[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







   Available via the World Wide Web: http://www.gpo.gov/fdsys/browse/
        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 [email protected].
    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\
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    \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.
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  --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.
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    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\
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    \3\ Hicks LS, et al. The Quality of Chronic Disease Care in US 
Community Health Centers. Health Affairs 2006;25(6):1713-1723.
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  --A high proportion of health center patients receive appropriate 
        diabetes care.\4\
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    \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.
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  --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\
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    \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.
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  --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\
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    \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.
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  --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.
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  --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 
([email protected]) 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.
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    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.
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                        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.
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    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.
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    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.
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                       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.
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    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.
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                      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\
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    \1\ Rehm J, et al. The Lancet 373(9682): 2223-2233, June 27, 2009-
July 3, 2009.
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    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.
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    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.
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              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.
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               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.
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        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 
[email protected].

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\
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    \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.
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    \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.
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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.
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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.
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    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 [email protected].
    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 [email protected] 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: [email protected].
                                 ______
                                 
     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 [email protected].
                                 ______
                                 
  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 [email protected].
                                 ______
                                 
     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.
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    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.
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    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.
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    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 
[email protected].
                                 ______
                                 
    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.
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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.
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    \2\ NIH all-hands town meeting, 17 August 2009. http://
videocast.nih.gov/Summary.asp?File=15247.
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    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 ([email protected]) or Katie Shoemaker at HCZ 
([email protected]).
                                 ______
                                 
  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 
[email protected] or (301) 563-6001. You may also contact our 
Washington representative, Emily Holubowich, at [email protected] 
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 
[email protected]. You may also contact Susan L. Vaughn, 
Director of Public Policy, at 573-636-6946 or [email protected] 
or William A.B. Ditto, Chair of the Public Policy Committee, at 
[email protected].
    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\
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    \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.
---------------------------------------------------------------------------
    \1\ American Cancer Society. Cancer Facts and Figures 2010. http://
www.cancer.org/Research/CancerFactsFigures/CancerFactsFigures/cancer-
facts-and-figures-2010.
---------------------------------------------------------------------------
    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 
([email protected]), Pat Smith from The Reinvestment Fund 
([email protected]), or John Weidman from The Food Trust 
([email protected])
                                 ______
                                 
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.
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  --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.
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    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 [email protected].
 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, 
[email protected],
                                 ______
                                 
  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 [email protected].
    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



                                  


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