will encourage supermarket
            development through tax and zoning incentives and a single
            point of access to city government for supermarket operators.
      --The City of New Orleans recently launched the Fresh Food Retailer
            Initiative Program (FFRI) that will provide direct financial
            assistance to retail businesses by awarding forgivable and/or
            low-interest loans to grocery stores and other fresh food
            retailers.
      --The California Endowment, NCB Capital Impact, and other community,
            supermarket industry, and government partners have been working
            to create a supermarket financing program in California that is
            expected to be launched in the first half of 2011.
        A national Healthy Food Financing Initiative could amplify the
    impact in each of these States and leverage the work already underway
    to ensure swift implementation. Moreover, a national HFFI would insure
    that all State and communities could solve their food desert problems
    with new stores and other healthy food retail projects.
        In the midst of our current economic downturn, the need for a
    comprehensive Federal policy to address the lack of fresh food access
    in low-income is critical. We urge the Committee to support full
    funding for a Healthy Food Financing Initiative, for the benefit of
    communities across the Nation. Thank you for the opportunity to share
    our perspectives with you today. If you should need additional
    information about HFFI please contact Judith Bell from PolicyLink
    (Judith@policylink.org), Pat Smith from The Reinvestment Fund
    (patricia.smith@trffund.org), or John Weidman from The Food Trust
    (Jweidman@thefoodtrust.org)
                                     ______

    Prepared Statement of the Population Association of America/Association
                             of Population Centers
    Background on the PAA/APC and Demographic Research
        The Population Association of America (PAA) is a scientific
    organization comprised of over 3,000 population research professionals,
    including demographers, sociologists, statisticians, and economists.
    The Association of Population Centers (APC) is a similar organization
    comprised of over 40 universities and research groups that foster
    collaborative demographic research and data sharing, translate basic
    population research for policy makers, and provide educational and
    training opportunities in population studies. Population research
    centers are located at public and private research institutions
    nationwide.
        Demography is the study of populations and how or why they change.
    Demographers, as well as other population researchers, collect and
    analyze data on trends in births, deaths, and disabilities as well as
    racial, ethnic, and socioeconomic changes in populations. Major policy
    issues population researchers are studying include the demographic
    causes and consequences of population aging, trends in fertility,
    marriage, and divorce and their effects on the health and well being of
    children, and immigration and migration and how changes in these
    patterns affect the ethnic and cultural diversity of our population and
    the Nation's health and environment.
        The NIH mission is to support research that will improve the health
    of our population. The health of our population is fundamentally
    intertwined with the demography of our population. Recognizing the
    connection between health and demography, the NIH supports extramural
    population research programs primarily through the National Institute
    on Aging (NIA) and the National Institute of Child Health and Human
    Development (NICHD).
    National Institute on Aging
        According to the Census Bureau, by 2029, all of the baby boomers
    (those born between 1946 and 1964) will be age 65 years and over. As a
    result, the population age 65-74 years will increase from 6 percent to
    10 percent of the total population between 2005 and 2030. This
    substantial growth in the older population is driving policymakers to
    consider dramatic changes in Federal entitlement programs, such as
    Medicare and Social Security, and other budgetary changes that could
    affect programs serving the elderly. To inform this debate,
    policymakers need objective, reliable data about the antecedents and
    impact of changing social, demographic, economic, and health
    characteristics of the older population. The NIA Division of Behavioral
    and Social Research (BSR) is the primary source of Federal support for
    research on these topics.
        In addition to supporting an impressive research portfolio, that
    includes the prestigious Centers of Demography of Aging and Roybal
    Centers for Applied Gerontology Programs, the NIA BSR program also
    supports several large, accessible data surveys. One of these surveys,
    the Health and Retirement Study (HRS), has become one of the seminal
    sources of information to assess the health and socioeconomic status of
    older people in the United States. Since 1992, the HRS has tracked
    27,000 people, providing data on a number of issues, including the role
    families play in the provision of resources to needy elderly and the
    economic and health consequences of a spouse's death. HRS is
    particularly valuable because its longitudinal design allows
    researchers: (1) the ability to immediately study the impact of
    important policy changes such as Medicare Part D; and (2) the
    opportunity to gain insight into future health-related policy issues
    that may be on the horizon, such as HRS data indicating an increase in
    pre-retirees self-reported rates of disability. In August 2011, HRS
    will release genotyping data, enhancing the ability of researchers to
    track the onset and progression of diseases and conditions affecting
    the elderly.
        Currently, the NIA is paying grant applications requesting less
    than $500,000 in direct costs through the 11th percentile, while grants
    seeking $500,000 or more are being paid through the 8th percentile--
    making it one of the lowest paylines at NIH. As research costs
    increase, NIA faces the prospect of funding fewer grants to sustain
    larger ones in its commitment base. With additional support in fiscal
    year 2012, the NIA BSR program could fully fund its large-scale
    projects, including the existing centers programs and ongoing surveys,
    without resorting to cost cutting measures, such as cutting sample
    size, while continuing to support smaller investigator initiated
    projects
    Eunice Kennedy Shriver National Institute on Child Health and Human
            Development
        Since its establishment in 1968, the Eunice Kennedy Shriver NICHD
    Center for Population Research has supported research on population
    processes and change. Today, this research is housed in the Center's
    Demographic and Behavioral Sciences Branch (DBSB). The Branch
    encompasses research in four broad areas: family and fertility,
    mortality and health, migration and population distribution, and
    population composition. In addition to funding research projects in
    these areas, DBSB also supports a highly regarded population research
    infrastructure program and a number of large database studies,
    including the National Longitudinal Study of Adolescent Health (Add
    Health), Panel Study of Income Dynamics, and National Longitundinal
    Study of Youth.
        NIH-funded demographic research has consistently provided critical
    scientific knowledge on issues of greatest consequence for American
    families: work-family conflicts, marriage and childbearing, childcare,
    and family and household behavior. However, in the realm of public
    health, demographic research is having an even larger impact,
    particularly on issues regarding adolescent and minority health.
    Understanding the role of marriage and stable families in the health
    and development of children is another major focus of the NICHD DBSB.
    Consistently, research has shown children raised in stable family
    environments have positive health and development outcomes.
    Policymakers and community programs can use these findings to support
    unstable families and improve the health and well being of children.
        One of the most important programs the NICHD DBSB supports is the
    Population Research Infrastructure Program (PRIP). Through PRIP,
    research is conducted at private and public research institutions
    nationwide. The primary goal of PRIP is ``to facilitate
    interdisciplinary collaboration and innovation in population research,
    while providing essential and cost-effective resources in support of
    the development, conduct, and translation of population research.''
    Population research centers supported by PRIP are focal points for the
    demographic research field where innovative research and training
    activities occur and resources, including large-scale databases, are
    developed and maintained for widespread use.
        With additional support in fiscal year 2012, NICHD could sustain
    full funding to its large-scale surveys, which serve as a resource for
    researchers nationwide. Furthermore, the Institute could apply
    additional resources toward improving its funding payline, which has
    fallen from the 13th percentile in fiscal year 2010 to the 11th
    percentile in fiscal year 2011. Additional support could be used to
    support and stabilize essential training and career development
    programs necessary to prepare the next generation of researchers and to
    support and expand proven programs, such as PRIP.
    National Center for Health Statistics
        Located within the Centers for Disease Control (CDC), the National
    Center for Health Statistics (NCHS) is the Nation's principal health
    statistics agency, providing data on the health of the U.S. population
    and backing essential data collection activities. Most notably, NCHS
    funds and manages the National Vital Statistics System, which contracts
    with the States to collect birth and death certificate information.
    NCHS also funds a number of complex large surveys to help policy
    makers, public health officials, and researchers understand the
    population's health, influences on health, and health outcomes. These
    surveys include the National Health and Nutrition Examination Survey
    (NHANES), National Health Interview Survey (HIS), and National Survey
    of Family Growth. Together, NCHS programs provide credible data
    necessary to answer basic questions about the state of our Nation's
    health.
        Despite recent steady funding increases, NCHS continues to feel the
    effects of long-term funding shortfalls, compelling the agency to
    undermine, eliminate, or further postpone the collection of vital
    health data. For example, in 2009, sample sizes in HIS and NHANES were
    cut, while other surveys, most notably the National Hospital Discharge
    Survey, were not fielded. In 2009, NCHS proposed purchasing only ``core
    items'' of vital birth and death statistics from the States (starting
    in 2010), effectively eliminating three-fourths of data routinely used
    to monitor maternal and infant health and contributing causes of death.
    Fortunately, Congress and the new Administration worked together to
    give NCHS adequate resources and avert implementation of these
    draconian measures. Nonetheless, the agency continues to operate in a
    precarious state.
        The Administration recommends NCHS receive $161.9 million in fiscal
    year 2011; however, ultimately, the agency received $23.2 million less
    than the Administration requested. This reduced amount has postponed
    important initiatives to, for example, re-engineer collection of the
    Nation's vital statistics, using standard birth and death certificate
    items.
        PAA and APC, as members of The Friends of NCHS, support the
    Administration's request for fiscal year 2012, $162 million, in hopes
    many initiatives proposed by the Administration in fiscal year 2011 can
    proceed, including an effort to fully support electronic birth records
    in all 50 States.
    Bureau of Labor Statistics
        During these turbulent economic times, data produced by the Bureau
    of Labor Statistics (BLS) are particularly relevant and valued. PAA and
    APC members have relied historically on objective, accurate data from
    the BLS. In recent years, our organizations have become increasingly
    concerned about the state of the agency's funding.
        We are pleased the Administration has requested BLS receive a total
    of $647 million in fiscal year 2012. According to the agency, this
    funding level would enable BLS, for example, to add the Contingent Work
    Supplement to the Current Population Survey, making more data available
    on changing workplace arrangements and continue its work on developing
    an alternative poverty measure.
    Summary of fiscal year 2012 Recommendations
        In sum, the PAA and APC support the Administration's fiscal year
    2012 request for the National Institutes of Health, National Center for
    Health Statistics and the Bureau of Labor Statistics. With respect to
    the NIH, however, we support the Administration's request as a floor
    and encourage the Subcommittee to consider providing the NIH with
    funding as high as $35 billion. This amount, endorsed by the Ad Hoc
    Group for Medical Research, reflects not only inflation, but also the
    additional investment needed to sustain the new research capacity
    created by the American Recovery and Reinvestment Act.
        Thank you for considering our requests and for supporting Federal
    programs that benefit the population sciences.
                                     ______

                Prepared Statement of Prevent Blindness America
                            funding request overview
        Prevent Blindness America appreciates the opportunity to submit
    written testimony for the record regarding fiscal year 2012 funding for
    vision and eye health related programs. As the Nation's leading
    nonprofit, voluntary health organization dedicated to preventing
    blindness and preserving sight, Prevent Blindness America maintains a
    long-standing commitment to working with policymakers at all levels of
    government, organizations and individuals in the eye care and vision
    loss community, and other interested stakeholders to develop, advance,
    and implement policies and programs that prevent blindness and preserve
    sight. Prevent Blindness America respectfully requests that the
    Subcommittee provide the following allocations in fiscal year 2012 to
    help promote eye health and prevent eye disease and vision loss:
      --Provide at least $3.23 million to maintain vision and eye health
            efforts at the Centers for Disease Control and Prevention
            (CDC).
      --Support the Maternal and Child Health Bureau's (MCHB) National
            Center for Children's Vision and Eye Health (Center).
      --Provide additional resources for the National Eye Institute (NEI).
                           introduction and overview
        Vision-related conditions affect people across the lifespan from
    childhood through elder years. Good vision is an integral component to
    health and well-being, affects virtually all activities of daily
    living, and impacts individuals physically, emotionally, socially, and
    financially. Loss of vision can have a devastating impact on
    individuals and their families. An estimated 80 million Americans have
    a potentially blinding eye disease, 3 million have low vision, more
    than 1 million are legally blind, and 200,000 are more severely
    visually blind. Vision impairment in children is a common condition
    that affects 5 to 10 percent of preschool age children. Vision
    disorders (including amblyopia (``lazy eye''), strabismus (``cross
    eye''), and refractive error are the leading cause of impaired health
    in childhood.
        Alarmingly, while half of all blindness can be prevented through
    education, early detection, and treatment, the NEI reports that ``the
    number of Americans with age-related eye disease and the vision
    impairment that results is expected to double within the next three
    decades.'' \1\ Among Americans age 40 and older, the four most common
    eye diseases causing vision impairment and blindness are age-related
    macular degeneration (AMD), cataract, diabetic retinopathy, and
    glaucoma.\2\ Refractive errors are the most frequent vision problem in
    the United States--an estimated 150 million Americans use corrective
    eyewear to compensate for their refractive error.\2\ Uncorrected or
    under-corrected refractive error can result in significant vision
    impairment.\2\
    ---------------------------------------------------------------------------
        \1\ ``Vision Problems in the U.S.: Prevalence of Adult Vision
    Impairment and Age-Related Eye Disease in America,'' Prevent Blindness
    America and the National Eye Institute, 2008.
        \2\ Ibid.
    ---------------------------------------------------------------------------
        To curtail the increasing incidence of vision loss in America,
    Prevent Blindness America advocates sustained and meaningful Federal
    funding for programs that help promote eye health and prevent eye
    disease, vision loss, and blindness; needed services and increased
    access to vision screening; and vision and eye disease research. We
    thank the Subcommittee for its consideration of our specific fiscal
    year 2012 funding requests, which are detailed below.
     vision and eye health at the cdc: helping to save sight and save money
        The CDC serves a critical national role in promoting vision and eye
    health. Since 2003, the CDC and Prevent Blindness America have
    collaborated with other partners to create a more effective public
    health approach to vision loss prevention and eye health promotion. The
    CDC works to:
      --Promote eye health and prevent vision loss.
      --Improve the health and lives of people living with vision loss by
            preventing complications, disabilities, and burden.
      --Reduce vision and eye health related disparities.
      --Integrate vision health with other public health strategies.
    Integrating Vision Health into Broader Disease Prevention and Health
            Promotion Efforts
        One of the cornerstone activities of the vision and eye health work
    at the CDC is its support and encouragement of efforts to better
    integrate State-level initiatives to address vision and eye disease by
    approaching vision health through other public health prevention,
    treatment, and research efforts. Vision loss is associated with a
    myriad of other serious chronic, life threatening, and disabling
    conditions, including diabetes, depression, unintentional injuries, and
    other health problems and behavioral risk factors such as tobacco use.
    Leveraging scarce resources and recognizing the numerous connections
    between eye health and other diseases, the CDC works to integrate and
    connect vision health initiatives to other State, local, and community
    health programs.
        To advance State-based vision health integration, CDC funds are
    supporting a joint effort between the New York State Department of
    Health and Prevent Blindness Tri-State, focused on integrating vision-
    related services at the State and local level. Working together, these
    partners are promoting vision loss prevention strategies within the
    State Department of Health. One initiative resulting from this
    partnership has been the launch of a statewide tobacco cessation media
    campaign highlighting the impact of smoking on potential vision loss.
    Other examples include State-based programs to prevent and reduce
    diabetes, including efforts to educate patients and healthcare
    providers of the relationship between diabetes and certain eye
    problems, such as diabetic retinopathy and cataracts. A similar effort
    has recently been initiated in Texas.
        The goal of these integration efforts is to ensure that vision loss
    and eye health promotion are incorporated into all relevant local,
    State, and Federal public health interventions, prevention and
    treatment programs, and other initiatives that impact causes of--and
    factors that contribute to--vision problems and blindness. By
    integrating efforts and coordinating approaches in this manner, Federal
    and State resources will be used more efficiently, eye health problems
    and vision loss can be reduced, and the overall health and well-being
    of individuals and communities will be improved.
    Identifying and Preventing Vision Problems through Community-Based
            Strategies
        The CDC supports private sector efforts to develop and evaluate
    better ways to identify and treat individuals with potential eye
    disease, vision loss, and other ocular conditions. Among other efforts,
    CDC funding is currently supporting:
      --A study to assess the overall effectiveness and costs associated
            with implementing an adult vision and eye health history and
            risk assessment/referral program. This study, being conducted
            by Johns Hopkins University, in partnership with Prevent
            Blindness Ohio, is working in collaboration with the
            Physician's Free Clinic in Columbus, Ohio and Akron Community
            Health Resources to investigate the best methods for
            identifying patients who need eye care services and providing
            linkages to follow-up care.
      --An initiative spearheaded by Duke University and Prevent Blindness
            North Carolina to evaluate the benefit of pediatric and school-
            based vision screening. The project identified the need to
            ensure proper ongoing training and education of pediatricians
            on vision screening. In collaboration with the American Board
            of Pediatrics, the project has developed maintenance of
            certification module to improve office-based preschool vision
            screening.
    Data Collection
        Understanding the breadth and depth of vision and eye health issues
    across the Nation is paramount to ensuring appropriate allocation of
    resources and effective deployment of targeted interventions. Thus, the
    CDC supports programs and systems that collect, evaluate, and
    disseminate critical vision health data.
      --The CDC developed the first optional Behavioral Risk Factor
            Surveillance System (BRFSS) \3\ vision module, which collects
            State-based information on access to eye care and the
            prevalence of eye disease and eye injury. Early in 2011, the
            CDC will publish a report describing visual impairment as a
            serious public health issue affecting more than 2.9 million
            Americans. Unfortunately, in part due to insufficient funding,
            only 19 States currently use the vision module; this lack of
            broad adoption precludes the CDC, Congress, and other
            stakeholders from having the information they need to
            understand and address the full scope of vision loss and eye
            health problems facing the Nation.
    ---------------------------------------------------------------------------
        \3\ BRFSS is a State-based system of health surveys that collects
    information on chronic disease and injury.
    ---------------------------------------------------------------------------
      --CDC funding is supporting a joint endeavor between Duke University
            and Prevent Blindness America to conduct a systematic evidence
            review to describe the delivery systems of vision-related
            services and to identify new areas for policy evaluation or
            clinical research. This information will help identify the most
            at-risk populations and highlight gaps in care and service
            delivery to ensure that public and private resources are
            allocated to areas of greatest need.
        To that end, Prevent Blindness America respectfully requests the
    Subcommittee provide a $3.23 million allocation for vision and eye
    health initiatives at the CDC. This level of investment will help the
    CDC sustain its efforts to address the growing public health threat of
    preventable vision loss among at-risk and underserved populations.
    fiscal year 2012 resources will support strengthened State-based public
    health integration efforts to address vision and eye health and the
    development of additional evidence-based public health interventions
    that improve eye health among the Nation's most at-risk and
    underserved.
        investing in the vision of our nation's most valuable resource--
                                    children
        While the risk of eye disease increases after the age of 40, eye
    and vision problems in children are of equal concern. If left
    untreated, they can lead to permanent and irreversible visual loss and/
    or cause problems socially, academically, and developmentally. Although
    more than 12.1 million school-age children have some form of a vision
    problem, only one-third of all children receive eye care services
    before the age of six.\4\
    ---------------------------------------------------------------------------
        \4\ ``Our Vision for Children's Vision: A National Call to Action
    for the Advancement of Children's Vision and Eye Health, Prevent
    Blindness America,'' Prevent Blindness America, 2008.
    ---------------------------------------------------------------------------
        In 2009, the Maternal and Child Health Bureau established the
    National Center for Children's Vision and Eye Health, a national vision
    health collaborative effort aimed at developing the public health
    infrastructure necessary to promote eye health and ensure access to a
    continuum of eye care for young children. Prevent Blindness America is
    requesting ongoing support for the National Center for Children's
    Vision and Eye Health.
        With this support the Center, will continue to:
      --Provide national leadership in the development of best practices
            and guidelines for public health infrastructure, national
            vision screening guidelines, and statewide strategies that
            ensure early detection, vision screening, and a continuum of
            vision and eye healthcare for children.
      --Determine mechanisms for advancing State-based performance
            improvement systems, screening guidelines, and a mechanism for
            uniform data collection and reporting.
      --Collaborate with States to develop and implement statewide
            strategies for vision screening, establish quality improvement
            strategies, and determine mechanisms for the improvement of
            data systems and reporting of children's vision and eye health
            services.
                advance and expand vision research opportunities
        Prevent Blindness America calls upon the Subcommittee to provide
    additional support for the NEI to bolster its efforts to identify the
    underlying causes of eye disease and vision loss, improve early
    detection and diagnosis of eye disease and vision loss, and advance
    prevention and treatment efforts. Research is critical to ensure that
    new treatments and interventions are developed to help reduce and
    eliminate vision problems and potentially blinding eye diseases facing
    consumers across the country. In 2009, Congress commended the NEI's
    leadership in basic and translational research through H. Res. 366 and
    S. Res. 209 (111th Congress), which recognized NEI's 40 years as the
    National Institutes of Health (NIH) Institute that leads the Nation's
    commitment to save and restore vision. The Resolutions also designated
    2010-2020 as the Decade of Vision in recognition of the increasing
    health and economic burden of eye disease, mainly as a result of an
    aging population.
        Through additional support, the NEI will be able to continue to
    grow its efforts to:
      --Expand capacity for research, as demonstrated by the significant
            number of high-quality grant applications submitted in response
            to American Recovery and Reinvestment Act opportunities.
      --Address unmet need, especially for programs of special promise that
            could reap substantial downstream benefits.
      --Fund research to reduce healthcare costs, increase productivity,
            and ensure the continued global competitiveness of the United
            States.
        By providing additional funding for the NEI at the NIH, essential
    efforts to identify the underlying causes of eye disease and vision
    loss, improve early detection and diagnosis of eye disease and vision
    loss, and advance prevention, treatment efforts and health information
    dissemination will be bolstered.
                                   conclusion
        On behalf of Prevent Blindness America, our Board of Directors, and
    the millions of people at risk for vision loss and eye disease, we
    thank you for the opportunity to submit written testimony regarding
    fiscal year 2012 funding for the CDC's vision and eye health
    initiatives, the MCHB's National Center for Children's Vision and Eye
    Health, and the NEI. Please know that Prevent Blindness America stands
    ready to work with the Subcommittee and other Members of Congress to
    advance policies that will prevent blindness and preserve sight. Please
    feel free to contact us at any time; we are happy to be a resource to
    Subcommittee members and your staff. We very much appreciate the
    Subcommittee's attention to--and consideration of--our requests.
                                     ______

                       Prepared Statement of ProLiteracy
        Chairman Harkin, Ranking Member Shelby, and members of the
    Subcommittee, on behalf of the millions of adult learners working to
    improve their basic reading, writing, math, and computer skills and
    pursue greater economic opportunity for themselves and their families,
    thank you for the opportunity to provide written testimony regarding
    the President's fiscal year 2012 budget request for adult education and
    family literacy, provided for under the Workforce Investment Act, Title
    II. We would be pleased to testify and participate in any future
    hearings regarding adult literacy and basic education.
        We strongly urge you to approve at the very least, the President's
    request of $658.3 million for Adult Basic and Literacy Education in
    fiscal year 2012 to better assist the one in seven adults nationally
    who struggle with illiteracy. At a time when millions of Americans are
    struggling to find work, it is essential to invest in adult learning in
    order to put more American families on the road to self-sufficiency and
    economic security.
    Background: ProLiteracy
        ProLiteracy is the world's oldest and largest organization of adult
    literacy and basic education programs in the United States. ProLiteracy
    traces its roots to two premiere adult literacy organizations: Laubach
    Literacy International and Literacy Volunteers of America. In 2002,
    these two organizations merged to create ProLiteracy.
        ProLiteracy represents more than 1,000 community-based
    organizations and adult basic education programs in the United States,
    and we partner with literacy organizations in 50 developing countries.
    In communities across the United States, these organizations use
    trained volunteers, teachers, and instructors to provide one-on-one
    tutoring, classroom instruction, and specialized classes in reading,
    writing, math, technology, English language skills, job-training and
    workforce literacy skills, GED preparation, and citizenship. Our
    members are located in all 50 States and in the District of Columbia.
    Through education, training and advocacy, ProLiteracy supports the
    frontline work of these organizations with regional conferences and
    other training events; credentialing; and the publication of materials
    and products used to teach adults basic literacy and English-as-a-
    second-language and to prepare adults for the U.S. citizenship exam and
    GED Tests.
    The Urgent Need to Invest in Adult Education
        In 2003, the U.S. Department of Education conducted the National
    Assessment of Adult Literacy (NAAL) in order to gauge the English
    reading and comprehension skills of individuals in the United States
    over the age of 16 on daily literacy tasks such as reading a newspaper
    article, following a printed television guide, and completing a bank
    deposit slip. The results indicated that 30 million adults--14 percent
    of this country's adult population--had below basic literacy skills;
    that is, their ability to read was so poor, they could not complete a
    job application without help or follow the directions on a medicine
    bottle. An additional 63 million adults read only slightly better, for
    a total of 93 million American adults who are considered low literate.
        Because under-educated adults are more likely to be unemployed and
    require public assistance, the high percentage of low-literate adults
    is having an adverse affect on our Nation's efforts to reduce
    unemployment and reduce the deficit. In 2009, 14.6 percent of those
    without a high school diploma were unemployed compared to 9.7 percent
    of high school graduates; 8.6 percent of those with some college; 6.8
    percent with an associate's degree; 4.6 percent with a 4-year degree or
    more.\1\ And the trends for these adults are not encouraging. For
    example, while 67 percent of the service industry's jobs in 1983
    required a high school diploma or less, this percentage is expected to
    drop to zero by 2018.\2\
    ---------------------------------------------------------------------------
        \1\ http://www.bls.gov/cps/cpsaat7.pdf.
        \2\ http://cew.georgetown.edu/(see Figure 4.17, pg. 86).
    ---------------------------------------------------------------------------
        In addition, we will fail to meet President Obama's goal of once
    again leading the world in college degree attainment unless we support
    more adults without college degrees to enroll in post-secondary
    education. To meet the President's goal, it is estimated that the
    United States will need to move at least 3.4 million adults with high
    school diplomas but no college degrees into postsecondary education.\3\
    Increasing the number of adults with high-school degrees or
    equivalents, and with the skills to succeed in college, will help us
    achieve this goal.
    ---------------------------------------------------------------------------
        \3\ http://www.womeningovernment.org/files/onemillion_letter.pdf.
    ---------------------------------------------------------------------------
        The bottom line is that a greater investment in adult education
    will increase employment and postsecondary enrollments, move
    individuals off of public assistance, and ultimately reduce the
    deficit.
        Despite the critical role that adult education plays in reducing
    unemployment and increasing postsecondary attainment, the adult
    education system currently only has the capacity to serve approximately
    2.5 million of these 93 million adults each year. Adult education has
    been basically flat funded for a decade, seeing only a modest overall
    increase from 2001-2010.\4\ In fiscal year 2011, the number of
    individuals served will almost certainly be reduced as a result of the
    $32.1 million cut to Title II State grants in the final fiscal year
    2011 CR. This cut comes at a time when many States are responding to
    drastically declining revenues by slashing budgets for education,
    training, and human services, including their investments in adult
    education.
    ---------------------------------------------------------------------------
        \4\ http://www2.ed.gov/about/overview/budget/history/edhistory.pdf.
    ---------------------------------------------------------------------------
    The Proposed Adult Basic and Literacy Education Budget
        The proposed fiscal year 2012 budget includes several significant
    features that we strongly support. First, the President requested $635
    million for State formula grants for adult education through the
    Workforce Investment Act (WIA), Title II, an increase of $6.8 million
    compared to the 2010 appropriation. As we have discussed above, the
    need for increased investment in adult education is clear, and we
    welcome the President's call for a modest increase.
        We recognize that in the current fiscal environment, the
    subcommittee will be reluctant to increase spending in many areas of
    the budget above this year's level. If an increase is not possible, it
    is critically important to hold spending for adult education and
    literacy at current levels. An additional cut to Title II funding on
    top of the $31 million cut in fiscal year 2011 would be devastating to
    State adult education systems around the country, and, as we have
    noted, would likely increase unemployment and contribute to the
    deficit.
    Workforce Innovation
        The administration proposes to set aside $50.8 million from the
    State formula funds to support a Workforce Innovation Fund (WIF), which
    will also include $30 million in funding from the Rehabilitation
    Services and Disability Research account, and almost $298 million from
    the Department of Labor.
        ProLiteracy applauds the administration's commitment to innovation.
    We urge the Subcommittee to ensure that innovation funding will benefit
    adults at all skill levels, particularly the millions who are estimated
    to possess less than basic literacy skills served by community-based
    organizations. We suggest, in fact, competitive priority for proposals
    that will address those at the lowest levels of literacy and those with
    significant barriers to learning.
        However, we also caution that after experiencing a dramatic cut to
    State formula funding in fiscal year 2011, care must be taken to ensure
    that State formula funding is sufficient to ensure the survival of
    existing programs. ProLiteracy urges the Subcommittee to ensure that
    the WIF, if it moves forward, is funded on top of annual WIA formula
    funds, rather than as a carve out of existing formula funds.
    National Leadership
        The President's proposal also includes an additional $12 million
    for national leadership funds to the Department of Education that would
    be used to evaluate the impact of college bridge programs that assist
    adult learners in transitioning from adult basic education to
    postsecondary education and training, and for building greater
    technology infrastructure for adult learners and adult educators.
        We believe these ideas reflect real needs in our field, and if
    these initiatives lead to new resources and better services on the
    ground for learners and the programs that serve them, than this could
    be a very positive development. Again, however, we would urge that any
    new programming that would not have an immediate, direct, benefit to
    adult learners not come at the expense of State formula funds.
    WIA Reauthorization and Use of National Leadership Funds
        The President's budget request also supports the reauthorization of
    WIA, and specifically calls for better alignment between Title I and
    Title II. We share the administration's desire for more streamlined
    service delivery systems that are more engaged with employers, and the
    promotion of innovative career pathways models--but in particular for
    those learners at the lowest levels of literacy.
        We strongly urge, therefore, expanding funding opportunities for
    community-based programs that have successfully implemented strategies
    for delivering basic literacy instruction together with employment
    training so that they may document and disseminate best practices
    related to the integration of title I job training programs with title
    II adult literacy programs.
        Through both reauthorization of the Workforce Investment Act and
    use of national leadership funding, we also recommend that the
    Department examine and publish successful strategies and best practices
    that can help adults with low literacy levels improve their overall
    skills and employment opportunities.
        We note that learners at the lowest levels of literacy often
    receive literacy instruction at community-based organizations (CBOs)
    that utilize trained volunteers. For decades, volunteers, and other
    types of non-career instructors such as such as VISTA or AmeriCorps
    members, have been a vital component in the delivery of education
    services for adults with low literacy in the United States. Volunteers
    serve in non-instructional roles as well such as mentoring, counseling,
    recruiting students, and serving as teaching aides to paid instructors.
        However, adult education career pathway programs are based largely
    on traditional career pathways programs that connect secondary and
    postsecondary students to further education and work in a specific
    industry. As a result, the limited existing research on career pathway
    approaches used with adult learners is largely focused on students with
    higher-level literacy skills.
        We therefore urge the subcommittee to ensure that CBOs that utilize
    trained volunteers are integrated into the Department's career pathways
    strategies. We suggest that the Department identify and disseminate
    successful strategies and best practices that will assist community-
    based organizations that utilize adult literacy volunteers to support
    the Department's career pathways initiatives; and implement strategies
    to increase participation by community-based organizations that utilize
    trained volunteers in any related technical assistance efforts.
        Thank you for the opportunity to present this testimony. We would
    be happy to respond to any questions that you may have.
                                     ______

                Prepared Statement of the Prostatitis Foundation
        We are the unpaid volunteers at the Prostatitis Foundation
    representing thousands of men nationwide with prostatitis. Our mission
    for 15 years has been to:
      --Educate the public about the prevalence of prostatitis by our
            website www.prostatitis.org, our newsletters, and newspaper and
            magazine articles. It is estimated that 10 percent of all males
            suffer from chronic prostatitis/pelvic pain syndrome (CP/PPS)
            and 50 percent of men will experience (CP/PPS) during their
            lifetime. Symptoms can include severe pelvic pain, urinary and
            sexual dysfunction and infertility. The possible connection of
            prostatitis to prostate cancer is uncertain and not adequately
            researched. Prostatitis is common in young men who are at an
            age where they are reluctant to discuss such personal matters
            as pelvic pain, voiding problems and sexual dysfunction with
            family, friends or co-workers. The result has been an
            unpublicized crisis and a costly, hopeless medical condition.
      --Encourage research funding. We have worked with the NIH research
            team personnel and research centers over three sets of multi-
            year clinical trial programs going back to 1996. We are now
            assisting with the fourth group of nationwide research centers.
            The Map Network is a group of researchers who have been
            assembled by National Institute of Diabetes and Digestive and
            Kidney Diseases (NIDDK) to include specialties besides urology
            to get some basic scientific research that will lead to
            determining a cause and cure for (CP/PPS). Everyone has too
            much time and expense invested to let these efforts expire
            without pushing to complete this search for a cause and cure
            for (CP/PPS). If we do not build on the efforts of the three
            previous accumulations of data to determine a cause and cure it
            will be lost and the next group will have to start at the
            beginning again.
        We request continuing funding and direction through The National
    Institutes of Health (NIH) to National Institute of Diabetes and
    Digestive and Kidney Diseases (NIDDK) who are over seeing this Mapp
    Network of research centers.
                                     ______

          Prepared Statement of the Pulmonary Hypertension Association
        Mr. Chairman, thank you for the opportunity to submit testimony on
    behalf of the Pulmonary Hypertension Association (PHA).
        I would like to extend my sincere thanks to the Subcommittee for
    your past support of pulmonary hypertension (PH) programs at the
    National Institutes of Health, Centers for Disease Control and
    Prevention, and Health Resources and Services Administration. These
    initiatives have opened many new avenues of promising research, helped
    educate hundreds of physicians in how to properly diagnose PH, and
    raised awareness about the importance of organ donation and
    transplantation within the PH community.
        I am honored today to represent the hundreds of thousands of
    Americans who are fighting a courageous battle against a devastating
    disease. Pulmonary hypertension is a serious and often fatal condition
    where the blood pressure in the lungs rises to dangerously high levels.
    In PH patients, the walls of the arteries that take blood from the
    right side of the heart to the lungs thicken and constrict. As a
    result, the right side of the heart has to pump harder to move blood
    into the lungs, causing it to enlarge and ultimately fail.
        PH can occur without a known cause or be secondary to other
    conditions such as: collagen vascular diseases (i.e., scleroderma and
    lupus), blood clots, HIV, sickle cell, or liver disease. PH impacts
    patients of all races, genders, and ages. Preliminary data from the
    REVEAL Registry suggests that the ratio of women to men who develop PH
    is 4:1. Patients develop symptoms that include shortness of breath,
    fatigue, chest pain, dizziness, and fainting.
        Unfortunately, these symptoms are frequently misdiagnosed, leaving
    patients with the false impression that they have a minor pulmonary or
    cardiovascular condition. By the time many patients receive an accurate
    diagnosis, the disease has progressed to a late stage, making it
    impossible to receive a necessary heart or lung transplant. PH is
    chronic and incurable with a poor survival rate. Fortunately, new
    treatments are providing a significantly improved quality of life for
    patients with some managing the disorder for 20 years or longer.
        In 1990, when three PH patients found each other with the help of
    the National Organization for Rare Diseases, and founded the Pulmonary
    Hypertension Association, there were less than 200 diagnosed cases of
    this disease. It was virtually unknown among the general population and
    not well known in the medical community. They soon realized that this
    was unacceptable, and formally established PHA, which is headquartered
    in Silver Spring, Maryland. I am pleased to report that we are making
    good progress in our fight against this deadly disease. Nine
    medications for the treatment of PH have been approved by the FDA in
    the past 16 years.
        Today, PHA includes:
      --More than 20,000 members and supporters.
      --A network of 230+ patient support groups and an active patient-to-
            patient telephone helpline.
      --Three research programs that, through partnerships with the
            National Heart, Lung and Blood Institute, American Heart
            Association and the American Thoracic Society, have leveraged
            our donors' funds to commit more than $10 million toward PH
            research as of 2011.
      --Numerous electronic and print publications, including the first
            medical journal devoted to pulmonary hypertension--published
            quarterly and distributed to all cardiologists, pulmonologists,
            and rheumatologists in the United States.
      --A state-of-the-art website(www.phassociation.org) dedicated to
            providing educational and support resources to patients,
            caregivers, and the public.
      --A medical education website (www.phaonlineuniv.org), supported in
            part by the CDC, providing accredited medical education and
            resources to the medical community
                fiscal year 2012 appropriations recommendations
    National Heart, Lung And Blood Institute
        Less than two decades ago, a diagnosis of PH was essentially a
    death sentence, with only one approved treatment for the disease.
    Thanks to advancements made through the public and private sector,
    patients today are living longer and better lives with a choice of nine
    FDA approved medications. Recognizing that we have made tremendous
    progress, we are also mindful that we are a long way from where we want
    to be in (1) the management of PH as a treatable chronic disease, and
    (2) a cure.
        We are grateful to the National Heart, Lung and Blood Institute for
    their leadership in advancing research on PH. Our Association is proud
    to jointly sponsor investigator training grants (K awards) with NHLBI
    aimed at supporting the next generation of pulmonary hypertension
    researchers.
        Moreover, we were very pleased that NHLBI recently convened some of
    the community's leading scientists for a Working on Group on Lung
    Vascular Research. The panel produced recommendations that should guide
    pulmonary vascular disease research and treatment, including PH
    research, in coming years. Their recommendations, published in the
    American Journal of Respiratory and Critical Care Medicine in October,
    2010 are as follows:
      --Advance basic scientific research in lung vascular biology
            utilizing emerging technologies.
      --Advance and coordinate basic and clinical knowledge of the
            pulmonary circulation-right heart axis through novel research
            efforts utilizing multidisciplinary teams.
      --Define interactions between lung vascular components and
            circulating elements and systemic circulations by fostering
            novel collaborations.
      --Encourage systems analysis to understand and define interactions
            between lung vascular genetics, epigenetics, metabolic
            pathways, andmolecular signaling.
      --Develop strategies using appropriate animal models to improve the
            understanding of the lung vasculature in health and in
            conditions that reflect human disease.
      --Enhance translational research in lung vascular disease by
            comparing cellular and tissue abnormalities identified in
            animal models to those in human specimens.
      --Improve lung vascular disease molecular and clinical phenotype
            coupling.
      --Develop in vivo imaging techniques which assess structural changes
            in lung vasculature, metabolic shifts, functional cell
            responses and right ventricular function.
      --Develop research consortia that advance basic, translational, and
            clinical studies, allow for multi-center epidemiological study
            feasibility, and support junior investigators' training in lung
            vascularbiology and disease.
        We encourage the Subcommittee to support the full implementation of
    these recommendations by the National Institutes of Health.
        Mr. Chairman, expanding clinical research remains a top priority
    for patients, caregivers, and PH investigators. We are particularly
    interested in establishing a pulmonary hypertension research network.
    Such a network would link leading researchers around the United States,
    providing them with access to a wider pool of shared patient data. In
    addition, the network would provide researchers with the opportunities
    to collaborate on studies and to strengthen the interconnections
    between basic and clinical science in the field of pulmonary
    hypertension research. Such a network is in the tradition of the NHLBI,
    which, to its credit and to the benefit of the American public, has
    supported numerous similar networks including the Acute Respiratory
    Distress Syndrome Network and the Idiopathic Pulmonary Fibrosis
    Clinical Research Network. We encourage the NHLBI to move forward with
    the establishment of a PH network in fiscal year 2012.
        For fiscal year 2012, PHA joins with other voluntary patient and
    medical organizations in recommending an appropriation of $35 billion
    for the National Institutes of Health. This level of funding will
    ensure continued expansion of research on rare diseases like pulmonary
    hypertension.
    Centers For Disease Control And Prevention
        Mr. Chairman, we are grateful to the subcommittee for providing
    past support of PHA's Pulmonary Hypertension Awareness Campaign. We
    know for a fact that Americans are dying due to a lack of awareness of
    PH, and a lack of understanding about the many new treatment options.
    This unfortunate reality is particularly true among minority and
    underserved populations. More needs to be done to educate both the
    general public and healthcare providers if we are to save lives.
        To that end, PHA has utilized the funding provided through the CDC
    to: (1) launch a successful media outreach campaign focusing on both
    print and online outlets; (2) expand our support programs for
    previously underserved patient populations; and (3) establish PHA
    Online University, an interactive curriculum-based website for medical
    professionals that targets pulmonary hypertension experts, primary care
    physicians, specialists in pulmonology/cardiology/rheumatology, and
    allied health professionals. The site is continually updated with
    information on early diagnosis and appropriate treatment of pulmonary
    hypertension. It serves as a center point for discussion among PH-
    treating medical professionals and offers Continuing Medical Education
    and CEU credits through a series of online classes.
        In fiscal year 2012, we encourage the subcommittee to establish a
    specific program at CDC to provide ongoing support for PH education and
    awareness activities. This would make a tremendous difference in the
    fight against this devastating disease.
    ``Gift Of Life'' Donation Initiative at HRSA
        PHA applauds the success of the Health Resources and Services
    Administration's ``Gift of Life'' Donation Initiative. This important
    program is working to increase organ donation rates across the country.
    Unfortunately, the only ``treatment'' option available to many late-
    stage PH patients is a lung, or heart and lung, transplantation. This
    grim reality is why PHA established ``Bonnie's Gift Project.''
        ``Bonnie's Gift'' was started in memory of Bonnie Dukart, one of
    PHA's most active and respected leaders. Bonnie battled with PH for
    almost 20 years until her death in 2001 following a double lung
    transplant. Prior to her death, Bonnie expressed an interest in the
    development of a program within PHA related to transplant information
    and awareness.
        PHA has had a very successful partnership with HRSA's ``Gift of
    Life'' Donation Program in recent years. Collectively, we have worked
    to increase organ donation rates and raise awareness about the need for
    PH patients to ``early list'' on transplantation waiting lists. For
    fiscal year 2012, PHA recommends an appropriation of $26 million for
    this important program.
    Social Security Disability
        Finally Mr. Chairman, PHA would like to thank the subcommittee for
    its commitment to address the longstanding backlog of disability claims
    at the Social Security Administration. We greatly appreciate this
    investment as a growing number of our patients are applying for
    disability coverage. On a related note, the SSA recently convened an
    Institute of Medicine panel to recommend revisions to the disability
    criteria for cardiovascular diseases. The IOM worked closely with our
    medical experts to update the disability criteria for our patient
    population and we were pleased to receive their recommendations earlier
    this year. We encourage Congress to support this process moving
    forward.
                                     ______

     Prepared Statement of the Research Working Group of the Federal AIDS
                               Policy Partnership
        Chairman Harkin, Ranking Member Shelby and members of the
    Committee, thank you for the opportunity to provide testimony on the
    National Institutes of Health (NIH) budget overall and for AIDS
    research in fiscal year 2012. Tomorrow's scientific and medical
    breakthroughs depend on your vision, leadership and commitment toward
    robust NIH funding over the next year. To this end, the Research
    Working Group (RWG) urges this Committee to support--at minimum--the
    President's NIH budget request and also recommends a funding target of
    $35 billion in fiscal year 2012 to maintain the U.S.'s position as the
    world leader in medical research and innovation.
        Investments in health research via NIH have paid enormous dividends
    in the health and well-being of people in the United States and around
    the world. NIH funded HIV and AIDS research has supported innovative
    basic science for better drug therapies, evidence-based behavioral and
    biomedical prevention interventions and vaccines which have saved and
    improved the lives of millions and holds great promise for
    significantly reducing HIV infection rates and providing more effective
    treatments for those living with HIV/AIDS in the coming decade.
        Despite these advances, the number of new HIV/AIDS cases continues
    to rise in various populations in the United States and around the
    world. There are over 1 million HIV-infected people in the United
    States, the highest number in the epidemic's 30-year history;
    additionally over 56,000 Americans become newly infected every year.
    The evolving HIV epidemic in the United States disproportionately
    affects the poor, sexual and racial minorities and the most
    disenfranchised and stigmatized members of our communities. However,
    with proper funding coupled with the promotion of evidence based
    policies, 2012 will be a time of great scientific progress in
    prevention science, vaccines and finding a cure for HIV as well as
    addressing the co-morbid illnesses that affect patients with HIV such
    as viral hepatitis and tuberculosis. Further, as Washington, DC is set
    to host the International AIDS Conference in the summer of 2012, the
    gains in science made by NIH funded research programs will reflect our
    preeminence as the world's most powerful research enterprise fighting
    this deadly epidemic.
        Major advances over the last 2 years in HIV prevention
    technologies--in particular with microbicides, HIV vaccines,
    circumcision, antiretroviral treatment as prevention and pre exposure
    prophylaxis using antiretrovirals (PrEP)--demonstrate that adequately
    resourced NIH programs can transform our lives. Federal support for
    AIDS research has also led to new treatments for other diseases,
    including cancer, heart disease, Alzheimer's, hepatitis, osteoporosis
    and a wide range of autoimmune disorders. Over the years, NIH has
    sponsored the evaluation of a host of vaccine candidates, some of which
    are advancing to efficacy trials. The recent successful iPrEx and HPTN
    052 trials have shown the potential of antiretroviral drugs to prevent
    HIV infection. Moreover increased funding will support the future
    testing of new microbicides and therapeutics in the pipeline via the
    implementation of a newly restructured, cross-cutting HIV clinical
    trials network which translates NIH funded scientific innovation into
    critical quality of life gains for those most affected with HIV.
        Increased funding for NIH in fiscal year 2012 makes good bipartisan
    economic sense, especially in shaky times. Robust funding for NIH
    overall will enable research universities to pursue scientific
    opportunity, advance public health, and create jobs and economic
    growth. In every State across the country, the NIH supports research at
    hospitals, universities, private enterprises and medical schools. This
    includes the creation of jobs that will be essential to future
    discovery. Sustained investment is also essential to train the next
    generation of scientists and prepare them to make tomorrow's HIV
    discoveries. NIH funding puts 350,000 scientists to work at research
    institutions across the country. According to NIH, each of its research
    grants creates or sustains six to eight jobs and NIH supported research
    grants and technology transfers have resulted in the creation of
    thousands of new independent private sector companies. Strong,
    sustained NIH funding is a critical national priority that will foster
    better health and economic revitalization.
        Let's not jeopardize our future. Since 2003, funding for the NIH
    has failed to keep up with our existing research needs--damaging the
    success rate of approved grants and leaving very little money to fund
    promising new research. The real value of the increases prior to 2003
    has been precipitously reduced because of the relatively higher
    inflation rate for the cost of research and development activities
    undertaken by NIH. According to the Biomedical Research and Development
    Price Index--which calculates how much the NIH budget must change each
    year to maintain purchasing power--between fiscal year 2003 and fiscal
    year 2011, the cost of NIH activities according to the BRDI will have
    increased by 32.8 percent. By comparison, the overall budget of the NIH
    increased by $3.6 billion or 13.4 percent over fiscal year 2003. So in
    real terms, the NIH has already sustained budget decreases of close to
    20 percent over the past 9 years due to inflation alone. As such, any
    further cuts to NIH will have the clear and devastating effects of
    undermining our Nation's leadership in health research and our
    scientists' ability to take advantage of the expanding opportunities to
    advance healthcare. The race to find better treatments and a cure for
    cancer, heart disease, AIDS and other diseases, and for controlling
    global epidemics like AIDS, tuberculosis and malaria, all depend on a
    robust long term investment strategy for health research at NIH.
        In conclusion, the RWG calls on Congress to continue the bipartisan
    Federal commitment toward combating HIV as well as other chronic and
    life threatening illnesses by increasing funding for NIH to $35 billion
    in fiscal year 2012, including funds for transfer to the Global Fund
    for HIV/AIDS, Tuberculosis, and Malaria. A meaningful commitment toward
    stemming the epidemic and securing the well being of people with HIV
    cannot be met without prioritizing the research investment at NIH that
    will lead to tomorrow's lifesaving vaccines, treatments and cures.
    Thank you for the opportunity to provide these comments.
                                     ______

                     Prepared Statement of Research!America
        Thank you for the opportunity to submit testimony regarding fiscal
    year 2012 appropriations for the Subcommittee on Labor, Health, and
    Human Services, Education and Related Agencies. Research!America is the
    Nation's largest 501(c)(3) alliance working to make research to improve
    health a higher national priority. Research!America's member
    organizations together represent the voices of more than 125 million
    Americans. Our mission is grounded in strong and consistent expression
    by the American public for robust funding and policies in support of
    health research in the public and private sector. We use evidence-based
    advocacy to demonstrate the benefits of research that improves public
    health, productivity, longevity, and prosperity while solidifying
    America's standing as the world's engine of innovation.
        Our remarks will focus on funding for the National Institutes of
    Health (NIH), the Centers for Disease Control and Prevention (CDC), the
    Food and Drug Administration (FDA) and the Agency for Healthcare
    Research and Quality (AHRQ)--agencies that play a pivotal role in
    advancing the health of Americans and fueling economic growth across
    our Nation. In addition to these agencies, Research!America also
    advocates for the National Science Foundation (NSF), which fosters
    basic science and discovery that also impacts the health of Americans.
        Research!America appreciates the subcommittee's past support for
    robust research funding conducted and supported by NIH, CDC, FDA, and
    AHRQ. Health research is in our Nation's best short- and long-term
    interests. Investing in research saves lives, saves dollars, produces
    jobs across multiple sectors of our economy, and positions our Nation
    for sustained global competitiveness.
        The Nation is facing a debt crisis. Our debt burden will increase
    if we underfund agencies that drive economic growth and the private
    sector innovation critical to our global competitiveness. Robust
    support for health research agencies is critical for solving the debt
    crisis, reigning in the cost of medical care, and getting the economy
    back on track.
        NIH, CDC, AHRQ and FDA each contribute in multifaceted ways to
    improved health and the economic growth our Nation.
      --Research funded by the National Institutes of Health at research
            institutions across the country provides the groundwork for new
            product development in the private sector, which creates jobs
            and pumps dollars into local economies.
      --The Centers of Disease Control and Prevention engage in
            epidemiological and public health research that stems deadly
            and costly pandemics, bolsters our Nation's defenses against
            bioterrorism, and addresses public health threats like drug-
            resistant infections that increase hospital costs and threaten
            lives.
      --Research supported by the Agency for Healthcare Research and
            Quality improves the efficiency and quality of healthcare in
            this country by reducing duplication and waste and improving
            healthcare outcomes;
      --By ensuring the safety and efficacy of new medicines and medical
            devices, The Food and Drug Administration plays a pivotal role
            in translating health research into improved treatments for
            patients.
        As polling commissioned by Research!America clearly demonstrates,
    the American public strongly supports robust investment in health and
    medical research. A recent poll that surveyed a mix of self-described
    conservatives (32 percent), liberals (32 percent) and moderates (36
    percent) found that, as we emerge from the recession:
      --78 percent of Americans think Federal funding for health research
            is important for job creation and the economy;
      --61 percent say accelerating our Nation's investment in research to
            improve health is a priority;
      --76 percent think global health R&D is important to the U.S.
            economy;
      --84 percent think it is important that the Government plays a role
            in research for prevention and wellness; and
      --53 percent of Americans think that spending cuts are necessary, but
            the United States must invest strategically to improve the
            health of the economy.
        The poll also confirms that Americans value public/private
    collaboration in order to rapidly build on discoveries made in
    federally funded labs to bring new drugs and devices to market. Some 84
    percent of Americans think it is important to invest in regulatory
    science, an increasingly important area of focus at FDA and NIH, to
    make the drug and device development process more efficient for
    businesses and safer for patients.
        Additional findings from Research!America polling include:
      --91 percent of Americans think R&D is important to their State's
            economy;
      --83 percent agree that basic scientific research should be funded by
            the Federal government;
      --66 percent think research to improve health is part of the solution
            to rising healthcare costs.
        The American public knows that research not only saves lives, but
    money. Disease and disability pose a major economic threat to our
    Nation, as the aging of our population and rising obesity rates
    increase the prevalence of heart disease, cancer, stroke, diabetes,
    Parkinson's disease, Alzheimer's disease and other major illnesses. It
    is estimated that chronic disease alone costs the United States $1.7
    trillion each year.\1\ Research conducted by both the public and
    private sectors is a potent weapon against rising healthcare costs. For
    example:
    ---------------------------------------------------------------------------
        \1\ Partnership to Fight Chronic Disease, Almanac of Chronic
    Disease, 2009.
    ---------------------------------------------------------------------------
      --An NIH-sponsored clinical trial showed treatment with aspirin could
            reduce stroke in Atrial Fibrillation (AF) victims by 80
            percent, resulting in a 10-year net benefit of $1.27
            billion.\2\
    ---------------------------------------------------------------------------
        \2\ Johnston SC, Rootenberg JD, Katrak S, et. al. Effect of a US
    NIH programme of clinical trials on public health and costs. The Lancet
    2006;367:1319-1327.
    ---------------------------------------------------------------------------
      --A breast cancer diagnostic test developed by a private company
            using data from the publicly funded human genome project saves
            an estimated $2,000 per patient by reducing the number of women
            who are prescribed chemotherapy.\3\
    ---------------------------------------------------------------------------
        \3\ Lyman, G.H. et al. Impact of a 21-gene RT-PCR assay on
    treatment decisions in early-stage breast cancer. Cancer. 2007;
    109:1011-1118.
    ---------------------------------------------------------------------------
      --A recent NIH-funded study shows that vaccinating healthy, employed
            adults (ages 18 to 50) against the flu saves as much as $31 per
            person.\4\
    ---------------------------------------------------------------------------
        \4\ Lee, Patrick Y. ``Economic Analysis Of Influenza Vaccination
    And Antiviral Treatment For Healthy Working Adults.'' Annals of
    Internal Medicine 137 (2002): 225-31.
    ---------------------------------------------------------------------------
        U.S. research leading to the control and eradication of global
    illnesses can dramatically increase global productivity, while helping
    to protect Americans. In addition to benefiting our troops abroad, U.S.
    research focused on global diseases is actually an investment in the
    health of Americans. International travel means that it is not a matter
    of if, but when, deadly global threats, such as multiple-drug resistant
    tuberculosis reach the United States. Every year, 60 million Americans
    travel to other countries and 50 million people from abroad travel to
    the United States.\5\
    ---------------------------------------------------------------------------
        \5\ ITA (International Trade Administration), Office of Travel and
    Tourism Industries, ``Total International Travelers Volume to and from
    the U.S. 1995-2005,'' available online at http://tinet.ita.doc.gov/
    outreachpages/inbound.total_intl_travel_volume_1995-2005.html.
    ---------------------------------------------------------------------------
        In an interconnected world, U.S. global research helps grow our
    economy and saves lives at home and abroad.
        Both the NIH and the CDC work closely with other agencies, like the
    U.S. Agency for International Development (USAID) to support the
    development of new biomedical, diagnostic, and other global health-
    related technologies. Through public private partnerships (PPP),
    including product development partnerships (PDP), these agencies
    leverage expertise from academia, private sector, and others to create
    new tools to combat neglected diseases throughout the world. This
    innovative collaborative PDP model has resulted in 12 novel products
    that could prove transformative for global health. We urge the
    committee to provide continued and robust support for these programs
    that touch every corner of our world, save lives, and strengthen the
    U.S. economy.
        Whether the goal is to save lives, bend the cost curve by
    progressively reducing the cost of treating chronic and life-
    threatening health conditions, or promote the kind of innovation that
    positions our Nation for global economic leadership now and in the
    future, ample funding for NIH, CDC, FDA, and AHRQ is a cost-effective
    investment. Research!America appreciates the difficult task facing the
    subcommittee and urges that you recognize the return on investment that
    these four Federal agencies bring to our country. Investing in these
    agencies is the right, and smart, choice.
                                     ______

                   Prepared Statement of Rotary International
        Chairman Harkin, members of the Subcommittee, Rotary International
    appreciates this opportunity to submit testimony to the in support of
    the polio eradication activities of the U.S. Centers for Disease
    Control and Prevention (CDC). The Global Polio Eradication Initiative
    is an unprecedented model of cooperation among national governments,
    civil society and U.N. agencies to work together to reach the most
    vulnerable through a safe, cost-effective public health intervention,
    and one which is increasingly being combined with opportunistic,
    complementary interventions such as the distribution of life-saving
    vitamin A drops, oral rehydration therapy, zinc supplements, and even
    something as simple as the distribution of soap. The goal of a polio
    free world is within our grasp because polio eradication strategies
    work even in the most challenging environments and circumstances.
               progress in the global program to eradicate polio
        Thanks to this committee's leadership in appropriating funds,
    progress toward a polio-free world continues.
      --Only 4 countries (Nigeria, India, Pakistan and Afghanistan) are
            polio-endemic--the lowest number in history.
      --The number of polio cases has fallen from an estimated 350,000 in
            1988 to less than 1300 in 2010--a more than 99 percent decline
            in reported cases.
      --As of April 21, 2011, Uttar Pradesh (UP) in India celebrated 1 year
            without reporting a single case of polio. The state has
            traditionally been a major exporter of virus to other parts of
            India and the world, and has been described as one of the most
            difficult places to eradicate polio.
      --The number of polio cases in the polio endemic countries of India
            and Nigeria declined by more than 90 percent in 2010 as
            compared to 2009. As of 2011, India has reported only 1 case;
            Nigeria--5 cases.
      --Incidence of type 3 polio, which accounted for 70 percent of all
            polio cases in 2009, decreased significantly in 2010 accounting
            for only 8 percent of all cases.
      --Bivalent oral polio vaccine, which was introduced at the end of
            2009, has proven to effectively target both of the remaining
            strains of polio, and has been a major factor in the progress
            made in 2010.
      --A shortfall in the funding needed for polio eradication activities
            in polio affected and at-risk countries continues to pose a
            serious threat the achievement of a polio free world.
        In summary, significant operational progress was made in 2010
    despite funding challenges and outbreaks which, will continue to
    threaten polio free countries until polio eradication is achieved.
    Rotary, as a spearheading partner of the GPEI, will continue to pursue
    aggressive progress as outlined in the Strategic Plan for 2010-12 which
    has already demonstrated results in terms of reducing the number of
    cases in 2010 and into 2011.
        The ongoing support of donor countries is essential to assure the
    necessary human and financial resources are made available to polio-
    endemic countries to take advantage of the window of opportunity to
    forever rid the world of polio. Access to children is needed,
    particularly in conflict-affected areas such as Afghanistan and its
    shared border with Pakistan. Polio-free countries must maintain high
    levels of routine polio immunization and surveillance. The continued
    leadership of the United States is essential to ensure we meet these
    challenges.
                        the role of rotary international
        Rotary International, a global association of more than 32,000
    Rotary clubs in more than 170 countries with a membership of over 1.2
    million business and professional leaders (more than 365,000 of which
    are in the United States), has been committed to battling polio since
    1985. Rotary International has contributed more than US$1 billion
    toward a polio free world--representing the largest contribution by an
    international service organization to a public health initiative ever.
    Rotary also leads the United States Coalition for the Eradication of
    Polio, a group of committed child health advocates that includes the
    March of Dimes Foundation, the American Academy of Pediatrics, the Task
    Force for Global Health, the United Nations Foundation, and the U.S.
    Fund for UNICEF. These organizations join us in thanking you for your
    staunch support of the Polio Eradication Initiative.
     the role of the u.s. centers for disease control and prevention (cdc)
        Rotary commends CDC for its leadership in the global polio
    eradication effort, and greatly appreciates the Subcommittee's support
    of CDC's polio eradication activities. The investment in this global
    effort has helped to make the United States the leader among donor
    nations in the drive to eradicate this crippling disease. Due to
    congressional support, in fiscal year 2010 and fiscal year 2011 CDC was
    able to:
      --Support the international assignment of more than 358 long- and
            short-term epidemiologists, virologists, and technical officers
            to assist the World Health Organization and polio-endemic
            countries to implement polio eradication strategies while on
            temporary duty travel from Atlanta, and 31 technical staff on
            direct 2-year assignments to WHO and UNICEF to assist polio-
            endemic and polio-reinfected countries.
      --Perform the lead technical monitoring role for the Global Polio
            Eradication Initiative (GPEI) Strategic Plan 2010-2012 released
            in May 2010. On a quarterly basis, beginning in Q4, 2010, CDC
            provided a detailed epidemiologic report and risk assessment on
            the progress toward achieving the goals outlined in the
            Strategic Plan to the Independent Monitoring Board (IMB) for
            policy and decisionmaking.
      --Provide $53.4 million in fiscal year 2010 to UNICEF for
            approximately 292 million doses of polio vaccine and $7.3
            million for operational costs for NIDs in all polio-endemic
            countries and other high-risk countries in Asia, the Middle
            East and Africa. Most of these NIDs would not take place
            without the assurance of CDC's support.
      --Collaborate with WHO, UNICEF, Rotary International, U.N. Foundation
            and the Bill and Melinda Gates Foundation to facilitate World
            Bank financing through its buy-down mechanism for the purchase
            of OPV. In 2010, this mechanism provided $14.1 million to
            Nigeria and $37.3 million to Pakistan. For 2011, Nigeria has
            been approved for $60 million, 1-year credit and Pakistan is
            eligible for a $41 million, 1-year credit.
      --Provide $30.9 million in fiscal year 2010 to WHO for surveillance,
            technical staff and NIDs' operational costs, primarily in
            Africa. As successful NIDs take place, surveillance is critical
            to determine where polio cases continue to occur. Effective
            surveillance can save resources by eliminating the need for
            extensive immunization campaigns if it is determined that polio
            circulation is limited to a specific locale.
      --Train virologists from around the world in advanced poliovirus
            research and public health laboratory support. CDC's Atlanta
            laboratories are a global reference center and training
            facility.
      --Provide, as the leading specialize polio reference lab in the
            world, the largest volume of operational (poliovirus isolation)
            and technologically sophisticated (genetic sequencing of polio
            viruses) lab support to the 145 laboratories of the global
            polio laboratory network.
      --Provide scientific and technical expertise to WHO on research
            issues regarding: (1) laboratory containment of wild poliovirus
            stocks following polio eradication, and (2) when and how to
            stop or modify polio vaccination following global certification
            of polio eradication.
      --Provide critical support for post-polio-eradication planning
            through research, new product development, strategy formulation
            and policy development.
      --Train and deploy public health professionals to improve AFP
            surveillance and to help plan, implement, and evaluate
            vaccination campaigns, communications, etc. through CDC's Stop
            Transmission of Polio (STOP) program. Since 1999, more than
            1,000 STOP team members have participated in 3-month
            assignments in 60 countries, providing 262 person-years of
            support at the national and State levels. In 2010, the STOP
            program deployed 185 professionals to 69 countries.
      --Launch a customized N (national)-STOP initiative in March 2011 in
            collaboration with the Pakistan Ministry of Health, WHO and the
            USAID Mission in Islamabad. Sixteen national epidemiologists
            from CDC's Field Epidemiology Training Program (FETP) were
            trained and deployed to the highest risk districts for
            circulation of wild polio virus in an effort to help improve
            the quality of disease surveillance and immunization activities
            there and to strengthen routine immunization systems.
      --Deploy E (enhanced)-STOP initiative teams to Nigeria, S. Sudan,
            Angola, Chad, and DRC. Those serving in E-STOP are assigned to
            support efforts in strategic areas, are more experienced, and
            serve for a longer durations. As part of E-STOP in 2010, 28
            professionals were deployed to Nigeria, 35 to South Sudan, 7 to
            Angola, 5 to Chad, and 5 to DRC. This initiative was
            facilitated by an expanding partnership with the Organization
            of Islamic Conference (OIC) facilitating outreach to Muslim
            states and the Pan American Health Organization facilitating
            Brazilian and Southern Cone support for Angola. With available
            funding, CDC plans to expand the number of participants in E-
            STOP in 2011.
      --Support global polio eradication by participating in technical
            advisory groups, EPI manager and other key meetings. The CDC
            also published 14 updates on progress toward polio eradication
            in the Morbidity and Mortality Weekly Report (MMWR) and other
            peer-reviewed journals.
                        fiscal year 2012 budget request
        For fiscal year 2012, we respectfully request that this
    subcommittee include $112 million for the targeted polio eradication
    efforts of the Centers for Disease Control and Prevention, the same
    level included in the President's fiscal year 2012 request. The funds
    we are seeking will allow CDC to continue intense supplementary
    immunization activities in Asia and to improve the quality of
    immunization campaigns in Africa to interrupt transmission of polio in
    these regions as quickly as possible. These funds will also help
    maintain certification standard surveillance. This will ensure that we
    protect the substantial investment we have made to protect the children
    of the world from this crippling disease by supporting the necessary
    eradication activities to eliminate polio in its final strongholds--in
    South Asia and sub-Saharan Africa.
        The United States' commitment to polio eradication has stimulated
    other countries to increase their support. Other countries that have
    followed America's lead and made special grants for the global Polio
    Eradication Initiative include the United Kingdom ($900.03 million),
    Japan ($418.65 million), Germany ($390.94 million), and Canada ($289.53
    million). Since 2002, the members of the G8 have committed to provide
    sufficient resources to eradicate polio. G8 member states, many of
    which were already leading donors to the Polio Eradication Initiative,
    have encouraged other donors to provide support, and have emphasized
    the importance of polio eradication when meeting with leaders of polio-
    endemic countries. As a result, the base of donor nations that have
    contributed to the Global Polio Eradication Initiative has expanded to
    include Spain, Sweden, Saudi Arabia, and even contributions from United
    Arab Emirates, Kuwait, Hungary, and Turkey.
        Endemic nations are also providing funds to support polio
    eradication activities. It is noteworthy that India has provided US$692
    million in funding for polio eradication activities there since 2003
    and Nigeria provided approximately US$61.75 million, and Pakistan has
    provided US$50 million.
                         benefits of polio eradication
        Since 1988, over 5 million people who would otherwise have been
    paralyzed will be walking because they have been immunized against
    polio. Tens of thousands of public health workers have been trained to
    manage massive immunization programs and investigate cases of acute
    flaccid paralysis. Cold chain, transport and communications systems for
    immunization have been strengthened. The global network of 145
    laboratories and trained personnel established for polio eradication
    also tracks measles, rubella, yellow fever, meningitis, and other
    deadly infectious diseases and will do so long after polio is
    eradicated. NIDs for polio have also been used to distribute essential
    vitamin A, thereby saving the lives of over 1.25 million children since
    1988.
        A study published in the November 2010 issue of the journal Vaccine
    estimates that the global polio eradication initiative to eradicate
    polio could provide net benefits of at least $40-50 billion if
    transmission of wild polio viruses is stopped within the next 5 years.
    Polio eradication is a cost-effective public health investment, as its
    benefits accrue forever. On the other hand, more than 10 million
    children will be paralyzed in the next 40 years if the world fails to
    capitalize on the more than $8 billion already invested in eradication.
    Success will ensure that the significant investment made by the United
    States, Rotary International, and many other countries and entities, is
    protected in perpetuity.
                                     ______

        Prepared Statement of the Ryan White Medical Providers Coalition
    Introduction
        I am James Raper, a nurse practioner and Director of the 1917 HIV/
    AIDS Outpatient Clinic at the University of Alabama at Birmingham. I am
    submitting written testimony on behalf of the Ryan White Medical
    Providers Coalition.
        Thank you for the opportunity to discuss the important HIV/AIDS
    care conducted at Ryan White Part C funded programs nationwide.
    Specifically, the Ryan White Medical Provider Coalition, the HIV
    Medicine Association, the CAEAR Coalition, and the American Academy of
    HIV Medicine estimate that approximately $407 million is needed to
    provide the standard of care for all Part C program patients. (This
    estimate is based on the current cost of care and the number of
    patients that Part C clinics serve.) Because these are exceptionally
    challenging economic times, we request $272 million for Ryan White Part
    C programs in fiscal year 2012, the amount that Congress authorized for
    Part C programs in its 2009 reauthorization of the Ryan White Program.
        The Ryan White Medical Providers Coalition was formed in 2006 to be
    a voice for medical providers across the Nation delivering quality care
    to their patients through Part C of the Ryan White program. We
    represent every kind of program, from small and rural to large urban
    sites in every region in the country. We speak for those who often
    cannot speak for themselves and we advocate for a full range of primary
    care services for these patients. Sufficient funding for Part C is
    essential to providing appropriate care for individuals living with
    HIV/AIDS.
        Part C of the Ryan White Program funds comprehensive Early
    Intervention Services (EIS) for HIV care and treatment, that are
    directly responsible for the dramatic decreases in AIDS-related
    mortality and morbidity over the last decade. The Centers for Disease
    Control and Prevention estimate that there are more than 1.1 million
    persons living with HIV/AIDS, and approximately 240,000, or almost 1 in
    4, of these individuals received services from Part C medical
    providers--a dramatic 30 percent increase in patients in less than 10
    years.
    The Cost of Care Is Reasonable; The Reimbursement for Care Isn't
        On average it costs $3,501 per person per year to provide the
    comprehensive outpatient care and treatment available at Part C funded
    programs (excluding medication costs), including lab work, STD/TB/
    Hepatitis screening, ob/gyn care, dental care, mental health and
    substance abuse treatment, and case management. Part C funding covers
    only a small percentage of the total cost of this comprehensive care,
    with some programs receiving $450 (12 percent of the total cost) or
    less per patient per year to cover the cost of care.
    Part C Programs Save Both Lives and Money
        Investing in Part C services improves lives and saves money. In the
    United States, nearly 50 percent of persons living with HIV/AIDS who
    are aware of their status are not in continuing care. Early and
    reliable access to HIV care and treatment both helps patients with HIV
    live relatively healthy and productive lives and is more cost
    effective. One study from my Part C Clinic at the University of Alabama
    at Birmingham found that patients treated at the later stages of HIV
    disease required 2.6 times more healthcare dollars than those receiving
    earlier treatment meeting Federal HIV treatment guidelines.
    Patient Loads Are Increasing at an Unsustainable Rate
        Patient loads have been increasing at Part C clinics nationwide,
    despite the fact that there has not been significant new Federal
    funding, and in most cases, State and/or local funding has been cut. A
    steady increase in patients has occurred on account of higher diagnosis
    rates and declining insurance coverage resulting in part from the
    economic downturn. The CDC reports that the number of HIV/AIDS cases
    increased by 15 percent from 2004 to 2007 in 34 States.\1\
    ---------------------------------------------------------------------------
        \1\ Centers for Disease Control and Prevention. HIV/AIDS
    Surveillance Report, 2007. Vol. 19. U.S. Department of Health and Human
    Services, Centers for Disease Control and Prevention; 2009:5.
    www.cdc.gov/hiv/topics/surveillance/resources/reports/.
    ---------------------------------------------------------------------------
        For example, at a clinic in Greensboro, North Carolina, the number
    of patients has more than doubled from 321 patients in 2002 to more
    than 800 in 2009. The clinic continues to deliver care in the same
    space with the same staffing as in 2002 despite the 250 percent
    increase in patients. In Sonoma County, California, funding became so
    scarce that the Part C clinic there closed its doors, and had to patch
    together new medical homes in other locations for 350 patients. In New
    York, when St. Vincent's Hospital in New York City closed, including
    the HIV/AIDS clinic, a Part C clinic at St. Luke's-Roosevelt Hospital
    had to absorb almost the entire St. Vincent's clinic, approximately
    1,000 patients, over the course of just a few days.
        Our patients struggle in times of plenty, and during this economic
    downturn they have relied on Part C programs more than ever. While
    these programs have been under-funded for years, State and local
    economic pressures are creating a crisis in our communities. Clinics
    are discontinuing primary care and other critical medical services,
    such as laboratory monitoring; suffering eviction from their clinic
    locations; operating only 4 days per week; and laying off staff just to
    get by. Years of nearly flat funding combined with large increases in
    the patient population and the recent economic crisis are negatively
    impacting the ability of Part C providers to serve their patients.
        The following graph demonstrates the growing disparity between
    funding for Part C and the increasing patient population. I refer to
    this gap between funding and patients as the ``Triangle of Misery''
    because it represents both the thousands of patients who deserve more
    than we can offer and the Part C programs nationwide that are
    struggling to serve them with shrinking resources.

    Conclusion
        These are challenging economic times, and we recognize the severe
    fiscal constraints Congress faces in allocating limited Federal
    dollars. The significant financial and patient pressures that we face
    in our clinics at home propel us to make this funding request for
    fiscal year 2012 funding of Ryan White Part C programs. This funding
    would help to support medical providers nationwide in delivering
    appropriate and effective HIV/AIDS care to their patients. As the
    survey below of Part C providers nationwside shows, this Federal
    support is urgently needed.
        Thank you for your time and consideration of our request. If you
    have any questions, please do not hesitate to contact me at the 1917
    HIV/AIDS Outpatient Clinic, University of Alabama at Birmingham,
    Birmingham, Alabama 35294-2050, e-mail at jimraper@uab.edu.
     rwmpc survey: budgetary constraints continue to drive cutbacks in hiv
                                      care
        In January 2011, the Ryan White Medical Providers Coalition, which
    represents Ryan White Part C programs nationwide that provide
    comprehensive HIV medical care and treatment, asked members to indicate
    their top three concerns as well as their frontline experiences
    providing HIV care and treatment in the current, constrained economic
    environement. The results of the brief survey included:
      --The top three concerns (in order of importance):
        --Funding cuts/shortfalls
        --Sustaining the Ryan White Program and Part C programs and
                preparing for health reform
        --Clinic management issues, including:
          -- HIV medical workforce recruitment and retention
          -- Access to medications for patients (including the amount of
                work that clinics are doing to secure this access now that
                the ADAP crisis has worsened)
          -- Increasing patient loads and the fact that clinics are
                reaching the limits of what they can do within their
                current financial and workforce resources.
      --For those who are worried about funding cuts and shortfalls, 57
            percent are worried about cuts to Federal funds.
      --More than 56 percent of respondents have made cuts or changes to
            their programs because of funding cuts or shortfalls (both
            state and Federal).
      --The types of cuts or changes that have been made include:
        --More than 32 percent of clinics have either reduced or cut the
                services they provide.
        --21.5 percent have either frozen their hiring or laid off staff
        --13.5 percent have reduced coverage for lab monitoring
        These survey results indicate the need to support and increase the
    investment in Part C programs, a valuable, effective and cost efficient
    resource that provides medical homes to tens of thousands of persons
    with HIV nationwide. Unless Part C programs receive additional funding,
    more services and infrastructure will be lost during this critical time
    period before the implementation of healthcare reform in 2014. Loss of
    such resources and infrastructure would reduce the availability of
    quality HIV care and treatment at just the time when the National HIV/
    AIDS Strategy is hoping to increase access to these life-saving
    services.
                                     ______

                Prepared Statement of the Scleroderma Foundation
                fiscal year 2012 appropriations recommendations
        Funding for the National Institutes of Health (NIH) at a level of
    $35 million.
        An increase for the National Institute of Arthritis and
    Musculoskeletal and Skin Diseases (NIAMS) concurrent with the overall
    increase to NIH.
        Committee recommendation encouraging the Centers for Disease
    Control and Prevention to partner with the Scleroderma Foundation in
    promoting increased awareness of scleroderma among the general public
    and healthcare providers.
        Mr. Chairman, I am Cynthia Cervantes, I am 12 and in the ninth
    grade. I live in Southern California and in October 2006 I was
    diagnosed with scleroderma. Scleroderma means ``hard skin'' which is
    literally what scleroderma does and, in my case, also causes my
    internal organs to stiffen and contract. This is called diffuse
    scleroderma. It is a relatively rare disorder effecting only about
    300,000 Americans.
        About 2 years ago I began to experience sudden episodes of
    weakness, my body would ache and my vision was worsening, some days it
    was so bad I could barely get myself out of bed. I was taken to see a
    doctor after my feet became so swollen that calcium began to ooze out.
    It took the doctors (period of time) to figure out exactly what was
    wrong with me, because of how rare scleroderma is.
        There is no known cause for scleroderma, which affects three times
    as many women as men. Generally, women are diagnosed between the ages
    of 25 and 55, but some kids, like me, are affected earlier in life.
    There is no cure for scleroderma, but it is often treated with skin
    softening agents, anti-inflammatory medication, and exposure to heat.
    Sometimes a feeding tube must be used with a scleroderma patient
    because their internal organs contract to a point where they have
    extreme difficulty digesting food.
        The Scleroderma Foundation has been very helpful to me and my
    family. They have provided us with materials to educate my teachers and
    others about my disease. Also, the support groups the foundation helps
    organize are very helpful because they help show me that I can live a
    normal, healthy life, and how to approach those who are curious about
    why I wear gloves, even in hot weather. It really means a lot to me to
    be able to interact with other people in the same situation as me
    because it helps me feel less alone.
        Mr. Chairman, because the causes of scleroderma are currently
    unknown and the disease is so rare, and we have a great deal to learn
    about it in order to be able to effectively treat it. I would like to
    ask you to please significantly increase funding for the National
    Institute of Health so treatments can be found for other people like me
    who suffer from scleroderma. It would also be helpful to start a
    program at the Centers for Disease Control and Prevention to educate
    the public and physicians about scleroderma.
                     overview of the scleroderma foundation
        The Scleroderma Foundation is a nonprofit organization based in
    Danvers, Massachusetts with a three-fold mission: support, education,
    and research. The Foundation provides support for people living with
    scleroderma and their families through programs such as peer
    counseling, doctor referrals, and educational information, along with a
    toll-free telephone helpline for patients.
        The Foundation also provides education about the disease to
    patients, families, the medical community, and the general public
    through a variety of awareness programs at both the local and national
    levels. Over $1 million in peer-reviewed research grants are awarded
    annually to institutes and universities to stimulate progress in the
    search for a cause and cure for scleroderma.
                             who gets scleroderma?
        There are many clues that define the susceptibility to develop
    scleroderma. A genetic basis for the disease has been suggested by the
    fact that it is more common among patients whose family members have
    other autoimmune diseases (such as lupus). In rare cases, scleroderma
    runs in families, although for the vast majority of patients there is
    no other family member affected. Some Native Americans and African
    Americans suffer a more severe form of the disease Caucasians. Women
    between the ages of 25-55 are more likely to develop scleroderma.
                             causes of scleroderma
        The cause of scleroderma is unknown. However, we do understand a
    great deal about the biological processes involved. In localized
    scleroderma, the underlying problem is the overproduction of collagen
    (scar tissue) in the involved areas of skin. In systemic sclerosis,
    there are three processes at work: blood vessel abnormalities, fibrosis
    (which is overproduction of collagen) and immune system dysfunction, or
    autoimmunity.
                                    research
        Unfortunately, support for scleroderma research at the National
    Institutes of Health over the past several years has been flat funded
    at $19 million since fiscal year 2009, and is again estimated at $19
    million for fiscal year 2012. This absence of increase is extremely
    frustrating to our patients who recognize biomedical research as their
    best hope for a better quality of life. It is also of great concern to
    our researchers who have promising ideas they would like to explore if
    resources were available.
                              types of scleroderma
        There are two main forms of scleroderma: systemic (systemic
    sclerosis, SSc) that usually affects the internal organs or internal
    systems of the body as well as the skin, and localized that affects a
    local area of skin either in patches (morphea) or in a line down an arm
    or leg (linear scleroderma), or as a line down the forehead
    (scleroderma en coup de sabre). It is very unusual for localized
    scleroderma to develop into the systemic form.
    Systemic Sclerosis (SSc)
        There are two major types of systemic sclerosis or SSc: limited
    cutaneous SSc and diffuse cutaneous SSc. In limited SSc, skin
    thickening only involves the hands and forearms, lower legs and feet.
    In diffuse cutaneous disease, the hands, forearms, the upper arms,
    thighs, or trunk are affected.
        People with the diffuse form of SSc are at risk of developing
    pulmonary fibrosis (scar tissue in the lungs that interferes with
    breathing, also called interstitial lung disease), kidney disease, and
    bowel disease. The risk of extensive gut involvement, with slowing of
    the movement or motility of the stomach and bowel, is higher in those
    with diffuse rather than limited SSc. Symptoms include feeling bloated
    after eating, diarrhea or alternating diarrhea and constipation.
        Pulmonary Hypertension (PH) is high blood pressure in the blood
    vessels of the lungs. It is totally independent of the usual blood
    pressure that is taken in the arm. This tends to develop in patients
    with limited SSc after several years of disease. The most common
    symptom is shortness of breath on exertion. However, several tests need
    to be done to determine if PH is the real culprit. There are now many
    medications to treat PH.
    Localized Scleroderma
                Morphea
        Morphea consists of patches of thickened skin that can vary from
    half an inch to 6 inches or more in diameter. The patches can be
    lighter or darker than the surrounding skin and thus tend to stand out.
    Morphea, as well as the other forms of localized scleroderma, does not
    affect internal organs.
                Linear scleroderma
        Linear scleroderma consists of a line of thickened skin down an arm
    or leg on one side. The fatty layer under the skin can be lost, so the
    affected limb is thinner than the other one. In growing children, the
    affected arm or leg can be shorter than the other.
                Scleroderma en coup de sabre
        Scleroderma en coup de sabre is a form of linear scleroderma in
    which the line of skin thickening occurs on the forehead or elsewhere
    on the face. In growing children, both linear scleroderma and en coup
    de sabre can result in distortion of the growing limb or lack of
    symmetry of both sides of the face.
                                     ______

               Prepared Statement of Senior Service America, Inc.
        We urge the subcommittee to restore funding for the Senior
    Community Service Employment Program (SCSEP), currently administered by
    the Department of Labor, to no less than $600 million for fiscal year
    2012. would return funding for this proven and unique Federal
    employment and training program to pre-ARRA levels.
        SCSEP is the only Federal program targeted at assisting low income
    workers over the age of 55 either regain employment or provide minimum
    wage employment through community service in communities across the
    Nation. A restoration of funding for SCSEP to $600 million would
    provide community service employment to an additional 24,000 unemployed
    and low-income older workers and at least 7 million lost staffing hours
    in participants' community service to local government agencies and
    nonprofit organizations meeting basic human needs.
        We estimate that the public return on investment is more than
    double its appropriations level. The value of the community service by
    SCSEP participants would exceed $900 million. In addition to the value
    of the this service, SCSEP produces savings to the Federal Government
    by helping many thousands of vulnerable older adults to avoid becoming
    totally dependent on government transfer payments, including Medicaid,
    Supplemental Security Income, and early receipt of Social Security
    benefits.
        SCSEP's severe cut in fiscal year 2011 will have devastating impact
    on older workers and communities.--Restoring funding in fiscal year
    2012 would lessen the impact of the 45 percent reduction in SCSEP as a
    result of the fiscal year 2011 year-long Continuing Resolution, The cut
    of $375 million from fiscal year 2010 is larger than the WIA core
    funding cut. As a result, during the year starting July 1, 2011, nearly
    50,000 fewer jobless older adults will be employed and almost 35
    million staff hours will be lost by over 30,000 local agencies and
    programs throughout the 50 States. Using tables from the Independent
    Sector, the value of these lost SCSEP community service hours exceeds
    $740 million.
        SCSEP currently supports a wide range of community services and
    local government programs. For example, in 2011 over 1,100 public
    libraries (at least one in every State, most in rural areas) employed
    at least one SCSEP participant in a variety of library-related
    assignments. About one-fourth of all SCSEP community service hours are
    performed in service to other older adults, such as senior centers,
    nutrition, Meals on Wheels, and adult day care centers.
        SCSEP is a unique Federal workforce development program.--According
    to a January 2011 GAO report on multiple employment and training
    programs, SCSEP is one of only three Federal workforce development
    programs that do not overlap with any other program. Since 1998, it is
    the only Federal program targeted to assist older adults return to the
    workforce and serves almost twice the number of adults 55 and over who
    receive training under WIA. Previous research by GAO and others have
    documented that WIA has consistently underserved older jobseekers.
        Older adults, especially those eligible for SCSEP, continue to
    suffer in the current economy. Older workers have been described as the
    ``new unemployables'' in a recent report by Rutgers University. The
    current jobless rate for all older workers continues to be lower than
    the rate for all workers, but in 2010 the unemployment rate of older
    adults 55-74 years of age eligible for SCSEP was 23 percent, more than
    three times the national average for all adult workers. Among displaced
    workers 55 and older, the reemployment rate was only 38 percent, the
    lowest of any age group, with those from lower income households and
    with less than a college education faring the worst. Finally, the
    average duration of unemployment among adults 55 and over continued to
    increase in April 2011 to 53.6 weeks, with more than half of all older
    jobseekers out of work for 27 or more weeks, also an increase from the
    prior month. (More information is available from AARP and Senior
    Service America websites.)
        The job market is not likely to improve significantly for most of
    these low-income and disadvantaged older job seekers in the foreseeable
    future. Too many will remain out of work and be forced to sustain
    themselves by becoming totally reliant on government transfers such as
    Medicaid, Supplemental Security Income, and early receipt of Social
    Security income benefits. Many will be highly unlikely to return to the
    labor force. Restoring SCSEP appropriations to pre-ARRA levels is a
    wise investment in a program of demonstrated effectiveness operated by
    a network of proven performers.
        DOL's SCSEP grantee network consistently achieves its performance
    measures.--According to official statistics, in PY2009 the aggregate
    performance of the 18 national grantees and 56 State and territorial
    grantees achieved 98 percent or more of each of the common performance
    measures established for the program by DOL. For example, the grantee
    network achieved a 46.2 percent Entered Employment Rate (compared to
    the goal of 47 percent established by DOL); 70 percent Retention (68
    percent goal); and $6,900 6 month earnings ($6,229 goal). For
    comparison, the Entered Employment Rate achieved was 48.1 percent in
    PY2008 and 52.4 percent in PY2007.
        In addition, ratings by SCSEP participants and participating host
    agencies using the American Customer Satisfaction Index have been
    consistently higher for SCSEP than for WIA. In PY2009, participants
    gave SCSEP an ACSI score of 82.7 and host agencies gave a score of
    81.3. Additional information from these independent national surveys:
    SCSEP Participants (number of respondents=24,358)
        ACSI score of 82.7 (about the same as prior year's score)
        Nearly 92 percent of respondents reported that, compared to the
    time before they entered SCSEP, their physical health is the same or
    better, 73 percent reported that their outlook on life is a little more
    positive or much more positive.
        Participants were in moderate to strong agreement (7.9 on a scale
    of 1 to 10) with the statement that their community service wages have
    made a substantial improvement in their quality of life.
    SCSEP Host Agencies (number of respondents=10,567)
        ACSI score of 81.3 (nearly identical to prior year's score)
        75 percent indicated that participation in SCSEP increased their
    ability to provide services to the community either ``somewhat'' or
    ``significantly.''
        The impact of the fiscal year 2011 cuts to SCSEP will be felt in
    every State. For example:
        Impact on Iowa: Loss of nearly $5 million in SCSEP funding and over
    $7 million in services.
        During fiscal year 2010, about 490 local programs in 153 Iowa towns
    and cities hosted at least one SCSEP participant, including: 171 local
    and State government agencies; 71 programs serving older adults,
    including at least 20 senior centers; 36 schools and post-secondary
    institutions; 31 workforce development offices; 24 public libraries and
    11 museums; and 10 community action agencies.

    ----------------------------------------------------------------------------------------------------------------
                                                                 Current fiscal     Final fiscal
                                                                    year 2010         year 2011          Impact
                                                                 appropriations     funding level
    ----------------------------------------------------------------------------------------------------------------
    Funding Allocation for Iowa (all SCSEP grantees)..........     $10.5 million      $5.6 million     -$4.9 million
    Number of Participants in Paid Community Service               1,520 persons       880 persons      -640 persons
     Employment in Iowa.......................................
    Number of SCSEP Hours Serving Iowa Communities............     944,700 hours     507,700 hours    -437,000 hours
    Value of SCSEP Hours Serving Iowa Communities @$16.77/hour     $15.8 million      $8.5 million     -$7.3 million
     (www.independentsector.org/volunteer_time)...............
    ----------------------------------------------------------------------------------------------------------------

        The U.S. Department of Labor awards SCSEP funding for Iowa to the
    AARP Foundation, Experience Works, Senior Service America, Inc., and
    the Iowa Dept. on Aging. Local agencies in Iowa that operate SCSEP are
    Community Action Agency of Siouxland, Generations Area Agency on Aging,
    Hawkeye Area Community Action Program, and West Central Community
    Action.
        Impact on Alabama: A loss of $6.4 million in SCSEP funding and $10
    million in services.
        During fiscal year 2010, more than 600 local government and
    nonprofit programs hosted at least one SCSEP participant, including:
      --Nearly 300 local government agencies and programs, including 35
            libraries and 31 senior centers, and
      --More than 220 nonprofit organizations, including the American Red
            Cross, Boys and Girls Clubs, and Chambers of Commerce.
        Starting July 1, 2011, the fiscal year 2011 cut in SCSEP funding
    will mean over 800 fewer job opportunities and 568,000 fewer community
    service hours to Alabama agencies (valued at least $10 million,
    according to tables provided by the Independent Sector).

    ----------------------------------------------------------------------------------------------------------------
                                                                 Current fiscal     Final fiscal
                                                                    year 2010         year 2011          Impact
                                                                 appropriations     funding level
    ----------------------------------------------------------------------------------------------------------------
    Funding Allocation for Alabama (all SCSEP grantees).......     $14.5 million      $8.1 million     -$6.4 million
    Number of Participants in Paid Community Service               2,090 persons     1,280 persons      -810 persons
     Employment in Alabama....................................
    Number of SCSEP Hours Serving Alabama Communities.........    1,302,000 hrs.      734,000 hrs.     -568,000 hrs.
    Value of SCSEP Hours Serving Iowa Communities @$17.70/hour       $23 million       $13 million      -$10 million
     (www.independentsector.org/volunteer_time)...............
    ----------------------------------------------------------------------------------------------------------------

        The U.S. Department of Labor provides SCSEP funding to the Alabama
    Department of Senior Services, Easter Seals, and Senior Service
    America, Inc.
        The following local government agencies in Alabama receive SCSEP
    funding: Alabama-Tombigbee Regional Commission, East Alabama Regional
    Planning and Development Commission, Jefferson County Commission,
    Middle Alabama Area Agency on Aging, North-central Alabama Regional
    Council of Governments, Northwest Alabama Council of Local Governments,
    South Central Alabama Development Commission, Southeast Alabama
    Regional Planning and Development Commission, Top of Alabama Regional
    Council of Governments, and West Alabama Regional Commission.
    Summary
        We recognize that these are challenging times for the Subcommittee
    and difficult funding decisions must be made. A partial restoration of
    SCSEP funding to $600 million will ensure that an additional 24,000 of
    the hardest to reemploy, low income older workers will be able to
    provide an additional 7 million hours in service to communities across
    the Nation, with a return on investment double the appropriations
    provided to SCSEP. Thank you for considering this funding request.
    About Senior Service America, Inc.
        Senior Service America, Inc. (SSAI) has been awarded a national
    SCSEP grant from DOL since 1968, including competitive grants in 2003
    and 2006. As the third largest national grantee, SSAI operates SCSEP
    exclusively through subgrants to 81 local organizations that serve 430
    counties in 16 States. Its diverse network of subgrantees includes 25
    area agencies on aging, 11 community action agencies, 10 regional
    councils of government, 13 workforce development agencies, eight faith-
    based organizations, two community colleges, and one local United Way.
        For more information, please visit www.seniorserviceamerica.org. or
    contact Tony Sarmiento, Executive Director, at 301-578-8469,
    tsarmiento@ssa-i.org,
                                     ______

      Prepared Statement of the Sickle Cell Disease Association of America
        Mr. Chairman and distinguished Members of the Subcommittee, my name
    is Sonja L. Banks. I was recently elected President and Chief Operating
    Officer of the Sickle Cell Disease Association of America, Inc (SCDAA).
    Since 1971, SCDAA has served as the Nation's only volunteer
    organization working full time on a national level to resolve issues
    surrounding sickle cell disease. We have grown to approximately 55
    community-based member organizations focused on serving the needs of
    individuals with Sickle Cell Disease or Sickle Cell Trait, their
    families, and over 300 communities nationwide and in Canada.
        On behalf of the organization, I am honored to submit this
    testimony to your Subcommittee as a public witness in conjunction with
    your consideration of fiscal year 2012 Appropriations legislation.
        SCDAA respectfully urges the Subcommittee to support President
    Obama's continuation of funding for the Sickle Cell Anemia
    Demonstration Program, and the Registry and Surveillance System for
    Hemoglobinopathy and Hemoglobinopathy Program Initiative. We also urge
    the Subcommittee to restore funding to the Sickle Cell Disease and
    Newborn Screening Program, a crucial program to fulfilling Secretary
    Kathleen Sebelius' charge to the Department of Health and Human
    Services (HHS) to make SCD a priority area of focus.
        SCD is an inherited blood disorder that is a major problem in the
    United States. An estimated 72,000 Americans live with the disease.
    More than 2.5 million Americans have the Sickle Cell Trait (SCT),
    including 1 in 12 African Americans. The average life span of an adult
    with SCD is only 45 years.
        Common complications include early childhood death from infection,
    stroke in young children and adults, infection of the lungs similar to
    pneumonia, pulmonary hypertension, chronic damage to organs such as the
    kidney resulting in chronic kidney failure, and frequent severe painful
    episodes. These unpredictable, intermittent, devastating pain events
    can begin as early as six months of age and can span a lifetime,
    impacting school and work attendance.
        As the Nation addresses issues associated with healthcare reform, a
    real and rare opportunity exists to support, a population in dire need
    of treatment and care through innovative research and improved care.
        First, we respectfully request that the Subcommittee provide
    $4,740,000 for the Sickle Cell Anemia Demonstration Program and Data
    Coordination Center. In fiscal year 2011, the Program received an
    appropriation of $4,750,000, and for fiscal year 2012 the President's
    budget recommends $4,740,000. Funding this national program will
    improve the lives of SCD patients through disease management programs
    to help them live longer, healthier lives while supporting research
    toward a comprehensive cure and providing community education about
    this disease and its treatment options.
        Second, we respectfully request that the Subcommittee include
    $20,165,000 for the Public Health Approach to Blood Disorders Program.
    The President's fiscal year 2012 budget request consolidates existing
    budget sub-lines into one line called ``Public Health Approach to Blood
    Disorders.'' As part of this coordinated effort, a Hemoglobinopathy
    Data Center will operate surveillance and registry program entitled
    RuSH (Registry and Surveillance System for Hemoglobinopathies) in seven
    States for 2 years.
        The RuSH health data systems will provide researchers, policy
    makers, and the public with imperative information about SCD and SCD-
    related diseases that is currently unavailable. The lack of this type
    of data system for Sickle-Cell-related diseases limits the research and
    treatment communities' ability to fully understand the impact of the
    disease and to develop healthcare planning at the local, State, and
    national levels. Additionally, funding also will support a multi-agency
    collaboration to form an HHS Hemoglobinopathy Program Initiative to
    offer more effective care and lower societal and medical costs for
    individuals affected by blood disorders such as SCD.
        Finally, we respectfully request that the Subcommittee restore
    $3,774,000 for the Sickle Cell Disease and Newborn Screening Program
    (SCD-NBS). Unfortunately, the President has proposed to eliminate this
    program in fiscal year 2012. On the other hand, Secretary Sebelius has
    launched an SCD initiative aimed at increasing access to and improving
    care. We believe that continuing the SCD-NBS program is critical to the
    initiative's goal, and invaluable to families and individuals suffering
    from this debilitating disease.
        The SCD-NBS Program provides a continuity of medical services,
    education and counseling from birth to adulthood for persons afflicted
    with Sickle Cell Disease and Sickle Cell Trait. Since 2002, the project
    has supported a National Coordinating and Evaluation Center and 17
    community-based demonstration sites across the country. Because of
    changes in the eligibility requirements for demonstration sites due
    next month, we also ask that report language be included in the fiscal
    year 2012 Subcommittee bill to direct the Program's funding to
    community-based or faith-based organizations involved with Sickle Cell
    Disease.
        Thank you for considering these requests. We look forward to
    working with the Senate Appropriations Subcommittee on Labor, Health,
    and Education to fund these three critical programs that will help
    African Americans and other historically underserved children and
    families with Sickle Cell Disease live longer and healthier lives.
                                     ______

         Prepared Statement of the Society for Maternal-Fetal Medicine
        Mr. Chairman and Members of the Committee: The Society for
    Maternal-Fetal Medicine is pleased to have the opportunity to submit
    testimony on behalf of the fiscal year 2012 budget for the Eunice
    Kennedy Shriver National Institute of Child Health and Human
    Development (NICHD). We urge the Committee, as you move forward with
    your deliberations on the fiscal year 2012 budget for the National
    Institutes of Health (NIH), to keep in mind the enormous lost
    opportunities that the NIH, and in particular the NICHD, will
    experience if the level of funding is not sustained.
        Established in 1977, the Society for Maternal-Fetal Medicine (SMFM)
    is dedicated to improving maternal and child outcomes; and raising the
    standards of prevention, diagnosis, and treatment of maternal and fetal
    disease.
        Maternal-fetal medicine specialists, also known as MFM specialists,
    perinatologists, and high-risk pregnancy physicians, are highly trained
    obstetrician/gynecologists with advanced expertise in obstetric,
    medical, and surgical complications of pregnancy and their effects on
    the mother and fetus.
        The most common medical illnesses managed by MFM's include
    hypertension, diabetes, seizure disorders, autoimmune diseases, and
    blood clotting disorders. We also provide care for women who are at
    increased risk for preterm birth, including multiple gestations, women
    with cervical insufficiency who may require a surgery to prevent
    preterm birth, and women with placental problems such as bleeding from
    premature separation. In addition, MFM specialists are often
    responsible for the management of preterm labor, premature rupture of
    membranes, and other complications during labor that have the potential
    to impact newborn and long-term infant outcomes.
        The special problems faced by these mothers may lead to death,
    short-term or in some cases life-long problems for their babies. For
    example:
      --Pre-term birth (birth before the fetus is at 37 weeks'
            gestation).--Over half a million children are born preterm each
            year. Preterm infants are at high risk for a variety of
            disorders, including mental retardation, cerebral palsy, and
            vision impairment. These infants are also at risk for long-term
            health issues, including cardiovascular disease (heart attack,
            stroke, and high blood pressure) and diabetes. The annual cost
            to society (medical, educational, and lost productivity) of
            preterm birth is at least $26 billion (in 2005 dollars).
      --Hypertension.--High blood pressure during pregnancy endangers the
            health of both the mother and the baby and is increasingly
            common as women delay pregnancy until they are older, and as
            they are more frequently overweight. Chronic hypertension
            complicating pregnancy is associated with a risk of fetal
            growth restriction and a risk of preterm birth. Hypertension in
            pregnancy is also the second leading cause of maternal death in
            the United States.
      --Diabetes.--The hormonal changes of pregnancy often bring about a
            diabetic state (gestational diabetes) in predisposed women or
            can seriously worsen preexisting diabetes. Whether diabetes
            mellitus existed before conception or gestational diabetes
            develops during pregnancy, maternal glucose intolerance can
            have significant medical consequences. Poorly controlled
            diabetes is associated with miscarriage, congenital
            malformations, abnormal fetal growth, stillbirth, obstructed
            labor, increased cesarean delivery, and neonatal complications.
        NICHD's commitment to basic, clinical and translational research
    has lead to new ways to treat and improve the health of pregnant women
    and infants. One of the most successful approaches for testing research
    questions is the NICHD Maternal-Fetal Medicine Units (MFMU) Network
    which allows researchers from across the country to coordinate clinical
    studies to improve maternal, fetal and neonatal health. The studies to
    date have not only identified new therapies and evaluated technologies
    used in maternal fetal medicine, but also have helped to abolish
    practices that are not useful.
      --Researchers supported through the MFMU were responsible for the
            groundbreaking finding related to preterm birth and
            progesterone. Following a series of studies in the 1970s and
            1980s, a national clinical trial showed that progesterone
            treatment resulted in a substantial reduction in the rate of
            preterm delivery among women who had a previous preterm birth,
            reduced the risk of newborn complications, and was effective in
            both African American and Non-African American women. This
            preventive therapy has been translated into practice. The drug
            was widely available through compounding pharmacies at a cost
            of $15-$30 per injection or $300 for a 20 week treatment
            course. However, in February 2011 the FDA granted KV
            Pharmaceutical orphan status for its drug named Makena, a
            manufactured version of the identical compound drug. After
            which, KV Pharmaceutical increased the price of the drug to
            $1,500 per injection, and later reduced it to $690 per
            injection. (SMFM is actively engaged in efforts to ensure that
            this medication is accessible and affordable to every pregnant
            woman who is at risk for recurrent preterm birth.)
      --Until recently, there was no evidence to show whether treating the
            mild form of gestational diabetes benefited or posed risks for
            mothers and infants. A recent Network study found women who
            were treated for mild gestational diabetes were half as likely
            to have an unusually large baby, and their babies were half as
            likely to experience shoulder dystocia, an emergency condition
            in which the baby's shoulder becomes lodged inside the mother's
            body during birth. Treated women in the study also had fewer
            caesarean deliveries. In addition, they had fewer problems with
            hypertension and preeclampsia, a life-threatening complication
            of pregnancy that can lead to maternal seizures and death.
            Research supported by the MFMU provided the first conclusive
            evidence that treating pregnant women who have even the mildest
            form of gestational diabetes can reduce the risk of common
            birth complications among infants, as well as blood pressure
            disorders among mothers. These findings will change clinical
            practice.
      --Recent research conducted by the network found that antenatal
            magnesium sulfate, when administered to women at risk of
            delivering preterm, reduces the risk of cerebral palsy in
            surviving preterm infants by 45 percent. This finding has been
            translated into clinical practice.
          Cerebral palsy refers to a group of neurological disorders
            affecting control of movement and posture and which limit
            activity. The brain may be injured or develop abnormally during
            pregnancy, birth or in early childhood. The causes of cerebral
            palsy are not well understood. Both economically and
            emotionally, the burden of cerebral palsy is enormous. The
            Centers for Disease Control and Prevention (CDC) estimates the
            lifetime costs including direct medical, direct non-medical,
            and indirect for all people born with cerebral palsy in 2000 to
            be $11.5 billion (in 2003 dollars).
        Research that disproves a current therapy or treatment can also
    provide valuable guidance to clinicians and their patients.
      --Translational research in the 1990s found that the use of
            corticosteroids in pregnancies at risk of preterm birth
            improved the outcomes for infants born preterm, reducing rates
            of breathing problems, bleeding into the brain, and problems
            with the intestines. However, NICHD sponsored research that
            evaluated the use of repeated doses of corticosteroids found
            that repeated doses resulted in smaller birth weights and head
            circumstances. Researchers also found a concerning increase in
            cerebral palsy in children who were exposed to four or more
            courses of corticosteroids. This study, along with an NIH
            Consensus Development Conference to pull together all available
            data, stopped the routine use of repeated courses of antenatal
            corticosteroids.
        NICHD is at the forefront of several novel and important research
    areas, but there are still many areas about maternal health, pregnancy,
    fetal well-being, labor and delivery and the developing child that are
    not close to being understood. The challenges of the NICHD to
    investigate these problems remain. For example:
      --Preterm Birth and Stillbirth.--Preterm birth and stillbirth
            represent two of the most important complications of pregnancy.
            Prevention of preterm birth and stillbirth depends on
            identifying women at risk and understanding the mechanisms of
            disease. It is imperative that NICHD take advantage of high
            throughput technologies to understand the causes of preterm
            birth and stillbirth and support genomics, proteomics, and
            metabolomics studies focusing on prediction and prevention of
            preterm birth and stillbirth, as well as the use of existing
            biobanks. The promise of these new technologies is that a
            better understanding of the biologic processes involved in
            pregnancy and pregnancy complications will lead to improved
            prediction, prevention, and treatment strategies that will
            improve maternal and infant health.
      --Severe, Early Adverse Pregnancy Outcomes.--Women with severe, early
            adverse pregnancy outcome, such as multiple losses, demises,
            and severe preeclampsia, are at increased risk for long-term
            chronic health problems, including hypertension, stroke,
            diabetes, and obesity. Studies have shown that women who have
            had preeclampsia are more likely to develop chronic
            hypertension, to die from cardiovascular disease and to require
            cardiac surgery later in life. In addition, approximately 50
            percent of women with gestational diabetes will develop
            diabetes later in life. Studies to identify women at risk for
            long term morbidity, and to develop strategies to prevent long
            term adverse outcomes in these women are urgently needed.
      --Maternal Fetal Medicine Units Network.--Vigorous support of the
            MFMU Network is needed so that therapies and preventive
            strategies that have significant impact on the health of
            mothers and their babies will not be delayed. Until new options
            are created for identifying those at risk and developing cause
            specific interventions, preterm birth will remain one of the
            most pressing problems in obstetrics.
        SMFM applauds NICHD efforts to move forward with the development of
    a scientific vision process for the Institute that will set an
    ambitious agenda and inspire the Institute, the research community, and
    its many partners to achieve critical scientific goals and meet
    pressing public health needs.
        Mr. Chairman, we understand the budgetary constraints that are
    facing the Congress, but as providers of care for women with high-risk
    pregnancies we have seen emerging technologies that have provided
    greater opportunity to evaluate and treat the complicated problems
    involving the mother and fetus. Without a sustained investment in the
    critical medical research being conducted by the National Institutes of
    Health, and the National Institute of Child Health and Human
    Development in particular, the health of pregnant women and their
    babies will be at risk and NICHD's mission of promoting healthy
    development throughout the lifespan will be hindered.
    Recommendation
        The Society for Maternal-Fetal Medicine joins with the Ad Hoc Group
    for Medical Research in urging the Committee to provide an
    appropriation of $35 billion in fiscal year 2012 for the National
    Institutes of Health.
        The Society joins with the Friends of the National Institute of
    Child Health and Human Development in support of a fiscal year 2012
    budget of $1.352 billion for the National Institute of Child Health and
    Human Development.
        Thank you for the opportunity to submit our concerns to the
    Committee.
                                     ______

               Prepared Statement of the Society for Neuroscience
    Introduction
        Mr. Chairman and Members of the Subcommittee, my name is Susan
    Amara, Ph.D. I am the Thomas Detre Professor of Neuroscience and Chair
    of the Department of Neurobiology as well as Co-Director of the Center
    for Neuroscience at the University of Pittsburgh and President of the
    Society for Neuroscience. My major research efforts have been focused
    on the structure, physiology, and pharmacology of a group of proteins
    in the brain that are the primary targets for addictive drugs including
    cocaine and amphetamines, for the class of therapeutic antidepressants,
    known as reuptake inhibitors, and for methylphenidate, which is used to
    treat attention deficit hyperactivity disorders.
        On behalf of the more than 41,000 members of the Society for
    Neuroscience (SfN) and myself, I would like to thank you for your past
    support of neuroscience research at the National Institutes of Health
    (NIH). Over the past century, researchers have made tremendous progress
    in understanding cell biology, physiology, and chemistry of the brain.
    Research funded by NIH has made it possible to make advances in brain
    development, imaging, genomics, circuit function, computational
    neuroscience, neural engineering and many other disciplines. In this
    testimony, I will highlight how these advances have benefited taxpayers
    and why we should continue to strengthen this investment, even as the
    Nation makes difficult budget choices.
    Fiscal Year 2012 Budget Request
        The Society respectfully requests that Congress provide a fiscal
    year 2012 appropriation in the amount of $35 billion for NIH. This
    level of funding will enable the field to serve the long-term needs of
    the Nation by continuing to improve health for the benefit of the
    American people and the world, advance science, and promote America's
    near-term and long-range economic strength. This level will build on
    the research activities supported under prior year appropriations,
    enabling neuroscience-related NIH institutions to aggressively fund
    strategic plans that will significantly advance the understanding of
    the brain and the nervous system. In so doing, these investments will
    contribute to economic growth in hundreds of communities nationwide, as
    more than 83 percent of NIH funding is distributed to more than 3,000
    institutions in communities in every State. Moreover, it will help
    preserve and expand America's role as leader in biomedical research,
    which fosters a wide range of private enterprises in the
    pharmaceutical, biotechnology, medical device, hospitality industries
    as well as many others.
        SfN hopes that such an appropriation will be the first step on the
    path to providing a consistent and reliable long-term investment in the
    NIH and in particular the field neuroscience. This will ensure that
    there is not a dramatic drop in research activity or a loss of jobs,
    and serve as an inducement to keeping our young researchers in the
    training pipeline.
    What is the Society for Neuroscience
        SfN is a nonprofit membership organization of basic scientists and
    physicians who study the brain and nervous system. The SfN mission is
    to:
      --Advance the understanding of the brain and the nervous system by
            bringing together scientists of diverse backgrounds, by
            facilitating the integration of research directed at all levels
            of biological organization, and by encouraging translational
            research and the application of new scientific knowledge to
            develop improved disease treatments and cures.
      --Provide professional development activities, information and
            educational resources for neuroscientists at all stages of
            their careers, including undergraduates, graduates, and
            postdoctoral fellows, and increase participation of scientists
            from a diversity of cultural and ethnic backgrounds.
      --Promote public information and general education about the nature
            of scientific discovery and the results and implications of the
            latest neuroscience research. Support active and continuing
            discussions on ethical issues relating to the conduct and
            outcomes of neuroscience research.
      --Inform legislators and other policymakers about new scientific
            knowledge and recent developments in neuroscience research and
            their implications for public policy, societal benefit, and
            continued scientific progress.
    What is Neuroscience?
        Neuroscience is the study of the nervous system. It advances the
    understanding of human function on every level: movement, thought,
    emotion, behavior, and much more. Neuroscientists use tools ranging
    from computers to special dyes to examine molecules, nerve cells,
    networks, brain system, and behavior. From these studies, they learn
    how the nervous system develops and functions normally and what goes
    wrong in neurological and psychiatric disorders.
        Neuroscience is now a unified field that integrates biology,
    chemistry, and physics with studies of structure, physiology, and
    behavior, including human emotional and cognitive functions.
    Neuroscience research includes genes and other molecules that are the
    basis for the nervous system, individual neurons, and ensembles of
    neurons that make up systems and behavior. Through their research,
    neuroscientists work to demonstrate normal functions of the brain and
    determine how the nervous system develops, matures, and maintains
    itself through life. They seek to prevent or cure many devastating
    neurological and psychiatric disorders.
        As the committee works to set funding levels for critical research
    initiatives for fiscal year 2012 and beyond we need to do more than
    establish a budget that is ``workable'' in the context of the current
    fiscal situation. We ask you to help establish a national commitment to
    advance the understanding of the brain and the nervous system--an
    effort that has the potential to transform the lives of thousands of
    people living with brain-based diseases and disorders. Help us to
    fulfill our commitment to overcoming the most difficult obstacles
    impeding progress, and to identifying critical new directions in basic
    neuroscience.
    Brain Research and Discoveries
        The power of basic science unlocks the mysteries of the human body
    by exploring the structure and function of molecules, genes, cells,
    systems, and complex behaviors. Every day, neuroscientists are
    advancing scientific knowledge and medical innovation by expanding our
    knowledge of the basic makeup of the human brain. In doing so,
    researchers exploit these findings and identify new applications that
    foster scientific discovery which can lead to new and ground-breaking
    medical treatments. Basic research funded by the National Institutes of
    Health continues to be essential to ensuring discoveries that will
    inspire scientific pursuit and medical progress for future generations.
    The funds provided in the past have helped neuroscientists make
    tremendous strides in diagnosing and treating neurological and
    psychiatric disorders. Due to federally funded research, scientists and
    healthcare providers now have a much better understanding of how the
    brain functions.
        As we look ahead to the long-term trajectory for NIH funding,
    steady, sustainable growth is essential to maintaining a continuous
    research pipeline that spans from basic science to clinical outcomes.
    Without a long-term sustainable plan for investing in research,
    dramatic swings in the funding cycle have a stifling, often
    irreversible impact on progress, shutting down laboratories, driving
    away talented young investigators and disillusioning students who have
    just discovered a passion for biomedical research. As support declines,
    gaps emerge between levels of funding and the need for scientific
    advance. There are two kinds of gap--the ones you see and the ones you
    don't. In times of limited resources, it is easier to deal
    strategically with the gaps you know. For example, with an aging
    population it makes sense to maintain support for research on
    Alzheimer's and other chronic neurodegenerative diseases. But it's the
    gaps we are unaware of that I also worry about. We know from past
    experience that it is not always clear where the next critical
    breakthrough or innovative approach will come from--progress in science
    depends on imaginative curiosity-driven research that makes leaps in
    ways no one could have anticipated. Where would neuroscience and cell
    biology be without a rainbow of fluorescent proteins from jellyfish,
    which are now illuminating neurological diseases and disorders? Where
    would cutting edge work in systems neuroscience be today without
    research on channel rhodopsins from algae, which now hold promise for
    novel, noninvasive treatments for brain disorders? When resources are
    limited, balancing support for high-risk high-payoff ideas with
    disease-driven translational research presents a huge challenge--it is
    easy to see why the latter is important, yet ultimately both kinds of
    research have the potential to contribute to the development of life
    changing therapies and cures for different diseases. More than ever is
    it important to support and fund research at many levels from the most
    basic to translational. The following are just two of the many basic
    research success stories in neuroscience research emerging now thanks
    to strong historic investment in NIH and other research agencies:
                Nicotine Addiction
        Although tobacco has been used legally for hundreds of years,
    nicotine addiction takes effect through pathways similar to those
    involving cocaine and heroin. During addiction, drugs activate brain
    areas that are typically involved in the motivation for other
    pleasurable rewards such as eating or drinking. These addictions leave
    the body with a strong chemical dependence that is very hard to get
    over. In fact, almost 80 percent of smokers who try to quit fail within
    their first year. The lack of a reliable cessation technique has
    profound consequences. Tobacco-related illnesses kill as many as
    440,000 Americans every year, and thus the human and economic costs of
    nicotine addiction are staggering. One out of every five U.S. deaths is
    related to smoking.
        Past Federal funding has enabled scientists to understand the
    mechanisms of nicotine addiction, enabling them develop successful
    treatments for smoking cessation. The discoveries that lead to these
    findings started back in the 1970's, when scientists identified the
    substance in the brain that nicotine acted on to transmit its
    pleasurable effects. They found that nicotine was hijacking a receptor,
    a protein used by the brain to transmit information. This receptor,
    called the nicotinic acetylcholine receptor, regulates the release of
    another key transmitter, dopamine, which in turn acts within reward
    circuits of the brain to mediate both the positive sensations and
    eventual addiction triggered by nicotine consumption. This knowledge
    has been the basis for the development of several therapeutic
    strategies for smoking cessation: nicotine replacement, drugs that
    target nicotine receptors, as well as drugs that prevent the reuptake
    of dopamine have all been shown to increase the long-term odds of
    quitting by several fold.
        More recently, using mice genetically modified to have their
    nicotinic acetylcholine receptors contain one specific type of subunit,
    scientists determined that some kinds of receptor subunits are more
    sensitive to nicotine than others, and because each subunit is
    generated from its own gene, this discovery indicated that genetics can
    influence how vulnerable a person is to nicotine addiction. Further
    research to spot genetic risk factors and to generate genetically
    tailored treatment options is ongoing. Other studies are also testing
    whether a vaccine that blocks nicotine's effects can help discourage
    the habit. Since people who are able to quit smoking immediately lower
    their risk for certain cancers, heart disease and stroke, reliable and
    successful treatments are clearly needed. Today's continued research
    funding can make it possible for these emerging therapies to ultimately
    help people overcome the challenges of nicotine addiction.
                Brain-machine interface
        The brain is in constant communication with the body in order to
    perform every minute motion from scratching an itch to walking.
    Paralysis occurs when the link between the brain and a part of the body
    is severed, and eliminates the control of movement and the perception
    of feeling in that area. Almost 2 percent of the U.S. population is
    affected by some sort of paralysis resulting from stroke, spinal cord
    or brain injury as well as many other causes. Previous research has
    focused on understanding the mechanisms by which the brain controls a
    movement. Research during which scientists were able to record the
    electrical communication of almost 50 nerve cells at once showed that
    multiple brain cells work together to direct complex behaviors.
    However, in order to use this information to restore motor function,
    scientists needed a way to translate the signals that neurons give into
    a language that an artificial device could understand and convert to
    movement.
        Basic science research in mice lead to the discovery that thinking
    of a motion activated nerve cells in the same way that actually making
    the movement would. Further studies showed that a monkey could learn to
    control the activity of a neuron, indicating that people could learn to
    control brain signals necessary for the operation of robotic devices.
    Thanks to these successes, brain-controlled prosthetics are being
    tested for human use. Surgical implants in the brain can guide a
    machine to perform various motor tasks such as picking up a glass of
    water. These advances, while small, are a huge improvement for people
    suffering from paralysis. Scientists hope to eventually broaden the
    abilities of such devises to include thought-controlled speech and
    more. Further research is also needed to develop non-invasive
    interfaces for human-machine communication, which would reduce the risk
    of infection and tissue damage. Understanding how neurons control
    movement has had and will continue to have profound implications for
    victims of paralysis.
        A common theme of both these examples of basic research success
    stories is that they required the efforts of basic science researchers
    discovering new knowledge, of physician scientists capable adapting
    those discoveries into better treatments for their patients and of
    companies willing to build on all of this knowledge to develop new
    medications and devices.
    The future of American science
        Finally, as the subcommittee considers this year's funding levels
    and in future years, I hope that the members will consider that
    significant advancements in the biomedical sciences often come from
    younger investigators who bring new insights and approaches to bear on
    old or intractable problems. Without sustained investment, I fear that
    flat or falling funding will begin to take a toll on the imagination,
    energy and resilience of younger investigators and I wonder about the
    impact of these events on the next generation. America's scientific
    enterprise--and its global leadership--has been built over generations,
    but without sustained investment, we could lose that leadership
    quickly, and it will be difficult to rebuild. When we undermine a
    research enterprise--whether a single lab or a national infrastructure
    built through decades of Federal funding--it is a loss to us all and
    difficult to recover. In the United States--traditionally a pacesetter
    for strong investment--threatened cuts in science funding jeopardize a
    global training system that fosters and encourages scientific
    creativity, flexibility, and enterprise. As a young girl interested in
    science, I was inspired by the idea that the United States was a place
    where anyone with imagination, drive, and a passion for research could
    come, learn, and potentially do something great. Without funding, that
    culture of entrepreneurship and curiosity--driven research could be
    hindered for decades.
    Conclusion
        We live at a time of extraordinary opportunity in neuroscience.
    When I read an exciting research article, I get a sense of awe and
    pride at the extraordinary progress in our field. A myriad of questions
    once impossible to consider are now within reach as a consequence of
    new technologies, an ever-expanding knowledge base, and a willingness
    to embrace many disciplines.
        As a result of NIH investments, the field of neuroscience research
    holds great potential for making great progress to understand basic
    biological principles and for addressing the numerous neurological and
    psychiatric illnesses that strike more than 100 million Americans
    annually. And we have entered an era in which knowledge of nerve cell
    function has brought us to the threshold of a more profound
    understanding of behavior and of the mysteries of the human mind.
    However, continued progress can only be accomplished by a consistent
    and reliable funding source.
        An NIH appropriation of $35 billion for fiscal year 2012 and
    sustained reliable growth is required to take the research to the next
    level in order to improve the health of Americans and to maintain
    American leadership in science worldwide. As a field we look forward to
    realizing that goal. Thank you for this opportunity to testify.
                                     ______

         Prepared Statement of the Society for Women's Health Research
        The Society for Women's health Research (SWHR) and the Women's
    Health Research Coalition (WHRC), is pleased to have the opportunity to
    submit the following testimony in support of ongoing Federal funding
    for biomedical research--specifically sex differences and total women's
    health research--within the Department of Health and Human Services
    (HHS) at the National Institutes of Health (NIH), Centers for Disease
    Control and Prevention (CDC), and the Agency for Healthcare and
    Research Quality (AHRQ).
        SWHR and WHRC believe that sustained funding for biomedical and
    women's health research programs conducted and supported across the
    Federal agencies is absolutely essential if the United States is going
    to meet the health needs of women and men. A well-designed and
    appropriately funded Federal research agenda does more than avoid
    dangerous and expensive ``trial and error'' medicine for patients--it
    advances the Nation's research capability, continues growth in a sector
    with proven return on investment, and takes a proactive approach to
    maintaining America's position as world-wide leader in medical
    research, education, and development.
        SWHR and WHRC believe that sustained funding for biomedical and
    women's health research programs conducted and supported across the
    Federal agencies is absolutely essential if the United States is to
    meet the health needs of women, and men, and advance the nation's
    research capability.
        As President Obama stated in his State of the Union Address,
    investment in biomedical research ``will strengthen our security,
    protect our planet, and create countless new jobs for our people''.
    Proper investment in health research will save valuable dollars that
    are currently wasted on inappropriate treatments and procedures.
    Further, SWHR and WHRC want targeted research into sex differences that
    will help in determining targeted treatments that will help women and
    men to receive quality appropriate care.
    National Institutes of Health
        Past Congressional investment for the NIH positioned the United
    States as the world's leader in biomedical research and has provided a
    direct and significant impact on women's health research and the
    careers of women scientists over the last decade. In recent years, that
    investment has declined along with America's place as the Number 1 in
    biomedical research. These two facts are interrelated. Cutting NIH
    funding threatens scientific advancement, substantially delays cures
    becoming available in the United States, and puts the innovative
    research practices and reputation that America is known for in
    jeopardy.
        When faced with budget cuts, NIH is left with no other option but
    to reduce the number of grants it is able to fund. The number of new
    grants funded by NIH had dropped steadily with declining budgets,
    growing at a percent less than that of inflation since fiscal year
    2003. Cuts to investments in biomedical research also negatively impact
    the economy. A shrinking pool of available grants has a significant
    impact on scientists who depend upon NIH support to cover both salaries
    and laboratory expenses to conduct high quality biomedical research,
    putting both medical advancement and job creation at risk. More than 83
    percent of NIH funding is spent in communities across the Nation,
    creating jobs at more than 3,000 universities, medical schools,
    teaching hospitals, and other research institutions in every State.
        Reducing the number of grants available to researchers further
    decreases publishing of new findings and decreases the number of
    scientists gaining experience in research, both reducing a scientist's
    likelihood of achieving tenure in a university setting. New and less
    established researchers are forced to consider other careers, or take
    positions outside the United States, and results in the loss of the
    skilled bench scientists and researchers so desperately needed to
    sustain America's cutting edge in biomedical research.
        While the U.S. deficit requires careful consideration of all
    funding and investments, cutting relatively small discretionary funding
    within the NIH budget will not make a substantial impact on the
    deficit, but will drastically hamper the ability of the United States
    to remain the global leader in biomedical research. SWHR and WHRC
    recommend that Congress set, at a minimum, a budget that matches the
    administration's request for a $1 billion increase for NIH for fiscal
    year 2012.
                Study of Sex Differences
        It has only been within the past decade that scientists have begun
    to uncover the significant biological and physiological differences
    between women and men and its impact health and medicine. Sex-based
    biology, the study of biological and physiological differences between
    women and men, has revolutionized the way that the scientific community
    views the sexes. Sex differences play an important role in disease
    susceptibility, prevalence, time of onset and severity and are evident
    in cancer, obesity, heart disease, immune dysfunction, mental health
    disorders, and many other illnesses. Medications can have different
    effects in woman and men, based on sex specific differences in
    absorption, distribution, metabolism and elimination. It is imperative
    that research addressing these important differences be supported and
    encouraged.
        SWHR recommends that NIH, with the funds provided, report sex/
    gender differences in all research findings. Further, NIH should seek
    to expand its inclusion of women in basic, clinical and medical
    research to Phase I, II, and III studies. By currently only mandating
    sufficient female subjects in Phase III, researchers often miss out on
    the chance to look for variability by sex in the early phases of
    research, where scientists look at treatment safety and determine safe
    and effective dose levels for new medications. By mandating that sex
    differences research occur in earlier phases of clinical research
    studies, the NIH can continue to serve as a role model for industry
    research, as well as other nations. Only by gaining more information on
    how therapies work in women will medicine be able to advance toward
    more targeted and effective treatments for all patients, women and men
    alike.
    Office of Research on Women's Health
        The NIH's Office of Research on Women's Health (ORWH) serves as the
    focal point for coordinating women's health and sex differences
    research at NIH, advising the NIH Director on matters relating to
    research on women's health and sex differences research, strengthening
    and enhancing research related to diseases, disorders, and conditions
    that affect women; working to ensure that women are appropriately
    represented in research studies supported by NIH; and developing
    opportunities for and support of recruitment, retention, re-entry and
    advancement of women in biomedical careers. In September 2010, ORWH
    celebrated its 20th anniversary and unveiled a new strategic plan for
    women's health and sex difference research, Moving Into The Future With
    Dimensions and Strategies: A Vision For 2020 For Women's Health
    Research.
                BIRCWH and SCOR
        The Building Interdisciplinary Research Careers in Women's Health
    (BIRCWH) and Specialized Centers of Research on Sex and Gender Factors
    Affecting Women's Health (SCOR) are two ORWH programs that benefit the
    health of both women and men through sex and gender research,
    interdisciplinary scientific collaboration, and provide tremendously
    important support for young investigators in a mentored environment.
        The BIRCWH program, created in 2000, is an innovative, trans-NIH
    career development program that provides protected research time for
    junior faculty by pairing them with senior investigators in an
    interdisciplinary mentored environment. Each BIRCWH receives
    approximately $500,000 a year, most from the ORWH budget. To date, 407
    scholars have been trained in 41 centers, and 80 percent of those
    scholars are female. The BIRCWH centers have produced over 1,300
    publications, 750 abstracts, 200 NIH grants and 85 awards from industry
    and institutional sources.
        SCORs, established in 2003, are designed to increase innovative,
    interdisciplinary research focusing on sex differences and major
    medical problems that affect women through centers that facilitate
    basic, clinical, and translational research. Each SCOR program results
    in unique research and in 2010, resulted in over 150 published journal
    articles, 214 abstracts and presentations and 44 other publications.
        Additionally, ORWH has created several additional programs to
    advance the science of sex differences research and research into
    women's health. The Advancing Novel Science in Women's Health Research
    (ANSWHR) program, created in 2007, promotes innovative new concepts and
    interdisciplinary research in women's health research and sex/gender
    differences. The Research Enhancement Awards Program (REAP) supports
    meritorious research on women's health that otherwise would have missed
    the IC pay line.
        In addition to its funding of research on women's health and sex
    differences research, ORWH has established several methods for
    dissemination information about women's health and sex differences
    research. ORWH created the Women's Health Resources web portal in
    collaboration (http://www.womenshealthresources.nlm.nih.gov) with that
    National Library of Medicine, to serve as a resource for researchers
    and consumers on the latest topics in women's health and uses social
    media to connect the public to health awareness campaigns.
        To allow ORWH's programs and research grants to continue make their
    impact on research and the public, Congress must direct that NIH
    continue its support of ORWH and provide it with $1 million budget
    increase, bringing its fiscal year 2012 total to $43.9 million.
    Health and Human Services' Office of Women's Health
        The HHS Office of Women's Health (OWH) is the Government's champion
    and focal point for women's health issues. It works to redress
    inequities in research, healthcare services, and education that have
    historically placed the health of women at risk. Without OWH's actions,
    the task of translating research into practice would be only more
    difficult and delayed.
        Under HHS, the agencies currently with offices, advisors or
    coordinators for women's health or women's health research include the
    Food and Drug Administration, Centers for Disease Control and
    Prevention, Agency for Healthcare Quality and Research, Indian Health
    Service, Substance Abuse and Mental Health Services Administration,
    Health Resources and Services Administration, and Centers for Medicare
    and Medicaid Services. It is imperative that these offices are funded
    at levels which are adequate for them to perform their assigned
    missions, and are sustainable so as to support needed changes in the
    long term. We ask that the committee report reflect Congress's support
    for these Federal women's health offices, and recommend that they are
    appropriately funded on a permanent basis to ensure that these programs
    can continue and be strengthened in the coming fiscal year.
        It is only through consistent funding that the OWH will be able to
    achieve its goals. The budgets for theses offices have been flat-lined
    in recent years, which results in effectively a net decrease due to
    inflation. Considering the impact of women's health programs from OWH
    on the public, we urge Congress to provide an increase of $1 million
    for the HHS OWH, a total $34.7 million requested for fiscal year 2012.
                Centers for Disease Control and Prevention
        SWHR supports the national and international work of the CDC,
    especially the work of CDC's Office of Women's Health (OWH). While SWHR
    is delighted that the CDC's OWH is now codified in statue, we are
    concerned that proposed cuts to the CDC budget by the administration
    will significantly jeopardize programs that benefit women, leaving them
    with even fewer options for sound clinical information. Research and
    clinical medicine are still catching up from decades of a male-centric
    focus, and when diseases strike women, there remains a paucity of basic
    knowledge on how diseases affect female biology, a lack of drugs that
    have been adequately tested in women, and now even fewer options for
    information through the many educational outreach programs of the CDC.
        The OWH within CDC is fundamental to promoting and improving the
    health, safety, and quality of life of women across their lifespan. The
    office led the CDC in the collaboration and development of text4baby,
    which sends free text messages on health and pregnancy issues, to
    pregnant women and new moms. In the year since its launch, over 135,000
    subscribers have signed up for the service and millions of text
    messages have been sent. More than 300 outreach partners, including
    national, State, business, academic, nonprofit, and other groups, help
    to promote the service.
        With its small budget, the OWH actively participated with others in
    CDC, HHS, and the State Department in the early development of the
    Global Health Initiative, and routinely collaborates with other
    agencies to advance the knowledge and research into women's health
    issues. This year, OWH worked closely with HHS OWH on the development
    of the Action Agenda on Women's Health: Beyond 2010 and with NIH on the
    development of the research conference on Advances in Uterine
    Leiomyoma. SWHR and WHRC recommend that Congress provide the CDC OWH
    with a 1.06 percent increase for fiscal year 2012, bringing their total
    to $478,000.
                Agency for Healthcare and Research Quality
        The Agency for Healthcare Research and Quality's work serves as a
    catalyst for change by promoting the results of research findings and
    incorporating those findings into improvements in the delivery and
    financing of healthcare. Through AHRQ's research projects, lives have
    been saved. For example, it was AHRQ who first discovered that women
    treated in emergency rooms are less likely to receive life-saving
    medication for a heart attack. AHRQ funded the development of two
    software tools, now standard features on hospital electrocardiograph
    machines, which have improved diagnostic accuracy and dramatically
    increased the timely use of ``clot-dissolving'' medications in women
    having heart attacks. As efforts to improve the quality of care, not
    just the quantity of care, progress, findings such as these coming out
    of AHRQ reveal where relatively modest investments can offer
    significant improvement to women's health outcomes, as well as a better
    return on investment for scarce healthcare dollars.
        While AHRQ has made great strides in women's health research, its
    budget has been dismally funded for years, though targeted funding
    increases in recent years for dedicated projects, including funds from
    the American Recovery and Reinvestment Act (ARRA), moved AHRQ in the
    right direction. ARRA funds more than doubled AHRQ's investment in
    patient-centered research relevant to women. AHRQ is now supporting
    studies that examining comparative effectiveness in diabetes and breast
    cancer prevention in women, and comprehensive care for adults with
    serious mental illness.
        With the ARRA funds, total investment in women's health increased
    from $52 million to $109 million, however, more core and sustained
    funding is needed to help AHRQ continue doing the research that helps
    patients and doctors make better medical decisions. Lack of investment
    in AHRQ will hinder advancements that will improve medical
    decisionmaking of doctors and patients and will result in improved
    health outcomes. Any decreased level of funding seriously jeopardizes
    the research and quality improvement programs that Congress mandates
    from AHRQ.
        SWHR and WHRC recommend Congress fund AHRQ at $405 million for
    fiscal year 2012, an increase 2 percent over 2010 enacted levels. This
    investment ensures that adequate resources are available for high
    priority research, including women's healthcare, sex- and gender-based
    analyses, and health disparities--valuable information that can help to
    better personalize treatments, lower overall medical spending, and
    improve outcomes for female and male patients nationwide.
        In conclusion, Mr. Chairman, we thank you and this Committee for
    its strong record of support for medical and health services research
    and its commitment to the health of the Nation through its support of
    peer-reviewed research. We look forward to continuing to work with you
    to build a healthier future for all Americans.
                                     ______

               Prepared Statement of the Spina Bifida Association
    Background and Overview
        On behalf of the estimated 166,000 individuals and their families
    who are affected by all forms of Spina Bifida--the Nation's most
    common, permanently disabling birth defect--Spina Bifida Association
    (SBA) appreciates the opportunity to submit public written testimony
    for the record regarding fiscal year 2012 funding for the National
    Spina Bifida Program and other related Spina Bifida initiatives. SBA is
    a national voluntary health agency, working on behalf of people with
    Spina Bifida and their families through education, advocacy, research
    and service. SBA stands ready to work with Members of Congress and
    other stakeholders to ensure our Nation mounts and sustains a
    comprehensive effort to reduce and prevent suffering from Spina Bifida.
        Spina Bifida, a neural tube defect (NTD), occurs when the spinal
    cord fails to close properly within the first few weeks of pregnancy
    and most often before the mother knows that she is pregnant. Over the
    course of the pregnancy--as the fetus grows--the spinal cord is exposed
    to the amniotic fluid, which increasingly becomes toxic. It is believed
    that the exposure of the spinal cord to the toxic amniotic fluid erodes
    the spine and results in Spina Bifida. There are varying forms of Spina
    Bifida occurring from mild--with little or no noticeable disability--to
    severe--with limited movement and function. In addition, within each
    different form of Spina Bifida the effects can vary widely.
    Unfortunately, the most severe form of Spina Bifida occurs in 96
    percent of children born with this birth defect.
        The result of this NTD is that most people with it suffer from a
    host of physical, psychological, and educational challenges--including
    paralysis, developmental delay, numerous surgeries, and living with a
    shunt in their skulls, which seeks to ameliorate their condition by
    helping to relieve cranial pressure associated with spinal fluid that
    does not flow properly. As we have testified previously, the good news
    is that after decades of poor prognoses and short life expectancy,
    children with Spina Bifida are now living into adulthood and
    increasingly into their advanced years. These gains in longevity,
    principally, are due to breakthroughs in research, combined with
    improvements generally in healthcare and treatment. However, with this
    extended life expectancy, our Nation and people with Spina Bifida now
    face new challenges, such as transitioning from pediatric to adult
    healthcare providers, education, job training, independent living,
    healthcare for secondary conditions, and aging concerns, among others.
    Individuals and families affected by Spina Bifida face many
    challenges--physical, emotional, and financial. Fortunately, with the
    creation of the National Spina Bifida Program in 2003, individuals and
    families affected by Spina Bifida now have a national resource that
    provides them with the support, information, and assistance they need
    and deserve.
        As is discussed below, the daily consumption of 400 micrograms of
    folic acid by women of childbearing age, prior to becoming pregnant and
    throughout the first trimester of pregnancy, can help reduce the
    incidence of Spina Bifida, by up to 70 percent. The Centers for Disease
    Control and Prevention (CDC) calculates that there are approximately
    3,000 NTD births each year, of which an estimated 1,500 are Spina
    Bifida, and, as such, with the aging of the Spina Bifida population and
    a steady number of affected births annually, the Nation must take
    additional steps to ensure that all individuals living with this
    complex birth defect can live full, healthy, and productive lives.
    Cost of Spina Bifida
        It is important to note that the lifetime costs associated with a
    typical case of Spina Bifida--including medical care, special
    education, therapy services, and loss of earnings--are as much as $1
    million. The total societal cost of Spina Bifida is estimated to exceed
    $750 million per year, with just the Social Security Administration
    payments to individuals with Spina Bifida exceeding $82 million per
    year. Moreover, tens of millions of dollars are spent on medical care
    paid for by the Medicaid and Medicare programs. Efforts to reduce and
    prevent suffering from Spina Bifida will help to not only save money,
    but will also save--and improve--lives.
    Improving Quality-of-Life through the National Spina Bifida Program
        Since 2001, SBA has worked with Members of Congress and staff at
    the CDC to help improve our Nation's efforts to prevent Spina Bifida
    and diminish suffering--and enhance quality-of-life--for those
    currently living with this condition. With appropriate, affordable, and
    high-quality medical, physical, and emotional care, most people born
    with Spina Bifida will likely have a normal or near normal life
    expectancy. The CDC's National Spina Bifida Program works on two
    critical levels--to reduce and prevent Spina Bifida incidence and
    morbidity and to improve quality-of-life for those living with Spina
    Bifida.
        The National Spina Bifida Program established the National Spina
    Bifida Resource Center housed at the SBA, which provides information
    and support to help ensure that individuals, families, and other
    caregivers, such as health professionals, have the most up-to-date
    information about effective interventions for the myriad primary and
    secondary conditions associated with Spina Bifida. Among many other
    activities, the program helps individuals with Spina Bifida and their
    families learn how to treat and prevent secondary health problems, such
    as bladder and bowel control difficulties, learning disabilities,
    depression, latex allergies, obesity, skin breakdown, and social and
    sexual issues. Children with Spina Bifida often have learning
    disabilities and may have difficulty with paying attention, expressing
    or understanding language, and grasping reading and math. All of these
    problems can be treated or prevented, but only if those affected by
    Spina Bifida--and their caregivers--are properly educated and given the
    skills and information they need to maintain the highest level of
    health and well-being possible. The National Spina Bifida Program's
    secondary prevention activities represent a tangible quality-of-life
    difference to the estimated 166,000 individuals living with all forms
    of Spina Bifida, with the goal being living well with Spina Bifida.
        An important resource to better determine best clinical practices
    and the most cost effective treatments for Spina Bifida is the National
    Spina Bifida Registry, now in its third year. Nine sites throughout the
    Nation are collecting patient data, which supports the creation of
    quality measures and will assist in improving clinical research that
    will truly save lives, while also realizing a significant cost savings.
        SBA understands that the Congress and the Nation face unprecedented
    budgetary challenges. However, the progress being made by the National
    Spina Bifida Program must be sustained to ensure that people with Spina
    Bifida--over the course of their lifespan--have the support and access
    to quality care they need and deserve. To that end, SBA respectfully
    urges the Subcommittee to Congress allocate $6.25 million (level
    funding) in fiscal year 2012 to the program, so it can continue and
    expand its current scope of work; further develop the National Spina
    Bifida Patient Registry; and sustain the National Spina Bifida Resource
    Center. Sustaining funding for the National Spina Bifida Program will
    help ensure that our Nation continues to mount a comprehensive effort
    to prevent and reduce suffering from--and the costs of--Spina Bifida.
    Preventing Spina Bifida
        While the exact cause of Spina Bifida is unknown, over the last
    decade, medical research has confirmed a link between a woman's folate
    level before pregnancy and the occurrence of Spina Bifida. Sixty-five
    million women of child-bearing age are at-risk of having a child born
    with Spina Bifida. As mentioned above, the daily consumption of 400
    micrograms of folic acid prior to becoming pregnant and throughout the
    first trimester of pregnancy can help reduce the incidence of Spina
    Bifida, by up to 70 percent. There are few public health challenges
    that our nation can tackle and conquer by nearly three-fourths in such
    a straightforward fashion. However, we must still be concerned with
    addressing the 30 percent of Spina Bifida cases that cannot be
    prevented by folic acid consumption, as well as ensuring that all women
    of childbearing age--particularly those most at-risk for a Spina Bifida
    pregnancy--consume adequate amounts of folic acid prior to becoming
    pregnant.
        Since 1968, the CDC has led the Nation in monitoring birth defects
    and developmental disabilities, linking these health outcomes with
    maternal and/or environmental factors that increase risk, and
    identifying effective means of reducing such risks. The good news is
    that progress has been made in convincing women of the importance of
    folic acid consumption and the need to maintain a diet rich in folic
    acid. This public health success should be celebrated, but still too
    many women of childbearing age consume inadequate daily amounts of
    folic acid prior to becoming pregnant, and too many pregnancies are
    still affected by this devastating birth defect. The Nation's public
    education campaign around folic acid consumption must be enhanced and
    broadened to reach segments of the population that have yet to heed
    this call--such an investment will help ensure that as many cases of
    Spina Bifida can be prevented as possible.
        The goal is to increase awareness of the benefits of folic acid,
    particularly for those at elevated risk of having a baby with neural
    tube defects (those who have Spina Bifida themselves, or those who have
    already conceived a baby with Spina Bifida). With continued funding in
    fiscal year 2012, CDC's folic acid awareness activities could be
    expanded to reach the broader population in need of these public health
    education, health promotion, and disease prevention messages. SBA
    advocates that Congress provide adequate funding to CDC to allow for a
    targeted public health education and awareness focus on at-risk
    populations (e.g., Hispanic-Latino communities) and health
    professionals who can help disseminate information about the importance
    of folic acid consumption among women of childbearing age.
        In addition to a $6.25 million fiscal year 2012 allocation for the
    National Spina Bifida Program, SBA urges the Subcommittee to provide
    $5.126 million for the CDC's national folic acid education and
    promotion efforts to support the prevention of Spina Bifida and other
    NTD; $26.342 million to strengthen the CDC's National Birth Defects
    Prevention Network; and $144 million to fund the National Center on
    Birth Defects and Developmental Disabilities.
    Improving Health Care for Individuals with Spina Bifida
        As you know, Agency for Health Research and Quality's (AHRQ)
    mission is to improve the outcomes and quality of healthcare, reduce
    healthcare costs, improve patient safety, decrease medical errors, and
    broaden access to essential health services. AHRQ's work is vital to
    the evaluation of new treatments, which helps ensure that individuals
    living with Spina Bifida continue to receive state-of-the-art care and
    interventions. To that end, we request a $405 million fiscal year 2012
    allocation for AHRQ, to help improve quality of care and outcomes for
    people with Spina Bifida.
    Sustain and Seize Spina Bifida Research Opportunities
        Our Nation has benefited immensely from our past Federal investment
    in biomedical research at the NIH. SBA joins with other in the public
    health and research community in advocating that NIH receive increased
    funding in fiscal year 2012. This funding will support applied and
    basic biomedical, psychosocial, educational, and rehabilitative
    research to improve the understanding of the etiology, prevention, cure
    and treatment of Spina Bifida and its related conditions. In addition,
    SBA respectfully requests that the Subcommittee include the following
    language in the report accompanying the fiscal year 2012 L-HHS
    appropriations measure:
        ``The Committee encourages NIDDK, NICHD, and NINDS to study the
    causes and care of the neurogenic bladder in order to improve the
    quality of life of children and adults with Spina Bifida; to support
    research to address issues related to the treatment and management of
    Spina Bifida and associated secondary conditions, such as
    hydrocephalus; and to invest in understanding the myriad co-morbid
    conditions experienced by children with Spina Bifida, including those
    associated with both paralysis and developmental delay.''
    Conclusion
        Please know that SBA stands ready to work with the Subcommittee and
    other Members of Congress to advance policies and programs that will
    reduce and prevent suffering from Spina Bifida. Again, we thank you for
    the opportunity to present our views regarding fiscal year 2012 funding
    for programs that will improve the quality-of-life for the estimated
    166,000 Americans and their families living with all forms of Spina
    Bifida.
                                     ______

                    Prepared Statement of The AIDS Institute
        The AIDS Institute, a national public policy research, advocacy,
    and education organization, is pleased to comment in support of
    critical HIV/AIDS and Hepatitis programs as part of the fiscal year
    2012 Labor, Health and Human Services, Education and Related Agencies
    appropriation measure. We thank you for your past support of these
    programs and hope you will do your best to adequately fund them in the
    future in order to provide for and protect the public health.
                                    hiv/aids
        HIV/AIDS remains one of the world's worst health pandemics in
    history. According to the CDC, over 617,000 people have died of AIDS in
    the United States and there are 56,300 new infections each year. At the
    end of 2007, an estimated 1.1 million people in the United States were
    living with HIV/AIDS. Persons of minority races and ethnicities are
    disproportionately affected. African Americans account for half of the
    cases. HIV/AIDS disproportionately affects the poor and about 70
    percent of those infected rely on publicly funded healthcare.
        The vast majority of the discretionary programs supporting HIV/AIDS
    efforts domestically are funded through your Subcommittee. The AIDS
    Institute, working in coalition, has developed funding requests for
    each of these programs. We ask that you do your best to adequately fund
    them at the requested level.
        We are keenly aware of budget constraints and competing interests
    for limited dollars, but programs that prevent and treat HIV are
    inherently Federal, as they help protect the public health against a
    highly infectious virus, which if left untreated will most likely lead
    to death and increased infections. Federal funding is particularly
    critical at this time since State and local budgets are being severely
    cut during the economic downturn.
    National HIV/AIDS Strategy
        President Obama released a comprehensive National HIV/AIDS Strategy
    (NHAS) which seeks to reduce new HIV infections, increase access to
    care and improving health outcomes for people living with HIV, and
    reduce HIV-related health disparities. The Strategy sets ambitious
    goals and seeks a more coordinated national response with a focus on
    those communities most affected and on programs that work. In order to
    attain the goals, additional investment will be needed and health
    reform must be implemented.
        The budget proposed by the President requests that up to 1 percent
    of HHS discretionary funds appropriated for domestic HIV/AIDS
    activities be provided to the Office of the Assistant Secretary for
    Health to foster collaborations across HHS agencies and finance high
    priority initiatives in support of the NHAS. Such initiatives would
    focus on improving linkages between prevention and care, coordinating
    Federal resources within targeted high-risk populations, enhancing
    provider capacity, and monitoring key Strategy targets. The AIDS
    Institute supports this provision and encourages you to include it in
    the fiscal year 2012 appropriation measure.
    Centers for Disease Control and Prevention--HIV Prevention and
            Surveillance
    Fiscal year 2011--$800.4 million
    Fiscal year 2012 community request--$1,325.7 million

        The United Staes allocates only about 4 percent of its domestic
    HIV/AIDS spending on prevention. Investing in prevention today will
    save money tomorrow. Preventing all the new 56,000 cases in just one
    year would translate into an astounding $20 billion in lifetime medical
    costs.
        The CDC is focused on carrying out several goals of the NHAS by
    2015. Specifically, they are seeking to lower the annual number of new
    infections by 25 percent, reduce the HIV transmission rate by 30
    percent, and increase from 79 to 90 the percentage of people living
    with HIV who know their serostatus.
        While it is estimated that an increase of over $500 million would
    be needed to achieve the goals of the NHAS, The AIDS Institute supports
    an increase of at least the $57.2 million over fiscal year 2011 as the
    President has proposed, including $30.4 million from the Prevention and
    Public Health Fund. We are also supportive of a transfer of $40 million
    from the Chronic Disease Prevention and Public Health Promotion for HIV
    school health programs to achieve closer coordination of CDC's HIV
    prevention programs.
        With this funding, the CDC would improve surveillance and use of
    community viral load, enhance prevention among most affected
    communities, integrate care and prevention, expand HIV testing and
    linkage to care, build capacity, develop social marketing campaigns,
    and improve monitoring.
    Ryan White HIV/AIDS Programs
    Fiscal year 2011--$2,336.7 million
    Fiscal year 2012 community request--$2,687.0 million

        The centerpiece of the Government's response to caring and treating
    low-income people with HIV/AIDS is the Ryan White HIV/AIDS Program,
    which currently serves over half a million low-income, uninsured, and
    underinsured people. In fiscal year 2011, almost all parts of the
    Program experienced funding cuts at a time of increased need and
    demands on the program. Consider the following:
      --Caseloads are increasing. People are living longer due to
            lifesaving medications, there are over 56,000 new infections
            each year, and increased testing programs identify thousands of
            new people infected with HIV. With rising unemployment, people
            are losing their employer-sponsored health coverage.
      --State and local budgets are experiencing cutbacks due to the
            economic downturn. A survey by the National Alliance of State
            and Territorial AIDS Directors found that State funding
            reductions totaled more than $170 million in 29 States during
            fiscal year 2009.
      --States are cutting and the Federal Government is proposing massive
            cuts to Medicaid. As the payer of last resort cuts to
            entitlement programs, such as Medicaid, place further pressure
            on the Ryan White Program.
      --There are significant numbers of people in the United States who
            are not receiving life-saving AIDS medications. An IOM report
            concluded that 233,069 people in the United States who know
            their HIV status do not have continuous access to Highly Active
            Antiretroviral Therapy.
        Specifically, The AIDS Institute requests the following funding
    levels for each part of the Program:
        Part A provides medical care and vital support services for persons
    living with HIV/AIDS in the metropolitan areas most affected by HIV/
    AIDS. We request an increase of $74.2 million, for a total of $752
    million.
        Part B base provides essential services including diagnostic, viral
    load testing and viral resistance monitoring, and HIV care to all 50
    States, District of Columbia, Puerto Rico, and the territories. We are
    requesting a $76.8 million increase, for a total of $495 million.
        The AIDS Drug Assistance Program (ADAP) provides life-saving HIV
    drug treatment to over 200,000 people, or about one in four HIV
    positive people in care in the United States. The majority of whom are
    people of color and very poor. ADAPs are experiencing unprecedented
    growth and are in crisis. Over the course of 1 year, HRSA reported an
    increase of over 30,000 new people to the program. Because of a lack of
    funding, there are currently 8,100 people in 13 States on waiting
    lists, thousands more have been removed from the program due to lowered
    eligibility requirements, and drug formularies have been reduced.
        According to NASTAD's recent annual ADAP monitoring report, State
    funding for ADAPs increased 61 percent in fiscal year 2009 to a total
    of $346 million, and drug company rebates grew 5 percent to $522
    million. The Federal share of the overall ADAP budget has decreased to
    less than 50 percent.
        The AIDS Institute is very appreciative of the $50 million increase
    to ADAP in fiscal year 2011, but it is far from what is currently
    required to meet the growing number of new people needing ADAP
    medications in the coming year. The true need is an increase of $360
    million. The AIDS Institute requests that you provide an increase that
    is as close as possible to that amount. We note the President has
    requested an increase of $55 million, which would only provide
    medications to fewer than 4,800 people.
        Part C provides early medical intervention and other supportive
    services to over 248,000 people at over 380 directly funded clinics. We
    are requesting a $66.6 million increase, for a total of $272 million.
        Part D provides care to over 84,000 women, children, youth, and
    families living with and affected by HIV/AIDS. We are requesting a $5.8
    million increase, for a total of $83.1 million.
        Part F includes the AIDS Education and Training Centers (AETCs)
    program and the Dental Reimbursement program. We are requesting a $15.4
    million increase for the AETC program, for a total of $50 million, and
    a $5.5 million increase for the Dental Reimbursement program, for a
    total of $19 million.
    National Institutes of Health--AIDS Research
    Fiscal year 2011--$3.07 billion
    Fiscal year 2012 community request--$3.5 billion

        The NIH conducts research to better understand HIV and its
    complicated mutations, discover new drug treatments, develop a vaccine
    and other prevention programs such as microbicides, and ultimately
    develop a cure. The critically important work performed by the NIH not
    only benefits those in the United States, but the entire world. This
    research has already helped in the development of many highly effective
    new drug treatments, prolonging the lives of millions of people. NIH
    also conducts the necessary behavioral research to learn how HIV can be
    prevented best in various affected communities. We ask the Committee to
    fund critical AIDS research at the community requested level of $3.5
    billion.
    Comprehensive Sexuality Education
        Since the vast majority of HIV infection occurs through sex, age
    appropriate education on how HIV is transmitted and HIV prevention is
    critical. It is for this reason, The AIDS Institute is supportive of
    funding the Teen Pregnancy Prevention Initiative for a total of $135
    million and we oppose funding of abstinence only education programs,
    which have proven not to be effective.
    Minority AIDS Initiative
        The AIDS Institute supports increased funding for the Minority AIDS
    Initiative, which is funded by numerous Federal agencies to address the
    disproportionate impact that HIV has on communities of color. For
    fiscal year 2012, we are requesting a total of $610 million.
    Policy Riders
        The AIDS Institute is opposed to using the appropriations process
    as a vehicle to repeal or prevent the implementation of current law or
    ban funding for certain activities or organizations, such as the
    Affordable Care Act and syringe exchange programs which are
    scientifically proven to be effective in the prevention of HIV and
    Hepatitis.
                                viral hepatitis
        The Institute of Medicine (IOM) report Hepatitis and Liver Cancer:
    A National Strategy for Prevention and Control of Hepatitis B and C
    outlines recommendations on how the incidence of Hepatitis B and C
    infections can be decreased. They include increased public awareness
    campaigns, heightened testing and vaccination programs, continued
    research, along with improved surveillance. The Administration recently
    announced the first ever national strategy to eliminate Viral
    Hepatitis.
        In fiscal year 2011, Congress funded CDC's Viral Hepatitis Division
    at only $19.8 million. Given the huge impact that Hepatitis B and C
    have on the health of so many people, and the large treatment costs,
    and to begin to implement the IOM recommendations and the national
    strategy, The AIDS Institute urges the Federal Government to make a
    greater commitment to Hepatitis prevention. For fiscal year 2012, we
    request a total of $59.8 million.
        The AIDS Institute asks that you give great weight to our testimony
    as you develop the fiscal year 2012 appropriation bill. Should you have
    any questions or comments, feel free to contact Carl Schmid, Deputy
    Executive Director, The AIDS Institute or cschmid@theaidsinstitute.org.
        Thank you very much.
                                     ______

                  Prepared Statement of The Endocrine Society
        The Endocrine Society is pleased to submit the following testimony
    regarding fiscal year 2012 Federal appropriations for biomedical
    research, with an emphasis on appropriations for the National
    Institutes of Health (NIH). The Endocrine Society is the world's
    largest and most active professional organization of endocrinologists
    representing more than 14,000 members worldwide. Our organization is
    dedicated to promoting excellence in research, education, and clinical
    practice in the field of endocrinology. The Society's membership
    includes thousands of scientists and clinicians who receive Federal
    support for their research and, in turn, contribute greatly to the
    Nation's scientific and healthcare advances.
        A half century of sustained investment by the United States Federal
    Government in biomedical research has dramatically advanced the health
    and improved the lives of the American people. The NIH specifically has
    had a significant impact on the United State's global preeminence in
    research and fostered the development of a biomedical research
    enterprise that is unrivaled throughout the world. As the world's
    largest supporter of biomedical research, the NIH competitively awards
    extramural grants and supports in-house research. However, with the
    continued decline in real dollars allocated to biomedical research each
    year by the Federal Government, the opportunities to discover life-
    changing cures and treatments have already begun to decrease.
        Biomedical research funds allocated by the Federal government
    support both basic and translational research, ensuring that the
    discoveries made in the laboratory become realistic treatment options
    for patients suffering from debilitating and life-threatening diseases.
    Diabetes is a devastating condition that affects an increasingly large
    number of Americans and requires a large proportion of the Nation's
    healthcare spending. Almost 26 million people (8.3 percent of the U.S.
    population) have diabetes, and the estimated cost of diabetes was $174
    billion in 2007.\1\
    ---------------------------------------------------------------------------
        \1\ Centers for Disease Control and Prevention. National Diabetes
    Fact Sheet, 2011.
    ---------------------------------------------------------------------------
        No new diabetes medications would have been developed without
    federally supported basic and clinical research. The discovery of
    insulin and the collaborative research effort of basic and clinical
    scientists eventually led to the approval of a new class of medications
    for diabetes, essentially the first new treatments of diabetes in the
    past 80 years. Without the continued support of both basic and clinical
    research in diabetes, these medications would have never been
    developed. Now, with this broadened portfolio of treatments, it is
    possible to help most people with diabetes achieve optimal blood sugar
    control.
        Beyond the multitude of health benefits that result from NIH-funded
    research, national and local economies benefit from the dollars that
    flow out of NIH into the communities. Researchers in all 50 States and
    90 percent of congressional districts receive funding from NIH, and
    these funds stimulate local economies through salaries and purchase of
    equipment, laboratory supplies, and vendor services. For instance, for
    each dollar of taxpayer investment, UCLA generates almost $15 in
    economic activity, resulting in a $9.3 billion impact on the Los
    Angeles region. The estimated economic impact of Baylor on the
    surrounding community in Houston is more than $358 million, generating
    more than 3,300 jobs.\2\ The governors of 25 States acknowledged the
    economic impact that NIH-funded research has on their States in an
    April 2010 letter to House and Senate Budget Committee members. The
    letter states,

        \2\ Federation of American Societies for Experimental Biology. NIH
    Advocacy Slides: California, Texas.
    ---------------------------------------------------------------------------
        ``During a time of recession, investment in biomedical research
    makes sense because it leads to cures and treatments for debilitating
    diseases while at the same time generating significant economic
    activity for local communities throughout the country.''

        The Endocrine Society remains deeply concerned about the future of
    biomedical research in the United States without sustained support from
    the Federal Government. The Society strongly supports the continued
    increase in Federal funding for biomedical research in order to provide
    the additional resources needed to enable American scientists to
    address the burgeoning scientific opportunities and new health
    challenges that continue to confront us. The Endocrine Society
    recommends that NIH receive at least $35 billion in fiscal year 2012 to
    ensure the steady and sustainable growth necessary to continue building
    on the advances made by scientists and physicians during the past
    decade.
                                     ______

         Prepared Statement of The Humane Society of the United States
        On behalf of The Humane Society of the United States (HSUS) and the
    Humane Society Legislative Fund (HSLF), and our joint membership of
    over 11 million supporters nationwide, we appreciate the opportunity to
    provide testimony on our top NIH funding priorities for the Senate
    Labor, Health and Human Services, Education and Related Agencies
    Appropriations Subcommittee in fiscal year 2012.
                      breeding of chimpanzees for research
        The HSUS requests that no Federal funding be appropriated for the
    breeding of chimpanzees for laboratory research. The basis of our
    request is as follows:
      --The National Center for Research Resources (NCRR) of the National
            Institutes of Health (NIH), responsible for the oversight and
            maintenance of federally owned and supported chimpanzees,
            placed a moratorium on breeding federally owned and supported
            chimpanzees in 1995, primarily due to the excessive costs of
            lifetime care of chimpanzees in laboratory settings. NCRR
            extended the moratorium indefinitely in 2007. As a result, none
            of the 500 federally owned chimpanzees should have given birth
            or sired infants since 1995.
      --There is evidence, however, that at least one laboratory has used
            millions of Federal dollars in recent years to support breeding
            of government owned chimpanzees. There are major financial
            implications to the Federal Government and taxpayers if this
            breeding continues. Therefore, we seek to simply reinforce NIH
            policy and ensure that no laboratory can use funding provided
            by NIH or any other HHS agency for breeding of government-owned
            or supported chimpanzees.
      --According to records provided by the New Iberia Research Center
            (NIRC) and the National Institutes of Health 123 infants were
            born to a federally owned mother and/or federally owned father
            at NIRC between 2000 and 2009.
      --The cost of maintaining chimpanzees in laboratories is exorbitant,
            up to $67 per day per chimpanzee; over $1,000,000 per
            chimpanzee over an individual's approximately 60-year lifetime.
            Breeding of additional chimpanzees into laboratories will only
            perpetuate and increase the burdens on the government in
            supporting and managing the chimpanzee research colony.
      --The U.S. currently has a surplus of chimpanzees available for use
            in research due to overzealous breeding for HIV research and
            subsequent findings that they are a poor HIV model.\1\
    ---------------------------------------------------------------------------
        \1\ NRC (National Research Council) (1997) Chimpanzees in research:
    strategies for their ethical care, management and use. National
    Academies Press: Washington, D.C.
    ---------------------------------------------------------------------------
      --Expansion of the chimpanzee population in laboratories only creates
            more concerns than presently exist about their quality of
            care--an issue of great public concern.
    Background and history
        Beginning in 1995, the National Research Council (NRC) confirmed a
    chimpanzee surplus and recommended a moratorium on breeding of
    federally owned or supported chimpanzees,\1\ which includes nearly all
    of the approximately 1,000 chimpanzees available for research in the
    United States. On May 22, 2007 the NCRR of NIH indefinitely extended
    its moratorium on breeding federally-owned and supported chimpanzees.
    Further, it has also been noted that ``a huge number'' of chimpanzees
    are not being used in active research protocols and are therefore
    ``just sitting there.'' \2\ If no breeding is allowed, it is projected
    that the government will have almost no financial responsibility for
    the chimpanzees it owns within 30 years due to the age of the
    population--any breeding today will extend this financial burden to 60
    years.
    ---------------------------------------------------------------------------
        \2\ Cohen, J. (2007) Biomedical Research: The Endangered Lab Chimp.
    Science. 315:450-452.
    ---------------------------------------------------------------------------
        There is no justification for breeding of additional chimpanzees
    for research; therefore lack of Federal funding for breeding will
    ensure that no breeding of federally owned or supported chimpanzees for
    research will occur in fiscal year 2012.
    Concerns regarding chimpanzee care in laboratories
        A nine month undercover investigation by The HSUS at University of
    Louisiana at Lafayette New Iberia Research Center (NIRC)--the largest
    chimpanzee laboratory in the world--revealed some chimpanzees living in
    barren, isolated conditions and documented over 100 alleged violations
    of the Animal Welfare Act at the facility regarding conditions for and
    treatment of chimpanzees. The U.S. Department of Agriculture (USDA) and
    NIH's Office of Laboratory Animal Welfare (OLAW) launched formal
    investigations into the facility and NIRC paid an $18,000 stipulation
    for violations of the Animal Welfare Act.
        Aside from the HSUS investigation, inspections conducted by the
    USDA demonstrate that basic chimpanzee standards are often not being
    met. Inspection reports for other federally funded chimpanzee
    facilities have reported violations of the Animal Welfare Act in recent
    years, including the death of a chimpanzee during improper transport,
    housing of chimpanzees in less than minimal space requirements,
    inadequate environmental enhancement, and/or general disrepair of
    facilities. These problems add further argument against the breeding of
    even more chimpanzees into this system.
    Chimpanzees have often been a poor model for human health research
        The scientific community recognizes that chimpanzees are poor
    models for HIV because chimpanzees do not develop AIDS even after being
    infected with HIV. Similarly, chimpanzees do not model the course of
    the human hepatitis C virus yet they continue to be used for this
    research, adding to the millions of dollars already spent without a
    sign of a promising vaccine. According to the chimpanzee genome, some
    of the greatest differences between chimpanzees and humans relate to
    the immune system, \3\ calling into question the validity of infectious
    disease research using chimpanzees.
    ---------------------------------------------------------------------------
        \3\ The Chimpanzee Sequencing and Analysis Consortium/Mikkelsen,
    TS, et al.,(1 September 2005) Initial sequence of the chimpanzee genome
    and comparison with the human genome, Nature 437, 69-87.
    ---------------------------------------------------------------------------
    Ethical and public concerns about chimpanzee research
        Chimpanzee research raises serious ethical issues, particularly
    because of their extremely close similarities to humans in terms of
    intelligence and emotions. Americans are clearly concerned about these
    issues: 90 percent believe it is unacceptable to confine chimpanzees
    individually in government-approved cages (as we documented during our
    investigation at NIRC); 71 percent believe that chimpanzees who have
    been in the laboratory for over 10 years should be sent to sanctuary
    for retirement \4\; and 54 percent believe that it is unacceptable for
    chimpanzees to ``undergo research which causes them to suffer for human
    benefit.'' \5\
    ---------------------------------------------------------------------------
        \4\ 2006 poll conducted by the Humane Research Council for Project
    Release & Restitution for Chimpanzees in laboratories.
        \5\ 2001 poll conducted by Zogby International for the Chimpanzee
    Collaboratory.
    ---------------------------------------------------------------------------
        We respectfully request the following bill or committee report
    language:

        ``No funds made available in this Act, or any prior Act, may be
    used for ``The Committee directs that no funds provided in this Act be
    used to support the breeding of federally owned or federally supported
    chimpanzees for research.''

        We appreciate the opportunity to share our views for the Labor,
    Health and Human Services, Education and Related Agencies
    Appropriations Act for Fiscal Year 2012. We hope the Committee will be
    able to accommodate this modest request that will save the government a
    substantial sum of money, benefit chimpanzees, and allay some concerns
    of the public at large. Thank you for your consideration.
     high throughput screening, toxicity pathway profiling, and biological
     interpretation of findings--national institutes of health--office of
                                  the director
        In 2007, the National Research Council published its report titled
    ``Toxicity Testing in the 21st Century: A Vision and a Strategy.'' This
    report catalyzed collaborative efforts across the research community to
    focus on developing new, advanced molecular screening methods for use
    in assessing potential adverse health effects of environmental agents.
    It is widely recognized that the rapid emergence of omics technologies
    and other advanced technologies offers great promise to transform
    toxicology from a discipline largely based on observational outcomes
    from animal tests as the basis for safety determinations to a
    discipline that uses knowledge of biological pathways and molecular
    modes of action to predict hazards and potential risks.
        In 2008, NIH, NIEHS and EPA signed a memorandum of understanding
    \6\ to collaborate with each other to identify and/or develop high
    throughput screening assays that investigate ``toxicity pathways'' that
    contribute to a variety of adverse health outcomes (e.g., from acute
    oral toxicity to long-term effects like cancer). In addition, the MOU
    recognized the necessity for these Federal research organizations to
    work with ``acknowledged experts in different disciplines in the
    international scientific community.'' Much progress has been made,
    including FDA joining the MOU, but there is still a significant amount
    of research, development and translational science needed to bring this
    vision forward to where it can be used with confidence for safety
    determinations by regulatory programs in the government and product
    stewardship programs in the private sector. In particular, there is a
    growing need to support research to develop the key science-based
    interpretation tools which will accelerate using 21st century
    approaches for predictive risk analysis. We believe the Office of the
    Director at NIH can play a leadership role for the entire U.S.
    Government by funding both extramural and intramural research.
    ---------------------------------------------------------------------------
        \6\ http://www.genome.gov/pages/newsroom/currentnewsreleases/
    ntpncgcepamou121307finalv2.pdf.
    ---------------------------------------------------------------------------
        We respectfully request the following committee report language,
    which is supported by The HSUS, HSLF, Procter & Gamble, and the
    American Chemistry Council.

        ``The Committee supports the implementation of the National
    Research Council's report ``Toxicity Testing in the 21st Century: A
    Vision and a Strategy'' to create a new paradigm for chemical risk
    assessment based on the incorporation of advanced molecular biological
    and computational methods in lieu of animal toxicity tests within
    integrated evaluation strategies, and urges the National Institutes of
    Health to play a leading role by funding a coordinated, long-term
    program of relevant intramural and extramural research. Current
    activities at the NIH Chemical Genomics Center, National Institute of
    Environmental Health Sciences, the Environmental Protection Agency and
    the Food and Drug Administration show considerable potential and the
    NIH Director should explore opportunities to augment this effort by
    identifying additional resources that could be directed to priority
    research projects. The Director shall report on the NIH funding of and
    progress on these activities to the Committee commencing September 30,
    2012 and annually thereafter.''
                                     ______

        Prepared Statement of the University of Virginia Medical Center
        Mr. Chairman and Members of the Subcommittee, thank you for the
    opportunity to submit testimony on behalf of the University of Virginia
    Medical Center. As members of this committee you have jurisdiction for
    funding the agencies responsible for the delivery of healthcare in the
    United States. As a healthcare provider in Virginia and a
    representative of a major institution responsible for training the
    healthcare providers of tomorrow, I want to use this opportunity to
    discuss the vital importance of Federal funding for Graduate Medical
    Education (GME) in the United States. I urge you to support an increase
    in the number of appropriately trained physicians in the United States
    while protecting the integrity and structure of the GME program.
    Overview of the University of Virginia Health System
        The University of Virginia Health System is an academic medical
    center composed of the Hospital and its satellite facilities and
    programs, the School of Medicine, School of Nursing, other allied
    health programs, and faculty physicians. The University of Virginia
    Health System plays a critical role in the Nation's healthcare
    structure as well as the healthcare structure of Virginia. We have
    multiple key missions: training the next generation of healthcare
    workers, caring for the sickest patients and the underserved who have
    nowhere to turn, providing innovative treatments with state-of-the-art
    technology, and performing medical research. Our key missions are what
    distinguish us from regular community hospitals.
        The University of Virginia Medical Center and its Graduate Medical
    Education training programs provide an essential bridge for medical
    school graduates to become well-trained practicing physicians. At the
    University of Virginia Medical Center, we continuously provide an
    environment of excellence in which our trainees gain the necessary
    experience to practice in their specialties in a setting that
    emphasizes quality and patient safety.
        Our training programs have been recognized by the Accreditation
    Council for Graduate Medical Education for their compliance in meeting
    the necessary training standards and for their innovative educational
    techniques. We currently sponsor 68 accredited core specialty and
    subspecialty training programs. All of our programs are fully
    accredited, and many have been awarded the maximum accreditation cycle
    length.
        Our programs are well positioned to meet the growing national
    workforce shortages in primary care (Family Medicine, Internal Medicine
    including General Medicine, Obstetrics and Gynecology, Pediatrics, and
    General Surgery), as well as in those specialties where workforce
    shortages have been identified in the Commonwealth of Virginia
    (Emergency Medicine, Child and Adolescent Psychiatry).
        We have excellent training programs that are well-suited to train
    physicians who will care for our aging population, including
    Geriatrics, Palliative and Hospice Medicine, Orthopedic Surgery
    (including Reconstructive Spine), Endocrinology (Diabetes, Obesity, and
    Osteoporosis), Cardiology and Cardiothoracic Surgery, Oncology, and
    Neurology (Alzheimer's Disease).
    Funding of Graduate Medical Education
        Training of future physicians is a core mission that distinguishes
    academic medical centers and teaching hospitals like the University of
    Virginia Medical Center from other healthcare institutions. Congress
    has recognized the critical role that teaching hospitals play in the
    training of America's physicians; however, this key endeavor is very
    expensive. Consequently, Congress has agreed that teaching hospitals
    should be paid for their increased patient care expenses as well as for
    their costs associated with GME training programs. This is accomplished
    through two mechanisms: Direct Graduate Medical Education (DGME)
    payments and the Indirect Medical Education (IME) adjustment.
        The Direct Graduate Medical Education payment (DGME) is a Medicare
    payment intended to reimburse teaching hospitals directly for resident
    stipends, the costs of teaching by attending physicians, the expenses
    incurred with educational classrooms and the administrative costs of
    the residency program office. Medicare DGME payments are based upon the
    number of residents and the number of Medicare beneficiaries in the
    hospital (i.e., it does not cover the entire cost of teaching to the
    institution.) Currently UVa Medical Center is reimbursed under DGME for
    approximately 38 percent of the cost of training each resident.
        The Indirect Medical Education adjustment (IME) was created in 1983
    by Congress. ``This adjustment is provided in light of doubts . . .
    about the ability of the DRG case classification system to account
    fully for factors such as severity of illness of patients requiring the
    specialized services and treatment programs provided by teaching
    institutions and the additional costs associated with the teaching of
    residents . . . . The adjustment for indirect medical education costs
    is only a proxy to account for a number of factors which may
    legitimately increase costs in teaching hospitals.'' (House Ways and
    Means Committee Report, No. 98-25, March 4, 1983 and Senate Finance
    Committee Report, No. 98-23, March 11, 1983).
        The IME adjustment is based on a complex formula that was
    empirically determined to be related to the ratio of residents to beds
    (IRB). The hospital's IME payment is determined by its individual
    intern/resident-to-bed ratio in a formula established under the
    Medicare statute. For every Medicare case paid, a teaching hospital
    receives an additional IME payment, calculated as a percentage add-on
    to the basic price per case. In 1983, payments added 11.59 percent to
    each DRG amount for every 10 percent increase in the IRB. The IME
    adjustment as originally calculated, in conjunction with DGME payments,
    more satisfactorily reimbursed teaching hospitals for the cost of
    training the next generation of doctors. However, the Balanced Budget
    Act of 1997 (BBA) caused the IME adjustment to substantially decline.
    Over time, Congress has periodically reduced the adjustment--by 30
    percent since 1997--to the current 5.5 percent adjustment.
        According to the American Association of Medical Colleges (AAMC),
    the Medicare program annually provides about $3 billion in DGME
    payments and $6 billion in IME payments to nearly 1,100 teaching
    hospitals. While these payments represent less than 2 percent of total
    Medicare payments, for teaching hospitals they are extremely important
    in supporting the mission of training physicians. These payments
    provide the backbone for our Nation's healthcare system, and they
    ultimately contribute to better patient care by providing the support
    necessary for excellent training programs.
        The BBA also capped the number of resident slots that Medicare will
    support. It limited the number of allopathic and osteopathic resident
    physicians who may be counted for purpose of calculating IME and DGME
    reimbursement to the number that the teaching hospital reported on its
    1996 Medicare cost report. This cap is preventing academic medical
    centers and teaching hospitals from expanding the number of residents
    and fellows even while the Nation continues to suffer a physician
    shortage. At a time when we should be producing more physicians,
    especially in the key areas mentioned previously, this outdated rule is
    thwarting our efforts.
        The University of Virginia Medical Center trains more than 750
    residents and fellows each year. It is significantly over its Medicare
    limit or cap for training slots. For purposes of Direct Graduate
    Medical Education, the University of Virginia's cap is 538 residents,
    and it is 121 positions over its cap; for purposes of Indirect Graduate
    Medical Education, the University of Virginia's cap is 508 residents,
    and it is 131 positions over its cap. The cost of training a resident
    is approximately $100,000 per year, thus, the University of Virginia
    Medical Center is spending about $12,100,000 per year on resident
    positions over the cap.
        Graduate Medical Education training helps ensure that healthcare
    delivery in the United States continues to be the highest quality. The
    additional costs incurred at teaching hospitals for the training of
    tomorrow's doctors are real and should be reimbursed at a level
    commensurate with the expense. Without specific appropriate
    reimbursement from Medicare, teaching hospitals will run deficit
    budgets and be forced to cut the very programs that differentiate them
    and allow them to provide the best and most innovative care.
    Challenges Facing Graduate Medical Education
        Recently, the National Commission on Fiscal Responsibility and
    Reform recommended reducing the IME adjustment from 5.5 percent to 2.2
    percent annually, which represents an approximate two-thirds cut in the
    IME payment. The potential loss of approximately two-thirds support
    from the Federal Government would severely compromise the ability of
    the University of Virginia Medical Center, and other academic medical
    centers, to fund this crucial educational mission. The estimated impact
    of this reduction on the University of Virginia Medical Center is
    approximately $26,700,000 per year.
        Although we recognize the importance of a balanced Federal budget
    and the need to control healthcare spending, reducing the funds
    available for training future physicians will lead to a severe lack of
    access to healthcare in the near future. This will occur at the very
    time that hospitals are being asked to expand access to care.
        For example, the Patient Protection and Affordable Care Act (i.e.,
    the healthcare reform law) will provide health insurance coverage to 32
    million more Americans; however, health insurance does not guarantee
    timely access to care. There must be a well trained workforce to care
    for the additional patients to ensure that implementation of the new
    healthcare reform law is successful. Unfortunately, the United States
    is already experiencing a shortage of physicians. As healthcare reform
    is fully implemented and the population of the United States continues
    to age, the shortage of physicians is expected to worsen. By 2020 the
    demand for physicians will significantly outweigh the supply. According
    to the AAMC's Center for Workforce Studies, by 2020 there will be a
    shortage of 45,000 primary care physicians, and a shortage of 46,000
    surgeons and medical specialists.
        Only 700 Medicare-funded training slots were awarded during the
    most recent reallocation authorized by the healthcare reform law. Most
    teaching hospitals, including the University of Virginia, did not
    receive any additional Medicare-funded residency slots. Unless the cap
    is increased or lifted, it is expected that there will be more medical
    school graduates than residency positions in the near future. Indeed,
    in its April GME e-letter (http://www.ama-assn.org/resources/doc/med-
    ed-products/gmee-04-2011.pdf) the American Medical Association stated
    that we may have already reached the point where U.S. medical school
    graduates are not able to find a residency position because there are
    now more graduates than available GME slots.
        Specifically, the University of Virginia School of Medicine, along
    with dozens of medical schools nationally, has increased class size to
    meet the needs of the impending workforce shortages. However, medical
    students looking to join a residency program have begun to face a
    significant bottleneck after graduation. While institutions like the
    University of Virginia are graduating exceptional medical students, the
    University of Virginia Medical Center can only accept a finite number
    Medicare-funded residency positions due to the cap. Thus, the shortage
    of open residency positions for medical students creates another
    barrier to the supply of well-trained physicians.
        To address the severe doctor shortage crisis facing the United
    States and to ensure that there is a well-trained healthcare workforce
    to successfully care and treat the increasing number of patients in the
    future, it is critical that Congress support Graduate Medical Education
    by increasing the number of resident slots available for medical
    students, and continue to invest in Graduate Medical Education. I
    respectfully request that this committee do everything within its
    jurisdiction to achieve these important goals.
                                     ______

               Prepared Statement of the Tri-Council for Nursing
        The Tri-Council for Nursing, comprised of the American Association
    of Colleges of Nursing, the American Nurses Association, the American
    Organization of Nurse Executives, and the National League for Nursing,
    respectfully request $313.075 for the Nursing Workforce Development
    programs authorized under Title VIII of the Public Health Service Act
    (42 U.S.C. 296 et seq.) in fiscal year 2012. This is the amount
    requested in the recommended funding levels for the President's fiscal
    year 2012 budget.
        The Tri-Council is a long-standing nursing alliance focused on
    leadership and excellence in the nursing profession. This marks the
    13th year of the nurse and nurse faculty shortages which have eroded
    the ability of the nursing profession to provide the highest quality of
    care that all patients rightfully desire and morally deserve. As the
    Nation looks toward restructuring the healthcare system by focusing on
    expanding access, decreasing cost, and improving quality, a significant
    investment must be made in strengthening the nursing workforce, a
    profession which The U.S. Bureau of Labor Statistics expects a 22
    percent growth in employment through 2018.
                                     ______

              Prepared Statement of the United Negro College Fund
        Mr. Chairman and distinguished Members of the subcommittee, I am
    Dr. Michael L. Lomax, President and CEO of UNCF--the United Negro
    College Fund. I want to thank you for allowing me to submit funding
    recommendations and priorities relevant to the fiscal year 12 Labor-
    HHS-Education Appropriations bill.
        Statistically, HBCUs graduate a preponderant share of all black
    Americans receiving postsecondary degrees. While comprising only 3
    percent of the Nation's 4,197 institutions of higher learning, the 106
    HBCUs are responsible for producing approximately 25 percent of all
    bachelor's degrees, 10 percent of all master's degrees and 26 percent
    of all first professional degrees earned by African Americans annually.
        UNCF institutions are a critical component and significant subset
    of the larger community of HBCUs. Specifically, UNCF is the national
    fundraising and advocacy representative for 38 private historically
    black colleges and universities. There are more than 350,000 persons
    who are counted as alumni of UNCF member colleges and universities. Our
    alumni include persons such as Rev. Dr. Martin Luther King, Jr., Brown
    University President Dr. Ruth Simmons, three former surgeon generals,
    numerous current Members of Congress and a host of noted authors,
    poets, attorneys, professors and philanthropists.
        UNCF--the Nation's oldest and most successful minority higher
    education assistance organization--fulfills its primary goal by
    increasing opportunities for access to higher education. During its 66-
    year existence, UNCF has raised more than $3 billion to support its
    historically black college and university member institutions and
    administered nearly 400 programs, including scholarships, mentoring
    programs, summer enrichment, study abroad, curriculum, faculty, and
    leadership development. Today, UNCF supports more than 65,000 students
    at over 900 colleges and universities across the country.
        We recognize that working with the Administration and Congress will
    continue to be particularly challenging in a budget-constrained
    environment where more diverse students with unique academic and
    familial circumstances are dependent upon need-based aid. The face of
    our Nation is changing and nowhere is the change more evident than in
    education. Compared with the last century, we are increasingly changing
    with more of us being born in other nations, speaking other languages
    and carrying different cultures. Minority
        populations are growing more quickly than the U.S. population as a
    whole. In keeping with this, UNCF continues to endorse the following
    policies and positions as the focal point of its legislative agenda for
    fiscal year 2012. These recommendations continue a basic commitment to
    enrolling, nurturing, and graduating students, some of whom lack the
    social, educational, and financial advantages of other college bound
    populations. This agenda reflects what is needed to level the playing
    field for both UNCF member schools and students as we continue to
    pursue educational excellence.
        The following fiscal year 2012 programs are of particular relevance
    and importance to UNCF.
    Title III, Part B, Strengthening Historically Black Colleges and
            Universities--$267 million (Section 323)
        Because of its flexibility, this program is the fundamental source
    of institutional assistance for HBCUs and is used to support strategic
    planning initiatives, academic enhancements, administrative and fiscal
    management, student services, physical plant improvements, and general
    institutional development.
        The current level of funding to Title III, Part B must be
    maintained in order to continue to enhance and sustain the quality of
    HBCUs, and to meet the national challenges associated with global
    competitiveness, job creation and changing demographics. For fiscal
    year 2012, UNCF requests $267 million to support Section 323.
    Title III, Part D, HBCU Capital Financing Program--a minimum of $20.58
            million, plus increase the statutory cap to at least $1.7
            billion. Bill language is needed to make funding available to
            institutions that have a need but fall into a category that has
            exhausted resources within the current cap of $1.1 billion.
        Funded through Title III, Part D of the Higher Education Act, the
    HBCU Capital Financing Program is intended to provide low-interest
    capital financing loans to historically disadvantaged institutions
    throughout the HBCU community. In light of economic hardships and
    challenges confronting several of our member institutions, UNCF has
    worked with national stakeholders, officials at the Department of
    Education, and Congressional leadership to propose a comprehensive
    revision of the capital financing provisions.
        For fiscal year 2012, UNCF requests at least $20.58 million to
    allow the Secretary to support the administration of additional loans
    through the Capital Financing Program. Further, we request the
    assistance of Federal leaders in working with the HBCU Capital
    Financing Board to ensure that recommendations made to Congress will
    promote increased participation within the program among all eligible
    institutions.
    The Hawkins Centers of Excellence Program--$40 million
        Under this budget proposal, the Administration proposes giving
    grants to minority-serving institutions to prepare teachers by
    providing extensive training, creating a system for tracking program
    graduates and raising exit standards. The Centers are named after the
    recently deceased Augustus F. Hawkins in honor of his historic
    leadership as a champion for expanding education as well as job
    opportunity.
        For fiscal year 2012, UNCF requests $40 million to implement the
    Hawkins Centers of Excellence Program. This program would help expand
    the pool of effective minority teachers thus working to close the
    achievement gap for minority students.
    Pell Grants Program--$5,550 (current maximum reward)
        This program assists so many deserving students in getting into
    college. As college costs increase, the amount of jobs available to
    solely high school graduates is rapidly decreasing. It is imperative to
    preserve the maximum award of $5,550 and continue to fund Pell at the
    appropriate level. The budget would call for a cut of $100 billion in
    Pell grants over 10 years, paid for by eliminating the ``Two Pell''
    benefits and the in-school interest subsidy for graduate and
    professional student loans.
        For fiscal year 2012, UNCF requests the current maximum awards of
    $5,550 to continue the support of the Pell Grants Program. Maintaining
    the maximum Pell award is critical to ensure that the growing pool of
    first generation and low income college students are provided much
    needed financial support to access higher education and minimize the
    burden of costly education loans.
        UNCF and our member schools have, among them, many years of
    experience in making the dream of a college education a reality for
    low-income students and the colleges they attend. My staff and I, as
    well as the presidents of our member schools, stand ready to continue
    to work closely with your committee to formulate and craft a plan that
    will work for all the young people who are seek and deserve college
    education.
                                     ______

           Prepared Statement of the United Network for Organ Sharing
        Highlighting the urgent need to address the ever-growing waiting
    list for organs for transplantation and the number of people that die
    every day just waiting for an organ, by strengthening programs at HRSA,
    the National Institutes of Health and within the Office of the
    Secretary.
        Mr. Chairman and Members of the Subcommittee, thank you for giving
    the United Network for Organ Sharing (UNOS) the opportunity to provide
    testimony as the Subcommittee begins to consider funding priorities for
    fiscal year 2012. My name is Mary Ellison and I am the Acting Executive
    Director of UNOS, the organization with the Federal contract to
    coordinate the Nation's organ transplant system, providing vital
    services to meet the needs of men, women and children awaiting
    lifesaving organ transplants. Based in Richmond, Virginia, UNOS is a
    private, nonprofit membership organization. UNOS members encompass
    every transplant hospital, tissue matching laboratory and organ
    procurement organization in the United States, as well as voluntary
    health and professional societies, ethicists, transplant patients and
    organ donor advocates.
        Transplantation has saved and enhanced the lives of more than
    450,000 people in the United States. It is the leading form of
    treatment for many forms of end-stage organ failure. With this success,
    however, has come increasing demand for donated organs. Living donation
    (transplanting all or part of an organ from a living person) has
    increased dramatically in the last few years, helping increase the
    number of transplants performed. In addition, UNOS has enacted a number
    of policies to encourage more efficient use of available organs, such
    as ``splitting'' livers from deceased donors to allow two recipients to
    be transplanted. The only long-term solution to the organ shortage,
    however, is for more people to agree to become organ donors. UNOS works
    closely with medical professionals to increase their understanding and
    support of the organ donation process.
        Mr. Chairman, as you know the primary Federal agency with
    jurisdiction over organ transplantation issues is the Health Resources
    Services Administration. However, as we will describe below, the Office
    of the Secretary and NIH also have important roles to play to help
    people in need of an organ transplant.
    Health Resources Services Administration
        Even with advances in the use of living liver donors, the increase
    in the demand for organs needed for transplantation will continue to
    exceed the number available. The need to increase the rate of organ
    donation is critical. On April 11, 2011 there were 110,676 men, women
    and children on the national transplantation waiting list. Last year an
    average of 74 patients were transplanted each day; however a daily
    average of 18 patients died because the organ they needed did not
    become available in time to save them. HRSA's Division of
    Transplantation has a proven track record of successfully increasing
    the rate of organ donation with limited resources.
        Recognizing the importance of this issue, Congress passed, and the
    President signed, the Organ Donation and Recovery Improvement Act of
    2004 (Public Law 108-216) authorizing an increase of $25 million for
    organ donation activities in the first year, and such sums as necessary
    in following years, and yet, it was only last year that additional
    funding of $1 million has been provided to implement this legislation.
    To address these needs, UNOS recommends that the Division of
    Transplantation receive a $2 million increase in fiscal year 2012, to
    allow the Division to more aggressively pursue program efforts to
    increase the supply of organs available for transplantation.
        In addition, the shortage of organs for donation can be positively
    impacted by healthcare professionals, particularly physicians, nurse,
    and physician assistants that are frequently the first to identify and
    refer a potential donor. These professionals also have an established
    relationship with the family members that weigh the option to donate
    their loved one's organs. In order to improve the knowledge and skills
    of the several key health professions, UNOS requests funding to develop
    curriculum and continuing medical education programs for targeted
    health professions. To launch a new 5 year effort to improve the
    competency of health professionals to help meet the goal of increasing
    the number or organs available for transplantation $450,000 is
    requested for the United Network for Organ Sharing (UNOS) to be made
    available from within the base funding of the Division of Health
    Professions based on the authority provided in Section 765 of Title VII
    to improve the workforce.
    Office of the Secretary
        On March 3, 2008 the Department published a request for information
    in the Federal Register to gather information to assist the Department
    to determine whether it should engage in a rulemaking with respect to
    vascularized composite allografts (VCAs). Three years later, the
    Department still has not finalized this decision. As it currently
    stands, the Food and Drug Administration has jurisdiction over VCA
    transplants, as they are currently defined as human tissue. However, as
    the numbers of these transplants are growing, finalizing the decisions
    associated with this issue and allowing HRSA's Division of
    Transplantation to have jurisdiction over VCA's will permit this
    category of transplants to benefit from the policy oversight and
    expertise of the Organ Procurement Transplant Network (OPTN).
        Worldwide there have been more than two dozen limb transplants, a
    growing number of transplants of portions of the face, and a small
    number of transplants of other anatomical parts. Although the body
    parts vary significantly, they share important common characteristics
    with organ transplantation. As with organs, the VCA graft is subject to
    damage or death from the lack of blood flow and the need for
    revascularization is done through a surgical reconnection of blood
    vessels. Additionally, all the expertise and skills of healthcare
    professional trained to work with families, individuals and hospitals
    in the organ donation and procurement process are also needed in the
    donation and procurement of VCAs. All of these vital activities are
    already performed and overseen by the organ transplant community.
    Further, for 25 years the OPTN has overseen the processes and crafted
    policies to regulate them under Federal contract. It therefore seems
    logical, efficient and will serve the best interests of patients and
    the Nation's transplant system to bring VCAs under the umbrella of the
    OPTN.
        UNOS urges the Office of the Secretary to take action on this
    decision, and issue the rule and begin the necessary process of
    amending the definition of human organs. This is especially critical
    given the recent activities of private entities that, lacking Federal
    leadership, have begun taking the necessary steps to form registries
    for VCAs. As we learned over 20 years ago when the OPTN was
    established, it is crucial to have Government oversight over registries
    such as this in order to establish fair and ethical distribution of
    body parts.
    National Institutes of Health
        Mr. Chairman, as you know, the National Institute of Allergy and
    Infectious Diseases has jurisdiction over transplantation research at
    the NIH. Recent research funded by NIAID has resulted in the
    development of desensitization protocols related to kidney
    transplantation that have shown remarkable progress in helping allow
    the most vulnerable of patients live with a transplant. Up to 30
    percent of the people on the renal transplant waiting list--without
    special intervention--will likely never have the chance to receive a
    transplant due to an inability to find a compatible donor. These
    patients have become ``sensitized'' to human antigens (HLA) through
    pregnancy, transfusions, or prior transplants and therefore must wait
    significantly longer for a compatible donor. This added time on the
    wait list directly increases both their disease-related complications
    and mortality.
        To improve access to transplantation for most these broadly
    sensitized patients, desensitization protocols have evolved to decrease
    the breadth and strength of their antibodies. Survival rates are
    excellent, equaling or exceeding the rates for kidney transplantation
    generally. It is reasonable to estimate that if these protocols were
    confirmed to be as safe and effective as early peer reviewed data has
    suggested, a large number of these long-suffering people could be
    successfully transplanted and removed from the waiting list each year.
    UNOS recommends that NIAID support a multi-center initiative with a
    companion data collection and analysis center to facilitate the use of
    this protocol at an increasing number of transplant centers across the
    country.
    Summary and Conclusion
        Mr. Chairman, again we wish to thank the Subcommittee for the
    opportunity to submit testimony and for your leadership in these
    difficult times. While UNOS recognizes the demands on our Nation's
    resources, we believe the ever-growing waiting list for organs for
    transplantation, and the number of people that die every day just
    waiting for an organ, continue to justify higher funding levels for
    HRSA's Division of Transplantation.
        In conclusion, we specifically request the following for fiscal
    year 2012:
      --A $2 million increase for HRSA's Division of Transplantation;
      --$450,000 from within the base funding of the Division of Health
            Professions to develop curriculum and continuing medical
            education programs for targeted health professions;
      --Report language urging the Office of the Secretary to finalize a
            decision to amend the definition of human organs to include
            vascularized composite allografts, and allow this category to
            come under the umbrella of the OPTN; and
      --Report language within the National Institute of Allergy and
            Infectious Disease to support a multi-center initiative focused
            on ``desensitizing ``patients previously found incompatible
            with most human organs.
                                     ______

           Prepared Statement of the United Tribes Technical College
        For 42 years, United Tribes Technical College (UTTC) has provided
    postsecondary career and technical education, job training and family
    services to some of the most impoverished, high risk Indian students
    from throughout the Nation. We are governed by the five tribes located
    wholly or in part in North Dakota. We are not part of the North Dakota
    State college system and do not have a tax base or State-appropriated
    funds on which to rely. We have consistently had excellent retention
    and placement rates and are a fully accredited institution. Section 117
    Carl Perkins Act funds represent about half of our operating budget and
    provide for our core instructional programs. The requests of the United
    Tribes Technical College Board for fiscal year 2012 is for the
    following authorized Department of Education programs:
      --$10 million for base funding authorized under Section 117 of the
            Carl Perkins Act for the Tribally Controlled Postsecondary
            Career and Technical Institutions program (20 U.S.C. Section
            2327). This is $1.8 million above the fiscal year 2010 level
            and the President's requests for fiscal years 2011 and 2012.
            These funds are awarded competitively and are distributed via
            formula.
      --$30 million as requested by the American Indian Higher Education
            Consortium for Title III-A (Section 316) of the Higher
            Education Act (Strengthening Institutions program).
      --Maintain Pell Grants at the $5,550 maximum award level.
                                 authorization
        United Tribes Technical College began operations in 1969. We
    realized that in order to more effectively address the unique needs of
    Indian people to acquire the academic knowledge and skills necessary to
    enter the workforce we needed to expand our curricula and services. We
    were scraping by with small amounts of money from the Bureau of Indian
    Affairs, and so decided to work for an authorization in the Department
    of Education. That came about in 1990 when the Carl Perkins Act was
    reauthorized and it included specific authorization for what is now
    called the Tribally Controlled Postsecondary Career and Technical
    Institutions program (Section 117). The Perkins Act has been
    reauthorized twice since then--in 1998 and in 2006, with Congress each
    time continuing the Section 117 Perkins program.
        Some Important Facts About United Tribes Technical College.--We
    have:
      --A dedication to providing an educational setting that takes a
            holistic approach toward the full spectrum of student needs--
            educational, cultural, necessary life skills--thus enhancing
            chances for success.
      --Services including campus security, a Child Development Center, a
            family literacy program, a wellness center, area
            transportation, a K-8 elementary school, tutoring, counseling,
            and family and single student housing.
      --A semester completion rate of 80-90 percent.
      --A graduate placement rate of 94 percent (placement into jobs and
            higher education).
      --A projected return on Federal investment of 20-1 (2005 study).
      --Highest level of accreditation from the North Central Association
            of Colleges and Schools.
      --Over 30 percent of our graduates move on to 4-year or advanced
            degree institutions.
      --A student body representing 87 tribes who come mostly from high-
            poverty, high unemployment tribal nations in the Great Plains;
            many students have children or dependents.
      --81 percent of undergraduate students receive Pell Grants, the
            highest percentage of Pell Grant recipients of any North Dakota
            college.
      --21 2-year degree programs, eight 1-year certificates, and 3
            bachelor degree programs pending final accreditation this
            spring.
      --An expanding curricula to meet job-training needs for growing
            fields including law enforcement, energy auditing and health
            information management. We have also broadened our online
            program offerings.
      --A critical role in the regional economy. Our presence brings $31.8
            million annually to the economy of the Bismarck region.
      --A workforce of over 300 people.
      --An award-winning annual powwow which last year had participants
            from 70+ tribes, featuring over 1,500 dancers and drummers, and
            drawing over 20,000 spectators. We annually feature indigenous
            dance groups from other countries.
                                funding requests
        Section 117 Perkins Base Funding.--Funds requested under Section
    117 of the Perkins Act above the fiscal year 2010 level are needed to:
    (1) maintain 100 year-old education buildings and 50 year-old housing
    stock for students; (2) upgrade technology capabilities; (3) provide
    adequate salaries for faculty and staff (who have not received a cost
    of living increase for the past 2 years and who are in the bottom
    quartile of salary for comparable positions elsewhere); and (4) fund
    program and curriculum improvements, including at least three 4-year
    degree programs.
        Acquisition of additional base funding is critical as UTTC has more
    than tripled its number of students within the past 8 years while
    actual base funding, including Interior Department funding, have not
    increased commensurately (increased from $6 million to $8 million for
    the two programs combined). Our Perkins funding provides a base level
    of support while allowing the college to compete for desperately needed
    discretionary contracts and grants leading to additional resources
    annually for the college's programs and support services.
        Title III-A (Section 316) Strengthening Institutions.--We support
    Title III-A funding for tribal colleges. Among its statutorily
    allowable uses is facility construction and maintenance. We are
    constantly in need of additional student housing, including family
    housing. We work hard to cobble together various sources for housing
    construction. We would like to educate more students but lack of
    housing has at times limited the admission of new students. With the
    completion this past year of a new Science and Math building on our
    South Campus on land acquired with a private grant, we urgently need
    housing for up to 150 students, many of whom have families. New housing
    on the South Campus could also accommodate those persons we expect to
    enroll in a new police training program.
        While UTTC has constructed three housing facilities using a variety
    of sources in the past 20 years, approximately 50 percent of students
    are housed in the 100-year-old buildings of the old Fort Abraham
    Lincoln, as well as in duplexes and single family dwellings that were
    donated to UTTC by the Federal Government along with the land and Fort
    buildings in 1973. These buildings require major rehabilitation. New
    buildings for housing are actually cheaper than trying to rehabilitate
    the old buildings that now house students.
        Pell Grants.--We support maintaining the Pell Grant maximum amount
    to at least a level of $5,550. As mentioned above, 81 percent of our
    students are Pell Grant-eligible. This program makes all the difference
    in the world of whether these students can attend college. We also
    support the continuation of appropriations to fund two scheduled award
    years per year, as this has helped many of our students shorten the
    time to obtain their degrees.
                    government accountability office report
        As you know, the Government Accountability Office (GAO) in March of
    this year issued two reports regarding Federal programs which may have
    similar or overlapping services or objectives (GAO-11-318SP of March 1
    and GAO-11-474R of March 18). Funding from the Bureau of Indian
    Education (BIE) and the Department of Education's Perkins Act for
    Tribally Controlled Postsecondary Career and Technical Institutions
    were among the programs listed in the supplemental report of March 18.
    The GAO did not recommend defunding these or other programs; in some
    cases consolidation or better coordination of programs was recommended
    to save administrative costs. We are not in disagreement about possible
    consolidation or coordination of the administration of these funding
    sources so long as funds are not reduced.
        Perkins funds represent about 46 percent of UTTC's core operating
    budget. The Perkins funds supplement, but do not duplicate, the BIE
    funds. It takes both sources of funding to frugally maintain the
    institution. In fact, even these combined sources do not provide the
    resources necessary to operate and maintain the college. Therefore,
    UTTC actively seeks alternative funding to assist with academic
    programming, deferred maintenance of its physical plant and scholarship
    assistance, among other things.
        Second, as mentioned, UTTC and other tribally chartered colleges
    are not part of State educational systems and do not receive State-
    appropriated general operational funds for their Indian students. The
    need for postsecondary career and technical education in Indian Country
    is so great and the funding so small, that there is little chance for
    duplicative funding.
        There are only two institutions targeting American Indian/Alaska
    Native career and technical education and training at the postsecondary
    level--United Tribes Technical College and Navajo Technical College.
    Combined, these institutions received less than $15 million in fiscal
    year 2010 Federal funds ($8 million from Perkins; $7 million from the
    BIE). That is not an excessive amount of money for two campus-based
    institutions which offer a broad (and expanding) array of programs
    geared toward the educational and cultural needs of their students and
    toward job-producing skills.
        UTTC offers services that are catered to the needs of our students,
    many of whom are first generation college attendees and many of whom
    come to us needing remedial education and services to address the
    sociobehavioral, socioeconomic, and academic characteristics that pose
    problems. Our students disproportionately possess more high risk
    characteristics than other student populations. We also provide
    services for the children and dependents of our students. Although BIE
    and Section 117 funds do not pay for remedial education services, UTTC
    must make this investment with our student population through other
    sources of funding to ensure they succeed at the postsecondary level.
        Federal funding for American Indian/Alaska Native employment and
    training is barely 1 percent of the annual Federal employment and
    training budget but has an enormous impact on the people and
    communities it serves.
        Perkins funds are central to the viability of our core
    postsecondary educational programs. Very little of the other funds we
    receive may be used for core career and technical educational programs;
    they are competitive, often one-time supplemental funds which help us
    provide the services our students need to be successful. We cannot
    continue operating without Carl Perkins funds. Thank you for your
    consideration of our requests.
                                     ______

        Prepared Statement of the U.S. Hereditary Angioedema Association
        Thank you for the opportunity to present the views of the U.S.
    Hereditary Angeioedema Association (USHAEA) regarding the importance of
    hereditary angioedema (HAE) research.
        USHAEA was founded in 1999 with the express purpose of helping
    those living with HAE and their families to live healthy lives, provide
    support, and find a cure. The Association provides patient services to
    those living with HAE, including referrals to knowledgeable healthcare
    providers and information on the disease. USHAEA also provides research
    funding to scientific investigators to increase the knowledge base on
    HAE. Additionally, USHAEA also provides research materials and forums
    to educate the patients and their families, healthcare providers, and
    the general public on HAE. Finally, USHAEA acts as a voice for those
    living with HAE to the world at large.
        HAE is caused by a genetic defect which controls C1-Inhibitor blood
    protein, causing an inability to regulate complex biochemical
    interactions in blood-based systems involved in disease fighting,
    inflammatory response, and coagulation. Episodes of HAE are
    characterized by swelling in the body including the hands, feet,
    gastrointestinal tract, face, and airway. During an episode, HAE
    patients experience abdominal pain, nausea, vomiting, and airway
    swelling, which can lead to asphyxiation. Episodes are often caused by
    infections, minor injuries or dental procedures, emotional or mental
    stress, and certain hormonal or blood medications. HAE impacts
    approximately 1 in 10,000 to 1 in 50,000, making proper diagnosis
    difficult. Many of the initial HAE episodes occur in children and
    adolescents. In families were one parent has HAE, there is a 50 percent
    probability that their children will inherit this condition. HAE has an
    annual cost which can exceed $500,000 per year per patient in addition
    to the human and economic burdens associated with the disease.
    Research Through the National Institutes of Health
        In years past, HAE research was conducted at the National
    Institutes of Health (NIH) through the National Institute of Allergy
    and Infectious Diseases, the National Institute of Neurological
    Disorders and Stroke, the National Heart, Lung, and Blood Institute,
    the National Institute of Child Health and Human Development, National
    Center for Research Resources, and the National Institute on Diabetes
    and Digestive and Kidney Diseases. However, NIH has not engaged in any
    basic or clinical research on HAE since 2009, nor is there any Federal
    research as it relates to HAE. As a rare disease, HAE stands to benefit
    from from recent NIH commitments such as the Cures Acceleration Network
    and the Therapeutics for Rare and Neglected Diseases program, as well
    coordination with the Office of Rare Diseases Research.
        In order to enable research to resume on HAE, it is vital that NIH
    receive increased support in fiscal year 2012. USHAEA recommends an
    overall funding level of $35 billion for NIH in fiscal year 2012 and
    the inclusion of recommendations emphasizing the importance of HAE
    research.
        Thank you for the opportunity to present the view of the HAE
    community.
                                     ______

                         Prepared Statement of YWCA USA
        Thank you Chairman Harkin, Ranking Member Shelby and members of the
    Subcommittee for the opportunity to submit testimony. My name is Gloria
    Lau, and I am the Chief Executive Officer of the YWCA USA. As Congress
    works on the appropriations and priorities for the fiscal year 2012
    Federal budget, I am here to speak about one priority in particular
    under the jurisdiction of this subcommittee: the critical need for
    childcare for women and families.
        The YWCA USA is a national not-for-profit (501(c)(3)) membership
    organization committed to social service, advocacy, education,
    leadership development, economic empowerment and racial justice. The
    YWCA is dedicated to eliminating racism, empowering women and promoting
    peace, justice, freedom and dignity for all. We represent more than 2
    million women and girls, and we can be found in many communities in the
    United States. With nearly 300 local associations nationwide, we serve
    thousands of women, girls, and their families annually through a
    variety of programs; including violence prevention and recovery
    programs, housing programs, job training and employment programs,
    childcare and early education programs, and more. Our clients include
    women and girls from all walks of life, including those escaping
    violence, low-income women and children, women veterans, elderly women,
    disabled women, and homeless women and their families.
        The YWCA is one of the largest providers of childcare in the United
    States. Many of our associations provide accessible, affordable, and
    high-quality childcare services to working families nationwide. In one
    example close to the Nation's Capital, the YWCA of Baltimore, Maryland,
    an association committed to providing quality childcare for all
    children, serves more than 600 children annually. At this and other
    YWCA childcare centers, the day is designed to meet the developmental
    needs and the interests of each child. Each day includes a variety of
    intellectual, physical, social, emotional, and creative activities as
    well as opportunities to interact with other children and adults. In
    another example, the childcare program at the YWCA in Lawrence,
    Massachusetts has been ranked in the top 10 childcare programs in
    Massachusetts by Root Cause, an organization that encourages social
    innovation and helps corporations source exceptional programs. Starting
    with this program, many children join YWCA as infants or toddlers and
    stay in programming into their teen years, which provides continuity of
    care for children and siblings. Finally, at the YWCA Greater
    Cincinnati, the State of Ohio has recognized that association's
    programs with a three-star rating for having met all State benchmarks
    for quality. If members of the Subcommittee wish, we can provide you
    far more examples of how YWCAs are providing quality childcare critical
    to the country's children and their families.
        As a major provider of childcare throughout the United States, the
    YWCA is a strong supporter of the Childcare Development Block Grant
    (CCDBG). Across the country, YWCAs use CCDBG funding for a variety of
    programs, including childcare for infants and toddlers, and before- and
    after-school care for children in school. CCDBG also provides childcare
    subsidies for low-income and moderate-income YWCA clients who attend
    our job training programs, live in our housing facilities, or are
    served by domestic violence and sexual assault programs. Every day, in
    communities across this country, we witness the important role CCDBG
    plays in helping parents find and keep employment and in helping
    children learn and grow.
        Because of our strong support for the CCDBG, the YWCA asks the
    Subcommittee to concur--at a minimum--with the President's fiscal year
    2012 funding request, which includes $2.9 billion for the CCDBG in the
    Department of Health and Human Services. This call for support comes
    directly from communities across the country, as local YWCA
    associations surveyed in December 2010 identified this vital block
    grant as one of their most critical funding sources. We also support
    Head Start and Early Head Start, which the President has requested for
    fiscal year 2012 at $8.1 billion and which rounds out the continuum of
    services for young children and their families.
        The YWCA wholeheartedly supports the core purpose of the CCDBG,
    which is to help make quality childcare affordable for low-income and
    moderate-income women and families, through block grant funding for
    States and tribes. CCDBG is not a cookie-cutter/one size fits all
    program: it provides States flexibility in developing childcare
    programs and policies most appropriate to fulfill the needs of children
    and parents within that State, as well as empowers working parents to
    make their own decisions on childcare services that best suit their
    family's needs. CCDBG helps keep parents educated about their childcare
    options through consumer information so that they can make informed
    choices, while helping them to achieve economic stability and
    independence.
        The need is simple--if working parents do not have access to
    affordable, quality childcare for their children, they cannot be full
    contributors to the economy. Each week, more than 11 million children
    under 5 years of age are in some type of childcare setting \1\.
    ---------------------------------------------------------------------------
        \1\ U.S. Census Bureau, 2006-2008 American Community Survey. U.S.
    Census Bureau. (2008, March). Who's minding the kids? Childcare
    arrangements: Spring 2005: Detailed tables. Retrieved April 19, 2010,
    from http://www.census.gov/population/www/socdemo/child/ppl-2005.html.
    ---------------------------------------------------------------------------
        The problem is: childcare costs are high--compared to family income
    and household expenses--and they are growing. The average amount
    parents paid for full-time care for an infant in a center ranged from
    more than $4,560 in Mississippi to more than $18,773 a year in
    Massachusetts ($5,356 in Alabama and $8,273 a year in Iowa) \2\.
    Furthermore, the average center-based childcare fees for an infant
    exceeded the average annual amount that families spent on food in every
    region of the country. In addition, childcare fees per month for two
    children of any age exceeded the median monthly amount for rent, and
    were nearly as high, or even higher than, the average monthly mortgage
    payment in every State. YWCAs offer quality childcare at a low cost to
    the families they serve, but many of them would have to turn people
    away or simply end programs without State CCDBG funds. This, in turn,
    would result in parents losing childcare which would impact their
    ability to work and could possibly result in children being placed in
    unfit or unsafe childcare situations, further impacting their ability
    to learn and grow.
    ---------------------------------------------------------------------------
        \2\ Parents and the High Cost of Childcare: 2010 Update from the
    National Association of Childcare Resource and Referral Agencies
    (provides average costs of childcare for infants, 4-year-olds, and
    school-age children in centers and family childcare homes in every
    State), http://www.naccrra.org/publications/naccrra-publications/
    parents-and-the-high-cost-of-child-care.php.
    ---------------------------------------------------------------------------
        Investments in early education are critical to our effort to build
    a smarter and stronger country, even in economic times that call for
    budget-cutting measures. Quality, affordable early childhood care and
    education result in positive outcomes for children, such as preparing
    them for school and helping parents find and keep jobs. It also
    benefits taxpayers and enhances economic vitality. Research\3\--by
    Nobel Prize-winners and Federal Reserve economists, in economic studies
    in dozens of States and counties, and in longitudinal studies spanning
    40 years--demonstrate that return on public investment in high quality
    childhood education is substantial.
    ---------------------------------------------------------------------------
        \3\ Early Childhood Education for All: A Wise Investment. U.S.
    Census Bureau (2005, April). ``The Economic Impacts of Childcare and
    Early Education: Financing Solutions for the Future;'' a conference
    sponsored by Legal Momentum's Family Initiative and the MIT Workplace
    Center. Retrieved April 7, 2011, from http://web.mit.edu/
    workplacecenter/docs/Full%20Report.pdf.
    ---------------------------------------------------------------------------
        Specifically, it was found that, in the short term, quality,
    affordable childcare provides significant return as an industry:
    employing nearly 3 million people nationwide; providing employees wages
    to spend, pay taxes and purchase goods and services; and enabling
    employers to attract and retain employees and increase productivity. In
    the long term, quality, affordable childcare has been found to result
    in lower costs for remedial and special education and grade repetition;
    higher rates of completing school and building skills; improved job
    preparedness and ability to meet future labor force demands; and higher
    incomes and tax payments from those who complete school.
        As stated in a letter to both of you and the Chair and Ranking
    Member of the Senate Appropriations Committee signed by 17 Senators on
    February 24, 2011, ``noted economists agree that investing in early
    childhood education is fiscally responsible because it yields a
    tremendous return on investment, ranging from $3 to $17 for every
    dollar invested.'' The letter goes on to state, ``Given these gaps and
    the importance of early learning to our country's economic success, the
    American Recovery and Reinvestment Act (ARRA) included a prudent and
    essential expansion of these programs. We strongly believe that
    Congress must build on this progress, not reverse it.'' \4\ The YWCA
    strongly believes that as Congress focuses on effective and efficient
    uses of Federal funds, Congress should not overlook the benefits of
    allocating Federal dollars toward childcare and early education
    programs, particularly to cultivate younger generations.
    ---------------------------------------------------------------------------
        \4\ The letter includes support for Head Start and Early Head
    Start.
    ---------------------------------------------------------------------------
        Congress and several Presidential administrations have historically
    shown strong bipartisan support for CCDBG. Even so, for the 21 years
    CCDBG has been in existence, the program has always been underfunded
    and supply has never met demand. Even before the current economic
    downturn, it was estimated that only 1 in every 7 children who were
    eligible for CCDBG received assistance. It was also not uncommon for
    children and their families to be put on waiting lists, to see their
    assistance cut, or to see it eliminated altogether. The economic
    downturn has exacerbated this already alarming situation as States
    continue to cut back social service programs more than they had been
    scaled back, prior to economic collapse.
        In a positive response, as referred to in the joint Senate letter
    to the Appropriations Committee referenced earlier, the ARRA made a
    major, $2 billion investment in childcare. The significant increase for
    CCDBG included in the President's fiscal year 2012 budget request would
    allow children served by ARRA funding to continue receiving services.
    This level of funding would allow 1.7 million children to receive
    childcare assistance, an increase of 220,000 children--at great relief
    to their working parents. The $1.3 billion increase would translate
    into an increase of $800 million for discretionary funding (which does
    not require a State match) and $500 million for mandatory funding
    (which requires a State match. Approving the President's proposed level
    of funding will ensure positive impact to the working women and
    families that are an essential part of our Nation's economic recovery.
        The need for and importance of investments in childcare and early
    childhood education, including CCDBG funding, to the viability of our
    country is now greater than ever. In addition, the current budget
    crises facing States across this Nation illustrate why Federal
    investments in quality childcare and early educations programs are both
    necessary and vital. For example, the National Women's Law Center
    (NWLC) reported on April 7, 2011 \5\, States have begun to cut back on
    childcare assistance:
    ---------------------------------------------------------------------------
        \5\ Additional Childcare Funding Essential to Prevent State Cuts
    from the National Women's Law Center. Retrieved April 8, 2011, from
    http://www.nwlc.org/resource/additional-child-care-funding-essential-
    prevent-state-cuts.

        ``Until recently, most States have managed to maintain their
    childcare assistance programs, largely thanks to an additional $2
    billion in Childcare Development Block Grant (CCDBG) funding for fiscal
    year 2009 and fiscal year 2010 from the American Recovery and
    Reinvestment Act (ARRA). However, as States exhaust these funds, and as
    State budget gaps persist, many will be forced to scale back childcare
    assistance for families unless additional Federal funding is provided.
    Already, a number of States and communities have begun to cut back on
    childcare assistance''. . . .
      --California's governor is proposing to eliminate childcare
            assistance for 11- and 12-year-olds, lower the income
            eligibility limit for childcare assistance from 75 percent of
            State median income to 60 percent of State median income, and
            reduce reimbursement rates to childcare providers serving
            children receiving childcare assistance--which would likely
            result in families being forced to make up the difference.
      --Florida's waiting list for childcare assistance increased from
            approximately 67,000 children in early 2010 to 89,000 children
            as of December 2010.
      --Maryland will place all families who apply for childcare assistance
            after February 28, 2011 on a waiting list.
      --North Carolina's waiting list for childcare assistance increased
            from approximately 37,900 children in early 2010 to nearly
            45,700 children in December 2010.
      --New York City's mayor is proposing to cut childcare assistance to
            more than 16,600 children.

        YWCA childcare programs in these States, and many more States
    across the country, are already being impacted by State cutbacks. These
    cutbacks will be amplified, and their impacts will be amplified, if
    CCDBG funding does not continue at the levels requested by the
    President's fiscal year 2012 budget request. For the YWCA, this means
    our associations will have to cut vital programs and services, reduce
    the number of families served, and possibly even close YWCA facilities
    leaving many women and families without affordable, quality, childcare
    to allow them to work and provide their children a safe,
    developmentally appropriate environment.
        The YWCA recognizes these are unique times in our Nation's history
    and we agree that our Nation must address its deficit and debt. Yet,
    the YWCA believes strongly that investments in childcare and early
    education programs are wise uses of Federal funds that provide
    substantial returns to our Nation. Childcare and early education
    programs help not only our Nation's current workforce, but also help
    prepare the next generation our Nation's children. On behalf of YWCAs
    nationwide and the many women, children and families we serve, we look
    to you for a continued commitment to women and families through the
    provision of essential childcare resources. That is why we respectfully
    ask you to support the President's fiscal year 2012 budget request for
    $1.3 billion in additional funding for CCDBG. Thank you once again for
    the opportunity to provide testimony in support of childcare services,
    and CCDBG especially, to your Subcommittee. Your attention and
    assistance are greatly appreciated.
    .................................................................

           LIST OF WITNESSES, COMMUNICATIONS, AND PREPARED STATEMENTS

                                  ----------
                                                                       Page

    Ad Hoc Group for Medical Research, Prepared Statement of the.....   505
    ADAP Advocacy Association, Prepared Statement of the.............   502
    Adult Congenital Heart Association, Prepared Statement of the....   511
    AIDS:
        Healthcare Foundation, Prepared Statement of the.............   507
        United, Prepared Statement of................................   508
    Alexander, Senator Lamar, U.S. Senator From Tennessee, Questions
      Submitted by I60143, 411.......................................
    Alliance for Aging Research, Prepared Statement of the...........   513
    Alliance of Information and Referral Systems, Prepared Statement
      of the.........................................................   516
    Alluviam LLC, Prepared Statement of..............................   517
    Alving, Barbara M., M.D., Director, National Center for Research
      Resources, National Institutes of Health, Department of Health
      and Human Services, Prepared Statement of......................   277
    American:
        Academy of:
            Family Physicians, Prepared Statement of the.............   518
            Physician Assistants, Prepared Statement of the..........   520
            Sleep Medicine, Prepared Statement of the................   522
        Association for:
            Cancer Research, Prepared Statement of the...............   525
            Dental Research, Prepared Statement of the...............   528
            Geriatric Psychiatry, Prepared Statement of the..........   530
        Association of:
            Colleges of Nursing, Prepared Statement of the...........   533
            Colleges of Osteopathic Medicine, Prepared Statement of
              the....................................................   535
            Colleges of Pharmacy, Prepared Statement of the..........   537
            Immunologists, Prepared Statement of the.................   540
            Nurse Anesthetists, Prepared Statement of the............   543
        Congress of Obstetricians and Gynecologists, Prepared
          Statement of the...........................................   546
        Dental Education Association, Prepared Statement of the......   549
        Dental Hygienists' Association, Prepared Statement of the....   551
        Diabetes Association, Prepared Statement of the..............   553
        Foundation for Suicide Prevention, Prepared Statement of the.   556
        Geriatrics Society, Prepared Statement of the................   559
        Heart Association, Prepared Statement of the.................   562
        Indian Higher Education Consortium, Prepared Statement of the   565
        Institute for Medical and Biological Engineering, Prepared
          Statement of the...........................................   568
        Lung Association, Prepared Statement of the..................   571
        National Red Cross, Prepared Statement of the................   574
        Nurses Association, Prepared Statement of the................   576
        Physical Therapy Association, Prepared Statement of the......   578
        Psychological Association, Prepared Statement of the.........   581
        Public:
            Health Association, Prepared Statement of the............   584
            Power Association, Prepared Statement of the.............   586
        Society for:
            Microbiology, Prepared Statements of the...............587, 590
            Nutrition, Prepared Statement of the.....................   594
            Pharmacology & Experimental Therapeutics, Prepared
              Statement of the.......................................   595
        Society of:
            Nephrology, Prepared Statement of the....................   597
            Plant Biologists, Prepared Statement of the..............   599
            Tropical Medicine and Hygiene, Prepared Statement of the.   601
        Thoracic Society, Prepared Statement of the..................   603
    Americans for Nursing Shortage Relief, Prepared Statement of the.   606
    Arthritis Foundation, Prepared Statement of the..................   609
    ASME International, Prepared Statement of........................   611
    Association for:
        Professionals in Infection Control and Epidemiology (APIC),
          Prepared Statement of the..................................   614
        Research in Vision and Ophthalmology, Prepared Statement of
          the........................................................   616
    Association of:
        Academic Health Sciences Libraries, Prepared Statement of the   733
        American Cancer Institutes, Prepared Statement of the........   619
        American Medical Colleges, Prepared Statement of the.........   621
        American Veterinary Medical Colleges, Prepared Statement of
          the........................................................   624
        Independent Research Institutes, Prepared Statement of the...   626
        Maternal & Child Health Programs, Prepared Statement of the..   627
        Minority Health Professions Schools, Prepared Statement of
          the........................................................   629
        Public Television Stations, Prepared Statement of the........   631
        Rehabilitation Nurses, Prepared Statement of the.............   634
    Astrue, Michael J., Commissioner, Social Security Administration.     1
        Introduction of..............................................     5
        Prepared Statement of........................................     7
        Summary Statement of.........................................     5

    Battey, James F., Jr., M.D., Ph.D., Director, National Institute
      on Deafness and Other Communication Disorders, National
      Institutes of Health, Department of Health and Human Services,
      Prepared Statement of..........................................   298
    Berg, Jeremy M., Ph.D., Director, National Institute of General
      Medical Sciences, National Institutes of Health, Department of
      Health and Human Services, Prepared Statement of...............   321
    Birnbaum, Linda S., Ph.D., D.A.B.T., A.T.S., Director, National
      Institute of Environmental Health Sciences and Health Services,
      National Institutes of Health, Department of Health and Human
      Services, Prepared Statement of................................   303
    Brain Injury Association of America, Prepared Statement of the...   636
    Briggs, Josephine P., M.D., Director, National Center for
      Complementary and Alternative Medicine, National Institutes of
      Health, Department of Health and Human Services, Prepared
      Statement of...................................................   274
    Brown, Senator Sherrod, U.S. Senator From Ohio, Questions
      Submitted by.................................................207, 481

    CAEAR Coalition, Prepared Statement of the.......................   638
    Centers for Disease Control and Prevention (CDC) Coalition,
      Prepared Statement of the......................................   640
    Charles R. Drew University of Medicine and Science, Prepared
      Statement of the...............................................   643
    Children's Environmental Health Network, Prepared Statement of
      the............................................................   645
    Coalition for:
        Health Funding, Prepared Statement of the....................   648
        Health Services Research, Prepared Statement of the..........   650
        International Education, Prepared Statement of the...........   653
        The Advancement of Health Through Behavioral and Social
          Science Research, Prepared Statement of the................   658
        Workforce Solutions, Prepared Statement of the...............   656
    Coalition of Heritable Disorders of Connective Tissue, Prepared
      Statement of the...............................................   661
    Cochran, Senator Thad, U.S. Senator From Mississippi:
        Prepared Statements of......................................81, 154
        Questions Submitted by................................142, 409, 487
    Collins, Dr. Francis S., Director, National Institutes of Health,
      Department of Health and Human Services........................   221
        Prepared Statement of........................................   259
        Summary Statement of.........................................   225
    Commissioned Officers Association of the U.S. Public Health
      Service, Prepared Statement of the.............................   663
    Consortium for Citizens With Disabilities, Letter From the.......    62
    Corporation for Public Broadcasting, Prepared Statement of the...   495
    Council of Academic Family Medicine, Prepared Statement of the...   664
    Council on Social Work Education, Prepared Statement of the......   667
    Crohn's and Colitis Foundation of America, Prepared Statement of
      the............................................................   670
    Cystic Fibrosis Foundation, Prepared Statement of the............   672

    Digestive Disease National Coalition, Prepared Statement of the..   676
    Duncan, Hon. Arne, Secretary, Office of the Secretary, Department
      of Education...................................................   417
        Opening Statement of.........................................   421
        Prepared Statement of........................................   423
    Durbin, Senator Richard J., U.S. Senator From Illinois:
        Prepared Statement of........................................   453
        Questions Submitted by................................133, 399, 475
    Dystonia Medical Research Foundation, Prepared Statement of the..   678

    Elder Justice Coalition, Prepared Statement of the...............   679
    Eldercare Workforce Alliance, Prepared Statement of the..........   680

    Fauci, Anthony S., M.D., Director, National Institute of Allergy
      and Infectious Diseases, National Institutes of Health,
      Department of Health and Human Services........................   221
    Federation of American Societies for Experimental Biology,
      Prepared Statement of the......................................   686
    Friends of the:
        Health Resources and Services Administration, Prepared
          Statement of...............................................   688
        National Center on Birth Defects and Developmental
          Disabilities Advocacy Coalition, Prepared Statement of.....   689
        National Institute on Aging (NIA), Prepared Statement of the.   691
    FSH Society, Inc., Prepared Statement of the.....................   682
    Futures Without Violence, Prepared Statement of..................   693

    Garcia, Dr. A. Isabel, D.D.S., M.P.H., Director, National
      Institute of Dental and Craniofacial Research, National
      Institutes of Health, Department of Health and Human
      Services,Prepared Statement of.................................   300
    Glass, Roger I., M.D., Ph.D., Director, Fogarty International
      Center, National Institutes of Health, Department of Health and
      Human Services, Prepared Statement of..........................   285
    Global Health Technologies Coalition, Prepared Statement of the..   696
    Goodwill Industries International, Prepared Statement of.........   699
    Grady, Patricia A., Ph.D., RN, FAAN, Director, National Institute
      of Nursing Research, National Institutes of Health, Department
      of Health and Human Services, Prepared Statement of............   312
    Graham, Senator Lindsey, U.S. Senator From South Carolina,
      Questions Submitted by..................................148, 414, 489
    Green, Eric D., M.D., Ph.D., Director, National Human Genome
      Research Institute, National Institutes of Health, Department
      of Health and Human Services, Prepared Statement of............   280
    Guttmacher, Alan E., M.D., Director, Eunice Kennedy Shriver
      National Institute of Child Health and Human Development,
      National Institutes of Health, Department of Health and Human
      Services, Prepared Statement of................................   294

    Harkin, Senator Tom, U.S. Senator From Iowa:
        Opening Statements of..........................1, 79, 151, 221, 417
        Questions Submitted by...........................112, 176, 352, 458
    Harlem Children's Zone, Prepared Statement of the................   701
    Health Professions and Nursing Education Coalition, Prepared
      Statement of the...............................................   704
    Hepatitis B Foundation, Prepared Statement of the................   707
    HIV Medicine Association, Prepared Statement of the..............   710
    Hodes, Richard, M.D., Director, National Institute on Aging,
      National Institutes of Health, Department of Health and Human
      Services, Prepared Statement of................................   283
    Howard University, Prepared Statement of.........................   713
    Inouye, Chairman Daniel K., U.S. Senator From Hawaii:
        Prepared Statement of........................................    81
        Questions Submitted by...........................115, 198, 383, 464
    Insel, Thomas R., M.D., Director, National Institute of Mental
      Health, National Institutes of Health, Department of Health and
      Human Services, Prepared Statement of..........................   305
    International:
        Foundation for Functional Gastrointestinal Disorders,
          Prepared Statement of the..................................   715
        Myeloma Foundation, Prepared Statement of the................   717
    Interstate Mining Compact Commission, Prepared Statement of the..   719
    Interstitial Cystitis Association, Prepared Statement of the.....   720
    Iowa Statewide Independent Living Council, Prepared Statement of
      the............................................................   721

    Joint Advocacy Coalition of the: Association for Clinical
      Research Training, Association for Patient-Oriented Research,
      and Clinical Research Forum, Prepared Statement of the.........   722

    Katz, Stephen I., M.D., Ph.D., Director, National Institute of
      Arthritis and Musculoskeletal and Skin Diseases, National
      Institutes of Health, Department of Health and Human Services,
      Prepared Statement of..........................................   289
    Kohl, Senator Herb, U.S. Senator From Wisconsin, Questions
      Submitted by.................................................122, 394

    Landis, Story C., Ph.D., Director, National Institute of
      Neurological Disorders and Stroke, National Institutes of
      Health, Department of Health and Human Services, Prepared
      Statement of...................................................   310
    Landrieu, Senator Mary L., U.S. Senator From Louisiana, Questions
      Submitted by.......................................131, 204, 396, 471
    Lindberg, Donald A.B., M.D., Director, National Library of
      Medicine, National Institutes of Health, Department of Health
      and Human Services, Prepared Statement of......................   314
    Lions Clubs International, Prepared Statement of.................   724

    March of Dimes Foundation, Prepared Statement of the.............   727
    Meals On Wheels Association of America, Prepared Statement of the   731
    Medical Library Association, Prepared Statement of the...........   733
    Meharry Medical College, Prepared Statement of the...............   737
    Mikulski, Senator Barbara A., U.S. Senator From Maryland,
      Statement of...................................................     4
    Moran, Senator Jerry, U.S. Senator From Kansas, Question
      Submitted by.................................................415, 491
    Morehouse School of Medicine, Prepared Statement of the..........   740
    Murray, Senator Patty, U.S. Senator From Washington, Questions
      Submitted by............................................125, 200, 467

    National:
        AHEC Organization, Prepared Statement of the.................   742
        National Alliance for Eye and Vision Research, Prepared
          Statement of the...........................................   742
        Alliance of State & Territorial AIDS Directors, Prepared
          Statement of the...........................................   745
        Association for Public Health Statistics and Information
          Systems, Prepared Statement of the.........................   748
        Association of:
            Community Health Centers, Prepared Statement of the......   751
            County and City Health Officials, Prepared Statement of
              the....................................................   753
            Nutrition and Aging Services Programs, Prepared Statement
              of the.................................................   756
            State Comprehensive Health Insurance Plans, Prepared
              Statement of the.......................................   757
            State Head Injury Administrators, Prepared Statement of
              the....................................................   757
            Workforce Boards, Prepared Statement of the..............   760
        Coalition for:
            Cancer Survivorship, Prepared Statement of the...........   761
            Osteoporosis and Related Bone Diseases, Prepared
              Statement of
              the....................................................   763
        Consumer Law Center, Prepared Statement of the...............   765
        Council of Social Security Management Associations, Prepared
          Statement of the...........................................   767
        Head Start Association, Prepared Statement of the............   770
        Health Council, Prepared Statement of the....................   773
        Healthy Mothers Healthy Babies Coalition, Prepared Statement
          of the.....................................................   774
        Hispanic Council on Aging (NHCOA), Prepared Statement of the.   776
        Kidney Foundation, Prepared Statement of the.................   779
        League for Nursing, Prepared Statement of the................   780
        Marfan Foundation, Prepared Statement of the.................   783
        Minority AIDS Council, Prepared Statement of the.............   785
        Minority Consortia, Prepared Statement of the................   786
        Multiple Sclerosis Society, Prepared Statement of the........   789
        Network to End Domestic Violence, Prepared Statement of the..   792
        Postdoctoral Association, Prepared Statement of the..........   795
        Primate Research Centers, Prepared Statement of the..........   797
        Psoriasis Foundation, Prepared Statement of the..............   800
        REACH Coalition, Prepared Statement of the...................   803
        Respite Coalition, Prepared Statement of the.................   805
        Rural Health Association, Prepared Statement of the..........   808
        Senior Corps Association, Prepared Statement of the..........   810
        Technical Institute for the Deaf, Prepared Statement of the..   813
    Nemours, Prepared Statement of...................................   818
    Nephcure Foundation, Prepared Statement of the...................   820
    Neurofibromatosis, Inc., Prepared Statement of...................   821
    Nursing Community, Prepared Statement of the.....................   823

    Oncology Nursing Society, Prepared Statement of the..............   826
    Ovarian Cancer National Alliance, Prepared Statement of the......   829

    Pancreatic Cancer Action Network, Prepared Statement of the......   832
    Pettigrew, Roderic I., Ph.D., M.D., Director, National Institute
      of Biomedical Imaging and Bioengineering, National Institutes
      of Health, Department of Health and Human Services, Prepared
      Statement of...................................................   292
    Physician Assistant Education Association, Prepared Statement of
      the............................................................   833
    PolicyLink, The Food Trust, and The Reinvestment Fund, Prepared
      Statement of...................................................   835
    Population Association of America/Association of Population
      Centers, Prepared Statement of the.............................   838
    Prevent Blindness America, Prepared Statement of.................   840
    ProLiteracy, Prepared Statement of...............................   843
    Prostatitis Foundation, Prepared Statement of the................   846
    Pryor, Senator Mark, U.S. Senator From Arkansas, Questions
      Submitted by............................................137, 403, 478
    Pulmonary Hypertension Association, Prepared Statement of the....   846

    Railroad Retirement Board, Prepared Statement of the.............   498
        Inspector General, Prepared Statement of the.................   500
    Reed, Senator Jack, U.S. Senator From Rhode Island, Questions
      Submitted by............................................136, 206, 476
    Research Working Group of the Federal AIDS Policy Partnership,
      Prepared Statement of the......................................   848
    Research!America, Prepared Statement of..........................   850
    Rodgers, Dr. Griffin, Director, National Institute of Diabetes,
      Digestive and Kidney Diseases, National Institutes of Health,
      Department of Health and Human Services........................   221
        Prepared Statement of........................................   270
    Rotary International, Prepared Statement of......................   852
    Ruffin, John, Ph.D., Director, National Institute on Minority
      Health and Health Disparities, National Institutes of Health,
      Department of Health and Human Services, Prepared Statement of.   307
    Ryan White Medical Providers Coalition, Prepared Statement of the   854

    Scleroderma Foundation, Prepared Statement of the................   857
    Sebelius, Hon. Kathleen, Secretary, Office of the Secretary,
      Department of Health and Human Services........................    79
        Prepared Statement of........................................    85
        Summary Statement of.........................................    83
    Senior Service America, Inc., Prepared Statement of..............   859
    Shelby, Senator Richard C., U.S. Senator From Alabama:
        Statements of..................................3, 81, 153, 223, 419
        Questions Submitted by.......................29, 139, 212, 403, 485
    Shurin, Susan B., M.D., Acting Director, National Heart, Lung,
      and Blood Institute, National Institutes of Health, Department
      of Health and Human Services...................................   221
        Prepared Statement of........................................   267
    Sickle Cell Disease Association of America, Prepared Statement of
      the............................................................   861
    Sieving, Paul A., M.D., Ph.D., Director, National Eye Institute,
      National Institutes of Health, Department of Health and Human
      Services, Prepared Statement of................................   279
    Society for:
        Healthcare Epidemiology of America (SHEA), Prepared Statement
          of
          the........................................................   614
        Maternal-Fetal Medicine, Prepared Statement of the...........   862
        Neuroscience, Prepared Statement of the......................   865
        Women's Health Research, Prepared Statement of the...........   868
    Solis, Hon. Hilda L., Secretary, Office of the Secretary,
      Department of Labor............................................   151
        Prepared Statement of........................................   158
        Summary Statement of.........................................   155
    Spina Bifida Association, Prepared Statement of the..............   872

    Tabak, Lawrence A., D.D.S., Ph.D., Principal Deputy Director,
      National Institutes of Health, Department of Health and Human
      Services, Prepared Statement of................................   319
    The AIDS Institute, Prepared Statement of the....................   874
    The Endocrine Society, Prepared Statement of.....................   877
    The Humane Society of the United States, Prepared Statement of...   878
    Tri-Council for Nursing, Prepared Statement of the...............   883

    U.S. Hereditary Angioedema Association, Prepared Statement of the   889
    United:
        Negro College Fund, Prepared Statement of the................   883
        Network for Organ Sharing, Prepared Statement of the.........   885
        Tribes Technical College, Prepared Statement of the..........   887
    University of Virginia Medical Center, Prepared Statement of the.   881

    Varmus, Harold, M.D., Director, National Cancer Institute,
      National Institutes of Health, Department of Health and Human
      Services.......................................................   221
        Prepared Statement of........................................   265
    Volkow, Nora, M.D., Director, National Institute on Drug Abuse,
      National Institutes of Health, Department of Health and Human
      Services, Prepared Statement of................................   296

    Warren, Dr. Kenneth, Ph.D., Director, National Institute on
      Alcohol Abuse and Alcoholism, National Institutes of Health,
      Department of Health and Human Services, Prepared Statement of.   287
    Whitescarver, Jack, Ph.D., Director, Office of AIDS Research,
      National Institutes of Health, Department of Health and Human
      Services, Prepared Statement of................................   317

    YWCA USA, Prepared Statement of..................................   890

                                 SUBJECT INDEX

                                  ----------

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                         National Institutes of Health

                                                                       Page

    A New Era in the Fight Against Health Disparities................   309
    Academia-Industry Collaboration to Repurpose Drug Compound.......   345
    Accelerating:
        Basic Discovery..............................................   301
        Progress Through Technology..................................   311
    Additional Committee Questions...................................   352
    Advances in:
        Knowledge....................................................   250
        Toxicology and Exposure Assessment...........................   303
    Advancing:
        Innovative Biomedical Technologies...........................   278
        Translational Science......................................263, 310
    Affordable Hearing Healthcare....................................   298
    Alcohol and Healthcare--Transforming the Landscape...............   287
    Antiviral Development for Flu....................................   398
    Applying Genetics, Genomics, and Other Cutting-edge Research to
      New Treatments.................................................   290
    Average Cost of Research Project Grants..........................   323
    Basic and Applied Research Balance...............................   404
    Biomedical Research Resources and Workforce......................   331
    Broadening the IdEA Program......................................   406
    Budgetary:
        Constraints on:
            Universal Flu Vaccine....................................   377
            Vaccine Research.........................................   378
        Effects on the NCI Programs..................................   415
    Building:
        A Framework for Translation..................................   281
        Clinical and Translational Research Capabilities.............   277
        On a Decade of Progress......................................   308
    CAM Research Challenges..........................................   276
    Cancer:
        Clusters.....................................................   340
        Prevelance and Research in Hawaii............................   390
    Cardiovascular Disease Research..................................   411
    Challenges and Changes in an Aging Population....................   313
    Childhood and Adolescence: Risk and Resilience...................   313
    Chronic Obstructive Pulmonary Disease (COPD) Research............   380
    Clinical Trial Process...........................................   408
    Clinical Trials Cooperative Group Program Reorganization Impact
      on the Gynecological Cooperative Group.........................   381
    Clyde, Ohio Cancer Cluster.......................................   341
    Comparison of Age-related Macular Degeneration Treatments Trials.   394
    Congenital Heart Disease (CHD)...................................   401
    Cost of:
        De-Risking Pharmaceuticals...................................   326
        Pharmaceuticals..............................................   339
    Creation of SUAA.................................................   382
    CTSA Program Mission.............................................   412
    Cystic Fibrosis..................................................   347
        Research.....................................................   407
    Developing:
        New Clinical Treatments......................................   302
        Tools to Diagnose and Monitor Disease........................   290
    Diabetes.........................................................   324
    Disaster Information Management..................................   316
    Disseminating Research Results to Improve Public Health..........   271
    Division of Program Coordination, Planning, and Strategic
      Initiatives (DPCPSI)...........................................   319
    DNA Databanks....................................................   412
    Early Opportunities for Genomic Medicine.........................   282
    Economic Benefits of Biomedical Research.........................   399
    Effects of:
        A Government Shutdown........................................   336
        Reseach on Healthcare Costs..................................   350
    Emerging:
        And Re-emerging Infectious Diseases..........................   273
        Psychoactive Threats to Public Health........................   297
    Enabling Research................................................   281
    Encouraging New Investigators and New Ideas......................   312
    End of Life: Supporting Individuals and Families.................   313
    Energizing Research Communities..................................   277
    Enhancement of Evidence Base for:
        Healthcare Decisions........................279, 286, 306, 310, 323
        Oral Health Care.............................................   302
    Eosinophilic:
        Associated Disorders Research................................   402
        Disorders Working Group......................................   414
    Epigenetics, Endocrine Disrupters, and Environmental Health......   304
    Expanding Research Capabilities to Address Human Health..........   278
    Extramural Research Budget.......................................   403
    Fiscal Year 2012 Scientific Priorities...........................   318
    Flu Vaccine......................................................   341
    Future:
        Directions in Nursing Science................................   314
        Of R01 Funds.................................................   405
    Generating Research Opportunities................................   271
    Genetics and Genomics............................................   268
    Geographic:
        Distribution of Small Business Innovative Research (SBIR)
          Grants.....................................................   397
        Health Disparities for Stroke and Obesity....................   410
    Global Competitiveness...........................................   328
        The Importance of U.S. Leadership in Science and Innovation
          for the Future of Our Economy and Our Health...............   244
    Global Health....................................................   272
    Guidance for Use of Class B CATS.................................   379
    Gulf Oil Spill Health Effects Research...........................   407
    Health:
        Data Standards and Electronic Health Records.................   315
        Improvements.................................................   250
        Messages for the Native Hawaiian Population..................   388
        Preparedness and Obesity.....................................   327
    Healthcare Spending Policy Options...............................   348
    Hereditary Angiodema Research Support............................   389
    Immune-mediated Disorders........................................   274
    Impacts on U.S. Economy..........................................   247
    Improving:
        Healthcare for Women and Children............................   294
        Patient Care Through Research................................   270
        Public Healthcare--Delivery and Performance..................   297
    Industry Investment in Genome Sequencing.........................   413
    Inflation Effects on Purchasing Power............................   337
    Information Services for the Public..............................   315
    Inter-Agency Collaborations......................................   346
    Interdisciplinary Research.......................................   332
    Interim Status of IdEA Program...................................   396
    Investing in Basic Science.......................................   262
    Jackson Heart Study Impacts......................................   409
    Kidney Disease and Diabetes Research in Hawaii...................   392
    Leveraging Basic Science to Improve Patient Care.................   290
    Loan Repayment and Scholarship Programs..........................   321
    Lupus Research...................................................   379
    Medical Milestones...............................................   343
    Molecular Libraries Program as Part of the NCATS.................   405
    National Center for Advancing Translational Sciences (NCATS).....   263
        And Preventative Medicine....................................   377
        Budget Amendment.............................................   325
    National Center for Complementary and Alternative Medicine
      (NCCAM) Advisory Council.......................................   352
    National Institutes of Health....................................   253
        AIDS Research Program........................................   317
        And Economic Growth..........................................   260
        Turning Discovery Into Health................................   244
    NCI Priorities...................................................   399
    New:
        And Better Treatments Through Animal Models..................   278
        Investigators................................................   338
            New Ideas..........................280, 285, 293, 298, 307, 323
        Scientific Advances and Opportunities........................   317
        Strategic Plan for NIDCD.....................................   300
        Technoliges Advance Hope for Autism and Parkinson's..........   295
    NIC:
        And the National Blood Cord Registry.........................   329
        Volker Treatment Details.....................................   329
    Olfactory Deficits Early Warning of Alzheimer's Disease..........   300
    Pain and Symptom Mangement.......................................   275
    Pediatric Research...............................................   329
    Personalized Medicine............................................   412
        As a Priority................................................   403
    Placement of:
        IdEA Within the National Institute of Minority Health
          Disparities (NIMHD)........................................   396
        National Center for Research Resources (NCRR) Programs.......   396
    Planning for the Future..........................................   305
    Process Innovation and the NCATS.................................   406
    Proposed National Center for Advancing Translational Sciences....   253
    Providing a Catalyst for Research Collaboration..................   278
    Provocative Questions............................................   267
    Public Health Burden of Mental Illness...........................   305
    Rare and Neglected Diseases......................................   351
    Regenerative Medicine............................................   268
    Reorganization of:
        National Center for Research Resources (NCRR) Programs.....403, 411
        The Comparative Medicine Program.............................   406
    Research Information Resources...................................   315
    Return on Investment: Technologies to Speed Discovery............   296
    Revitalizing the Cancer Clinical Trials System...................   266
    Scope of the Problem.............................................   287
    Staffing the Jackson Heart Study.................................   409
    Strategies for Promoting Health and Well-being...................   276
    Stroke:
        Disparities in the United States.............................   393
        In Women.....................................................   398
    Stuttering.......................................................   300
    Support of NIH...................................................   334
    Technologies to Accelerate:
        Discoveries..................................................   293
        Discovery...................................279, 284, 286, 306, 322
    Technologies to Improve Evidence-based Clinical Decisions........   293
    The AIDS Pandemic................................................   317
    The Cancer Genome Atlas..........................................   401
    The Clinical and Translational Science Awards (CTSAS) and the
      National Center for Advancing Translational Sciences (NCATS)...   397
    The National Children's Study (NCS)..............................   295
    The National Institute of Nursing Research (NINR) Support for
      End-of-Life Care and Health Disparities Research...............   388
    The National Institute on Minority Health and Health Disparities
      (NIMHD) Centers of Excellence (COE) in Hawaii..................   389
    The National Institutes of Health (NIH) Research Support to
      Hawaii Academic Institutions...................................   383
    The NCCAM Research:
        Approaches...................................................   376
        Successes....................................................   353
    The NIH, Academia, and Industy Relationship......................   405
    The NIH-FDA Collaborations.......................................   408
    The Office of:
        AIDS Research................................................   320
        Behavioral and Social Sciences Research......................   320
        Disease Prevention...........................................   320
        Research on Women's Health...................................   320
        Science Education............................................   321
        Strategic Coordination and the Common Fund...................   320
    Tinnitus.........................................................   299
    Training the Next Generation of Scientists.......................   314
    Trans-NIH Plan and Budget........................................   318
    Transfer of the IdEA Program to the National Institute of General
      Medical Sciences (NIGMS).......................................   409
    Translating:
        Basic Science Into Improved Public Health....................   301
        Science to Advance Rehabilation..............................   295
    Translation--Therapeutics Development............................   298
    Translational:
        Medicine.....................................................   269
        Sciences and Therapeutics Development..279, 283, 287, 292, 306, 322
    Uncovering the Genetic and Environmental Causes of Disease to
      Inform Therapy and Prevention..................................   270
    Use of Chimpanzees in Biomedical Research........................   382
    Using Science to Inform Health Care Reform.......................   284
    Vestibular Prosthesis............................................   299
    Vision for the Future............................................   296
    Workforce Pipeline...............................................   335
    Working Collaboratively to Combat Suicide........................   307

                            Office of the Secretary

    Additional Committee Questions...................................   112
    Adoption of Best Practices by Healthcare Professionals and Their
      Patients.......................................................   116
    Advance Scientific Knowledge and Innovation......................    87
    Advance the Health, Safety, and Well-being of the American People    88
    Affordable Care Act.............................................96, 109
    Centers for Disease Control......................................   128
        Environmental Health (Healthy Homes/Lead Poisoning
          Prevention)................................................   137
        State Cancer Registries (Pediatric Cancer Surveillance)......   136
    Chafee Foster Care Independence Program..........................   132
    Child Welfare Finance Reform.....................................   131
    Children's Hospital Graduate Medical Education.............95, 101, 105
    Chronic Disease Grant Program....................................   107
    CLASS Act..................................................92, 106, 139
    Community Health Centers.........................................    92
    Congressional Requests for Information...........................   108
    Federal Funding for Planned Parenthood...........................   126
    Funding for the National Institute for Occupational Safety and
      Health's:
        Agriculture, Fishing and Forestry Program....................   131
        Education and Research Centers...............................   127
    Grants for Occupational Safety and Health Educational Resource
      Centers........................................................   128
    Head Start.......................................................    91
    Immunization--Section 317 Funds..................................   100
    Impact of a Federal Government Shutdown..........................   103
    Increase Efficiency, Transparency, and Accountability of HHS
      Programs.......................................................    90
    Independent Payment Advisory Board...............................   110
    Low Income Home Energy Assistance Program........................    99
    Makena, KV Pharmaceutical........................................   101
    Medicare Sustainable Growth Rate.................................   111
    Mississippi State Department of Health Funding...................   142
    NCATS and the Effect on CTSAS....................................   123
    NINR's:
        Participation in Programs to Keep Up the Supply of Nurse
          Researchers................................................   116
        Plans in Research on Autism, Cancer and Alzeimer's Disease...   117
        Role in the National Center for Advancing Translational
          Sciences (NCATS)...........................................   115
    Pediatric Cancer.................................................   102
    Prevention and Public Health Fund................................   141
    Program Guidelines...............................................   128
    Rural Access Hospitals...........................................    98
    Strengthen the Nation's Health and Human Service Infrastructure
      and Workforce..................................................    89
    The Effect of Reducing NIH Funding to 5 Percent Below Fiscal Year
      2010...........................................................   133
    Title X Funding..................................................   125
    Transform Healthcare.............................................    86
    Trauma Funding...................................................   125
    Waste, Fraud and Abuse...........................................    94
        In Medicare..................................................   105

                            DEPARTMENT OF EDUCATION

                            Office of the Secretary

    Academic Year Calandar...........................................   446
    Access to 4-Year Institutions....................................   465
    Accreditation and Transparency of For-Profit Schools.............   452
    Additional Committee Questions...................................   458
    Alabama and Race to the Top Competition..........................   419
    Ayp Waiver Request...............................................   481
    Bipartisanship Approach to Education Bill........................   439
    Budget:
        Request in Current Economic Conditions.......................   421
        Savings......................................................   419
    Career and Technical Education.......................467, 470, 489, 493
        In Hawaii....................................................   467
    Carol M. White Physical Educaton Program.........................   465
    Charter Schools..................................................   445
    College Completion...............................................   426
    Common:
        Core State Standards.........................................   480
        Standards Benefit Military Families..........................   446
    Cost Savings:
        And Efficiencies Initiated by the Department of Education in
          Fiscal Year 2009 and Fiscal Year 2010......................   463
        Planned for Fiscal Year 2011 and Fiscal Year 2012............   463
    Distance:
        Education Regulations........................................   467
        Learning and State Authorizations............................   420
    Early Childhood Education........................................   467
    Education:
        Accountability...............................................   448
        And Employment...............................................   479
        And Job Demands of Next Decade...............................   429
        Priorities--Cradle-To-Career Continuum.......................   431
        Reform.......................................................   431
        Support for Children of Military Families....................   445
    Educational Stability for Foster Youth...........................   474
    Elimination of:
        In-School Subsidy for Undergraduate Students.................   481
        Two Pells and In-School Subsidies............................   428
    Emergency Preparedness in Schools................................   472
    Ensuring Achievement Gains Within Flexibility....................   450
    ESEA Title I Accountability Structure............................   493
    Ethnic and Immigrant Student Performance.........................   464
    Expanding Charter School Opportunities...........................   446
    Extended-Day and After-School Programs...........................   468
    Family Engagement in Educational Outcomes for Children...........   483
    FAPE--A Constitutional Requirement...............................   455
    Federal:
        Assistance to States in Provision of FAPE....................   455
        Direct Student Loan Origination Fees.........................   437
        Funds as Percent of Kansas Education Budget..................   438
        Partnerships and Need-based Student Grant Aid................   477
        Role in Education..........................................434, 449
        TRIO Programs..............................................473, 482
    Final Fiscal Year 2011 Appropriation.............................   423
    First:
        Generation Students--College Dropout Rate....................   435
        In the World--Building a College Completion Culture..........   436
    Fiscal Year 2012 Department of Education Budget Request..........   419
    Flexibility in Exchange for Results..............................   439
    For-Profit Schools...............................................   451
    Formula Grant Programs Form Majority of ED Budget................   432
    Funding Increase for Teach for America...........................   441
    Funds for Implementing Academic Standards and Assessments........   481
    Geography Education..............................................   489
    Great Teachers and Leaders.......................................   425
    Growth in Rate of Student Indebtedness...........................   451
    Helping First Generation Students Graduate.......................   436
    High School:
        Dropout Recovery/Prevention Programs.........................   475
        Graduation Initiative and the College Pathways and
          Accelerated Learning Program...............................   486
    Impact Aid:
        Funding......................................................   470
        Payment Process..............................................   470
    Impact of:
        Competitive-based Funding on Rural Areas.....................   456
        The ESEA on Student Achievement..............................   492
    Improving:
        Competitive Stance of Rural Communities for Education Funding   488
        Partnerships With States and LEAS............................   438
    Inadequacy of Education for Current High Skill Jobs..............   429
    Incentive Compensation Regulations...............................   489
    Increased:
        Demand for Pell Grants.......................................   427
        Efficiency Through Program Consolidation.....................   439
    Increasing College Completion Rates..............................   433
    Initiatives and Investment in Educational Technology.............   469
    Innovative Strategies in Early Learning..........................   488
    Institutional Participation in the TEACH Program.................   466
    Investing in:
        Community Colleges...........................................   436
        Education....................................................   418
        Programs That Work...........................................   421
    Job and Education Requirements of Next Decade....................   429
    Key Investments in Fiscal Year 2012 Budget Request...............   421
    Large-Scale Competitive vs. Formula-based Grant Programs.........   431
    Level Playing Field for Rural Areas in Grant Competitions........   478
    Leveraging Power of Teach for America............................   441
    Literacy:
        Funding......................................................   468
        Through School Libraries.....................................   434
    Longer School Year Needed........................................   447
    Maintaining Access Through Pell Grants...........................   436
    Making Tough Choices.............................................   424
    Mathematics and Science Partnerships.............................   457
    Maximizing Public and Private Partnerships.......................   462
    Maximum Pell Grant...............................................   428
    Measuring Student Academic Growth................................   491
    Mississippi's Gains in Literacy in Early Grades..................   434
    Misuse of Student Aid by For-Profit Institutions.................   454
    National:
        Impact of Fiscal Year 2011 Budget Cuts on CIBERS.............   491
        NFP Organizations Set-Aside Competition......................   487
        Nonprofit Competitions and ESEA Reauthorization..............   488
        Not-for-Profit Organizations and the Improving Teacher
          Quality State Grants Program...............................   487
    Need for:
        Full Range of Student Aid Programs...........................   432
        Library Programs.............................................   431
        Recognizing, Funding More Promising Programs.................   443
    Need to Keep Education Support in Tough Economy..................   422
    No Child Left Behind.............................................   439
        Flexibility and Accountability...............................   449
        Requirements Flexibility Plan................................   481
    Pell:
        Grant Program................................................   422
        Grants.......................................................   458
            And Total Education Budget Request.......................   427
            Funding..................................................   485
            Growth in Cost...........................................   420
            How Do We Pay for Them?..................................   430
            Integral to Education Budget and Goals...................   430
            Versus Student Loans.....................................   451
        Maximum Grant................................................   428
        Shortfall After Elimination of Year Round Pell...............   428
    Plan for CIBER Program Funding in Fiscal Year 2012...............   491
    Possible Waivers of ESEA Requirements............................   491
    President Obama's 2012 Budget Request............................   424
    Presidential Teaching Fellows....................................   467
    Projects Funded Under Teacher Quality Partnership Grants.........   477
    Promise Neighborhoods............................................   462
        Applicants and Awards........................................   444
        Applications.................................................   484
        Competition--Absolute Priority for Rural Communities.........   488
        Funding....................................................443, 485
        Program......................................................   443
    Public-Private Partnerships as Tool in Ensuring College- and
      Career-Readiness...............................................   480
    Race to the Top:
        Accountability...............................................   442
        Amendments...................................................   442
        Application Process and Rural District Applicants............   479
        Application Scoring Process..................................   456
        Budget Request...............................................   419
        Competition..................................................   457
        Early Learning Challenge Program.............................   482
        Funding:
            And Vendors..............................................   478
            Competition..............................................   471
        Phase 3......................................................   472
    Reauthorization of Perkins Act--Career and Technical Education...   470
    Recovery Act of 2009 and the Education Jobs Fund of 2010.........   462
    Reducing Pell Grants Costs.......................................   485
    Repayment of Student Loan Debt...................................   453
    Savings From Eliminating Two Pells and In-School Subsidy.........   430
    School:
        Libraries....................................................   476
        Turnaround Program...........................................   422
    School-based Counseling Programs.................................   484
    Science, Technology, Engineering and Mathematics.................   444
    Special Education:
        Free, Appropriate Public Education...........................   455
        Maintenance of Effort Waivers................................   454
    State:
        And Local Flexibility........................................   438
        Authorization of Distance Education Programs.................   486
        Flexibility..................................................   450
            And Waivers..............................................   438
            To Innovate..............................................   420
    STEM Teacher Shortage............................................   444
    Strengthening Literacy in the Early Grades.......................   433
    Strong Education Support Needed Despite Tough Economy............   429
    Student:
        Health Initiatives...........................................   465
        Loan Conversion..............................................   481
    Study Abroad and Foreign Language Instruction....................   475
    Supplemental Educational Services:
        Evaluation...................................................   480
        Oversight....................................................   480
    Support for:
        At-risk Students and Adults..................................   426
        Innovation and Achievement...................................   432
        Literacy Programs............................................   433
    Sustaining Reform Momentum.......................................   425
    Targeting of Title I Funds to Local Educational Agencies.........   487
    Teach for America..............................................440, 471
        And Stem Instruction.........................................   441
        Funding....................................................441, 442
        Leadership Development Benefits..............................   441
    TEACH Grants and Proposed Presidential Teaching Fellows Program..   466
    Teacher:
        And Student Classroom Experience.............................   438
        Incentive Fund...............................................   450
            Vanderbilt and Rand Studies on Performance-based Pay.....   460
        Preparation and Classroom Innovation.........................   422
        Quality Partnership Grants...................................   476
        Quality Partnerships.........................................   432
    Tech Prep Program................................................   482
    Technical Assistance to Promise Neighborhoods Grantees...........   485
    Title:
        I Rewards Program............................................   435
        VI:
            Centers for International Business Education (CIBER)
              Program................................................   490
            Culture and Foreign Language Programs....................   437
    2011 Continuing Resolution Impact on Education Budget............   417
    21st Century Community Learning Centers........................466, 468
    Unemployment Impact on Pell Grant Program........................   427
    Waiver for McPherson USD School District 418.....................   440
    Well-Rounded:
        Classroom and After School Programs..........................   422
        Education....................................................   458
    Working to Ensure Efficacy of Federal Student Aid................   452
    Workload of Direct Loan Program..................................   459

                              DEPARTMENT OF LABOR

                            Office of the Secretary

    Additional Committee Questions...................................   176
    Administrative Structures........................................   203
    Adult Employment and Training Activities.........................   194
    African-American Unemployment....................................   168
    Budget Deficit...................................................   215
    Bureau of International Affairs (ILAB)...........................   189
    Bureau of Labor Statistics (BLS).................................   186
    CFTC.............................................................   213
    Community Service Employment for Older Americans (CSEOA).........   198
    Davis-Bacon Act..................................................   200
    Dislocated Worker Employment and Training Activities.............   194
    Department of Labor's:
        Civil Rights Center (CRC)....................................   192
        Fiduciary Rules..............................................   212
        Performance Measures.........................................   171
    Duplication in Department of Labor Training Programs.............   153
    Emerging Industries and High Growth Occupations..................   192
    Employee Benefits Security Administration........................   176
    Employment of People With Disabilities...........................   160
    Evaluations and Performance......................................   200
    Expansion of Trade Adjustment Assistance.........................   169
    Fiscal Year:
        2011 Appropriations Bill.....................................   151
        2012.........................................................   152
    Government Accountability Office Report........................153, 170
    Getting America Back to Work.....................................   158
    Helping Workers Provide for Their Families and Keep What They
      Earn...........................................................   159
    International Labor Comparisons (ILC)............................   212
    Investing in the Future..........................................   158
    Investment Compared to Need......................................   202
    Job Corps........................................................   197
        Center, Gulfport, Mississippi................................   165
        Evaluation...................................................   174
        Program......................................................   164
    Keeping Workers Safe.............................................   159
    Mine Safety and Health Administration (MSHA).....................   184
    National Labor Relations Board...................................   163
    National Longitudinal Youth Survey...............................   211
    Occupational Safety and Health Administration (OSHA).............   184
    Office of:
        Disability Employment Policy (ODEP)........................167, 191
        Federal Contract Compliance Programs.........................   179
        Labor-Management Standards (OLMS)............................   181
        The Solicitor (SOL)..........................................   188
        Workers' Compensation Programs (OWCP)........................   182
    Payroll Fraud Prevention Act.....................................   210
    Program Effectiveness............................................   218
    Recovery Efforts in Alabama......................................   162
    Return on Investment.............................................   175
    Trade Adjustment Assistance Community College Training Grants....   214
    Transition Assistance Program....................................   172
    2012 Budget Resolution Passed By House...........................   168
    Unemployment:
        Compensation (UC)............................................   199
        Rate for African Americans...................................   207
    Voluntary Protection Programs (VPP)..............................   204
    Wage and Hour Division (WHD)...................................161, 177
    Women Vets.......................................................   174
    Women's Bureau (WB)..............................................   191
    Worker Protection................................................   156
    Workforce:
        Innovation Fund..............................................   197
        Investment Act.............................................156, 215
            Reauthorization..........................................   207
            Workforce Innovation Fund................................   198
        Training Strategies..........................................   209
    Workshare........................................................   206
    YouthBuild.......................................................   197
    Youthbuild Program...............................................   166

                           RAILROAD RETIREMENT BOARD

    Agency Staffing..................................................   498
    Budget Request...................................................   500
    Financial Status of the Trust Funds..............................   499
    Information Technology Improvements..............................   499
    Office of Audit..................................................   500
    Office of Investigations.........................................   501
    Operational Components...........................................   500
    Other Requested Funding..........................................   499
    Proposed Funding for Agency Administration.......................   498

                         SOCIAL SECURITY ADMINISTRATION

    Additional Committee Questions...................................    29
    Adequate Resources Needed for SSA................................    27
    Administrative Funding for Social Security.......................    17
    Annual Earnings Statements.......................................    17
    Continuing to Reduce the Disability Backlogs.....................    12
    Cost-Benefit Analysis of Hearing Versus Approving a Case
      Initially......................................................    23
    Disability:
        Waiting Times................................................    18
        Work Incentives Simplification Pilot (WISP)..................    16
    Effects of Continuing Resolutions................................10, 24
    Funding Need to Run an Efficient, Effective SSA..................    24
    Improving Service to the Public..................................    13
    Ongoing Funding--Fiscal Years 2011 and 2012......................    11
    Possible Effects of Government Shutdown..........................    25
    Program Integrity................................................    18
    Recent Accomplishments...........................................     8
    Recovery Act Funding for SSA.....................................    19
    Reversal Rate for Disability Decisions...........................    20
    SSA Administrative Overhead......................................    26
    Saving Taxpayer Dollars..........................................    14
    Service Cuts Due to a Lack of Funding............................    27