    [Senate Hearing 112-718]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 112-718

                                                            Senate Hearings

                                     Before the Committee on Appropriations

    _______________________________________________________________________

                                                      Departments of Labor,

                                                 Health and Human Services,

                                                 and Education, and Related

                                                    Agencies Appropriations

                                                           Fiscal Year 2013

                                             112th CONGRESS, SECOND SESSION

                                                                    S. 3295

            DEPARTMENT OF HEALTH AND HUMAN SERVICES
            DEPARTMENT OF LABOR
            NONDEPARTMENTAL WITNESSES

                                                           S. Hrg. 112-718

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2013

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

                                    HEARINGS

                                    before a

                              SUBCOMMITTEE OF THE

                COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                          ONE HUNDRED TWELFTH CONGRESS

                                 SECOND SESSION

                                       on

                                    S. 3295

     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, 2013, AND FOR OTHER PURPOSES

                                   __________

                    Department of Health and Human Services
                              Department of Labor
                           Nondepartmental Witnesses

                                   __________

             Printed for the use of the Committee on Appropriations

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            committee.action?chamber=senate&committee=appropriations

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                          COMMITTEE ON APPROPRIATIONS

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

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

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

                               Professional Staff

                                  Erik Fatemi
                                  Mark Laisch
                                Adrienne Hallett
                                 Lisa Bernhardt
                                Michael Gentile
                                 Robin Juliano
                          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 7, 2012

                                                                       Page

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

                           Wednesday, March 14, 2012

    Department of Labor: Office of the Secretary.....................    81

                            Wednesday, May 28, 2012

    Department of Health and Human Services: National Institutes of
      Health.........................................................   151

    Departmental Witnesses...........................................   273
    Nondepartmental Witnesses........................................   281

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2013

                                  ----------

                            WEDNESDAY, MARCH 7, 2012

                                           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, Kohl, Landrieu, Pryor, Mikulski,
    Brown, Shelby, Alexander, Johnson, Graham, 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 Appropriations Subcommittee on Labor,
    Health and Human Services, and Education, and Related Agencies
    will come to order.
        Madam Secretary, welcome back to the subcommittee. I want
    to start by commending you for the outstanding work you are
    doing to implement the Affordable Care Act (ACA) since
    President Obama signed it into law almost 2 years ago.
        Some 3.6 million seniors--more than 42,000 in my State of
    Iowa--got discounts on their prescription drugs last year. Two-
    and-a-half million young adults are staying on their parents'
    insurance from graduation to age 26. I just ran into a family
    in Iowa where a student got off the family insurance, and then
    lost their job. That person came back on the family's
    insurance, went back to school again, took the college
    insurance, got out of school, came back on their family's
    insurance. And so it was a great comfort to this family to know
    that their child would not be without insurance coverage and
    they got insurance at the family rate.
        Most important of all, 54 million Americans received a free
    preventative screening service in 2011 all because of ACA. And
    I believe this is the right track for healthcare in America.
    You know how strongly I feel about prevention and wellness.
        Your Department is carrying out these reforms with great
    skill and dedication, and I commend you for your leadership.
        More work remains, of course. Fiscal year 2013 is a key
    year for implementing ACA because it ends just 3 months before
    health insurance exchanges will open their doors in the States.
    On that day, we will fulfill a promise to bring affordable
    healthcare to 30 million uninsured Americans.
        The President's budget request for fiscal year 2013
    includes additional funding at Centers for Medicare & Medicaid
    Services (CMS) for creating these exchanges. As the chairman of
    this subcommittee and also of the authorizing committee, I am
    determined to help you finish the job. Reforming healthcare is
    not only the right thing to do, it will save taxpayers money
    and reduce the deficit and again move us more toward a real
    healthcare system rather than a sick care system.
        The President's proposed budget also includes increases for
    key priorities like child care, Head Start, and rooting out
    fraud, waste, and abuse in Medicare and Medicaid.
        However, there were two areas in which I was disappointed.
    One area is, of course, the cuts in the budget for the
    prevention fund. The prevention fund is something that was
    worked out in great detail, and all the different compromises
    were made when we passed the ACA. And then the President
    requested a cut of $4.5 billion, which was then folded in the
    recent agreement by the Congress for a $5 billion cut in the
    prevention fund, again penny wise, pound foolish. We will just
    take funding away from prevention, but boy, when you get sick,
    we will take care of you later on and it will cost us a lot
    more money. I do not know when we are going to learn that our
    mothers were right. An ounce of prevention is worth a pound of
    cure. And that is true in healthcare. But no. Take money out of
    the prevention fund.
        The other part where I am disappointed is the lack of any
    additional funding for eliminating fraud and waste in
    healthcare. I chaired a hearing on this topic last February.
    Every $1 that CMS spends on reducing fraud and waste returns $7
    to the U.S. Treasury in real dollars. The Budget Control Act of
    2011 included a cap adjustment that encouraged the Congress to
    increase this funding by $270 million, an amount that would
    have saved taxpayers well over $1 billion. Yet, in conference
    at the insistence of the House majority, they refused any
    additional funding for this whatsoever in last year's bill.
    Again, penny wise and pound foolish.
        I am pleased that the President has once again requested an
    increase for eliminating healthcare waste and abuse in this
    year's budget. And I would like to discuss this topic more with
    you later.
        Some other provisions in the President's budget meanwhile
    are cause for concern. Once again, the President has proposed a
    nearly 50 percent cut to the Community Services Block Grants.
    This funding is critically important for community initiatives
    that provide a safety net for millions of low-income people
    across the country. The Congress rejected that cut last year. I
    expect it will do so again this year.
        But overall, I believe the President's budget is a good
    start.

                               prepared statement

        Madam Secretary, again, I commend you for your great
    leadership in these areas and especially what you are doing to
    implement ACA, and I look forward to hearing your testimony.
        First, before I yield to the ranking member, Senator
    Shelby, for his opening remarks, I have received a statement
    from the full committee chairman, Senator Inouye. His statement
    will be inserted into the record at this point.
        [The statement follows:]
                prepared statement of chairman daniel k. inouye
        Mr. Chairman, thank you for chairing this hearing to review the
    President's fiscal year 2013 budget for the Department of Health and
    Human Services.
        I would like to extend a warm aloha to Secretary of Health and
    Human Services, Kathleen Sebelius. These are challenging fiscal times,
    but I look forward to continuing to work with her to support critical
    investments in healthcare, disease prevention, social services, and
    scientific research.

        Senator Harkin. Senator Shelby.

                     STATEMENT OF SENATOR RICHARD C. SHELBY

        Senator Shelby.  Thank you, Mr. Chairman.
        Secretary Sebelius, thank you for appearing today to
    discuss the fiscal year 2013 Department of Health and Human
    Services (HHS) budget.
        We are living in difficult times. America's gross debt has
    increased more than $5 trillion during President Obama's first
    3 years in office, and the fiscal year 2013 budget request does
    nothing to curb spending or put our country on a fiscally
    sustainable path. In fact, the administration has built the
    fiscal year 2013 budget based, I believe, on the flawed
    philosophy of spend now, pay later. But as the turmoil in
    Greece is verifying, at some point the bill must be paid.
        One of the key fiscal challenges facing the Federal
    Government is healthcare spending. In the last 20 years, total
    funding for HHS has tripled. Since 2001, the HHS's
    discretionary appropriation has increased by 45 percent. The
    President's answer to control health spending, the Affordable
    Care Act (ACA) that Senator Harkin referenced, continues to
    grow our Nation's deficit, and its bills are piling up.
        In the fiscal year 2013, the budget requests a $1 billion
    increase in discretionary dollars for the Centers for Medicare
    & Medicaid Services to continue implementation of ACA
    activities. This is in addition to the $15.4 billion in
    mandatory funding ACA directly appropriated since fiscal year
    2011. By combining discretionary and mandatory funding streams,
    the majority of ACA circumvents the yearly appropriations
    process that is crucial to providing transparency and oversight
    to funding decisions.
        As we attempt to rein in Federal spending, it is clear that
    a comprehensive view to fund the healthcare programs is
    necessary. Instead of using budgetary smoke and mirrors, I
    believe we should examine all sources of funding, discretionary
    and mandatory, before the Appropriations Committee here
    determines an appropriate level of discretionary funding. Many
    programs advertise their baseline reduction when, in fact, they
    are recipients of significant mandatory funding from ACA.
    Agencies and programs I believe should no longer deceive the
    American taxpayer by arguing that spending is reduced when they
    also receive mandatory funding from ACA that supplements and,
    in many cases, greatly increases their spending level.
        It is also critical here that our subcommittee carefully
    consider the effects of ACA's mandatory funding on important
    healthcare programs that may not be able to continue if the act
    is not repealed. The administration has used ACA's mandatory
    spending, which is not subject to a vote by the Congress every
    year, to backfill key and discretionary programs. The
    administration then diverts discretionary dollars to fund new
    programs. If ACA is repealed, many important programs like
    community health centers and the section 317 immunization
    program at the Centers for Disease Control will be in jeopardy
    because their base funding provided by the Department of Labor,
    HHS appropriations has been so significantly reduced.
        I believe it is time to stop deceptive budgeting. We should
    be looking at the resources programs need for the fiscal year
    and not necessarily their long-enjoyed funding history. The
    Congress should carefully review programs to ensure funding is
    targeted to those that are the most successful and achieve the
    best results.

                               PREPARED STATEMENT

        That is why I am disappointed that the administration has
    cut funding for the National Institutes of Health (NIH). In the
    last 30 years, biomedical research has yielded significant
    scientific discoveries that have extended life, reduced
    illness, and cut healthcare costs considerably. Secretary
    Sebelius, your budget request, I believe, abandons our Nation's
    commitment to advancing medical research. In fact, the request
    does not keep pace with biomedical research inflation, and as a
    result, in inflationary adjusted dollars, NIH is nearly 20
    percent below where they were just 10 years ago. Our Nation's
    leading researchers will never find a cure, I believe, for the
    debilitating diseases that affect us without a commitment to
    advancing medical research. I believe it is critical to invest
    in biomedical research to ensure the United States continues to
    make progress toward medical discoveries that improve our lives
    and make treatment more effective and lower overall healthcare
    costs.
        I look forward to hearing from you this morning, but these
    are some of the concerns that I think we should look at.
        [The statement follows:]
                Prepared Statement of Senator Richard C. Shelby
        Secretary Sebelius, thank you for appearing today to discuss the
    Department of Health and Human Services (HHS) fiscal year 2013 budget.
        We are living in difficult times. America's gross debt has
    increased more than $5 trillion during President Obama's first 3 years
    in office, and the fiscal year 2013 budget request does nothing to curb
    spending or put our country on a fiscally sustainable path.
        In fact, the administration has built the 2013 budget based on the
    flawed philosophy of spend now, pay later. But as the turmoil in Greece
    is verifying, at some point the bill must be paid.
        One of the key fiscal challenges facing the Federal Government is
    healthcare spending. In the last 20 years, total funding for HHS has
    tripled. Since 2001, the Department's discretionary appropriation has
    increased by 45 percent.
        The President's answer to control health spending, the Affordable
    Care Act (ACA), continues to grow our Nation's deficit, and its bills
    are piling up.
        In fiscal year 2013, the budget requests a $1 billion increase in
    discretionary dollars for the Centers for Medicare & Medicaid Services
    to continue implementation of ACA activities. This is in addition to
    the $15.4 billion in mandatory funding the ACA directly appropriated
    since fiscal year 2011. By combining discretionary and mandatory
    funding streams, the majority of ACA circumvents the yearly
    appropriations process that is crucial to providing transparency to
    funding decisions.
        As we attempt to rein in Federal spending, it is clear that a
    comprehensive view to fund healthcare programs is necessary.
        Instead of using budgetary smoke and mirrors, we should examine all
    sources of funding--discretionary and mandatory--before the
    Appropriations Committee determines an appropriate level of
    discretionary funding. Many programs advertise their baseline
    reduction, when, in fact, they are recipients of significant mandatory
    funding from ACA. Agencies and programs should no longer deceive the
    American taxpayer by arguing their spending is reduced when they also
    receive mandatory funding from ACA that supplements and, in many cases,
    greatly increases their spending level.
        It is also critical that our subcommittee carefully consider the
    effects of the ACA's mandatory funding on important healthcare programs
    that may not be able to continue when the act is repealed. The
    administration has used the ACA's mandatory spending, which is not
    subject to a vote by the Congress every year, to backfill key
    discretionary programs. The administration then diverts discretionary
    dollars to fund new programs.
        When ACA is repealed, many important programs like community health
    centers and the section 317 immunization program at the Centers for
    Disease Control will be in jeopardy because their base funding provided
    by the Labor, Health and Human Services, and Education, and Related
    Agencies appropriations bill has been so significantly reduced.
        It is time to stop deceptive budgeting. We should be looking at the
    resources programs need for this fiscal year and not necessarily their
    long-enjoyed funding history. The Congress should carefully review
    programs to ensure funding is targeted to those that are the most
    successful and achieve the best results.
        That is why I am disappointed that the administration has cut
    funding for the National Institutes of Health (NIH).
        In the last 30 years, biomedical research has yielded significant
    scientific discoveries that have extended life, reduced illness, and
    cut healthcare costs considerably. Secretary Sebelius, your budget
    request abandons our Nation's commitment to advancing medical research.
    In fact, the request does not keep pace with biomedical research
    inflation and as a result, in inflationary adjusted dollars, the NIH is
    nearly 20 percent below where they were 10 years ago.
        Our Nation's leading researchers will never find a cure for the
    debilitating diseases that affect us without a commitment to advancing
    medical research. It is critical to invest in biomedical research to
    ensure the United States continues to make progress towards medical
    discoveries that improve lives, make treatment more effective, and
    lower overall healthcare costs.
        Mr. Chairman, I look forward to working with you this year to craft
    a bill that balances the needs of our healthcare system within our
    country's fiscal restraints.

        Senator Shelby.  Thank you, Mr. Chairman.
        Senator Harkin.  Thank you very much, Senator Shelby.
        Kathleen Sebelius became the 21st Secretary of the
    Department of Health and Human Services on April 29, 2009. In
    2003, she was elected Governor of Kansas and served in that
    capacity until her appointment by President Obama as the
    Secretary. Prior to her election as Governor, she served as the
    Kansas State Insurance Commissioner. She is a graduate of
    Trinity Washington University and the University of Kansas.
        My notes tell me this will make the Secretary's fifth
    appearance before this subcommittee since her appointment. You
    have always been forthright with us, Madam Secretary. We
    appreciate your being here. Your statement will be made a part
    of the record in its entirety, and please proceed as you so
    desire.

                     SUMMARY STATEMENT OF KATHLEEN SEBELIUS

        Secretary Sebelius. Well, thank you, Chairman Harkin and
    Ranking Member Shelby, and members of the subcommittee. A
    little shout-out to my home State senator, Senator Moran. And I
    appreciate the invitation to discuss the President's fiscal
    year 2013 budget for HHS.
        Our budget helps create an American economy built to last
    by strengthening our Nation's healthcare, supporting research
    that will lead to tomorrow's cures, and promoting opportunities
    for America's children and families so everyone has a fair shot
    to reach his or her potential. It makes the investments we need
    right now, while reducing the deficit in the long term, to make
    sure that the programs that millions of Americans rely on will
    be there for generations to come.
        I look forward to our discussion and answering your
    questions about the budget. But first, I would like to just
    share some of the highlights that fall under the jurisdiction
    of this subcommittee, which oversees almost $70 billion of our
    Department's nearly $77 billion discretionary budget.

                               HEALTHCARE REFORM

        Over the last 2 years, as the chairman said, we have worked
    to deliver the benefits of ACA to the American people. Thanks
    to the law, more than 2.5 million additional young Americans
    are already getting coverage through their parents' health
    plans. More than 25 million seniors across the country have
    taken advantage of the free recommended preventive services
    under Medicare. And small business owners are getting tax
    breaks on their health bills that allow them to hire more
    employees.
        This year, we will build on that progress by continuing to
    support States as they work to establish affordable insurance
    exchanges by 2014. Once these competitive marketplaces are in
    place, they will ensure that all Americans have access to
    quality, affordable health coverage.
        Because we know that a lack of insurance is not the only
    obstacle to care, our budget also invests in the healthcare
    workforce. This budget supports training more than 7,100
    primary care providers and placing them where they are needed
    most.
        It also invests in America's network of community health
    centers. Together with the 2012 resources, our budget will
    create more than 240 new access points for patient care, along
    with thousands of new jobs. Altogether, health centers will
    provide access to quality care for 21 million people, 300,000
    more than were served last year.
        This budget also continues our administration's commitment
    to improving the quality and safety of care by spending health
    dollars more wisely. It means investing in health information
    technology. It also means funding the first-of-its-kind Center
    for Medicare & Medicaid Innovation which is partnering with
    physicians, nurses, hospital administrators, private payers,
    and others who have accepted the challenge to develop a new,
    sustainable healthcare system.
        In addition, our budget ensures that 21st century America
    will continue to lead the world in biomedical research by
    maintaining funding for NIH.

                       HEALTHCARE FRAUD, WASTE, AND ABUSE

        At the same time, the budget recognizes the need to set
    priorities, making difficult tradeoffs and ensure we use every
    $1 wisely. That starts with support for President Obama's
    historic push to stamp out waste, fraud, and abuse in the
    healthcare system. Over the last 3 years, every $1 we have put
    into healthcare fraud and abuse control has returned more than
    $7 to taxpayers. Last year alone, these efforts recovered more
    than $4 billion. And just last week, our administration
    arrested the alleged head of the largest individual Medicare
    and Medicaid fraud operation in history. Our budget builds on
    those efforts by giving law enforcement the technology and data
    to spot perpetrators early and prevent payments based on fraud
    from going out in the first place.
        The budget also contains more than $360 billion in health
    savings over 10 years, most of which comes from reforms to
    Medicare and Medicaid. These are significant, but they are
    carefully crafted to protect beneficiaries. For example, we
    propose significant savings in Medicare by reducing drug costs,
    a plan that both puts money back in the Medicare Trust Fund and
    puts money back in the pockets of Medicare beneficiaries.

                               PREPARED STATEMENT

        The budget makes smart investments where they will have the
    greatest impact, and it puts us all on a path to build a
    stronger, healthier, more prosperous America for the future.
        Again, thank you, Mr. Chairman and members of the
    subcommittee, and I look forward to this discussion.
        [The statement follows:]
                    Prepared Statement of Kathleen Sebelius
        Chairman Harkin, Ranking Member Shelby, and members of the
    subcommittee, thank you for the invitation to discuss the President's
    fiscal year 2013 budget for the Department of Health and Human Services
    (HHS).
        The budget for HHS invests in healthcare, disease prevention,
    social services, and scientific research. HHS makes investments where
    they will have the greatest impact, build on the efforts of our
    partners, and lead to meaningful gains in health and opportunity for
    the American people.
        The President's fiscal year 2013 budget for HHS includes a
    reduction in discretionary funding for ongoing activities and
    legislative proposals that would save an estimated $350.2 billion over
    10 years. The budget totals $940.9 billion in outlays and proposes
    $76.7 billion in discretionary budget authority, including $69.6
    billion under the purview of this subcommittee. This funding will
    enable HHS to:
      --strengthen healthcare;
      --support American families;
      --advance scientific knowledge and innovation;
      --strengthen the Nation's health and human service infrastructure and
            workforce;
      --increase efficiency, transparency, and accountability of HHS
            programs; and
      --complete the implementation of the American Recovery and
            Reinvestment Act.
                             strengthen healthcare
        Delivering Benefits of the Affordable Care Act to the American
    People.--The Affordable Care Act (ACA) expands access to affordable
    health coverage to millions of Americans, increases consumer
    protections to ensure individuals have coverage when they need it most,
    and slows increases in health costs. Effective implementation of the
    ACA is central to the improved fiscal outlook and well-being of the
    Nation. The Centers for Medicare & Medicaid Services (CMS) is
    requesting an additional $1 billion in discretionary funding to
    continue implementing the ACA, including Affordable Insurance
    Exchanges, and to help keep up with the growth in the Medicare
    population.
        Expand and Improve Health Insurance Coverage.--Beginning in 2014,
    Affordable Insurance Exchanges will provide improved access to
    insurance coverage for millions of Americans. Exchanges will make
    purchasing private health insurance easier by providing eligible
    individuals and small businesses with one-stop shopping where they can
    compare benefit plans. New premium tax credits and reductions in cost-
    sharing will help ensure that eligible individuals can afford to pay
    for the cost of private coverage through Exchanges. Fiscal year 2013
    will be a critical year for building the infrastructure and initiating
    the many business operations critical to enabling Exchanges to begin
    operation on January 1, 2014. The expansion of health insurance
    coverage for millions of low-income individuals, who were previously
    not eligible for coverage, also begins in 2014. CMS has worked closely
    with States to ensure they are prepared to meet the 2014 deadline and
    will continue this outreach in fiscal year 2013.
        Many important private market reforms have already gone into
    effect, providing new rights and benefits to consumers that are
    designed to put them in charge of their own healthcare. The ACA's
    Patient's Bill of Rights allows young adults to stay on their parents'
    plans until age 26 and ensures that consumers receive the care they
    need when they get sick and need it most by prohibiting rescissions and
    lifetime dollar limits on coverage for care, and beginning to phase out
    annual dollar limits. The new market reforms also guarantee independent
    reviews of coverage disputes. Temporary programs like the Early Retiree
    Reinsurance Plan and the Pre-Existing Condition Insurance Plan are
    supporting affordable coverage for individuals who often face
    difficulties obtaining private insurance in the current marketplace.
    Additionally, rate review and medical loss ratio (MLR) provisions helps
    ensure that healthcare premiums are kept reasonable and affordable year
    after year. The already operational rate review provision gives States
    additional resources to determine if a proposed healthcare premium
    increase is unreasonable and, in many cases, help enable State
    authorities to deny an unreasonable rate increase. HHS reviews large
    proposed increases in States that do not have effective rate review
    programs. The MLR provisions guarantee that, starting in 2011,
    insurance companies use at least 80 percent or 85 percent of premium
    revenue, depending on the market, to provide or improve healthcare for
    their customers or give them a rebate.
        Strengthen the Delivery System.--ACA established a Center for
    Medicare & Medicaid Innovation. The Innovation Center is tasked with
    developing, testing, and--for those that prove successful--expanding
    innovative payment and delivery system models to improve quality of
    care and reduce costs in Medicare, Medicaid, and the Children's Health
    Insurance Program. Since the Innovation Center began operations it has
    undertaken an ambitious agenda encompassing patient safety,
    coordination of care among multiple providers, and enhanced primary
    care. These projects can serve as crucial stepping stones towards a
    higher-quality, more-efficient healthcare system.
        Ensuring Access to Quality Care for Vulnerable Populations.--Health
    centers are a key component of the Nation's healthcare safety net. The
    President's budget includes a total of $3 billion, including an
    increase of $300 million from mandatory funds under the ACA, to the
    health centers program. This investment will provide Americans in
    underserved areas--both rural and urban--with access to comprehensive
    primary and preventive healthcare services. Together with 2012
    resources, HHS' budget will create more than 240 new access points for
    patient care. Overall, HHS' investment in health centers will provide
    access to quality care for 21 million people, an increase of 300,000
    additional patients over fiscal year 2012. The budget also promotes a
    policy of steady and sustainable health center growth by distributing
    ACA resources over the long-term. This policy safeguards resources for
    new and existing health centers to continue services and ensures a
    smooth transition as health centers increase their capacity to provide
    care as access to insurance coverage expands.
        Improving Healthcare Quality and Patient Safety.--ACA directed HHS
    to develop a national strategy to improve healthcare services delivery,
    patient health outcomes, and population health. In fiscal year 2011,
    HHS released the National Strategy for Quality Improvement in Health
    Care, which highlights three broad aims:
      --better care;
      --healthy people and communities; and
      --affordable care.
        Since publishing the National Strategy for Quality Improvement in
    Health Care, HHS has focused on gathering additional input from private
    partners and aligning new and existing HHS activities with the
    strategy. HHS will enhance the strategy by incorporating input from
    stakeholders and developing metrics to measure progress toward
    achieving the strategy's aims and priorities. Already, the strategy is
    serving as a blueprint for quality improvement activities across the
    country.
        Investing in Innovation.--HHS is committed to advancing the use of
    health information technology (IT). The budget includes $66 million, an
    increase of $5 million, for the Office of the National Coordinator for
    Health Information Technology (ONC) to accelerate the adoption of
    health IT and promote electronic health records (EHRs) as tools to
    improve both the health of individuals and the healthcare system as a
    whole. The increase will allow ONC to provide more assistance to
    healthcare providers as they become meaningful users of health IT.
    Furthermore, through the Health Information Technology for Economic and
    Clinical Health Act provisions of the American Recovery and
    Reinvestment Act, CMS is providing hospitals and medical professionals
    who participate in Medicare and Medicaid with substantial incentive
    payments for the adoption and meaningful use of EHRs. As of February 1,
    2012, CMS had made incentive payments to more than 23,600 providers who
    have met the objectives for meaningful use in the Medicare EHR
    Incentive program and more than 19,600 providers who have adopted,
    implemented, or upgraded EHRs, or met meaningful use objectives in the
    Medicaid EHR Incentive program. By encouraging providers to modernize
    their systems, this investment will improve the quality of care and
    protect patient safety.
                           support american families
        Healthy Development of Children and Families.--HHS oversees many
    programs that support children and families. The fiscal year 2013
    budget request invests in early education, recognizing the role high-
    quality early education programs can play in preparing children for
    school success.
        Investing in Education by Supporting an Early Learning Reform
    Agenda.--The fiscal year 2013 budget supports critical reforms in Head
    Start and a child care quality initiative that, when taken together
    with the Race to the Top--Early Learning Challenge, are key elements of
    the administration's broader education reform agenda designed to
    improve our Nation's competitiveness by helping every child enter
    school ready for success.
        On November 8, 2011, the President announced important new steps to
    improve the quality of services and accountability at Head Start
    centers across the country. The budget requests more than $8 billion
    for Head Start programs, an increase of $85 million more than fiscal
    year 2012, to maintain services for the 962,000 children currently
    participating in the program. This investment will also provide
    resources to effectively implement new regulations that require
    grantees that do not meet high-quality benchmarks to compete for
    continued funding, introducing an unprecedented level of accountability
    into the Head Start program. By directing taxpayer dollars to programs
    that offer high-quality Head Start services, this robust, open
    competition for Head Start funding will help to ensure that Head Start
    programs provide the best available early education services to our
    most vulnerable children.
        The budget includes $300 million for a new child care quality
    initiative that States would use to invest directly in programs and
    teachers so that individual child care programs can do a better job of
    meeting the early learning and care needs of children and families. The
    funds would also support efforts to measure the quality of individual
    child care programs through a rating system or another system of
    quality indicators, and to clearly communicate program-specific
    information to parents so they can make informed choices for their
    families. These investments are consistent with the broader
    reauthorization principles outlined in the budget, which encompass a
    reform agenda that would help transform the Nation's child care system
    to one that is focused on continuous quality improvement and provides
    more low-income children access to high-quality early education
    settings that support children's learning, development, and success in
    school.
        Keeping America Healthy.--The President's budget includes resources
    necessary to enhance clinical and community prevention, support
    research, develop the public health workforce, control infectious
    diseases, and invest in prevention and management of chronic diseases
    and conditions.
        Tobacco Prevention Activities.--Tobacco use kills an estimated
    443,000 people in the United States each year. Despite progress in
    reducing tobacco use, 1 in 5 high school students and adults continue
    to smoke, costing our Nation $96 billion in medical costs and $97
    billion in lost productivity each year. The budget includes $586
    million in funding from the Centers for Disease Control and Prevention
    (CDC), the National Institutes of Health (NIH), and the Substance Abuse
    and Mental Health Services Administration (SAMHSA) to further help
    reduce smoking among teens and adults and support research on
    preventing tobacco use, understanding the basic science of the
    consequences of tobacco use, and improving treatments for tobacco-
    related illnesses. HHS is striving to reduce adults' annual cigarette
    consumption in the United States from 1,281 cigarettes per capita to
    1,062 cigarettes per capita by 2013.
        Million Hearts Initiative.--The Million Hearts Initiative is a
    national public-private initiative aimed at preventing 1 million heart
    attacks and strokes over 5 years, from 2012 to 2017. It seeks to reduce
    the number of people who need treatment and improve the quality of
    treatment that is available. It focuses on increasing the number of
    Americans who have their high blood pressure and high cholesterol under
    control, reducing the number of people who smoke, and reducing the
    average intake of sodium and trans fats. To achieve this overall goal,
    the initiative will promote medication management and support a network
    of EHR registries to track blood pressure and cholesterol control,
    along with many other public-private collaborations. In fiscal year
    2013, the budget requests $5 million for CDC to achieve measurable
    outcomes in these areas.
        Preventing Teen Pregnancy.--The budget includes $105 million for
    the Office of the Assistant Secretary for Health for teen pregnancy
    prevention programs. These programs will support community-based
    efforts to reduce teen pregnancy using evidence-based models and
    promising programs needing further evaluation. The budget also includes
    $15 million in funding for CDC teen pregnancy prevention activities to
    reduce the number of unintended pregnancies through science-based
    prevention approaches. Additionally, the budget would repurpose
    unobligated funds to create a new teen pregnancy prevention program
    specifically targeted to youth in foster care, who are at particularly
    high risk of becoming teen parents.
        Protect Vulnerable Populations.--HHS is committed to ensuring that
    vulnerable populations continue to receive critical services during
    this period of economic uncertainty. For example, the Administration
    for Children and Families (ACF) budget requests includes a $7 million
    increase in funding for the Family Violence Prevention programs in
    order to expand shelter capacity and services and to support higher
    call volume to the domestic violence hotline.
        Preventing and Treating HIV/AIDS.--The fiscal year 2013 budget
    includes $3.3 billion for domestic HIV/AIDS activities to increase the
    availability of treatment to people living with HIV/AIDS in the United
    States, improve adherence to medications, and support prevention
    programs in States and communities. This total investment includes $1
    billion, an increase of $67 million, to increase access to life-saving
    treatments through the AIDS Drug Assistance program, and $236 million,
    an increase of $20 million, to support care provided by HIV clinics
    across the country.
        This total also includes $826 million for CDC's domestic HIV/AIDS
    prevention activities, an increase of $40 million more than fiscal year
    2012, to support grants to health departments to reduce new HIV
    infections, identify previously unrecognized HIV infections, and
    improve health outcomes. In addition, funds will support research,
    surveillance, evaluation, and implementation of high-impact prevention
    programs among HIV-affected populations. In fiscal year 2013, CDC will
    award grants to 69 State and local health departments to implement HIV/
    AIDS prevention programs according to a revised funding algorithm
    instituted in fiscal year 2012, which better aligns the distribution of
    prevention resources with the disease burden rather than with
    historical AIDS data. CDC will also support up to 36 jurisdictions for
    an expanded testing initiative to focus on groups at highest risk for
    acquiring HIV such as men who have sex with men, African Americans, and
    injection drug users.
        Refugee Transitional and Medical Services.--The budget requests
    $805 million to provide time-limited cash and medical assistance to
    newly arrived refugees, helping them become self-sufficient as quickly
    as possible, and to provide shelter for unaccompanied alien children
    until they can be placed with relatives or other sponsors, repatriated
    to their home countries, or receive relief under U.S. immigration law.
    Additional funding will primarily cover rising medical costs--many
    refugees have spent their lives in camps where medical care is limited
    or nonexistent--and serve the growing number of unaccompanied alien
    children made eligible for benefits under the Trafficking Victims
    Protection Reauthorization Act of 2008.
        Elder Justice.--The budget includes $43 million for the
    Administration on Aging (AOA) to address the growing problem of elder
    abuse, neglect, and exploitation which affects more than 5 million
    seniors annually. Research indicates that older victims of even modest
    forms of abuse have dramatically higher morbidity and mortality rates
    than nonabused older people. To combat this abuse, the budget provides
    $8 million for newly authorized Adult Protective Services Demonstration
    grants, along with $9 million in ongoing funding for State grants to
    raise awareness of elder abuse and neglect and for resource centers and
    related activities that support nationwide elder rights activities. The
    budget also includes $17 million for the Long-term Care Ombudsman
    Program to improve the quality of care for the residents of long-term
    care facilities by resolving complaints on behalf of residents.
        Keeping People in Communities.--Part of HHS' strategic plan
    includes enabling seniors to remain in their own homes with a high-
    quality of life for as long as possible through the provision of home
    and community-based services, including supports for family caregivers.
    Some seniors, if unable to remain independent in the community, will be
    forced to move into a nursing home at a significant potential cost to
    Medicaid. The budget includes $1.4 billion in AOA to help seniors stay
    in their homes through home and community-based supportive services,
    senior nutrition programs, and Caregiver Support programs. The budget
    also proposes to transfer the Senior Community Service Employment
    program from the Department of Labor (DOL) to the AOA. This move
    provides greater alignment with the agencies that provide supportive
    services.
        Community Services Programs.--The budget includes $400 million for
    community services programs. This funding level includes $350 million
    for the Community Services Block Grant (CSBG), and proposes to use a
    system of standards and competition to target the funds to high-
    performing agencies that are most successful in meeting community
    needs. In support of the Healthy Food Financing Initiative, $10 million
    is available to fund community development corporations to eliminate
    food deserts by improving access to grocery stores, farmers' markets,
    and other venues for healthy, affordable groceries. Additionally, $20
    million is requested for the Community Economic Development program to
    sponsor enterprises providing employment, training, and business
    development opportunities for low-income Americans.
        Vulnerable Youth.--The ACFs' budget includes an additional $5
    million as part of a cross-agency effort to identify and test new ways
    to strengthen services for disconnected youth--14- to 24-year-olds who
    are neither working nor in school. This $5 million will be utilized in
    close cooperation with an additional $5 million requested by the
    Department of Education and $10 million from DOL. In addition to the
    funding request, the administration proposes a general provision in the
    appropriations act to support a limited number of ``performance
    partnerships'' that would provide States and localities with enhanced
    flexibility in determining how services are structured in return for
    strong accountability for results.
        Reduce Foodborne Illness.--The budget reflects the administration's
    commitment to transforming our Nation's food safety system into one
    that is stronger and that reduces foodborne illness and includes an
    increase of $17 million above fiscal year 2012 to support CDC's role in
    implementing the Food Safety and Modernization Act. HHS will continue
    to modernize and implement a prevention-focused domestic and import
    safety system. Collaboratively, the Federal Drug Administrative (FDA)
    and CDC are working to decrease the rate of Salmonella Enteritidis
    illness in the population from 2.6 cases per 100,000 to 2.1 cases per
    100,000 by December 2013. In fiscal year 2013, CDC will enhance
    surveillance systems and designate five Integrated Food Safety Centers
    of Excellence at State health departments.
                  advance scientific knowledge and innovation
        Biomedical and Behavioral Research.--The fiscal year 2013 budget
    maintains funding for the NIH at the fiscal year 2012 level of $30.9
    billion, reflecting the administration's priority to invest in
    innovative biomedical and behavioral research that spurs economic
    growth while advancing medical science to improve health. NIH is
    generating discoveries that are opening new avenues for disease
    treatment and prevention and revolutionizing patient care. In fiscal
    year 2013, NIH will seek to take advantage of such discoveries by
    investing in basic research on the fundamental causes and mechanisms of
    disease, accelerating discovery through new technologies, advancing
    translational sciences, and encouraging new investigators and new
    ideas.
        National Center for Advancing Translational Sciences.--In fiscal
    year 2013, NIH will continue to implement National Center for Advancing
    Translational Sciences (NCATS), established in fiscal year 2012, in
    order to re-engineer the process of translating scientific discoveries
    into new medical products. Working closely with partners in the
    regulatory, academic, nonprofit, and private sectors while not
    duplicating work going on in the private sector, NCATS will strive to
    identify innovative solutions to overcome hurdles that slow the
    development of effective treatments and cures. A total of $639 million
    is proposed for NCATS in fiscal year 2013, including $50 million for
    the Cures Acceleration Network.
        Medical Countermeasure Development.--The HHS Medical Countermeasure
    Enterprise includes initiatives across the Department covering the
    spectrum of medical countermeasure development, from early biological
    research to stockpiling of approved products. The fiscal year 2013
    budget includes $547 million for the Biomedical Advanced Research and
    Development Authority, an increase of $132 million more than fiscal
    year 2012, to develop and improve next-generation medical
    countermeasures (MCM) in response to potential chemical, biological,
    radiological, and nuclear threats. The budget also provides $50 million
    to establish a strategic investment corporation that would function as
    a public-private venture capital fund providing companies developing
    MCMs with the necessary financial capital and business acumen to
    improve the chances of successful development of new MCM technologies
    and products. Together, these investments will provide HHS with new
    tools to enhance the success of medical countermeasure development.
        Enhancing Healthcare Decisionmaking.--The HHS budget includes $599
    million for research that compares the risk, benefits, and
    effectiveness of different medical treatments and strategies, including
    healthcare delivery, medical devices, and drugs, including $78 million
    from the Patient-Centered Outcomes Research Trust Fund (PCORTF)
    established by the ACA. Evidence generated through this research is
    intended to help patients make informed healthcare decisions that best
    meet their needs. This level of funding will primarily support research
    conducted by NIH, core research activities within the Agency for
    Healthcare Research and Quality, and data capacity activities within
    the Office of the Assistant Secretary. Resources from PCORTF will
    support comparative clinical effectiveness research dissemination,
    improved research infrastructure, and training of patient-centered
    outcomes researchers. HHS core research will be coordinated to
    complement projects supported through PCORTF and through the
    independent Patient-Centered Outcomes Research Institute.
      strengthen the nation's health and human service infrastructure and
                                   work force
        Investing in Infrastructure.--A strong health workforce is key to
    ensuring that more Americans can get the quality care they need to stay
    healthy. The budget includes $677 million, an increase of $49 million
    more than fiscal year 2012, within Health Resources and Services
    Administration (HRSA) to expand the capacity and improve the training
    and distribution of primary care, dental, and pediatric health
    providers. The budget will support the placement of more than 7,100
    primary care providers in underserved areas and begin investments that
    expand the capacity of institutions to train 2,800 additional primary
    care providers more than 5 years.
        The fiscal year 2013 budget also supports State and local capacity
    for core public health functions. Within the Prevention Fund
    allocation, CDC will invest $20 million in new activities to coordinate
    with public health laboratories to improve efficiency through proven
    models, such as regionalizing testing in multi-State laboratories. To
    ensure an effective public health workforce, the budget requests $61
    million, of which $25 million is through 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 a prepared and sustainable health workforce to
    meet emerging public health challenges. In addition, the budget
    requests $40 million in the Prevention Fund to maintain support for
    CDC's Public Health Infrastructure program. This program will assist
    health departments in meeting national public health standards and will
    increase the capacity and ability of health departments in areas such
    as information technology and data systems, workforce training, and
    regulation and policy development.
    increase efficiency, transparency, and accountability of the department
                     of health and human services programs
        Living Within Our Means.--HHS is committed to improving the
    Nation's health and well-being while simultaneously contributing to
    deficit reduction. The fiscal year 2013 discretionary request
    demonstrates this commitment by maintaining ongoing investments in
    areas most central to advancing the HHS mission while making reductions
    to lower-priority areas, reducing duplication, and increasing
    administrative efficiencies. Overall, the fiscal year 2013 request
    includes more than $2.1 billion in terminations and reductions to fund
    initiatives while achieving savings in a constrained fiscal
    environment. Many of these reductions, such as the $177 million cut to
    the Children's Hospital Graduate Medical Education Payment program, the
    $327 million cut to CSBG, and the $452 million cut to the Low Income
    Home Energy Assistance Program (LIHEAP) were very difficult to make but
    are necessitated by the current fiscal environment.
        Regarding LIHEAP, the administration proposes to adjust funding for
    expected winter fuel costs and to target funds to those most in need.
    The request is $3 billion, $452 million below the fiscal year 2012
    level and $450 million more than both fiscal year 2008 and fiscal year
    2012 request. With constrained resources, the budget targets assistance
    where it is needed most. The request targets $2.8 billion in base
    grants using the State allocation the Congress enacted for fiscal year
    2012. The request also includes $200 million in contingency funds,
    which will be used to address the needs of households reliant on home
    delivered fuels (heating oil and propane) should expected price trends
    be realized, as well as other energy-related emergencies.
        In September 2011, the administration detailed a plan for economic
    growth and deficit reduction. The fiscal year 2013 budget follows this
    blueprint in its legislative proposals, presenting a package of health
    savings proposals that would save more than $360 billion more than 10
    years, with almost all of these savings coming from Medicare and
    Medicaid. Medicare proposals would encourage high-quality, efficient
    care, increase the availability of generic drugs and biologics, and
    implement structural reforms to encourage beneficiaries to seek value
    in their healthcare choices. The budget also seeks to make Medicaid
    more flexible, efficient, and accountable while strengthening Medicaid
    program integrity. Together, the fiscal year 2013 discretionary budget
    request and these legislative proposals allow HHS to support the
    administration's challenging yet complementary goals of investing in
    the future and establishing a sustainable fiscal outlook.
        Program Integrity and Oversight.--The fiscal year 2013 budget
    continues to make program integrity a top priority. The budget includes
    $610 million in discretionary funding for Health Care Fraud and Abuse
    Control (HCFAC), the full amount authorized under the Budget Control
    Act of 2011 (BCA). The budget also proposes to fully fund discretionary
    program integrity initiatives at $581 million in fiscal year 2012,
    consistent with the BCA. The discretionary investment supports the
    continued reduction of the Medicare fee-for-service improper payment
    rate; investments in prevention-focused, data-driven initiatives like
    predictive modeling; and HHS-Department of Justice Health Care Fraud
    Prevention and Enforcement Action Team (HEAT) initiatives, including
    Medicare Strike Force teams and fighting pharmaceutical fraud.
        From 1997 to 2011, HCFAC programs have returned more than $20.6
    billion to the Medicare Trust Funds, and the current 3-year return-on-
    investment of $7.2 recovered for every $1 appropriated is the highest
    in the history of the HCFAC program. Last year these efforts recovered
    more than $4 billion. The budget proposes a 10-year discretionary
    investment yielding a conservative estimate of $11.3 billion in
    Medicare and Medicaid savings and 16 program integrity proposals to
    build on the ACA's comprehensive fraud fighting authorities for savings
    of an additional $3.6 billion over 10 years.
        Additionally, the budget includes funding increases for significant
    oversight activities. The request includes $84 million for the Office
    of Medicare Hearings and Appeals, an increase of $12 million, to
    continue to process the increasing number of administrative law judge
    appeals within the statutory 90-day timeframe while maintaining the
    quality and accuracy of its decisions. The budget also includes $370
    million in discretionary and mandatory funding for the Office of
    Inspector General (OIG), a 4-percent increase from fiscal year 2012.
    This increase will enable OIG to expand CMS Program Integrity efforts
    in areas such as HEAT, improper payments, and focus on investigative
    efforts on civil fraud, oversight of grants, and the operation of new
    ACA programs.
        Additionally, Durable Medical Equipment (DME) Competitive Bidding
    is providing competitive pricing, while continuing to ensure access to
    quality medical equipment from accredited suppliers, which will save
    Medicare $25.7 billion over 10 years and help millions of Medicare
    beneficiaries save $17.1 billion in out-of-pocket costs over 10 years.
    The budget proposes to extend some of the efficiencies of DME
    Competitive Bidding to Medicaid by limiting Federal reimbursement on
    certain DME services to what Medicare would have paid in the same State
    for the same services. This proposal is expected to save Medicaid $3
    billion over 10 years.
        Consolidate and Improve Activities Related to Prevention and
    Behavioral Health.--The budget includes $500 million within SAMHSA for
    new, expanded, and refocused substance abuse prevention and mental
    health promotion grants to States and tribes. To maximize the
    efficiency and effectiveness of its resources, SAMHSA will use
    competitive grants to identify and test innovative prevention practices
    and will leverage State and tribal investments to foster widespread
    implementation of evidence-based prevention strategies.
        The budget also consolidates funding for initiatives aimed at
    addressing chronic disease prevention. Chronic diseases and injuries
    represent the major causes of morbidity, disability, and premature
    death and heavily 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 allocates $379 million, an increase of $129 million more
    than fiscal year 2012, to a new integrated 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 these leading causes of death. Because many
    inter-related 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.

        Senator Harkin.  Thank you very much, Madam Secretary.
        Madam Secretary, I am going to yield my opening position to
    Senator Mikulski who has to go chair another hearing here very
    shortly.

                    STATEMENT OF SENATOR BARBARA A. MIKULSKI

        Senator Mikulski.  Thank you very much, Mr. Chairman, for
    yielding.
        Senator Inouye is indisposed this morning and I am going to
    chair the Department of Defense appropriations hearing. So it
    is really the day of shooting straight.
        I am only 4 foot 11, so you cannot see me, but you have
    certainly been able to hear me.
        Secretary Sebelius. I can see you.

                          IMPROVING HEALTHCARE QUALITY

        Senator Mikulski.  Let me get right to my question, Madam
    Secretary.
        I want to thank you for the great job you are doing. I want
    to thank you for your respect of implementing the laws that the
    Congress passes, your respect for the Constitution and all of
    its amendments, and also creating the sense of your agencies
    working with the Congress. My work with Dr. Margaret Hamburg on
    the Prescription Drug User Fee Act (PDUFA), the way she has
    reached out in her agency to the business community has really
    been I think a model of how to work to keep our people safe and
    yet to not shackle them with unnecessary regulation.
        Let me get to my question on quality. When we worked on
    ACA, Senator Harkin, of course, was one of the leaders on the
    bill and on prevention. I worked with him on that. And I worked
    on the quality initiatives. The goal was two things: one, not
    only to improve access, but by improving quality, we could save
    lives and save money. We have the home of Dr. Pronovost at
    Hopkins, the famous Pronovost checklist.
        My question to you is, ``How are we training the cadre of
    scientists and physicians in the area of quality medical
    delivery services?'' I have been advised by the School of
    Public Health and Dr. Pronovost himself that there is this
    whole body of knowledge that could be taught at great schools
    of medicine and public health where it would not be just a few
    leaders like Pronovost, but we would be training people in the
    science of healthcare delivery and developing it so they would
    be in communities, they would become hospital administrators,
    et cetera. Would you look at all of your programs to see how we
    could encourage that?
        Secretary Sebelius.  I would be delighted to work with you
    on that, Senator Mikulski.
        I can tell you that what is happening now is very exciting
    for the next generation of providers and administrators because
    I think for the first time across this country, there is a
    focus and highlight on real changes, transformations in the
    delivery system, and a lot of that is focused on taking the
    best practices which exist in pockets--and certainly the
    checklist is a great example of that--but bringing them to
    scale and having every health system in the country adopt some
    of these practices in a much more timely fashion. So through
    our Innovation Center and through the Partnership for Patients,
    which now has engaged more than 5,000 partners, private
    employers, payers, and hospital systems, we are actually
    capturing the quality programs and----
        Senator Mikulski.  But you are going to need people to do
    this.
        Secretary Sebelius. You bet.
        Senator Mikulski.  And just as we have skilled surgeons,
    those who do the hands-on medicine, for those to advise those
    in the practice of medicine, hospital administrators, Governors
    looking at how to handle an increasing, burgeoning Medicaid
    costs. So would you look at that and respond to me?
        Secretary Sebelius. Yes, I would.

                         CHILD CARE QUALITY INITIATIVES

        Senator Mikulski.  My second and last question will be
    child care quality initiatives. I chair the subcommittee on
    Children and Families. We have had extensive hearings on
    reauthorizing the Child Care Development Block Grant. We have
    bipartisan cooperation. I cannot say enough about Senator
    Burr's work, how we are working together.
        My question goes, as we look forward to access, there is
    also child safety and child quality. There has been a recent
    story on ``Nightline'' that our current laws are inadequate in
    terms of background checks and so on. So we want to increase
    access, keep it affordable. But my God, when you go to a day
    care center, you have got to make sure that the people who are
    the day care providers, number one that it is a safe
    environment and also their education and training. Could you
    comment? Have you seen the ``Dateline'' story?
        Secretary Sebelius. I have not seen the ``Dateline'' story,
    but I have read the clips about it.
        Senator Mikulski.  You know what I mean.
        Secretary Sebelius. Absolutely.
        Senator Mikulski.  I know of your work as Governor and
    child advocate, do you have any comments or would you like to
    respond in writing because we hope to reauthorize this program,
    and we are looking to advice and guidance from the Department.
        Secretary Sebelius. Well, we very much are eager to work
    with you, and I think you have articulated very well the
    principles around which we think reauthorization should occur,
    not only making sure that there are additional slots for
    families, knowing that child care is really one of the work-
    friendly programs--you cannot go to work if your children are
    not in a safe and secure place--but also knowing that way too
    many parents either do not have a way to understand what is
    going on in the system and do not have the confidence that any
    place they put their child is a high-quality care system. So
    improving quality and getting that information into the hands
    of parents, sort of the rating system, so parents really can
    make the best choice for themselves and their children is an
    effort that is underway, as you know, and we think has to be
    part of the framework for reauthorization.
        Senator Mikulski.  Madam Secretary, my time is up, and
    Senator Harkin has been gracious. What we are looking at is how
    we can improve that background check without adding more cost
    and more regulation and, second, really how we get to the
    training of these child care workers and how they have perhaps
    a career ladder like we have done in nursing, CNA, licensed
    practical nurse, so they see a career.
        Secretary Sebelius. And, Senator, just so you know a little
    bit about my history, I went to the legislature in Kansas when
    my children were 2 and 5, and this became an issue that was
    near and dear to my heart and has been ever since. That was a
    very long time ago, but child care was something I was living
    at the time, so it became one of my causes. And I very much
    look forward to working with you.
        Senator Harkin.  Thank you, Senator Mikulski.
        Thank you, Madam Secretary.
        Senator Shelby.

                     NATIONAL INSTITUTES OF HEALTH FUNDING

        Senator Shelby.  Thank you.
        Madam Secretary, the 2013 budget proposal, with the Public
    Health Service Act evaluation tap increase included, reduces
    NIH's budget by $215 million below fiscal year 2012. How will
    NIH maintain its scientific rigor and innovation when the
    budget request does not keep pace with the biomedical inflation
    rate? Do we not have a problem here?
        Secretary Sebelius. Well, Senator, I first of all share
    your belief that continuing to make sure that America leads the
    world in biomedical research is a critical priority for the
    future, and we look forward to working with the Congress around
    the tap issue as we move forward.
        Having said that, I can tell you that Dr. Collins has
    allocated resources within NIH's budget, which is currently
    funded at the level that it was funded last year, and made sure
    that we continue to fund new grants. His report is that the
    fiscal year 2013 budget level will allow him to increase the
    grants by about 7.7 percent. An additional 672 new grants will
    be funded. He is also very appreciative of the notion that
    working with the Congress, the National Center for
    Translational Sciences was funded, and he is moving ahead on
    that. There are new resources where he feels is an enormously
    promising area to recapture and refocus some of the energy, as
    well as the Cures Acceleration Network has additional
    resources. So this budget not only reflects our desire to make
    sure that we continue to fund new scientific discoveries but
    also to focus the resources on the areas that are the most
    promising strategies for the future.

                           HEALTH INSURANCE EXCHANGES

        Senator Shelby.  In another area, the fiscal year 2013
    budget proposal includes $864 million for the implementation of
    the new health insurance exchanges. HHS has already received $1
    billion in ACA for the implementation activities and will
    receive a little more than $1 billion more in mandatory funding
    for the exchange in 2013. Why is it necessary to appropriate an
    additional $864 million for exchanges?
        Secretary Sebelius. Senator, the request before this
    subcommittee for the additional resources for the Centers for
    Medicare & Medicaid Services (CMS) reflects the fact that we
    anticipate that the first $1 billion funding that was included
    in ACA in 2010 will be fully spent by the end of fiscal year
    2012. The good news is we are spending significantly under what
    was estimated by the Congressional Budget Office (CBO) which
    estimated, at the time of passage, that we would need about $1
    billion a year to implement this. So here we are looking at the
    end of 2012, and the first $1 billion will be spent in the 2\1/
    2\ years since implementation.
        What we are requesting with the $800 million for new
    resources is basically a one-time cost to build the framework
    for the Federal exchange which will be run out of CMS. We are
    not clear at this point how many States will actually opt to
    run their own State-based exchanges, how many States will be in
    a so-called partnership where the Federal exchange will run
    part of the program and they will run part and how many will
    fully run. But we need an infrastructure, an IT system, an
    outreach system, an enrollment system. So this is the request
    for 2013 which again is not an ongoing request, but it is
    basically to build that framework for the federally funded
    exchanges.

                         ANTIDEFICIENCY ACT VIOLATIONS

        Senator Shelby.  Madam Secretary, in the area of
    Antideficiency Act violations, a lot of us are concerned about
    the series of Antideficiency Act violations by your Department
    and the lack of a corrective action to address these unlawful
    funding practices.
        Last July, you notified us that the Department had 47
    violations that amounted to more than $1.4 billion in illegal
    funding practices. At a time when the Department is receiving a
    historically high level of funding, I believe it is critical
    that you follow the letter of the law here.
        Clearly, there are significant weaknesses over there. Are
    you following the recommendations of the Office of Inspector
    General (OIG), or are you trying to just ignore those past
    violations and move to a clean slate? What is going on?
        Secretary Sebelius. Well, Senator, as we notified the
    committees in July, we were made aware that there were 47
    contracts that were improperly funded dating back to 2002. I
    would say the positive news about that is that the contracts
    were not structured properly according to the Antideficiency
    Act, but the monies were all appropriately spent. They were not
    overspent.
        Having said that, we took this violation very seriously. We
    self-reported it. We have engaged in a really robust activity
    at the Department working with the OIG, as well as working with
    GAO, on everything from changing policies and procedures. We
    have trained 12,000 staff members on how this has to be done.
    We have gone back through the corrections and we would be
    delighted to give you in writing the full report on what has
    occurred so far and how seriously we take this. We do take it
    very, very seriously.
        Senator Shelby.  Thank you.

                            IMPACT OF SEQUESTRATION

        Senator Harkin.  Thank you, Senator Shelby.
        Here is the order I have. I will ask the next round of
    questions for 5 minutes and then Senators Alexander, Brown,
    Johnson, Landrieu, Moran, Kohl, and Graham will speak.
        Madam Secretary, next January we are facing a possible
    sequestration to reduce the national debt. I applaud the
    President for presenting a fair and responsible budget to help
    avert this outcome except in the areas I noted in my opening
    statement. It is critical for this subcommittee to understand
    the potential impact of this possible sequestration. CBO
    estimated that most non-defense discretionary programs would
    face a cut of up to 7.8 percent. Others, such as the Center on
    Budget and Policy Priorities, think the cut could be even
    larger. But for the sake of discussion, we will go with CBO's
    number of 7.8 percent.
        My question. Have you looked at this? Could you give us
    some idea of what would be the impact of a 7.8-percent cut to
    programs like Head Start, the Child Care and Development Block
    Grant that you and Senator Mikulski were discussing, AIDS Drug
    Assistance Program, senior nutrition, all the other areas? What
    would be the impact of that 7.8-percent cut?
        Secretary Sebelius. Well, Mr. Chairman, as you well know,
    within our Department the application of sequestration becomes
    even more complicated. We have some programs that would be
    fully shielded from any cuts. We have some programs which are
    limited to a 2-percent cut, which means that there would be an
    even harsher application of sequestration across the board on
    our programs.
        So we think if it were a close to 8-percent cut, we would
    lose about 1 million slots in both Head Start and Child Care. I
    am sorry. Not 1 million. One hundred thousand slots in Head
    Start and Child Care. About 75,000 children would lose their
    places in Head Start and about 25,000 in Child Care.
        We have about 17 million meals that would not be delivered
    to seniors relying on congregate meals and home delivery.
        The AIDS Drug Assistance program would have to reduce its
    caseload by more than 12,000 people who are currently receiving
    antiretroviral drugs.
        And the NIH budget, which I know is a concern to members of
    this subcommittee, would lose about $2.5 billion. NIH is 40
    percent of our budget. They would take a huge hit, and we think
    that research project grants would decline by--about 2,300
    grants would be discontinued. More than one-quarter of the
    number estimated for fiscal year 2012 would be gone, and that
    would be about one-third of a reduction. One-third of the
    programs that we are estimating for fiscal year 2013 would
    cease to exist.
        So it would have a huge impact across our Department and
    particularly for the areas that are not shielded and therefore
    would take an even more significant hit.
        Senator Harkin.  Well, thank you, Madam Secretary. I am
    going to be asking that same question when the Secretaries of
    Labor and Education and the NIH Director are up here also. We
    have heard a lot from the defense community about what would
    happen to their portion of national security if they had a 7.8-
    percent cut. I think it is important for the American people to
    know about the rest of our national security because as
    President Truman once said so eloquently so many years ago, he
    said our national security is not measured just in tanks and
    guns alone but also in the health, welfare, and education of
    our people.
        Secretary Sebelius. And as you know, these programs affect
    real people every day and are often life and death issues.

                       HEALTHCARE FRAUD, WASTE, AND ABUSE

        Senator Harkin.  Exactly. Well, thank you.
        Last, could you address the fraud and waste issue that I
    mentioned in my opening statement? We had that Budget Control
    Act cap adjustment that allowed a $270 million increase, but
    when we got to conference, my friends on the other side of the
    aisle said no, and so we did not get that. What does that mean
    in terms of not returning money to the taxpayers?
        Secretary Sebelius. Well, over the last 3 years, as I said,
    Mr. Chairman, we have been able to return about $7 for every $1
    invested. So a $270 million cut is significant. We know that
    our OIG had plans for the use of those resources to further
    expand some of our footprint on the ground to new strike forces
    in new cities, and those will have to be on hold. And we would
    love to work with you in a full funding for this program, which
    I think is an absolute win-win situation to stop people from
    stealing health dollars, taxpayer dollars, to continue to build
    our data analytic system so that we can do far more prevention
    on the front end and to have the boots on the ground to go
    after the perpetrators who we think are committing these
    outrageous acts of fraud and stop them quickly on the ground.
        Senator Harkin.  Thank you, Madam Secretary.
        Senator Alexander.

                                    MEDICAID

        Senator Alexander. Thanks, Madam Secretary. Welcome. Thank
    you for coming.
        I have just two preliminary comments and then a question.
        Senator Mikulski mentioned Prescription Drug User Fee Act
    (PDUFA), and I wondered if we could not pause for a moment of
    bipartisan cooperation. We have four authorizing laws that
    establish fees for prescription drugs, medical devices,
    biosimilar drugs, and generic drugs, and we call them PDUFA,
    Medical Device User Fee Act, Biosimilar User Fee Act, and
    Generic Drug User Fee Act. And I wonder if we could have a
    prize for an elegant replacement for all of those ridiculous
    names that we just throw around up here.
        Secretary Sebelius. I have to say it took me most of the
    last 3 years to learn what people were even talking about when
    they would mention those to me. So I am all for it.
        Senator Alexander. Good. Well, I will work with the
    chairman and we will see what we can do about that.
        I wanted to mention simply to you--and I will write you a
    letter about this--the Tennessee Poison Control Center. It is a
    very small program located at Vanderbilt University, but when
    kids get in trouble at home, they can telephone this poison
    control center and the parent gets talked through what to do
    about it rather than their going to the emergency room. It is
    80 percent paid for by State and local funding. The Federal
    Government has a share of it. It saves about $11 million a
    year, people think, in emergency room costs. And I just wanted
    to call it to your attention and you do not need to respond to
    it now. But I think it is worth noting the importance of it.
        I wanted to just ask you a question in sort of a Governor-
    to-Governor way. You were a Governor. I was a Governor. We have
    these wistful--or at least I do--thoughts of those days as if
    they were trouble-free and everything was great, which is not
    exactly true, but it was a wonderful experience.
        And I am worried that the new healthcare law has created a
    situation where we are 1 budget year away from a ticking time
    bomb in the States for Governors as they seek to comply with
    the Federal requirements for expansion of Medicaid and then
    Federal requirements for paying doctors who want to serve
    people who get Medicaid. I know our former Governor, a
    Democrat, Governor Bredesen, called that the mother of all
    unfunded mandates. He estimated that it will cost Tennessee an
    additional $1.1 billion between 2014 and 2019. The Federal
    Government helps with that for a while, but then it is fully a
    State responsibility.
        And then we add to that by a Federal requirement that
    doctors be reimbursed, providers be reimbursed for seeing
    Medicaid patients, which needs to happen otherwise it is a
    ticket to a bus that does not run. So people need to be able to
    see a doctor. But that adds another $324 million a year to our
    State. And we are already in a situation where rising
    healthcare costs are squeezing money out of our State budgets
    that otherwise would be spent for higher education.
        Now, this is not something new with President Obama. This
    has been going on for 30 years. I used to deal with it in
    Tennessee almost every year. I imagine you dealt with it as
    Governor of Kansas. You get down to the end of the budget
    process and you have got money either for Medicaid or the
    University of Kansas, the University of Tennessee, and it is a
    very difficult choice. And the healthcare costs keep going like
    this. And as a result in Tennessee last year, there was a 16-
    percent increase in State Medicaid spending, a 15-percent
    decrease in State support for higher education. That is not a
    Washington cut. That is a real cut. And so tuition goes up at
    the universities and quality goes down.
        So as I said, this is not new. I first suggested to
    President Reagan a long time ago that we have a swap, that the
    Federal Government take all the Medicaid and the States take
    all of elementary and secondary education. Former Senator
    Kassebaum from Kansas came up with a similar idea in the 1980s
    because of this combination of Federal controls and State
    spending.
        Do we not have to do something to give States more
    flexibility in dealing with Federal Medicaid mandates in order
    to avoid exporting fiscal instability from Washington to State
    capitals that has the primary effect of squeezing down the
    quality of public higher education and raising tuition for the
    students who go there? And if that is a problem and it is going
    to start in the next budget year, 2014, can you suggest
    anything that we could do to make it easier?
        Secretary Sebelius. Well, Senator, I did deal as you did
    with these budget challenges at the State level, and I have
    dealt actively since I came to this position with my colleagues
    around the country who are coping with this.
        I will provide you in writing with some of this analysis,
    but just to give you a little snapshot. At least in the last 3
    years, State share of spending on Medicaid is actually reduced
    nationally. Their overall budget share that they were spending
    on Medicaid in 2007 was higher than it was in 2010, which is
    the last full year that we have. Per capita costs for Medicaid
    have dropped in that period of time. They were above $2,200 a
    person. They are now down below $1,800 a person for the
    Medicaid budgets on average. And the overall State expenditures
    have dropped during that period of time. Some of that was
    clearly helped by the Federal resources that were put in as
    part of the American Recovery and Reinvestment Act, but the
    State picture is actually different.
        The final thing that I asked our folks to do in terms of
    just analysis is look at underlying healthcare costs, which are
    continuing to rise, compared to higher education costs. And
    actually higher education costs are now up 63 percent in the
    last decade. And healthcare spending is up about 40 percent. So
    you are absolutely right. This is an ongoing challenge. It is
    one that people are coping with.
        I would tell you that the Medicaid expansion that is on the
    horizon for 2014 is some pretty good news for States, and it is
    not only fully paid for by the Federal Government for the first
    4 years, but the Federal share stays for the newly insured
    population between 100 and at the lowest 90 percent by the time
    the decade ends, so that the largest share that the State will
    pay in that period of time for millions of newly insured folks
    is a 10 percent match.
        Having said that, States now absorb enormous amounts of
    costs for uncompensated care where people are coming into
    community hospitals, are in the workforce, and States are
    paying a share of that cost out of taxpayer dollars. So on
    balance, I think this is an opportunity to not only have a
    payment system under a lot of folks, get them in a healthier
    condition, but also I think States--ironically those who have
    the lowest-insured population are the biggest winners in some
    ways that have had not very generous Medicaid systems and have
    the most people that will actually become fully insured as part
    of this program.
        We are also paying careful attention to the provider issue.
    As you say, there is a requirement that doctors who take care
    of Medicaid patients will be paid at the Medicare rate for the
    first 2 years fully out of Federal dollars. It is not a State
    mandate. It is fully out of Federal dollars. We know that it is
    not a long-term strategy. We look forward to working with the
    Congress on a long-term strategy, but again, there is no
    mandate beyond those 2 years and there is no mandated State
    funding beyond those 2 years.
        Senator Alexander. Mr. Chairman, I am out of time and I
    would welcome that information.
        Secretary Sebelius. I would be happy to provide it.
        [The information follows:]

        Medicaid spending in 2010 was estimated to be approximately 15.8
    percent of State general fund spending but was 17.4 percent in 2006.
        Numerous experts agree that States will actually realize a net
    savings from the provisions of the Affordable Care Act. States and
    local governments are estimated to save $70-80 billion in State-funded
    health coverage or uncompensated care. A subsequent Urban Institute
    analysis estimates that the costs to States from the Medicaid expansion
    will be more than fully offset by other effects of the legislation, for
    net savings to States of $92 to $129 billion from 2014 to 2019.

        Senator Alexander. Nevertheless, our former Governor says
    these mandates are $1.2 billion over 5 years in increased costs
    just for the expansion and $324 million a year for the Medicaid
    reimbursement requirement.
        Senator Harkin.  Thank you.
        Senator Brown.

                             PRIMARY CARE WORKFORCE

        Senator Brown. Thank you, Mr. Chairman.
        I note from the Secretary's comments that in those States
    where there was not a lot of support, at least from their
    elected officials, for ACA, those are the ones, because they
    are the poorer States, that tend to get the most. It is an
    interesting irony.
        First of all, thank you, Madam Secretary. Thank you for
    last week for coming to Ohio, and the support you have shown
    for Project One really means a lot for my State. Thank you for
    that.
        Thank you too for what you did, what CMS did, and what
    Federal Drug Administration (FDA) did on the progesterone
    issue, that pharmaceutical, the P7 to 17P, the progesterone
    that saved a huge--that have prevented a huge number of preterm
    births, resulted in tens and tens of thousands of babies born
    healthy instead of born with all kinds of illnesses and
    disabilities. And the work that you did, stepping up, having
    the FDA telling local compounders and local doctors and
    hospitals not to--to resist the cease and desist order and then
    the work that Mr. Berwick did at CMS in encouraging--in going
    to the States so that more and more States are using the
    progesterone at much less cost to taxpayers and to insurers
    than they are the KV Pharmaceuticals Makena. It has made a huge
    difference in public health.
        I want to talk about a couple other programs that are
    involved in preterm birth rates. The Community Health Access
    Program in Mansfield, my hometown, trains community health
    workers to address the health needs of at-risk pregnant women,
    low-income White and African-American women in two different
    ZIP codes, and Richland County sort of invented this program.
    The local officials did, local doctors, local foundations, and
    dropped the low-birth-weight baby rate from twice the national
    average to below the national average. And using that program,
    the Community Health Access program, as a model, we added the
    community health workers to the list of disciplines on which
    area health education centers should focus. I mean, that was
    the good news.
        Also, the good news is the program of the maternal, infant,
    and early childhood home visiting program which has made a huge
    difference in after the babies are born, making sure they get
    the proper services--well, starting with prenatal care up
    through early education for children. Now, that is the good
    news.
        The good news also is that the budget includes $400 million
    for the maternal and infant home visiting programs. The bad
    news is that health education centers are zeroed out in this
    year's budget, funded at $27 million in fiscal year 2012. It
    means increasing shortages of primary care providers especially
    in those rural and underserved areas.
        My question is what will happen to the number of primary
    care workers if these programs are eliminated. How do we make
    up for this? I mean, it clearly saves large amounts of money
    when people get to the doctor, get proper nutrition, get
    prenatal care the way they should and babies are born healthy
    instead of born with all kinds of illness and disabilities.
    What is going to happen to the number of primary care workers?
    What do we do about this with these cuts?
        Secretary Sebelius. Well, Senator, we are trying to focus
    as many resources throughout the Department as we have on
    increasing the primary care workforce, and that is everything
    from shifting graduate medical education slots to new funding
    for the National Health Service Corps for primary care
    providers has been tripled in the last 3 years, and we want to
    continue that effort. We are looking at all the strategies that
    we have, payment rates to encourage primary care choices for
    medical students, and a series of activities. So we certainly
    share your concern around that.
        I know that you and I have talked before about your
    Mansfield, Ohio success program, and I wanted to bring to your
    attention that we have recently launched an initiative we are
    calling Strong Start under the Center for Medicare & Medicaid
    Innovation that will be working with the March of Dimes, with
    the American College of Ob-Gyns, with providers across this
    country around a focus on births that occur 39 weeks and
    beyond, knowing that there is a huge health difference between
    preterm babies and post-term babies and that appropriate
    prenatal care, maternal information, encouraging hospitals to
    reduce the number of voluntary preterm deliveries that they are
    willing to engage in and adopting some of the best practices
    that you have in Ohio. I would love to get you some information
    about this program because actually there may be some ways to
    take what you have learned in Mansfield and make sure that we
    can not only spread it in Ohio but in various other parts of
    the country. But it is an initiative we think is not only
    hugely important to reduce long-term health costs, but good for
    moms, good for babies, good for the long-term community
    survival. So we are really looking at how to bring this program
    to scale throughout the country.
        Senator Brown. Thank you.
        Mr. Chairman, I will only make a comment, if I could, not
    another question. A comment.
        First of all, thank you for that. The Mansfield program has
    already spread to a couple other Ohio cities.
        I will make one comment about--you had mentioned Graduate
    Medical Education (GME) slots. A subset of that--and this is
    not a question, just a comment, if you would--is children's
    GME. Every administration in both parties cuts back this
    program after we began it. I first introduced it in the House
    in 1998, I think, after a visit to Akron Children's Hospital.
    We need a unique way, a separate way of funding graduate
    medical education for children because it does not fit in,
    obviously, the Medicare funding stream that creates money for
    GME. Every year a President cuts it or eliminates it. We need
    to get it back up at least to the level of $250 or $300
    million, which it has been many of the last few years. Chairman
    Harkin has been very helpful to that in the past. Many of my
    Republican colleagues too. It was a very bipartisan effort in
    the House when I first started it. And we will figure out a way
    to do that. I know you do not oppose it, but I know you know
    that we will restore it and come up with the money. And I
    appreciate that shift of responsibility every year.
        But thank you, Mr. Chairman.
        Senator Harkin.  Thank you, Senator Brown.
        Senator Johnson.

                           HEALTHCARE COST ESTIMATES

        Senator Johnson. Thanks, Mr. Chairman.
        Madam Secretary, welcome.
        I would like to concentrate on the cost estimates of the
    healthcare law because that is what I was concentrating on last
    year and there has certainly been new information to surface
    since then.
        So I would like to first start out by just pointing out
    that when they passed Medicare back in 1965, they estimated it
    out 25 years and said it would cost $12 billion in 1990. In
    fact, it ended up costing $109 billion, nine times the original
    cost estimate. So I do not have a great deal of faith in some
    of these estimated numbers, and I certainly do not have faith
    in the estimates for Obamacare.
        In the President's fiscal year 2013 budget just released,
    he has increased the mandatory outlays for health insurance
    exchanges by $111 billion from $367 billion in his last year's
    budget to $478 billion. Is that correct?
        Secretary Sebelius. Yes, Sir.
        Senator Johnson. The Community Living Assistance Services
    and Support program (CLASS Act)--I think we end up recognizing
    that that was not going to work out. That was not going to be
    financially solvent. So that was $86 billion of the claimed
    $143 billion of deficit reduction in the first 10 years.
    Correct?
        Secretary Sebelius. The original estimate, yes.
        Senator Johnson. Right. And the original estimate for
    deficit reduction in the first 10 years was $143 billion.
    Correct?
        Secretary Sebelius. Yes.
        Senator Johnson. So now we have reduced that $143 billion
    by $86 billion by not getting revenue from the CLASS Act and
    now $111 billion because we have increased the mandatory cost
    of the exchanges. Correct?
        Secretary Sebelius. I am assuming the numbers are correct.
    I am sorry. I do not have them.
        Senator Johnson. They are.
        So when you add those together, that is $197 billion added
    to the first 10-year cost estimate of Obamacare. So now we are,
    instead of saving $143 billion, adding $54 billion to our
    deficit. Correct?
        Secretary Sebelius. Sir----
        Senator Johnson. We will submit that for the record. That
    is basically true. So instead of saving $143 billion by this
    administration's own figures and budget, we are now adding $54
    billion to our deficit in the first 10 years. To me that would
    be the first broken promise.
        It is true that the President said that by enacting this
    healthcare law, every family would save $2,500 per year in
    their family insurance plan. Correct?
        Secretary Sebelius. He said that once the exchanges are up
    and running and you have an affordable marketplace, the
    insurance estimates were that the rates would go down by about
    $2,500, yes. That has not occurred yet clearly.
        Senator Johnson. The Kaiser Family Foundation has already
    released a study saying that the average cost for family
    healthcare plans is up $2,200. Correct?
        Secretary Sebelius. Again, there is no new marketplace yet
    for insurance policies.
        Senator Johnson. But the cost is already up. I mean, we are
    already different by $4,700. It is going to be hard to get us
    down to $2,500 as cost savings. I would consider that broken
    promise number two.
        It is also true that President Obama very famously said,
    ``If you like your doctor, you will be able to keep your
    doctor. Period. If you like your healthcare plan, you will be
    able to keep your healthcare plan. Period.'' No one will take
    it away no matter what.
        Now, we have granted quite a few waivers, about 1,200 to
    1,700 waivers on about 4 million Americans. Correct?
        Secretary Sebelius. I have no idea what waivers you are
    talking about.
        Senator Johnson. Those are waivers----
        Secretary Sebelius. Doctors and health plans? Is that----
        Senator Johnson. Just waivers from having to implement
    portions of the healthcare law that probably would have forced
    those workers off their employer-sponsored care.
        Secretary Sebelius. Again, I would be happy to answer these
    questions, but I have no idea what waivers you are talking
    about.
        Senator Johnson. The waivers that HHS has granted to
    employers.
        Secretary Sebelius. To do what?
        Senator Johnson. Not having to implement sections of the
    healthcare law.
        Secretary Sebelius. There have been waivers granted to
    employers, yes.
        Senator Johnson. And had those waivers not been granted,
    chances are those employees probably would have lost their
    employer-sponsored care. Correct?
        Secretary Sebelius. I have no idea. I mean, I am happy to
    answer those one at a time and look at the waivers and see
    what----
        Senator Johnson. Unfortunately, I am pretty short on time.
        The CBO alone estimated that 1 million people would lose
    their employer-sponsored care. Now, I think that is a wildly
    underestimated figure. The McKinsey Group has surveyed
    employers and said that 30 to 50 percent of employers plan on
    dropping coverage as soon as the healthcare law is implemented.
    Douglas Elmendorf I think has even admitted that that is
    credible evidence for him to retake a look at that estimate.
        The decision an employer is going to have is pretty linear.
    They can pay $15,000 for a family plan or pay the $2,000
    penalty, and they are not exposing their employees to financial
    risk. They are making them eligible for $10,000 subsidies if
    they make a $64,000 household income.
        Are you sure that only 1 million people--only 1 million
    people--will lose their employer-sponsored care? Last year you
    said there are 180 million to get coverage through their
    exchanges. Are you certain that only 1 million people are at
    risk of losing their employer-sponsored care and get put in
    those exchanges?
        Secretary Sebelius. Sir, you are quoting a CBO number. All
    we have to go on is what has happened in Massachusetts where
    actually more people have coverage today with the exchange,
    with a very similar framework, than did before. They have not
    lost employer coverage. More employers have come back into the
    market. So the practical application of a State-based exchange
    on the ground with similar penalties and a similar framework is
    employer coverage rose. It did not decrease.
        Senator Johnson. It is not similar because those employees
    lose coverage for 6 months before they are eligible for the
    exchanges, and there are not these types of subsidies that
    create a huge incentive for employers to drop coverage and make
    their employees eligible.
        Bottom line here. The cost of this healthcare law is so
    uncertain. Do you not think we maybe ought to put the brakes on
    it? You know, Nancy Pelosi said we have to pass this law to
    figure out what is in it. What I do not want to see is we have
    to implement it to figure how it is going to bust a hole in our
    already horribly broken budget.
        Secretary Sebelius. Well, I would just say, Senator, the
    statistics you gave on the rising healthcare costs for families
    and small business owners that Kaiser put out recently is the
    very reason that we desperately need a new insurance market.
    The private insurance market is basically on a death spiral
    where younger and healthier people are dropping out, where
    small employers who cannot afford to pay 18 percent more than
    their large employers are dropping out.
        Doing nothing is really not an option. We now have 50
    million uninsured in this country, and that number has gone up
    year in and year out, and the costs continue to rise. So a new
    market with competition putting people in a larger pool, making
    companies compete on the basis of price and quality, not who
    can lock out folks with a pre-existing condition or drop them
    out or drive them out of the market is desperately needed by
    millions and millions of Americans, which was part of the
    driving force of passing the healthcare law.
        Senator Johnson. Madam Secretary, if 50 percent of
    employees lose their coverage, that will cost us $500 billion a
    year, not $95 billion.
        Thank you, Mr. Chairman.
        Senator Harkin.  Thank you.
        Senator Kohl.

                               PHYSICIAN PAYMENTS

        Senator Kohl. Thank you, Mr. Chairman.
        Madam Secretary, I would like to ask you about
    implementation of the Physician Payments Sunshine Act which, as
    you know, is a law that I worked on with Senator Grassley. The
    Physician Payments Sunshine Act requires transparency that will
    help prevent conflicts of interest, while at the same time
    highlighting the legitimate and necessary relationships between
    doctors and industry.
        In my State of Wisconsin, the Milwaukee Journal Sentinel
    wrote a series of reports on problems that arise when consumers
    do not know these payments are exchanging hands. And recently
    leading national newspapers published editorials supporting the
    Physician Payments Sunshine Act. Industry and consumer groups
    alike are calling for CMS to act on this piece of legislation.
        With all of this support, I would like to ask you what the
    delay that has occurred is all about.
        Secretary Sebelius. Well, Senator, we share your interest
    in making sure that this act is fully realized and think it is
    a very important issue for consumers to know exactly what is
    going on.
        We had a proposed rule in December 2011. The comment period
    closed on February 17. So about 3 weeks ago. We are working
    with comments and stakeholders and we fully intend to publish a
    final rule later this year so our collection of data can begin
    before the end of 2012. And we would be eager to work with you
    on full implementation.
        Senator Kohl. Could I request that you make a strong effort
    to push up that implementation time to no later than the first
    half of this year?
        Secretary Sebelius. Well, as I say, we have got the
    comments in and, again, we will work aggressively to get this
    in place. But the comment period closed on February 17, and we
    are doing outreach to stakeholders and others reviewing the
    comments and we will make every effort to get it published as
    soon as possible and get data collection beginning this year.
        Senator Kohl. Thank you very much.
        Senator Harkin.  Senator Kohl, thank you.
        Senator Graham.

                          AFFORDABLE CARE ACT WAIVERS

        Senator Graham. Thank you, Mr. Chairman.
        Thank you, Madam Secretary, for coming over.
        Very quickly about the waivers. As I understand it, there
    have been, oh, several million people covered by a waiver from
    your Department basically saying to the healthcare entity we
    are going to waive the requirements in Obamacare for your
    organization. Do you know how many people have received that
    waiver?
        Secretary Sebelius. Senator, again, there are a variety of
    different provisions of the law where we were given some
    administrative authority. So people in the so-called mini-med
    plans who had some kind of health coverage but not a robust
    plan--a number of those employers were given waivers knowing
    that the mini-meds cease to exist in--I can get you in writing
    the numbers and the different categories, but I do not know off
    the top of my head.
        Senator Graham. I would appreciate that.
        What percentage of those plans are union plans?
        Secretary Sebelius. I can tell you in the waivers that we
    have given, the union waivers were, I think, the fourth-lowest
    category. Private employers were number one. City and State
    governments were number two. I think the education system was
    number three, and then I think union plans were in the fourth
    category.
        Senator Graham. Okay. So city and State governments. Union
    plans were four.
        What I would like from you is a detailed analysis of the
    number of waivers given, the number of plans affected, the
    number of people within those plans, and what percentage of
    those plans happen to be union plans.
        Secretary Sebelius. I would be glad to do that.
        [The information follows:]

        Starting in 2014, the Affordable Care Act bans annual
    dollar limits on coverage of essential health benefits. Until
    then, annual limits are restricted under the Department of
    Health and Human Services (HHS) regulations published in June
    2010.
        For plan years starting between September 23, 2010 and
    September 22, 2011, plans generally may not impose an annual
    dollar limit on coverage of essential benefits such as
    hospital, physician, and pharmacy benefits of less than
    $750,000. The minimum annual dollar limit is $1.25 million for
    plan years starting on or after September 23, 2011, and $2
    million for plan years starting between September 23, 2012 and
    January 1, 2014. For plans issued or renewed beginning January
    1, 2014, all annual dollar limits on coverage of essential
    health benefits will be prohibited.
        A small number of workers and individuals currently have
    access to only limited-benefit, or ``mini-med,'' plans with
    lower annual limits than are generally permitted by law and
    which provide very limited protection from high healthcare
    costs. Estimates by employers and insurers indicate that
    requiring mini-med plans to comply with the new rules could
    cause mini-med premiums to increase significantly. This
    increase in premiums could force employers to drop coverage
    leaving some workers without even the minimal insurance
    coverage they have today.
        In order to protect coverage for employees in mini-med
    plans until more affordable and more valuable coverage is
    available in 2014, the law and regulations issued on annual
    limits allow HHS to grant temporary waivers from this one
    provision of the law (PHS Act, section 2711(a)(2)) if
    compliance with annual-limit requirements would result in a
    significant decrease in access to benefits or a significant
    increase in premiums. Plans that have received such waivers
    must comply with all other provisions of the law, and, as a
    condition of the waiver, were required to alert consumers that
    the plan has restrictive coverage and includes low annual
    limits. Additionally, these waivers are temporary and after
    2014, no waivers of the annual limit provision are allowed.
        The following chart breaks out approved waiver applicants
    by type. Please note that the annual limit waiver data is
    publicly available at http://cciio.cms.gov/resources/files/
    approved_application_for_waiver.html and includes: applicant
    information, denials, reconsiderations, and health
    reimbursement arrangements.

    ------------------------------------------------------------------------
                                                                   Number of
                            Type of Plan                            waivers
    ------------------------------------------------------------------------
    Self-Insured employers......................................         722
    Multi-Employer plans........................................         417
    Non-Taft Hartley union plans................................          34
    Health insurance issuers....................................          50
    State-Mandated policies.....................................           5
    Association plans...........................................           3
    ------------------------------------------------------------------------

                                MEDICAID FUNDING

        Senator Graham. I appreciate that.
        Now, Medicaid. You know this program well. In South
    Carolina, as I understand it, if the Medicaid eligibility is
    expanded and implemented in 2014 as envisioned by Obama
    healthcare, my State will be required to come up with close to
    $1 billion of new State funding over a 6- or 7-year period.
    That is pretty true throughout the country. Is it not?
        Secretary Sebelius. No, Senator, it actually is not. And I
    had some of this discussion with Senator Alexander, and I
    continue to have it with Governors. The way the law is
    constructed, actually the first number of years of the plan is
    fully federally funded, 100 percent Federal funding.
        Senator Graham. How many years of Federal funding?
        Secretary Sebelius. There are 4 years where it is 100
    percent, and the Federal funding then goes from 100 to the
    lowest in a decade that the Federal Government contributes is
    90 percent of the----
        Senator Graham. What about the next decade?
        Secretary Sebelius. The next decade is not described in
    this bill, but what you are talking about is the budget window.
    What I keep hearing about is this concern that somehow in the
    next several years there will be $1 billion in South Carolina
    taxpayer money and that----
        Senator Graham. I guess my concern is that we are expanding
    Government healthcare programs, to me, that need to be
    reformed, not expanded. And you may not hear this when you talk
    to Governors, but I sure hear it from Democrats and
    Republicans. They are worried to death about Medicaid expansion
    as proposed in Obamacare.
        So I have got a simple proposition. Would you allow a State
    to opt out of Medicaid expansion if they chose to under Obama
    healthcare?
        Secretary Sebelius. Senator, what we have supported from
    the beginning and actually asked that it be accelerated is if a
    State has a proposal to cover the same number of people, to
    provide health coverage, and has a different methodology for
    doing that, we would be eager to take a look at that and work
    with them around that.
        Senator Graham. Well, but my question is would you allow a
    State to just simply opt out because they have responsibility
    for their citizens. The only way they can opt out is to do it
    the way you approve of. Is that right?
        Secretary Sebelius. Well, Senator, as you know, I do not
    even have the authority. Right now, the law provides for us to
    give an accelerated option to a State plan.
        Senator Graham. What if the Congress said to all the States
    if you want to stay in Obama healthcare Medicaid expansion, you
    can, but if you want out because you think it is going to
    bankrupt your State, you have that option. Would you oppose
    that?
        Secretary Sebelius. I would, Senator, without an
    alternative for what happens to those folks. Would they be
    eligible for the exchange which would be a more expensive
    strategy?

                               MEDICARE SOLVENCY

        Senator Graham. Well, I guess what I am saying is that
    Medicare and Medicaid are really Federal Government programs.
    Do you think Medicare is in a world of hurt financially?
        Secretary Sebelius. I think that the long-term solvency of
    Medicare is a topic that needs to absolutely be discussed.
        Senator Graham. Would you agree that Medicare and Medicaid
    have grown in unsustainable ways, and without serious reform,
    those two programs alone are going to bankrupt the country? And
    I guess my concern is before you add another Government program
    where you subsidize the private sector with a Government plan,
    I would like to fix the two that are going to bankrupt the
    country. And do you have a plan to save Medicare from
    insolvency?
        Secretary Sebelius. Well, as you know, Senator, in ACA, we
    began----
        Senator Graham. Does President Obama--and I will end this.
    My time is up. Does President Obama in his budget or anywhere
    else have a plan that would adjust the age for eligibility,
    means test for higher incomes in terms of premium subsidies? Is
    there a plan the President has come up with in the last 3 years
    to save Medicare from bankruptcy?
        Secretary Sebelius. Has he proposed a means test or raising
    the age? No, Sir.
        Senator Graham. Has he proposed a plan to save Medicare
    from bankruptcy?
        Secretary Sebelius. He has proposed certainly a plan that
    adds seriously to the life of Medicare. This budget continues
    that effort, and we are eager to work on an even longer-term
    strategy.
        Senator Graham. Finally, if Paul Ryan comes up with a plan
    to make Medicare more sustainable and fiscally sound over the
    next 75 years, would you at least applaud him for trying?
        Secretary Sebelius. Well, I think that what I have seen so
    far, Senator, from Congressman Ryan is really blowing up the
    program as we know it, not sustaining it. But I would be eager
    to engage in any conversations about protecting beneficiaries,
    fulfilling our commitment to long-term health benefits, and
    finding a sustainable way moving forward.
        Senator Graham. Thank you.
        Senator Harkin.  Senator Pryor.

                              HEALTHCARE EXCHANGES

        Senator Pryor. Thank you, Mr. Chairman.
        I wish that Senator Johnson were still here because I think
    that if I understand correctly, Madam Secretary, the CBO at
    some point this month is going to update the healthcare
    baseline and give us some updated numbers about healthcare. So
    that will be helpful. But I would like to see those when they
    come out and maybe visit with you further about that.
        Let me, though, jump into something that you mentioned a
    few moments ago in answering Senator Graham's questions about
    healthcare exchanges. I would like to get an update from you on
    where you are, as the Federal Government, but also where the
    States are in terms of setting up the exchanges. Where are they
    in that process?
        Secretary Sebelius. Well, Senator, every State in the
    country, I think with the exception of two, have actually drawn
    down a planning grant. A number are moving ahead with the next
    level of implementation. We have laid out a strategy and are
    working actively with States around the country around
    basically a choice of three pathways. Either the State fully
    runs their insurance exchange and will be up and going and we
    will certify them for activity somewhere in 2013. A State can,
    on the other hand, engage in a so-called partnership program
    where the Federal Government will run pieces of the program and
    they will run other pieces. And the final is that they decide
    that they are fully not going to engage and that the Federal
    exchange will take care of the exchange activities in their
    State.
        And States are in a variety of activities. A number have
    legislation pending this year. Some are issuing executive
    orders. So we will know more definitively by the end of this
    calendar year where exactly are the host of States because
    there are a lot kind of in that middle space where they are
    trying to figure out if they are going to be fully up and
    running or in a partnership.
        Senator Pryor. My impression is that the exchange part of
    healthcare reform is very important because it could--at least
    in theory--make health insurance much more available to many
    more people and hopefully you would get a better value for the
    dollars you spend on healthcare. So I would encourage you to
    keep pushing and keep trying that.
        Secretary Sebelius. We definitely are.

                                 MEDICARE FRAUD

        Senator Pryor. And also one other thing that Senator Graham
    asked about was Medicare and the sustainability of Medicare. I
    know that one of the things you have been working on is trying
    to come up with a better way to quantify the amount of real
    fraud in Medicare. And I think everybody in this room wants to
    do that and wants to know exactly how much fraud there is and
    how we can identify it and stop it better than we have in the
    past. So, as I understand it, you are working on some new
    measures on fraud. What is your timetable for trying to have
    these new fraud measures in place so we will have a better
    sense of how much actual fraud is in the system?
        Secretary Sebelius. Well, I think, thanks to the resources
    that we were given as part of ACA, which actually is the
    toughest anti-fraud legislation ever passed in this country, we
    have some new data analytic tools. Part of that led to this
    takedown of the Texas doctor who allegedly committed about $375
    million worth of fraud with home health agencies. But part of
    it is a predictive analytic system that finally catches us up
    with the private sector. A lot of that is in place now.
        Senator Pryor. It is really great.
        Secretary Sebelius. We did not have it 2 years ago and it
    is now there. We brought the billing systems into one place. We
    can now watch what is happening in one spot and share it with
    law enforcement.
        Senator Pryor. And it is in real time now?
        Secretary Sebelius. You bet. You bet.
        Senator Pryor. That was one of the problems before.
        Secretary Sebelius. It did not exist. There were 12
    different billing systems with Medicare. So it was almost
    impossible to track what was actually happening real time.
        Senator Pryor. I would love it if some of your folks could
    come into our office.
        Secretary Sebelius. We would be glad to do that.
        Senator Pryor. You do not have to do it. I know you have
    got staff who can brief my staff and me.
        Secretary Sebelius. Now, Dr. Peter Budetti is the head of
    that unit, and we have never had an administrator at CMS who
    has actually been in charge of anti-fraud activity.

                               HEALTH PROFESSIONS

        Senator Pryor. Let me just make two really closing comments
    because I am going to run out of time here.
        We have a program in Arkansas, the Arkansas Area Health
    Education Centers (AHEC) program. It works very well in our
    State. We have eight of these little regional offices. They are
    pretty much satellites of our medical school. They do a lot of
    training. They provide lots of important healthcare in eight
    different places around the State that people would not have
    access to otherwise.
        I am concerned that when I look at the President's budget,
    we are looking at cuts there, and I am afraid about cutting
    those programs. I do not know about every other State, but our
    program works very, very well. It is really a key component of
    trying to provide better healthcare all across the State, and
    obviously, like some other States here, we have some poverty
    issues and some real challenges in rural Arkansas trying to get
    healthcare providers, specialists and even primary care
    physicians, nurses, and dentists to some places in our State. I
    would hope you would look at Arkansas because we have an AHEC
    program that works very well. In fact, Senator Tom Coburn--
    medical doctor--is a product of that. He actually went through
    the Arkansas AHEC in western Arkansas.
        And the last thing I wanted to say is just thank you for
    helping with a Bureau of Health Professions issue. I want to
    thank you all for working very diligently to help correct a
    provider shortage designation in Lepanto, Arkansas, which again
    is one of these communities that just has almost no access to
    healthcare and you have paved the way for them to get a
    physician there in rural Arkansas. So thank you for doing that.
        Secretary Sebelius. Good. Glad it worked.
        Senator Harkin.  Senator Moran.

                           CRITICAL ACCESS HOSPITALS

        Senator Moran. Mr. Chairman, thank you.
        Secretary, nice to see you. Glad our paths have crossed
    this morning.
        Just a couple of questions. First of all, I assume that you
    had a role to play in the President's budget, and I wanted to
    raise with you or at least ask you to assure me that the cuts
    in the critical access hospital program you think are
    appropriate or necessary. The President's budget has a couple
    of proposals. One is a mileage restriction. Depending upon what
    that mile might turn out to be, it affects from a small number
    to a large number of critical access hospitals in Kansas, and
    then a reduction in the so-called 101 percent of costs to 100
    percent of costs. And I think we would agree that the word
    ``cost'' does not cover the cost.
        As you know, in our State, those critical access hospitals
    in many ways determine the future of a community, and the
    absence of their presence, no physicians, and the citizens
    reluctantly decide they no longer can call home home.
        I wanted your thoughts on the reductions in spending
    related to critical access hospitals.
        Secretary Sebelius. Well, Senator, you and I have talked
    about this in the past, and I do share your concerns about
    access to healthcare particularly in rural areas and know how
    important that is to community survival. I do think that in a
    better budget time, this would not have been recommended, but I
    think that the framework of a possible 10-mile differential, if
    there is another hospital within a 10-mile radius, then it is
    unlikely that that is a critical access hospital because there
    is another choice in a relatively close space.
        And making sure that 100 percent of payment is paid--it is
    not reduced below 100 percent. It is 100 percent. I think
    working on then the definition of what that cost means is a
    secondary issue, and I would be glad to work with you on that.
    But paying 100 percent I think is very important.
        Senator Moran. Well, I would agree that if we actually paid
    100 percent of actual costs, that is a different story than
    paying 101 percent of something less than costs or paying 100
    percent of something less than costs. And so the definition of
    what is actual costs needs attention, and the percentage would
    become much less important if actual costs were actually
    covered.
        I assume that the mileage change, if enacted, would be
    retroactive, would be current, and so hospitals that currently
    receive a critical access hospital designation would lose that.
    I would indicate that one of the things that has troubled me
    from the very beginning of this conversation about the mileage
    restriction is you can have two critical access hospitals
    within 10 miles, 25 miles, 20 miles, whatever that number is.
    Both of them then are affected by the change, and you lose the
    designation for both hospitals to be a critical access
    hospital, which very well may eliminate access anyplace within
    that region. And so this being prospective, taking into account
    the consequences to two hospitals in the same radius, I think
    this needs to receive greater thought than just a strict
    mileage requirement.
        Secretary Sebelius. Well, and again, we would be happy to
    work with you on that issue because that certainly is not the
    intent. As you say, applied arbitrarily, what you described
    could happen, but we will be glad to work with you on that.

                     NATIONAL INSTITUTES OF HEALTH FUNDING

        Senator Moran. I welcome that.
        The other topic I wanted to raise was NIH funding. The
    President's budget is a continuation of the current levels of
    funding. Budgeting is about priorities. And I understood from
    your testimony but from a conversation that you had with
    Senator Shelby, NIH indicates that--or at least the
    administration indicates that through new grant management
    policies, more can be done with less, I think is the summary of
    what is being suggested.
        But I notice that, for example, the CMS budget goes up $1
    billion while the budget for NIH is held constant. And if there
    is more bang with the buck, more able to do more with less, I
    wonder why that is not applicable elsewhere and why it seems to
    be directed toward NIH. I worry when there is not a consistent
    availability of money at NIH, that we begin to lose the
    infrastructure, the commitment of young people to research and
    to science wanting to pursue that career and know that they
    have a place to go to work. I think NIH is critical in our
    global competitiveness, and ultimately in saving healthcare
    costs that the chairman talks about, preventive medicine, NIH
    has a significant component to play in finding the cures and
    treatments that in the long run save dollars. So in that sense,
    for the quality of life and for the economics, NIH is something
    that is very important, and while other items within your
    budget received increases, NIH did not. And those priorities--I
    would welcome your thoughts on that.
        Before I run out of time 37 seconds ago, I have invited the
    Acting Administrator of CMS to Kansas, and I would ask you to
    help me accomplish that goal. Since I have been in the Congress
    now for 15 years, I have invited every CMS Administrator to
    come to our State. Over the years, two have accepted that
    invitation. And I certainly would welcome the opportunity to
    have Ms. Tavenner with us in Kansas and get a feel for how we
    deliver healthcare in our State and to meet with providers and
    patients. And if you can encourage your Acting CMS
    Administrator to join your Senator in your home State, I would
    appreciate that very much.
        Secretary Sebelius. I will certainly follow up on that with
    Marilyn. I know she is eager to get out and about and around
    the country. So I did not know that invitation was pending.
        Let me just, if I can, Mr. Chairman, briefly address the
    NIH situation, which again we share this priority.
        I would say that the requests for the new resources at CMS
    are, one, due to the growing needs in both the Medicare program
    with the baby boomers coming in. There are about $200 million
    dedicated to Medicare and Medicaid issues, and the $800 million
    is, again, basically a one-time cost for infrastructure.
        I do think the NIH budget with a new opportunity for
    clinical and translational science awards, which has an
    additional budget allocation with Dr. Collins able to allocate
    just under an 8-percent increase in new grants, about 670 new
    grants--we are trying to drive the resources toward just what
    you describe which is the most strategic way to keep not only
    young people involved and engaged but keep the acceleration of
    promising breakthroughs on the horizon. And he feels that this
    is a budget that does accomplish those goals.
        Senator Moran. Thank you, Madam Secretary. I will submit a
    question to you in writing related to Part D preferred network
    plans. If you could respond to the subcommittee, have the
    Department respond to the subcommittee, I would appreciate it.
        Secretary Sebelius. Sure.
        Senator Moran. Thank you, Mr. Chairman.
        Senator Harkin.  Senator Landrieu.

                               HEALTHCARE REFORM

        Senator Landrieu. Thank you, Madam Secretary. And I want to
    commend you for your tenacity and your focus on helping stand
    up a major reform, very few reforms of its nature in our
    Nation's history, as we try to press forward on the dream and
    goal of every American, being able to access affordable
    healthcare. It has been tried by many Presidents--Democrats and
    Republicans--in the past, and President Obama, with your
    leadership and with our help, despite organized and ferocious
    and in some cases vicious opposition from the other side, are
    actually beginning to implement the opportunity for every
    person, regardless of whether they come from a rural area, a
    suburban area, or an urban area, whether they are white, black,
    Hispanic, Asian, whether they have a full-time job or a part-
    time job, whether they have a pre-existing condition, a birth
    defect that they were born with, an accident that they get
    into, that they actually would not have to go bankrupt or die
    on the side of the road, that they would actually have quality
    care. It is quite remarkable.
        There are only a few countries in the world that have
    achieved that, some at great expense. Others are struggling
    with it. There are only a handful of countries that are trying
    to be as sophisticated in their private-public partnership. And
    as you know, we are not doing that by running government
    programs. We are doing it in an attempt to work with the
    private sector to provide this kind of care.
        And the numbers that you gave to Senator Alexander were
    particularly telling, that the cost per person seems to be
    coming down. Opportunities for new affordable insurance are
    showing themselves because I am personally a little tired of
    Republican Governors out there whining that the reasons that
    they have to cut higher education is because of the increase in
    spending for healthcare. Part of the reasons that their budgets
    are shrinking is because they are giving tax cuts they cannot
    afford. They are giving tax credits to corporations that should
    be paying taxes in their State.
        The second point that I want to make, Mr. Chairman, is that
    it is not just the Federal Government's responsibility to
    provide healthcare services to our citizens. It is a
    responsibility of the State, the Federal Government, and local
    government. When did this become a complete Federal problem? So
    State Governors need to man up and woman up and do their job to
    provide funding necessary to help kids that are born with
    defects, birth defects, to help their people that get into car
    accidents and lose their legs, their arms, their eyes, their
    ears, lose their hearing, and stop whining.
        Now, if they can come up with a better plan, if the
    Republicans--which they have not in 3 or 4 years or 5 years to
    fix this, then I will listen. Until then, we are going to
    implement the plan that we passed.

                     CHILD WELFARE AND ADOPTION ASSISTANCE

        Now, my question, which is a small part of your budget, but
    as you know, it is my focus. Your entire budget, which is $16.2
    billion, does a tremendous amount of good to help families in
    America. I guess we have about 150 million families. We have
    300 million people, 2 people per family. I am just roughly
    estimating--125 million families. You do a lot in this budget
    for their health, for helping them with day care so many of our
    families can go to work, providing good healthcare.
        A small number of our families, as you know, are very, very
    fragile and in critical situations, and we have tried with this
    subcommittee to give you some special funds to help keep these
    families together and particularly help children that get
    separated from their families. We call them orphans, children
    in foster care. They only represent one-half of percent of all
    the children in America are in foster care.
        So I just want to point you to your Child Welfare and
    Adoption Assistance program of about $362 million, the Chafee
    program $45 million for training of foster youth, the $39
    billion for adoption incentives, and the $63 million for
    promoting safe and stable families. We have worked across the
    aisle here for many years. While we do fight about healthcare,
    we really do not fight about adoption and foster care.
        And I just want to ask you and bring to your attention that
    your Department, prior to you getting there but continuing
    under your good leadership, has increased the number of
    adoptions from 14,000 in 1990 to 52,000 this year. That is an
    incredible----
        Secretary Sebelius. That is a big jump.
        Senator Landrieu. It is a big jump, Madam Secretary, and I
    want to thank you. A lot of this work was done by the Clinton
    administration. This was a big priority for President Clinton
    and First Lady Hillary Clinton. But I think that is a real
    testimony, Mr. Chairman, to your leadership as well. We have
    increased domestic adoptions from 14,000 a year to 52,000 a
    year.
        My question would be could you look more closely at these
    numbers that I have shared with you and see if you can more
    strategically align them with the goal of bringing this number
    up, Madam Secretary, from 52,000 to about 100,000. We have got
    to double it. That is the number of children that are available
    for adoption, but we are not connecting them well enough to a
    home. We are either failing to keep them with their birth
    families or we are not connecting them to be adopted. And you
    have got some resources in here specifically programmed by the
    Congress. So could you comment on that?
        And I want to thank you for your appointment of George
    Sheldon who seems to be a real expert in this area and has been
    working closely with us on it.
        Secretary Sebelius. Well, Senator, I would be remiss if I
    did not recognize your incredible leadership and tenacity
    around these issues looking out for kids who often do not have
    a champion, and you certainly have been one.
        We have a request before the Congress in this budget to
    increase spending by $250 million in the foster care and
    permanency area, $2.8 billion over 10 years. And it would be a
    new initiative to incentivize all kinds of improvements in
    foster care, requiring child support payments to be used in the
    best interest of the child rather than offset State and Federal
    welfare costs that often can be conflicting.
        So we agree that resources need to be increased and we need
    to do a better job targeting those strategic resources to make
    sure that these programs are enhanced, and we would really look
    forward to working with you who have thought about this for a
    long time and have some, I think, very good ideas about how to
    improve the well-being of our children in foster care, the
    transitioning issues, I know, you know, the huge step to
    provide healthcare to the kids aging out of foster care, the
    same way that other kids can be on their parents' plan. These
    are our children. So carrying them on a healthcare plan.
        We have a new proposal, Senator, that I will make you aware
    of which really deals with the reallocation of the State
    funding which currently is not accessed around abstinence-only
    education. A number of States have just said we are not going
    to take those resources. We would like to reallocate those
    funds and focus on pregnancy prevention in foster youth where
    the data is pretty alarming in terms of how many young girls
    end up becoming pregnant. So there are some strategies across
    our budget that I think focus some new resources.
        Senator Landrieu. Well, I would only say, Mr. Chairman, you
    have been very generous, but you are both in an excellent
    position to focus on this because really focusing on the needs
    of foster children, particularly helping them stay in the
    schools that give them the stability. And, Mr. Chairman, as the
    chairman of the Education Committee, I think there can be a
    tremendous amount of--there is a lot of interest of Senators on
    both parties, and I think we can make advancements.
        But remember that the best support for a child is a good
    parent. You know, we can give all the government services we
    want, but if we could just help these children get into the
    arms of a loving, responsible adult, either to the mother that
    they were born to with help and support or to an aunt or a kin
    or a relative or to someone in the community, that is the best
    prevention of pregnancy and jail and mental illness is to have
    a good, loving parent. So if we could just focus our efforts,
    build on this great, extraordinary work--we have doubled the
    number of children finding forever-homes--I would be grateful
    and so will the children.
        Secretary Sebelius. I look forward to working with you.

                         COMMUNITY TRANFORMATION GRANTS

        Senator Harkin.  Thank you very much, Senator Landrieu. And
    I join the Secretary in thanking you for your great leadership
    in all the years you have been here in this area. I think you
    have provided just sort of a beacon for the rest of us to
    follow in how we are going to address this issue of our foster
    kids and kids that just have a tough life and making sure that
    they just have a little bit more gentle care and loving care.
    So I thank you for your great leadership in that area.
        Madam Secretary, I am going to start a second round, but I
    guess I am going to be the only one.
        The one other thing I want to cover with you is something
    near and dear to my heart that I have worked on for a long
    time. I put it in ACA as part of the prevention and wellness
    program, and it was called Community Transformation Grants.
    This was based upon earmarking things that we had done in the
    past and looking at what the community has done. We had some
    tests around the country to see how communities could come to
    join together, such as getting grocery stores, YMCAs or YWCAs,
    schools, businesses to figure what they could do in a
    community-based setting to provide for healthier lifestyles.
    And that is why it was called a Community Transformation Grant.
        In fiscal year 2011, $145 million was allocated to this
    Community Transformation Grant. The CDC announced a competition
    that, for most of the country would require statewide programs.
    For example, in Iowa, Dubuque or Des Moines could not apply on
    their own; they had to be part of a statewide application.
    Well, that is not what we intended. As I look at the guidance
    put out by CDC, to be eligible, grantees had to serve either a
    city of 400,000 or more or a State. So in most States, YMCA or
    community health centers could not even apply directly. Grants
    were for $1 per capita.
        I often cite the Trust for America's Health. They did a
    very thorough study on this, and they found that investments in
    prevention could produce savings within 5 years based upon
    spending of $10 per person.
        So we can take that $145 million and just sort of spread it
    around, but I am not certain it is going to have that much of
    an impact unless it is targeted. So that is why we wanted it to
    be community-based programs.
        Also, the CDC said funding must be used on a minimum of
    three goals, reducing obesity by 5 percent, reducing smoking
    rates by 5 percent, increased access to preventative services
    by 5 percent. Now, again, maybe States are equipped to do all
    that, but in a lot of cases, community groups have just one
    focus. The CDC is now making them focus on the three specific
    goals.
        Well, that is not what we intended. So in our Senate bill
    last year, we got language in there to continue the program
    your Department designed but requiring that all new funds be
    used to support community-based programs. As I said earlier,
    because of the opposition by the Republicans on the Senate side
    and the House Republicans, we were not able to get the bill
    through. However, the language is there in the Senate bill.
        What I would like to seek from you is a commitment that the
    $81 million increase that we had this year. I want to make sure
    that all new funding is in accordance with the language we put
    in the Senate bill. I cannot do anything about the $145
    million. It is already out there. And I just wanted to know
    your sentiments on that.
        Secretary Sebelius. Well, Senator, Mr. Chairman, I
    certainly share your belief, although you have been at this a
    lot longer than I have, that the ounce of prevention is
    probably 10 pounds of cure. I mean, it is a strategy that we
    have to engage in. We think Community Transformation Grants can
    be a critical part of that testing strategies. As you know,
    there are some set-asides for rural communities and tribal
    communities to make sure that there is a representation in
    rural and frontier areas as well as larger communities and
    statewide programs.
        So 61 States and communities had received awards in 2011,
    and I know your interest in broadening the applicability. We
    will work with your office around the framework for moving
    forward. There are some issues around how many folks can really
    move the needle, but we would be eager to work with your office
    around what the next steps are.
        Senator Harkin.  Well, I appreciate that. Take a look at
    the language that we put in. I would love to work with you on
    it. This is something that we have been doing for a long time
    on this subcommittee, and we funded, as I said through the
    earmarking process, and some have failed, some have not. We
    kind of know what works, and it is on a community basis, not on
    a statewide basis. And certainly I never intended that it would
    only go to cities of 400,000 or more. Sometimes the smaller
    community can have a bigger impact just because they are
    smaller, people know each other, they can get together better
    in a smaller community sometimes. So a community of 40,000-
    50,000 can make great strides even better than perhaps a large
    metropolitan area. And then the idea of $1 per person might
    have some effect, but certainly not the kind of impact that a
    larger amount in more targeted areas would have. So I look
    forward to working with you on that.

                     NATIONAL INSTITUTES OF HEALTH FUNDING

        Last, I wanted to bring up the issue of community health
    centers, again something that we worked very hard on in ACA.
    Senator Sanders was also one of the leaders in that area on the
    authorizing committee. But we wanted to increase the number of
    community health centers prior to 2014. We wanted to get as
    many out there as possible. Yet, the President's budget
    proposed to hold back $280 million of the $300 million increase
    for fiscal year 2013. That is the budget we are working on.
        Now, I know all about the funding cliff that is out there
    in 2015, but that funding cliff was about $3.6 billion. Our
    intention on putting this money in there was to get as many
    community health centers up and running prior to 2014. It was
    not to smooth it out.
        So again, I am hopeful that we can use all of the
    additional $300 million to get as many centers up and running
    as possible before January 2014. We can worry about and take
    care of that funding cliff sometime later, but the most
    important thing is to get them up and running.
        Secretary Sebelius. Well, again, Mr. Chairman, I think your
    interest and passion in this area is not only well known but
    one that we share. Community Health Centers have been a
    resounding success, high-quality, lower-cost, preventive and
    primary care, often taking care of needs well beyond healthcare
    that impact people's health and well-being. As you know, the
    budget does anticipate an additional 200 sites be funded with
    the resources that we have requested, but we would again work
    with your subcommittee. I think there is a great deal of
    concern about the out-years and the cliff and how to make sure
    that we do not end up in a situation where having opened a lot
    of sites, we cannot staff them, we cannot fund them. So we
    would be eager to work with you around the best strategy to get
    people the desperately needed care.
        Senator Harkin.  Well, thank you, Madam Secretary. Just
    tell OMB I am not in favor of what they are trying to do. All
    right?
        Secretary Sebelius. I would be happy to convey that
    message.

                         ADDITIONAL COMMITTEE QUESTIONS

        Senator Harkin. Madam Secretary, thank you. Do you have
    anything else that you want to add for the record?
        Secretary Sebelius. No, Sir.
        Senator Harkin. Thank you very much.
        Secretary Sebelius. Thank you.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                    Question Submitted by Senator Tom Harkin
                   national health service corps and title x
        Question. To receive title X funding, a clinic is required to prove
    to Health Resources and Services Administration (HRSA) that they either
    provide or have in place referral agreements to provide comprehensive
    primary care services. Yet the Guttmacher Institute has shown that the
    biggest hurdle for title X clinics that want to participate in the
    National Health Service Corps (NHSC) is proving that they provide or
    have referral agreements to provide comprehensive primary care
    services. If HRSA is certain the clinics provide those services in one
    ongoing grant program and audits them regularly to ensure compliance,
    why would good standing in that program not be sufficient proof of
    those services for another HRSA program?
        Clinics that only receive title X funding provide the only primary
    care many low-income women receive, and they are plagued by the same
    workforce shortages as other clinics. Obstetrician/gynecologist and
    nurse midwife are two eligible categories for health professionals who
    participate in the NHSC. Furthermore, like other NHSC-eligible
    entities, clinics with only title X funding are required to serve
    anyone who walks through the door--women and men--in their communities
    regardless of income at free or reduced cost. What plans does the
    Department have to ensure that HRSA programs have a common definition
    for what constitutes providing comprehensive primary care services?
        Answer. The NHSC has taken steps through its refined policy to
    better inform sites of the program's definition of comprehensive
    primary care so that the site approval process is open and transparent.
    The program recognizes that many women, as well as men, use women's
    health clinics as their primary care provider because it meets their
    healthcare needs or may be the only provider in their community.
        The NHSC has published a new version of its Site Reference Guide,
    which defines comprehensive primary care as, ``the delivery of
    preventive, acute, and chronic primary health services in an NHSC-
    approved specialty. NHSC-approved primary care specialties are adult,
    family, internal medicine, general pediatric, geriatrics, general
    psychiatry, mental and behavioral health, women's health, and
    obstetrics/gynecology. Comprehensive primary care is a continuum of
    care not focused or limited to gender, age, organ system, a particular
    illness, or categorical population (e.g. developmentally disabled or
    those with cancer). Comprehensive primary care should provide care for
    the whole person on an ongoing basis.''

                                     ______

                Questions Submitted by Senator Daniel K. Inouye
                           native hawaiian healthcare
        Question. I appreciate that under your leadership the budget
    request for the Health Resources and Services Administration (HRSA)
    continues to support the Native Hawaiian Health Care Program, which
    improves the health status of Native Hawaiians by making health
    education, health promotion, and disease prevention services available
    through the support of the Native Hawaiian Health Care Systems. As you
    may be aware in 2010, the Department of Health and Human Services (HHS)
    consultation policy as related to American Indians and Alaska Natives
    was revised and the new formal consultation policy eliminated Native
    Hawaiians and their health organizations (NHOs). It is my
    understanding, that since that time Native Hawaiians and their NHOs
    have asked HHS to re-establish a separate formal consultation policy
    for Native Hawaiians. Native Hawaiians have among the highest morbidity
    rates of any ethnic or racial population for major chronic diseases,
    and consultation with the Native Hawaiian community could help to
    tailor HHS policies, programs, and priorities to improve health
    outcomes. Please describe the best path forward for HHS and the Native
    Hawaiian community to engage on health issues of concern. Is the
    reissuance of an HHS consultation policy for Native Hawaiians and their
    health organizations possible?
        Answer. HRSA understands the importance of supporting the Native
    Hawaiian Health Care Program, and will review existing relationships
    and partnerships with the Native Hawaiian community to determine the
    appropriate steps for moving forward, including the consideration of
    revised policies.
        Question. The Native Hawaiian Health Care Improvement Act (42
    U.S.C. 11701) is the major Federal statute providing for a
    comprehensive approach to improving the health and well-being of the
    indigenous peoples of Hawaii. The act states that the Secretary of HHS
    provide the President with a progress report on meeting the Federal
    policy of ``improving the health of Native Hawaiians to the highest
    possible level.'' The President, in turn, transmits the report to us in
    the Congress. When can my office anticipate receiving a copy of that
    report?
        Answer. HHS is committed to addressing the health needs and well-
    being of Asian American, Native Hawaiian, and Pacific Islander (AANHPI)
    populations. The Affordable Care Act (ACA) has mobilized HHS efforts
    and has served as the underlying framework for the development of the
    HHS AANHPI Agency Plan. The HHS plan illustrates measurable objectives
    that the Department will pursue to raise the visibility of AANHPI
    health issues, healthcare and human services disparities. This plan is
    meant to elevate AANHPI issues across the Department under the
    leadership of the Assistant Secretary for Health. I am pleased to
    provide a copy of the agency plan to your office which outlines, in
    detail, the components and accomplishments related our current work on
    improving data collection.
        The plan includes four overall-arching health goals to improve the
    well-being of AANHPIs. These goals include how the Department will
    carry out its plan to prevent, treat and control Hepatitis B infections
    in AANHPI communities, work to improve reporting of data, foster
    workforce diversity by developing workforce pipelines for AAs and
    NHPIs, and address some of the key health issues that specifically
    impact NH and PI populations. The plan also addresses a wide-ranging
    set of issues, including breast and cervical cancer, diabetes and
    tuberculosis, prevention, surveillance and response, communicable
    diseases in the Pacific jurisdictions, laboratory testing,
    environmental issues, and vaccinations.
        Our efforts to better serve Native Hawaiian populations and
    identify and understand health disparities will be enhanced through the
    efforts outlined in goal two. Detailed data is a fundamental step in
    identifying which populations are most at risk and what specific
    interventions are most effective in attaining improved healthcare
    quality for specific populations. HHS will continue to increase the
    capacity to collect more reliable health data for AANHPI populations to
    better understand the need of these growing populations. Efforts to
    improve data collection include:
      --Substance Abuse and Mental Health Services Administration:
        --Enhance the quality of data collected within Substance Abuse and
                Mental Health Services Administration's (SAMHSA) National
                Survey on Drug Use & Health (NSDUH) for AANHPI populations.
      --Centers for Disease Control and Prevention:
        --The fiscal year 2013 budget includes $161,833,000 for health
                statistics, an increase of $23,150,000 more than the fiscal
                year 2012 level to accomplish many of the activities
                described below.
        --Continue oversampling of Asian Americans in the National Center
                for Health Statistics' (NCHS) National Health Interview
                Survey (NHIS).
        --Include an oversampling of Asian Americans in the 2011-2014
                National Health and Nutrition Examination Survey (NHANES).
        --Implementation of section 4302 of ACA regarding data collection
                on race, ethnicity, sex, primary language, and disability
                status. This will provide an opportunity to obtain
                disaggregated data on AA, NH, and PI communities.
        --Develop improved tools for accessing and analyzing vital
                statistics and survey data for small populations.
        We look forward to improving our data collection, reporting and
    disaggregation of race, ethnicity, and primary language data related to
    the AANHPI community and to provide you with additional data related to
    the health objectives outlined in the Native Hawaiian Health Care
    Improvement Act. We look forward to including this information in the
    annual AANHPI Agency Plan end of year report.
     aligning hawaii's prepaid health care act and the affordable care act
        Question. Hawaii has traditionally experienced a much lower rate of
    uninsured individuals due to the landmark State law, the Prepaid Health
    Care Act (PHCA), which requires employers to provide healthcare
    coverage to full-time employees. As the State works to implement
    elements of ACA, questions have arisen regarding the ability for
    Hawaii's law to interact with the ACA in a manner that would allow
    Hawaii residents maximum benefits. Will there be further guidance from
    HHS, specific to Hawaii's healthcare environment, on how the Prepaid
    Health Care Act can work in conjunction with the requirements of the
    ACA? Is it HHS' desire for Hawaii to maintain the requirements of the
    PHCA?
        Answer. HHS is committed to working with the State of Hawaii
    regarding the coordination of the PHCA and ACA. HHS also works with our
    Federal partners in ACA implementation, such as the Department of the
    Treasury and the Department of Labor, on these issues, as necessary.
    Conversations about specific interactions have already begun.
                          compact of free association
        Question. In 1986, the United States entered into Compacts of Free
    Association with the Federated States of Micronesia and the Republic of
    the Marshall Islands. In 1994, the United States entered into a similar
    relationship with the Republic of Palau. The Compacts set forth the
    bilateral terms for government, economic, and security relations
    between the United States and the Freely Associated States (FAS), and
    the laws approving the Compact set forth the U.S. policy context and
    interpretation for Compacts. Section 141 of the Compact provides that
    certain FAS citizens ``may be admitted to, lawfully engage in
    occupations, and establish residence as a nonimmigrant in the United
    States and its territories.'' However, the Congress also stated, in
    section 104(e)(1), that ``it is not the intent of Congress to cause any
    adverse consequences for an affected jurisdiction.'' It is estimated
    that affected areas of the United States are spending upwards of $200
    million annually for healthcare, education, and other services for FAS
    migrants, including high-cost treatments such as dialysis and
    chemotherapy. These costs are increasing annually. Public health
    officials are particularly concerned about the rate of certain diseases
    such as tuberculosis and Hansen's disease, which have high incidence
    rates in Micronesia and among recent Compact migrants.
        House Report 112-331 directs the Department of the Interior to
    ``meet regularly with officials from the Freely Associated States,
    other Federal agencies and affected jurisdictions, and develop and
    implement a comprehensive plan to mitigate the costs of Compact
    migration.'' Please provide an update on the work of agencies within
    HHS on this interagency working group. How best can HHS assist States
    and territories in meeting the health and social service needs of
    Compact migrants?
        HHS/Office of Assistant Secretary for Health (OASH), Region IX
    assists States and territories in meeting the health and social service
    needs of Compact migrants by managing the following activities:
      --The OASH, Region IX office is coordinating with other HHS Operating
            Divisions (OPDIVS) on Pacific health issues; providing guidance
            on strategies and policy development that promote Pacific
            health and reduce health disparities; and participating in
            meetings of the Workgroup on Asian, Native Hawaiian, and
            Pacific Islander issues (WANHPII) and Insular Areas HHS Policy
            Group (IHHSPG).
      --The OASH, Region IX office is developing relationships with
            Micronesian Chief Executives Summit (MCES) policy leaders to
            advocate for increased health awareness, environmental health
            issues, and health disparities reduction; ensuring health and
            environmental health issues are elevated on the MCES agenda;
            and participating in semiannual MCES meetings to promote status
            of health and environmental health issues.
      --The OASH, Region IX office is improving the capacity to secure
            grants, and strengthen grant management and financial
            accountability capacity in the Pacific by increasing grant
            awareness by making knowledge of Federal grant funding
            opportunities more readily available to U.S. Associated Pacific
            Islands (USAPI) health departments and communities.
      --The OASH, Region IX office is promoting awareness of
            noncommunicable diseases (NCDs) crisis and Federal,
            nongovernmental organization (NGO) and international assistance
            for programs and policy development to prevent NCDs.
        --HHS Region 9 (RIX) is collecting NCD plans and promising
                practices from all the Pacific jurisdictions, report is
                forthcoming.
        --NCD program funding from CDC's consolidated grant program
                addresses diabetes prevention and treatment, tobacco
                control, and behavioral risk.
        --The Pacific Chronic Disease Coalition, a PIHOA affiliate, has
                been extremely active in supporting the development of NCD
                prevention programs in all of the USAPI.
      --The OASH, Region IX office is assisting Pacific health departments
            in addressing current, emerging, and emergency health issues
            including MDR-TB, Hansen's disease and dengue fever
            coordinating with CDC, HRSA, Department of Defense (DOD), World
            Health Organization, Pacific Regional Office (WHO/WPRO) and
            Secretariat for the Pacific Community (SPC), and DOI.
      --The OASH, Region IX office is involved in conversations with States
            and territories receiving Compact migrants, clarifying the
            circumstances in which Medicaid can be used to pay for
            emergency services. Although Compact migrants are not eligible
            for Medicaid, certain emergency services can be covered under
            the Medicaid program at the regular Federal Medical Assistance
            Percentage (FMAP).
      --The OASH, Region IX office is increasing the collection, accuracy,
            and utilization for health services of Maternal-Child Health
            (MCH) data in the USAPIs. In collaboration with HRSA's Title V
            MCH grant program, and in conjunction with WHO/WPRO, SPC and
            PIHOA data strengthening/HIT, there are efforts to determine
            weaknesses and revisions in current data collection, analysis,
            and utilization for health planning and service delivery.
      --The OASH, Region IX office is providing technical assistance to the
            USAPI nursing programs, including the Robert Wood Johnson (RWJ)
            Pacific PIN nursing grant, to enhance the capacity and quality
            of USAPI nursing programs.
      --The OASH, Region IX office is fostering recognition of the
            behavioral/mental health disparities in Pacific populations and
            creating resource linkages with potential resources SAMHSA,
            HRSA, CDC, Veterans Affairs, DOD, HI & Pacific M/DOH, NGOs
            including faith-based organizations, WHO/WPRO, and SPC.
      --The OASH, Region IX office is assisting USAPI health profession
            programs in incorporating emergency response content into their
            curricula. Coordinating with WPRO/WHO, CDC, ASPR, Medical
            Reserve Corps (MRC), HRSA, DOD, and the Red Cross regarding
            trainings and emergency prep curricula for health professions
            programs and assisting in establishing contacts to aid them in
            providing relevant trainings to nursing personnel and nursing
            programs.
      --The OASH, Region IX office is collaborating with Office of Minority
            Health Resource Center (OMHRC), HRSA, CDC, SAMHSA, WHO/WPRO,
            SPC, PIHOA, DOI, and Telecommunications and Information Policy
            Group (TIPG)/Pan-Pacific Education and Communication
            Experiments by Satellite (PEACESAT) on training opportunities
            for enhancing data, surveillance programs, and the combined
            utilization of HIT and tele-health to enhance service delivery
            and accessibility, to enhance capacity in data collection/
            analysis/surveillance that leads to better health services
            planning and service delivery.
      --The OASH, Region IX office is assisting in enhancement of the RIX
            Medical Reserve Corps program in the Pacific, collaborating
            with RIX MRC consultant to develop and strengthen MRC units in
            the Pacific.
        HHS/HRSA and CDC assists States and territories in meeting the
    health and social service needs of Compact migrants and Hansen's
    disease by managing the following activities:
      --HRSA's National Hansen's Disease Program (NHDP) offers assistance
            in selected aspects of HD control, such as training and
            technical assistance in the Republic of the Marshall Islands
            (RMI). NHDP intends to collaborate with other agencies such as
            CDC and WHO to assist in HD awareness and training and
            participate in activities similar to the meeting with WHO and
            others in Majuro in 2010, and the HD training workshop at NHDP
            headquarters in Baton Rouge. NHDP initiated preliminary
            training via video teleconference through PEACESAT in
            collaboration with HHS Region IX.
      --CDC provides technical assistance for the public-health related
            aspects of HD, including development and evaluation of
            surveillance systems, epidemiologic support such as outbreak
            and cluster investigation, and case reporting. The CDC notifies
            state and territorial health departments and the NHDP of
            patient immigration into the United States, facilitating
            patient care. In addition, the CDC is providing direct
            assistance for capacity development of the RMI TB Control
            Program.
                          hiv/aids prevention funding
        Question. The fiscal year 2013 President's budget request includes
    an increase of $40.231 million more than fiscal year 2012 level for
    Domestic HIV/AIDS Prevention and Research. The increase provides
    additional funding to achieve the goals of the National HIV/AIDS
    Prevention Strategy. What measures will HHS use to assess the impact of
    the funding priority and will the funds targeted for State and local
    programs be prioritized to states and localities most impacted by
    previous shortfalls?
        Answer. CDC aligns its HIV program priorities with the National
    HIV/AIDS Strategy (NHAS). The agency uses data from national HIV
    surveillance, behavioral surveillance, and program monitoring systems
    to assess progress toward achieving NHAS goals, as well as its own HIV
    prevention plans' impact objectives. These measurements, which are
    listed on page 80 of CDC's proposed budget for fiscal year 2013, are as
    follows:
    Prevent New HIV Infections
        By 2015, reduce the annual number of new HIV infections by 25
    percent--NHAS goal.
        By 2015, reduce the HIV transmission rate by 30 percent--NHAS goal.
        By 2015, increase the percentage of people living with HIV who know
    their serostatus to 90 percent--NHAS goal.
        Increase the percentage of people diagnosed with HIV infection at
    earlier stages of disease (not Stage 3: AIDS)--2013 target: 47.5
    percent.
        Increase the proportion of adolescents (grades 9-12) who abstain
    from sexual intercourse or use condoms if currently sexually active--
    2013 target: 86.9 percent.
    Increase Linkage to and Impact of Prevention and Care Services With
            People Living With HIV/AIDS
        By 2015, increase the percentage of persons diagnosed with HIV who
    are linked to clinical care to 85 percent--NHAS goal.
        Increase the percentage of HIV-infected persons in publicly funded
    counseling and testing sites who were referred to partner services--
    2013 target: 73.5 percent.
        Increase the percentage of HIV-infected persons in CDC-funded
    counseling and testing sites who were referred to HIV prevention
    services--2013 target: 68 percent.
        Increase the number of States that report all CD4 and viral load
    values for HIV surveillance purposes--2013 target: 36.
        Increase the number of States with mature, name-based HIV
    surveillance systems--2013 target: 50.
        Reduce the number of new AIDS cases among adults and adolescents
    per 100,000--2013 target: 12.7.
        CDC actively monitors and publicly reports on these national
    objectives each year as data are available. In addition, CDC's Division
    of HIV/AIDS Prevention aligns its program priorities with the
    principles of high-impact prevention, which represent the scientific
    foundation for its HIV prevention efforts. More information is
    available at: http://www.cdc.gov/hiv/strategy/hihp/.
        In order to monitor progress at the State and local level, CDC asks
    grantees to submit semi-annual progress reports that describe the
    implementation of HIV prevention program activities, and identify
    barriers and challenges to meeting programmatic objectives. CDC also
    uses site visits and conference calls with grantees, and its own
    surveillance and monitoring systems, to monitor grantee performance and
    develop plans for further improve performance, which involves the
    provision of capacity building, training, or other technical
    assistance.
        CDC would use the increased funding requested for fiscal year 2013
    to address priorities in NHAS. Specifically, CDC would increase HIV
    Adolescent and School Health funding over the fiscal year 2012 level
    for cooperative agreements to States, cities, territories, and tribes.
    This would enable HIV priority areas to develop and implement health
    policies, programs, and practices, as well as improve HIV and sex
    education efforts across the country. CDC would also restore funding to
    several national NGOs that provided professional development and
    technical assistance to State and local education agencies, health
    agency partners, and other organizations working in school health.
        Of the increase proposed for HIV Prevention by Health Departments
    and National Programs to Identify and Reach Highest-Risk Populations,
    CDC would award $22 million directly to State and local health
    departments. The increased funds are expected to improve the capacity
    of jurisdictions to conduct core HIV surveillance activities, and
    improve the use of surveillance and other programmatic data to improve
    HIV testing, retention, and re-engagement in medical care activities.
    Through its recent funding opportunity announcements, CDC emphasized
    the importance of aligning resources to better match the geographic
    burden of the HIV epidemic throughout the United States. This resulted
    in an equitable approach to CDC's HIV funding; additional funding for
    CDC would reflect a continuation of this approach. It is likely that a
    proportion of jurisdictions that experienced decreases in HIV funding
    would be recipients of these increased funds for HIV surveillance and
    prevention; however, CDC will prioritize the distribution of increased
    resources according to the burden of HIV.
                           viral hepatitis screening
        Question. The Congress enacted $10 million under ACA in fiscal year
    2012 for viral hepatitis screening. Please provide an overview of how
    the funds were utilized. Additionally, please provide an overview of
    how local and State health departments are participating in the
    formation and implementation of the national viral hepatitis strategy.
        Answer. In fiscal year 2012, CDC will use the increase provided for
    viral hepatitis to increase the proportion of persons with chronic
    viral hepatitis who are aware of their infection and who are referred
    to medical care. CDC is planning projects that involve direct provision
    of screening for at risk populations, evaluation of testing activities,
    and public and provider education to raise awareness of the need for
    viral hepatitis screening and provide the skills to do so.
    Specifically, CDC will provide resources to organizations to increase
    testing for at risk populations in multiple settings including
    federally Qualified Health Centers, local health department clinics
    (e.g., STD clinics or HIV/AIDS settings), correctional settings,
    intravenous drug use treatment centers, and community-based
    organizations. The resources will target efforts to reach persons at
    highest risk for severe hepatitis C virus (HCV)-related morbidity and
    mortality, communities experiencing health disparities related to
    hepatitis B (e.g., foreign born populations and their children) and
    hepatitis C (African Americans and current and former incarcerated
    populations), and young persons at risk for HCV-related to drug use.
    CDC will support a public awareness campaign for HCV, currently under
    development, and expand it to address chronic hepatitis B virus (HBV)--
    targeted to those populations most at risk for chronic HBV infection.
    CDC will also develop and disseminate education and training materials
    targeting public health and private sector healthcare professionals.
    These materials will build capacity to assess, test, and medically
    manage chronic HCV and HBV infection.
        HHS invited partners from State and local health departments,
    including HIV and STD directors and Adult Viral Hepatitis Prevention
    Coordinators (AVHPC), to participate in the development of Combatting
    the Silent Epidemic of Viral Hepatitis: Action Plan for the Prevention,
    Care, and Treatment of Viral Hepatitis (Action Plan). In particular,
    health department representatives participated in two community
    engagement meetings held by HHS on June 29, 2010, and September 21,
    2010, with health departments constituting a significant percentage of
    the participants at both meetings. At the first meeting, participants
    had the opportunity to comment on issue areas proposed by HHS, propose
    additional areas, suggest particular issues that HHS should address,
    and identify ways to make the Action Plan as meaningful and useful as
    possible. Input from that engagement session strongly influenced and
    helped to shape the draft of the Action Plan. After developing the
    first draft of the Action Plan, HHS held the second meeting to solicit
    feedback about its contents. Health department representatives and
    other viral hepatitis stakeholders offered suggestions to strengthen,
    improve, and focus elements of the Action Plan. This feedback was a
    vital component in development of the final version of the Action Plan.
        HHS and CDC will continue to work closely with state and local
    health departments to achieve the goals set forth by the Action Plan.
    The Action Plan recognizes the important role health departments must
    play in coordinating local efforts to advance viral hepatitis
    prevention and control activities. Numerous action steps in the Action
    Plan specifically mention AVHPC and other health department staff.
                        tuberculosis in high-risk areas
        Question. Senate Report 112-084 requested that the CDC ``review the
    epidemiology of TB in States and territories with more than double the
    average rate of TB cases.'' Please provide a status update on CDC's
    findings.
        Answer. CDC analyzes and reports tuberculosis (TB) cases and rates
    annually. Jurisdictions with case rates that are more than twice the
    national average rate of 3.4 cases per 100,000 (provisional 2011 data)
    include Alaska (9.3), Hawaii (8.95), and the District of Columbia
    (8.9). Territories with more than twice the average national rate
    include the Commonwealth of the Northern Mariana Islands (67.3), Guam
    (55.3), Federated States of Micronesia, (136.7), the Republic of the
    Marshall Islands (227.7), and Palau (47.7).
                children's hospitals graduate medical education
        Question. The President's budget for fiscal year 2013 proposes $88
    million to fund the Children's Hospitals Graduate Medical Education
    (CHGME) program. CHGME was funded at a level of $267.8 million in 2012.
    Even at CHGME's current annual funding level, children's hospitals
    struggle to train enough pediatricians and pediatric specialists to
    keep up with the growing demand. CHGME funds support graduate medical
    training at freestanding children's hospitals all over the United
    States. The importance of this program is especially acute in my home
    State where our CHGME recipient hospital--Kapiolani Medical Center for
    Women and Children--is the only tertiary children's hospital for the
    entire State of Hawaii and Pacific Basin. Kapiolani currently trains 6
    to 10 pediatric residents per year and of the those trained, more than
    30 percent choose to continue to practice in Hawaii after their
    residency. I am concerned that the proposed level of funding does not
    adequately support the gains we have made in pediatric health and
    ensuring access to care. If CHGME is not adequately funded, who will
    train these providers and support the future primary care workforce for
    our Nation's children?
        Answer. We recognize the vital role that children's hospitals and
    pediatric providers play in providing quality health care to our
    Nation's children.
        The fiscal year 2013 CHGME funding level continues to support
    direct costs for training pediatric residents at independent children's
    hospitals. This payment provides support for resident salaries,
    expenditures related to stipends and fringe benefits for residents,
    salaries and fringe benefits of supervising faculty, cost associated
    with providing the GME training program, and allocated institutional
    overhead costs.
        The fiscal year 2013 budget retains the incentive to maintain total
    resident levels. The administration recognizes that research has
    indicated that there is a significant shortage of pediatric
    subspecialists, resulting in children with serious illnesses being
    forced to travel long distances--or wait long periods--to see a
    pediatric specialist. In response to these shortages, the fiscal year
    2013 President's budget includes $5 million to implement the Pediatric
    Specialty Loan Repayment (PSLR) program that was authorized in ACA.
    Under this program, loan repayment agreements will be authorized for
    pediatric specialists who agree to work in underserved areas.
        While both the CHGME Payment and the PSLR programs support the
    pediatric medical workforce, the focus of each is different. The CHGME
    Payment Program serves the purpose of providing residency training in
    Children's Hospitals through the payments made to Children's Hospitals,
    while the PSLR program is designed to assist pediatric specialists more
    directly and increase the number of pediatric specialists in
    underserved areas.

                                     ______

                    Questions Submitted by Senator Herb Kohl
        Question. Secretary Sebelius, more than a year ago I wrote to you
    with Senator Snowe to express strong concern about proposed regulations
    that your Department has drafted regarding the Genetic Information
    Nondiscrimination Act (GINA). We raised two concerns. First, the
    proposed rule extends to private long-term care insurance the
    prohibition under GINA of the use of genetic information. This
    extension occurred despite clear congressional intent and history to
    exclude GINA in long-term care. Second, we objected to the proposed
    GINA expansion because a rule barring the use of genetic information
    would effectively cripple the long-term care insurance industry and
    leave millions without access to coverage.
        Given that Federal efforts to expand long-term care coverage have
    stalled and the administration's decision not to implement the
    Community Living Assistance and Support Services (CLASS) program, this
    proposed expansion comes at a particularly precarious time for the
    long-term care industry. As we are relying on private industry to
    accelerate its efforts and provide more coverage, the Federal
    Government should not inappropriately stymie these efforts.
        Will you assure that the Department of Health and Human Services
    (HHS) will eliminate its expansion of GINA to long-term care insurance
    and continue to allow private long-term care insurers to use genetic
    information in the final rule, as the Congress intended?
        Answer. I appreciate your concerns with the Department's proposed
    rule, which would prohibit long-term care insurers from using genetic
    information for underwriting purposes. A final rule to implement the
    GINA protections has been developed and is currently under review as
    part of a larger omnibus Health Insurance Portability and
    Accountability Act (HIPAA) privacy and security rule. As the rule has
    not yet been published, the Department is not in a position to discuss
    the final policies. However, be assured that in developing the final
    rule, the Department has been carefully considering the views expressed
    in response to the proposed rule and the potential impact of the
    proposed rule on the long-term care market.
        Question. I would like to follow up with you on an issue I raised
    in a November 15, 2011 letter I sent to CMS Administrator Berwick along
    with Senators Schumer, Gillibrand, Casey, and Klobuchar regarding the
    viability of farmer cooperative-provided health insurance plans under
    the Affordable Care Act (ACA). As you know, dairy cooperatives have a
    long history of providing their members with high-quality, low-cost
    coverage that is specially tailored to the needs of farmers. These
    plans are very important to me as I helped secure funding to create
    such plans in my home state of Wisconsin.
        As you know, under ACA, only individuals who purchase insurance
    through the State Exchanges qualify for the advanced premium tax
    credit. Unfortunately, this creates a financial incentive for thousands
    of lower-income farmer cooperative members to leave their cooperative-
    offered plan for the Exchange, which, in turn, would leave the farmer
    cooperative risk pool severely degraded. This outcome would inevitably
    lead to higher prices for remaining farmer coop members and is
    ultimately likely to lead to an elimination of dairy cooperative-
    sponsored coverage. This would be an unfortunate, and unintended,
    outcome of ACA, given the important and trusted role that dairy
    cooperatives play in the lives of their members.
        My colleagues and I have been pursuing, along with other groups,
    including some representatives of organized labor, a proposal to allow
    for section 1334 of ACA to serve as a mechanism by which nonprofit
    insurance providers like farmer cooperatives and Taft-Hartley plans,
    could offer their coverage through the multi-state exchanges, thus
    allowing for their lower-income members to avail themselves of the
    advanced premium tax credit. This approach could benefit both interests
    by providing continued access for cooperative-offered plans and the
    Taft-Hartley plans while staying within the construct of ACA.
        I want to see these efficient, successful, and popular plans
    continue and ask that you address the issue as soon as possible. Will
    you look into this important issue and help find a regulatory solution
    for this unintended problem?
        Answer. The Department is considering options to address these
    concerns. The administration is fully supportive of farmers receiving
    coverage through these farmer-owned cooperatives and intends to take
    feasible actions to preserve these organizations as health insurance
    options for American farmers. Farmers who do not receive such coverage
    will have access to Exchanges to obtain coverage through a qualified
    health plan, and may be eligible for premium tax credits and reduced
    cost-sharing of out of pocket costs. Eligibility for such benefits may
    depend upon the nature of the coverage available through a farmer-owned
    cooperative, and the farmer's income.
        Question. I have been in contact with you and the Food and Drug
    Administration (FDA) about the FDA's proposed rule to improve pregnancy
    drug labeling. As you know, an estimated 75 percent of pregnant women
    use between four to six prescriptions or over-the-counter drugs during
    their pregnancy. Since 1997, the FDA's Pregnancy Labeling Task Force
    has worked on updating the pregnancy labeling system and FDA issued
    proposed rule with revised labeling guidelines in 2008.
        In my previous inquiries, you have told me that the drug labeling
    rule is a priority for the FDA. But the proposed rule has been
    lingering since 2008. As of today, in March 2012, FDA has not yet
    issued a final rule governing the labeling of drugs for women during
    pregnancy. Is FDA planning on issuing the FDA pregnancy rule in 2012?
    Since this pregnancy rule is a priority for FDA, can you commit to
    finalizing the rule in 2012?
        Answer. FDA is committed to finalizing a rule that will improve
    drug labeling for women who are pregnant, and we are diligently working
    to issue this important rule. Because of the complexity of this rule
    and the time required to review and finalize this rule, it is not
    possible to say whether the final rule will publish during 2012.
        However, we want to emphasize that, in addition to finalizing the
    pregnancy and lactation rule, FDA has other important and ongoing
    projects related to the health of pregnant and lactating women. The
    Maternal Health Team and other offices in the Center for Drug
    Evaluation and Research are developing regulations, guidance documents,
    and procedures related to the use of medicines during pregnancy and
    lactation. For example, on April 30-May 1, 2012, FDA is holding a
    ``Public Workshop on Developing Animal Models of Pregnancy to Address
    Medical Countermeasures for Influenza.''
        In addition, FDA has issued five scientific guidances relating to
    pregnancy and lactation that support women's health:
      --Integration of Study Results to Assess Concerns about Human
            Reproductive and Developmental Toxicities;
      --Establishing Pregnancy Exposure Registries;
      --Pharmacokinetics During Pregnancy and Lactation;
      --Evaluating the Risks of Drug Exposure in Human Pregnancies; and
      --Clinical Lactation Studies-Study Design, Data Analysis, and
            Recommendations for Labeling.

                                     ______

                  Questions Submitted by Senator Patty Murray
                        title x family planning program
        Question. Federally funded family planning health centers are
    facing increased demand, with more than 4 in 5 centers reporting an
    increase in clients who are uninsured and more than two-thirds
    reporting a decrease in the proportion of clients able to pay the full
    fee for their services. Not surprisingly but of great concern--1 in 4
    women now report having put off a gynecological or birth control visit
    to save money in the past year. As the rates of uninsured steadily
    climb and many families lack access to basic healthcare services, these
    health centers struggle--with severely limited funding--to meet the
    ever increasing unmet need.
        What role do you see title X playing in an environment where
    increased need and increased costs are stretching women's health
    centers resources thin, consequently making it difficult for American
    families to access their most basic healthcare services?
        Answer. The Title X Family Planning program continues to play a
    critical role in ensuring access to high-quality, client-centered, and
    affordable primary and preventive health services to millions of
    uninsured and underinsured men, women, and adolescents at more than
    4,000 health centers across the United States, including federally
    qualified health centers, free-standing clinics, hospitals, and State
    and local health departments. Title X-funded services include
    contraceptive counseling and related services, physical exams,
    screening and treatment for sexually transmitted infections, HIV
    testing, clinical breast exams, and cervical cancer screening. In 2010,
    90 percent of clients had incomes at or below 200 percent of the
    Federal Poverty Level.
        In addition to supporting basic healthcare services for about 5
    million individuals, the title X program also provides support for the
    family planning infrastructure across the Nation, including critical
    support for training and salaries for reproductive health providers.
    The Title X program also has had a long history of establishing the
    rules governing the delivery of high-quality family planning services
    in clinic settings--a role the program will continue to play. The
    Department of Health and Human Services (HHS) also anticipates that
    title X centers will remain critical sources of care for vulnerable
    populations who are uninsured as well as individuals who will be newly
    insured or Medicaid eligible under the Affordable Care Act (ACA). These
    centers will play an important role in achieving a key goal of ACA--
    improving access to affordable preventive healthcare.
        While resources have been stretched thin, HHS fully anticipates
    that the program will continue to provide services through a broad
    range of community-based providers as well as leverage multiple sources
    of Federal and State funding, including Medicaid, state family planning
    dollars where available, the Maternal and Child Health Block Grant, and
    the Social Services Block grant. Although difficult to predict, it is
    possible that after the full implementation of the ACA, the payer mix
    will change at some family planning centers to include a greater share
    of funding from private insurance and Medicaid. The ACA requires that
    most private insurance cover certain contraceptive services with no
    cost-sharing. As demand continues to increase, title X sites will
    continue to support high-quality services delivered by experienced
    clinicians and a solid infrastructure able to address the needs of
    women, men, and vulnerable populations.
                                 contraception
        Question. According to the Guttmacher Institute, in 2006 only about
    one-half of the women who needed or wanted publicly funded family
    planning were able to receive those services, so won't requiring
    insurance plans to cover contraception help fill a public health gap
    that publicly funded family planning funding streams are not able to
    meet?
        Answer. Before ACA, too many Americans didn't get the preventive
    healthcare they need to stay healthy, avoid or delay the onset of
    disease, lead productive lives, and reduce healthcare costs. An
    estimated 20.4 million women are currently receiving expanded
    preventive services without cost-sharing because of ACA.
        On average, a woman uses contraception for 30 years of her life,
    with the average cost of contraception at $50 per month.
        By eliminating cost-sharing requirements for certain preventive
    services under most plans, ACA is improving access to these services.
    The guidelines for women's preventive services ensure that women have
    access to a comprehensive set of preventive services and fill the gaps
    in current preventive services guidelines for women's health. This
    means that most women will no longer have to pay often burdensome co-
    payments, co-insurance, and deductibles in order to access necessary
    preventive services such as contraception, breastfeeding support, and
    domestic violence screening. By removing coverage barriers, these
    guidelines will help improve access to comprehensive quality healthcare
    for all American women.
        Question. Opponents of insurance plans being required to coverage
    contraception claim that contraception does not actually lower
    healthcare costs in the long-term, but doesn't every $1 spent on family
    planning services stand to save $4 in pregnancy related healthcare?
        Answer. Actuaries and experts agree that covering contraception
    actually saves money for insurance companies. The cost of contraception
    coverage is low and tends to be more than offset by the savings that
    result from improved health and fewer unplanned pregnancies. For
    example:
      --A study by the National Business Group on Health estimated that it
            would cost employers 15-17 percent more not to provide
            contraceptive coverage in employee health plans than to provide
            such coverage, after accounting for both the direct medical
            costs of pregnancy and indirect costs such as employee absence
            and reduced productivity.
      --When contraceptive coverage was added to the Federal Employees
            Health Benefits Program, premiums did not increase.
      --Fifteen States including Pennsylvania have family planning
            demonstration programs under Medicaid that have significantly
            expanded coverage of these services without increasing State or
            Federal costs.
        national institute for occupational safety and health's spokane
                              research laboratory
        Question. As you know, the work conducted at the National Institute
    for Occupational Safety and Health's (NIOSH) Spokane Research
    Laboratory is vital to maintaining and improving the health and safety
    of workers in industries including metal and nonmetal mining throughout
    the Western United States. Over the last 3 years, the Spokane Research
    Laboratory has undergone internal reorganization that could lead to the
    Laboratory's closure, which would greatly impact the health and safety
    of Western United States miners. As one of NIOSH's lowest-cost
    laboratories, the work done at the Spokane Research Laboratory is also
    conducted at a value to taxpayers.
        What plans do you have to continue the critical work of Western
    United States mine health and safety research at the Spokane Research
    Laboratory?
        Answer. NIOSH continues to address the priority needs of all coal,
    metal, and nonmetal mineworkers, including those working at mines
    located in the Western United States through its national mining safety
    and health research program. The Office of Mine Safety and Health
    Research (OMSHR) maintains staff in Spokane, Washington and Pittsburgh,
    Pennsylvania who are assigned to the full range of projects in their
    research portfolio, and OMSHR plans to continue serving the needs of
    all of its customers and stakeholders through the work of staff at both
    the Spokane and Pittsburgh campuses.
        Question. Will you provide me with the Spokane Research
    Laboratory's fiscal year 2009-2013 budget allocations for staff/
    personnel, including full-time equivalent employee levels; and
    facilities maintenance and construction?
        Answer.

    ----------------------------------------------------------------------------------------------------------------
                                        Fiscal year     Fiscal year     Fiscal year     Fiscal year     Fiscal year
              NIOSH Spokane                2009            2010            2011            2012            2013
    ----------------------------------------------------------------------------------------------------------------
    Full-time equivalent............              50              50              45              38              36
    Personnel costs.................      $5,384,634      $5,444,656      $4,926,490      $4,142,030      $3,942,030
    Facilities maintenance/                 $601,335        $480,330        $689,559  \1\ $2,607,462        $757,462
     construction costs.............
    ----------------------------------------------------------------------------------------------------------------
    \1\ Fiscal year 2012 includes one-time funding ($1.85 million) to install a new fire suppression system in the
      Spokane facility.

        The CDC's Web site states that its mission is to: ``. . .
    collaborate to create the expertise, information, and tools that people
    and communities need to protect their health,'' and that this mission
    is to be accomplished by working with partners to ``. . . detect and
    investigate health problems, and conduct research to enhance
    prevention.'' The CDC follows this mission statement with a pledge to
    the American people that includes a commitment to: ``base all public
    health decisions on the highest quality scientific data, openly and
    objectively derived.''
        Question. How does the CDC plan to fulfill its mission and maintain
    their pledge to the American people to ``base all public health
    decisions on the highest quality scientific data'' within the area of
    workplace safety if they have eliminated funding for the Education and
    Research Centers and the National Occupational Research Agenda's
    Agricultural, Forestry, and Fishing Programs?
        Answer. The fiscal year 2013 budget eliminates the Education and
    Research Centers and the Agricultural, Forestry, and Fishing Sector of
    the National Occupational Research Agenda because in a resource-
    constrained environment, these programs are a lower priority relative
    to other CDC programs.
        When NIOSH's Education and Research Centers were originally created
    almost 40 years ago, there were a limited number of academic programs
    focusing on industrial hygiene, occupational health nursing,
    occupational medicine, and occupational safety. Now, many schools of
    public health include coursework and many have specializations in these
    areas. CDC will continue to provide technical assistance to the
    Education and Research Centers despite the proposed elimination of
    grant funding.
        The Agricultural, Forestry and Fishing Sector, when compared to
    other CDC programs, is considered lower-priority in terms of CDC's core
    mission and its ability to have a national impact on improved health
    outcomes. In fiscal year 2013, CDC will focus on other sectors of
    research within the National Occupational Research Agenda to promote
    widespread adoption of improved workplace safety and health practices
    based on research findings.

                                     ______

                Questions Submitted by Senator Mary L. Landrieu
                                   exchanges
        Question. As you said in your testimony, fiscal year 2013 will be a
    critical year for building the infrastructure and initiating the many
    business operations that are vital for the exchanges to begin operating
    in 2014.
        I understand that your agency has been working hard to build out
    the Federal exchanges in States that have officially declared that they
    are not intending to partner with Federal Government on this issue. As
    you know, Louisiana is one of these States.
        I want to stress to you how important it is to me, and to the
    people of Louisiana, that we have a strong exchange in our State. I
    stand by ready to assist you in creating a high-functioning Federal
    exchange in Louisiana.
        In the absence of partnership from State government, it will be
    very important to work with other stakeholders in Louisiana, such as
    consumer groups and providers, to ensure that the Federal exchange is
    as robust as possible.
        My question is: what plans does HHS have for engaging with
    nongovernment stakeholders and advocates within the States,
    particularly in States where the State government declines to partner
    with the Federal Government on this important issue?
        Answer. HHS is working diligently with our Federal and State
    partners to ensure Affordable Insurance Exchanges are available to all
    Americans by January 2014. Much of the needed infrastructure work will
    occur in 2012, and beginning in 2013, major business processes will
    become operational in anticipation of open enrollment in October 2013.
        HHS is committed to the successful implementation of the Federally
    Facilitated Exchanges (FFEs). The FFEs will coordinate with many State
    experts, including State Medicaid Agencies related to eligibility for
    insurance affordability programs, State Departments of Insurance
    related to certification and oversight of qualified health plans, and
    the State Governor's offices for intergovernmental affairs. The FFEs
    will also coordinate with nongovernment stakeholders such as the
    insurance community--beyond those offering qualified health plans--when
    operating Reinsurance and Risk Adjustment, and consumer groups who can
    help us understand each State's unique characteristics and challenges.
    We will provide more information about our plans to engage
    nongovernment stakeholders once we have a complete understanding of
    which States plan to implement their own Affordable Insurance Exchanges
    and which States plan to participate in the FFEs.
                                 health centers
        Question. Last August, the Health Resources and Services
    Administration (HRSA) announced the winners of the New Access Point
    grant. There were a total of 67 awards announced throughout the
    country.
        I was very concerned that not a single applicant from Louisiana was
    chosen to receive the award, despite the demonstrated competency of
    many of the applicants and the clearly established need for community
    health services throughout our state. The absence of additional New
    Access Point grantees in our State leaves many of our non-federally
    qualified health centers (FQHCs) without the resources they need to
    meet the needs of their community.
        The President's fiscal year 2013 request includes $3 billion for
    health centers, including an additional $300 million in mandatory money
    from the Affordable Care Act (ACA). You say that this money will
    provide 240 New Access Points.
        I will work to help ensure you receive the money your agency needs
    to fund these New Access Points, and I urge you to carefully consider
    all qualified applications from all States, particularly those that did
    not receive any awards in fiscal year 2012.
        Answer. As you know, the funding for fiscal year 2011 Health Center
    New Access Points was extremely competitive. In fiscal year 2011, HHS
    received 810 applications and funded 67 grants. In fiscal year 2012,
    HHS anticipates that up to $145 million will be available to support
    approximately 220 new access points grants. The funding will support
    the fiscal year 2011 approved but unfunded applications following the
    rank order list consistent with statutory health center requirements to
    make awards for fiscal year 2012. The fiscal year 2011 applicants will
    be required to submit information in March to verify continued
    eligibility for a New Access Point award. HHS anticipates making awards
    in June or July 2012. In addition, HHS anticipates awarding $20 million
    to support Beacon Communities long-term improvements in quality of
    care, health outcomes and cost efficiencies; $43 million for technical
    assistance to enhance the operations and performance of health centers,
    and $5 million for HIV/AIDS services to support enhanced HIV/AIDS
    treatment.
        In fiscal year 2013, the budget includes $19 million to establish
    approximately 25 new access points. These grants will support new full-
    time service delivery sites for the provision of comprehensive primary
    and preventive healthcare services to approximately 150,000 additional
    people.
     national institutes of health--institutional development award program
        Question. The National Center for Research Resources (NCRR), an
    institute within the National Institutes of Health (NIH), houses a
    program called the Institutional Development Award (IDeA program).
        The IDeA program funds research in states that are traditionally
    underrepresented within the NIH, including Louisiana.
        In the fiscal year 2012 HHS budget, the Congress increased the
    funding for the IDeA program by $46 million. However, for the fiscal
    year 2013 budget year, the President proposes a $48 million decrease.
    It appears that this money is being taken away in order to help fund
    the new National Center for Advancing Translational Sciences (NCATS).
        At a time when NIH budgets are flat, and when the most heavily
    funded States will continue to be funded as they always have, why would
    the administration propose reducing the one pot of money that is
    specifically designed for States that have traditionally been
    underfunded?
        Answer. For fiscal year 2012, the IDeA program was provided with a
    21-percent increase in the congressional appropriation, or
    approximately $50 million, in funding over fiscal year 2011, while most
    other NIH programs were held relatively flat. For fiscal year 2013, the
    budget proposes $225 million for the IDeA program, about the same as
    the fiscal year 2011 level, and approximately $50 million below fiscal
    year 2012. The IDeA program is valued by NIH and gives many
    investigators at less research-intensive institutions an opportunity to
    contribute to biomedical research. Within a constrained budget
    environment, NIH believes that the IDeA program should not be treated
    differently than most other programs in the fiscal year 2013 NIH budget
    which are flat with fiscal year 2011. With regard to NCATS, the fiscal
    year 2013 budget requests an increase because of the need for
    innovative solutions to the bottlenecks currently in the development
    pipeline that hinders the movement of basic research findings into new
    diagnostics and therapeutics for patients. The request for IDeA is made
    in the context of the total NIH budget and not as a particular offset
    to any one program or line item.
                   low-income home energy assistance program
        Question. I was dismayed to see that the budget again asks for
    another cut to Low-Income Home Energy Assistance Program (LIHEAP).
    Because of the way the LIHEAP law is written, warm weather States,
    growth States, and States experiencing high-energy prices don't receive
    a fair share of the funding except for that portion of Base grant
    appropriations more than the $2 billion mark.
        With an estimated 825,000 living in poverty, Louisiana has the
    second-highest poverty rate in the nation. Although 75,000 households
    were helped by LIHEAP in 2011, it is possible that only about 52,000
    can be reached under the fiscal year 2013 budget request. High summer
    temperatures are life-threatening especially to the at-risk populations
    we expect LIHEAP to help, and last summer was one of the hottest on
    record.
        I am concerned that further reducing LIHEAP imperils Louisiana
    households with seniors, disabled, and preschoolers. I believe the core
    of this program needs to be much better funded if these most vulnerable
    of children and families are to be given a fair shot at their
    potential.
        Please provide the subcommittee with the latest-available State-by-
    State estimates of the LIHEAP-eligible populations that cannot be met
    at the requested funding level. I recognize that such estimates are
    inherently imprecise, but believe they would nonetheless greatly help
    our decisionmaking and understanding.
        Answer. I understand your concern about the responsiveness of
    LIHEAP to cooling costs in States like Louisiana. While the Congress
    did not provide contingency funds in fiscal year 2012, the fiscal year
    2013 President's budget does include $200 million giving us the ability
    to respond to weather or other emergencies.
        The impact of the fiscal year 2013 request level on the number of
    LIHEAP-eligible households unserved by the program depend on a number
    of factors including the impact of the economy on the number of poor
    households, and State-level decisions on eligibility and payment
    levels. The number of households served is also affected by
    contributions from other sources including utility companies and good
    neighbor funds. For example, in fiscal year 2008, the most recent year
    where we have complete data, there were roughly 33.5 million LIHEAP
    eligible households. With an appropriation of $2.57 billion, the
    program served an estimated 5.4 million households with heating
    assistance and an estimated 500,000 households with cooling
    assistance.\1\ The most recent data, from special tabulations of the
    Census Bureau's 2010 American Community Survey which is based on a
    national sample of households, indicates that the number of LIHEAP-
    eligible households increased to 37.1 million in fiscal year 2010.
    Preliminary fiscal year 2010 program data shows that with an
    appropriation of $5.1 billion, the program provided heating assistance
    to 7.4 million households, cooling assistance to 900,000 households,
    and crisis assistance (both heating and cooling) to 2.3 million
    households. The fiscal year 2013 President's budget includes $3.02
    billion for LIHEAP, a 17-percent increase more than fiscal year 2008
    enacted and last year's budget request. Unfortunately, there are too
    many variables to estimate how the additional funding will affect the
    percentage of eligible households receiving LIHEAP in fiscal year 2013.
    ---------------------------------------------------------------------------
        \1\ See the following link for State-level information: http://
    www.acf.hhs.gov/programs/ocs/liheap/publications/
    FY08_congressional_state_data.html#TableIII2.
    ---------------------------------------------------------------------------
                          school-based health centers
        Question. School-based health centers (SBHCs), a program that you
    have voiced your support for on numerous occasions, was not funded in
    the administration's fiscal year 2013 budget.
        Understanding that SBHCs are a vital safety net provider for our
    school-aged children across the country and a federally authorized
    program, can you please inform the subcommittee of your plans for
    funding the SBHC authorization for the 2014 fiscal year?
        In addition, would you offer some examples on how the
    administration will support community health centers looking to form
    partnerships with school districts and local health departments that
    currently operate SBHCs within the service area of the community health
    center?
        Answer. ACA appropriated $200 million from fiscal year 2010-2013 to
    address capital needs, including new construction, alteration/
    renovations and equipment-only projects, to improve delivery and
    support expansion of services at school-based health centers. While
    funds have only been provided for the capital grants, experience has
    demonstrated that capital funding can significantly expand service
    delivery. In addition, SBHCs may apply for the Community Health Center
    New Access Point funding to support new healthcare service delivery
    sites, if they meet the health center program eligibility criteria.
    HRSA will continue to offer technical assistance to communities
    interested in developing partnerships and formal affiliations that
    support the provision of primary healthcare to underserved populations,
    including school-aged children. Priorities for the fiscal year 2014
    budget are in the preliminary stages of development. Programs with
    existing authorizations will be given appropriate consideration in the
    context of the total agency budget formulation process, including the
    SBHC program.
      centers for disease control and preventions chronic disease program
                                 consolidation
        Question. Would you please tell me specifically how the Coordinated
    Chronic Disease Prevention and Health Promotion program will be
    structured and how the funding for the components of the consolidation
    will operate?
        Answer. The budget includes $379 million, an increase of $129
    million more than fiscal year 2012, for the Coordinated Chronic Disease
    Prevention program. This program consolidates disease-specific chronic
    disease funding into a comprehensive program to address the leading
    chronic disease causes of death and disability, including heart disease
    and stroke. Because many inter-related chronic disease conditions share
    common risk factors, the new programs will improve health outcomes by
    coordinating the interventions that can reduce the burden of disease
    and disability. Programmatic activities that advance prevention and
    control of each disease will focus on epidemiology and surveillance,
    environmental interventions that promote healthful behaviors, work with
    the healthcare system to more effectively deliver quality clinical and
    other preventive services, and community-clinical supports for
    lifestyle interventions for those living with or at high risk of
    developing chronic conditions.
        The proposed structure and funding for the Coordinate Chronic
    Disease Prevention and Health Promotion program will be operationalized
    through a new 5-year cooperative agreement cycle. Funding will be
    allocated to States, tribes, and territories on a formula and
    competitive basis. Approximately one-third of grant funding will be
    formula based and the remaining two-thirds will be allocated
    competitively.
        Specific components of the proposed fiscal year 2013 program
    include:
      --Core, formula-based awards of approximately $82 million to State,
            tribal, and territorial health departments based on population
            size and chronic disease burden. Allocations for States will be
            based on a combination of population and poverty level. Poverty
            and chronic disease are closely related factors. This proposed
            allocation methodology is similar to the allocation formula
            used for the fiscal year 2011 Coordinated Chronic Disease grant
            program. The proposed formula-based allocation methodology for
            eligible tribal entities and territorial health departments
            will include a base amount and an increment based on population
            size. Core formula-based funding will build and strengthen
            State health department capacity and expertise to effectively
            prevent chronic disease and promote health. This capacity and
            expertise includes:
        --Ensuring that every State has a strong foundation to support
                chronic disease prevention and health promotion;
        --Maximize the reach of categorical chronic disease programs in
                States by leveraging shared basic services; and
        --Provide leadership and expertise to work in a coordinated manner
                across chronic disease conditions and risk factors to most
                effectively meet population health needs, particularly for
                populations with the greatest health disparities.
      --Competitive awards of approximately $16 million to State, tribal,
            and territorial health departments for specific chronic disease
            prevention and health promotion interventions, including:
        --Strategies that support and reinforce healthful behaviors and
                expand access to healthy choices;
        --Health systems interventions to improve the delivery and use of
                clinical and other preventive services, such as blood
                pressure control, appropriate aspirin use, and cancer
                screenings; and
        --Community-clinical linkage enhancement to better support chronic
                disease self-management.
      --The remaining funding will support:
        --Competitive awards to national organizations, national networks,
                and other entities to disseminate best practices and
                effective interventions; and
        --CDC's national chronic disease subject matter expertise;
                technical assistance to grantees; national program
                surveillance; evaluation and research activities; and
                program leadership.

                                     ______

                Questions Submitted by Senator Richard J. Durbin
                            congenital heart disease
        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 across the life-course for CHD. The healthcare
    reform law included a provision, which I authored, that authorizes the
    Centers for Disease Control and Prevention (CDC) to expand surveillance
    and track the epidemiology of CHD across the life-course, with an
    emphasis on adults. The Consolidated Appropriations Act of 2012
    provided the CDC with $2 million in new funding for enhanced CHD
    surveillance. Please describe how CDC is using this funding. It is my
    understanding that some funding will go toward pilot projects and an
    interdisciplinary expert meeting. Please summarize the status of these
    initiatives and how they will advance CHD surveillance and improve our
    understanding of CHD and the disease's prevalence across subgroups
    (including age and race/ethnicity). If additional money is appropriated
    for CHD surveillance in fiscal year 2013, how would that funding be
    utilized?
        Answer. In fiscal year 2012, CDC plans to provide support through
    cooperative agreements for CHD surveillance activities and to support a
    meeting of experts on CHDs across the lifespan. CDC developed a new
    funding opportunity announcement for CHD surveillance focused on
    adolescents and adults, which is planned for publication in May 2012.
    The purpose is to provide support through cooperative agreements for
    the development of robust, population-based estimates of the prevalence
    of CHDs focusing on adolescents and adults and better understand the
    survival, healthcare utilization, and longer-term outcomes of
    adolescents and adults affected by CHDs. CDC anticipates funding 3 to 4
    pilot sites. This is planned as a 3-year cooperative agreement, and
    preliminary data is anticipated after 2 years of funding.
        Also, CDC plans to support a meeting of experts on CHDs across the
    lifespan. This meeting will provide critical input to assist CDC in
    developing a public health research agenda for CHDs, and improve CDC's
    capacity to have a measurable public health impact on the lives of
    those with CHDs.
        For the CHD expert meeting, CDC has formed a steering committee and
    developed a draft invitation list. The steering committee includes CDC
    and the National Institutes of Health (NIH) representatives, pediatric
    cardiologists, and adult CHD specialists. The steering committee has
    developed a list of potential invitees including pediatric
    cardiologists, adult CHD specialists, epidemiologists, economists,
    health services researchers, and other areas of expertise to guide the
    development of a prioritized public health research agenda for CHDs.
    The meeting is tentatively scheduled for September 10-11, 2012 and will
    be held at CDC's main campus in Atlanta, Georgia.
        If additional funding is available in fiscal year 2013, CDC would
    provide supplements to existing pilot sites and enhance other ongoing
    activities based on the CHDs public health research agenda formulated
    by the CHD steering committee.
        Question. There continue to be higher rates of mortality and
    serious disability at all ages among people with congenital heart
    disease compared to the general population. Could you please describe
    current efforts at Agency for Healthcare Research and Quality (AHRQ)
    and NIH to better understand healthcare utilization and treatment
    outcomes for congenital heart disease across the life-span?
        Answer. AHRQ's research related to congenital heart disease focuses
    mainly on pediatric issues. This includes supporting the Children's
    Health Insurance Program Reauthorization Act (CHIPRA) Pediatric Quality
    Measures Program. While AHRQ has not yet developed specific measures of
    the quality of care for children with heart disease, congenital heart
    disease is a major birth defect and a major cause of infant morbidity
    and mortality. Therefore its care can be significantly impacted by
    various measures, including those that will track:
      --global pediatric patient safety;
      --child hospital readmissions;
      --neonatal costs, quality, and outcomes;
      --neonatal and pediatric intensive care unit quality and outcomes;
      --patient-reported outcomes and inpatient experiences of care; and
      --identification of, and coordination of care for children with
            special healthcare needs.
        AHRQ is also developing and supporting its Healthcare Cost and
    Utilization Project (HCUP), most notably the Kids' Inpatient Database
    (KID). KID is a unique and powerful database of hospital inpatient
    stays for children. It was specifically designed to permit researchers
    to study a broad range of conditions and procedures related to child
    health issues. KID includes data on volumes, costs, and charges of
    inpatient pediatric cardiac care. Researchers and policymakers can use
    KID to identify, track, and analyze national trends in healthcare
    utilization, access, charges, quality, and outcomes. For example,
    researchers at Children's Hospital Boston used KID data to examine
    factors associated with increased resource utilization for children
    with congenital heart disease. Furthermore, AHRQ is developing
    Pediatric and Inpatient Quality Indicators that include measures of
    procedure volume and risk-adjusted mortality following pediatric
    cardiac surgery. It is also supporting a contract on the prevention of
    Staph aureus infections in cardiac surgical patients, including adult
    survivors of congenital heart disease.
        Within NIH, the National Heart, Lung, and Blood Institute (NHLBI)
    has made a significant investment in answering these important
    questions through support of targeted programs as well as a large
    portfolio of investigator-initiated grants. The Bench to Bassinet (B2B)
    program supports an extensive collaboration among multidisciplinary
    investigators to improve outcomes for patients with congenital heart
    disease.\1\ Its longest-standing component is the Pediatric Heart
    Network (PHN) which conducts multicenter research in congenital heart
    disease.\2\
    ---------------------------------------------------------------------------
        \1\ http://www.benchtobassinet.org/.
        \2\ http://www.pediatricheartnetwork.com/.
    ---------------------------------------------------------------------------
        A major focus of PHN studies has been on the short- and long-term
    outcomes of medical and surgical interventions. One trial found that
    the initial surgical strategy typically used for infants with only a
    single functional heart-pumping chamber may improve short-term, but not
    intermediate-term, outcomes. The wealth of data obtained in this
    surgical study also allowed us to examine the considerable variation in
    medical care practice that existed across the 15 major academic centers
    that participated. Further analysis of this information is expected to
    shed light on how such variations affect outcomes and costs. Another
    PHN trial found that a commonly prescribed drug, enalapril, had no
    effect on outcomes. A follow-up study is now assessing whether this
    result has altered prescribing patterns in North America. An ongoing
    follow-up of a cohort of adolescents who have undergone staged surgical
    repair for single ventricle physiology is enabling us to examine the
    critical transition from pediatric to adult care. This transition has
    proven challenging for many who have serious CHD; appropriate care in
    adulthood is essential to optimizing their independence and function.
        Another B2B component is a consortium studying the genetic
    underpinnings of congenital heart disease outcomes. In the initial 15
    months, it has recruited some 3,000 children and adults (more than 20
    percent are older than 18 years of age), along with many of their
    parents, to study both genetic causes of congenital heart disease and
    genetic contributions to treatment outcomes. Tetralogy of Fallot (a
    ``blue-baby'' defect), for instance, can result from at least 6
    different genetic mutations. Once we know how the mutations influence
    outcomes, we will be able to risk-stratify patients for more- or less-
    intensive treatment and to offer personalized therapies.
        NHLBI is funding the Pumps for Kids, Infants, and Neonates
    (PumpKIN) program to design, develop, test, and make available to
    infants and young children a number of advanced circulatory support
    devices for congenital and acquired cardiovascular disease resulting in
    heart failure.\3\ Currently, very few options exist for these
    vulnerable heart failure patients. The program includes two small
    implantable ventricular assist devices based on the latest technologies
    and two advanced integrated and compact extracorporeal membrane
    oxygenator systems. They have been designed to address troublesome
    shortcomings of circulatory support devices for children such as
    reliability, biocompatibility, infection, thrombosis, and size. The
    four devices are in their last phases of bench-testing, with clinical
    trials expected to begin in October 2013. In contrast to older adults,
    for whom these devices may be definitive therapy, these devices are
    used in children as bridges to transplantation. The shortage of
    appropriate hearts for transplantation into children requires that
    better devices be available to support patients until a donor heart is
    available.
    ---------------------------------------------------------------------------
        \3\ http://public.nhlbi.nih.gov/newsroom/home/
    GetPressRelease.aspx?id=2689.
    ---------------------------------------------------------------------------
        NHLBI also funds a number of grants that address common issues
    faced by children and adults with congenital heart disease, such as
    exercise capacity, problems with neurological function and learning,
    and overall quality of life. These investments are aimed to ensure a
    brighter future for people of all ages with congenital heart disease.
                children's hospitals graduate medical education
        Question. The administration proposes cutting the Children's
    Hospitals Graduate Medical Education (CHGME) program by two-thirds to
    $88 million in fiscal year 2013. As you know, this program supports
    training of pediatric providers at two freestanding children's
    hospitals in Illinois--Children's Memorial and La Rabida Children's
    Hospital--and approximately 50 others around the country. The CHGME
    recipient hospitals train more than 5,600 full-time equivalent
    residents annually.
        I am concerned by the proposed cut to CHGME funding. Through
    Medicaid and the Children's Health Insurance Program, we've expanded
    the number of children with insurance coverage in the United States. I
    view this as a great success, however we must ensure we have an
    adequate supply of physicians to care for these children.
        Already, there are significant shortages in several pediatric
    subspecialties, including neurology, developmental-behavioral medicine,
    general surgery, and pulmonology, that are affecting patient care. A
    survey last year by the National Association of Children's Hospitals
    and Related Institutions found wait times of more than 10 weeks to see
    a pediatric endocrinologist, and 9 weeks for a pediatric neurologist.
        Is the administration concerned that reducing CHGME funding will
    worsen the shortage of pediatric subspecialists and affect children's
    access to care by general pediatricians?
        Answer. We recognize the vital role that children's hospitals and
    pediatric providers play in providing quality healthcare to our
    Nation's children. The fiscal year 2013 CHGME funding level continues
    to support direct costs for training pediatric residents at independent
    children's hospitals. This payment provides support for resident
    salaries, expenditures related to stipends and fringe benefits for
    residents, salaries and fringe benefits of supervising faculty, cost
    associated with providing the GME training program, and allocated
    institutional overhead costs.
        The fiscal year 2013 budget retains the incentive to maintain total
    resident levels. The administration recognizes that research has
    indicated that there is a significant shortage of pediatric
    subspecialists, resulting in children with serious illnesses being
    forced to travel long distances--or wait long periods--to see a
    pediatric specialist. In response to these shortages, the fiscal year
    2013 President's budget includes $5 million to implement the Pediatric
    Specialty Loan Repayment (PSLR) program that was authorized in the
    Affordable Care Act (ACA). Under this program, loan repayment
    agreements will be authorized for pediatric specialists who agree to
    work in underserved areas.
        While both the CHGME Payment and the PSLR programs support the
    pediatric medical workforce, the focus of each is different. The CHGME
    Payment Program serves the purpose of providing residency training in
    Children's Hospitals through the payments made to Children's Hospitals,
    while the PSLR program is designed to assist pediatric specialists more
    directly and increase the number of pediatric specialists in
    underserved areas.
                        section 317 immunization program
        Question. The Section 317 Immunization Program helps to ensure high
    immunization coverage levels and low incidence of vaccine preventable
    diseases by supporting state and local immunization programs in
    planning, developing, and maintaining a public health infrastructure.
    The administration's budget proposes a $58 million cut to the section
    317 program. Will this reduction impact the agency's ability to
    purchase grants or operational support for health departments? How do
    you see the role the section 317 program evolving with the
    implementation of ACA? The President's budget proposes transferring $72
    million from the Prevention and Public Health Fund to the section 317
    program. How would those funds be used?
        Answer. The fiscal year 2013 budget request includes funds for
    vaccine purchase to continue outreach to the hardest-to-serve
    populations, and critical immunization operations and infrastructure
    that supports national, State, and local efforts to implement an
    evidence-based, comprehensive immunization program. The request also
    specifically directs $25 million toward continuation of the billables
    project, which allows public health departments to vaccinate and bill
    for fully insured individuals in order to maintain section 317 vaccines
    for the most financially vulnerable and respond to time-urgent vaccine
    demands, such as outbreak response. The fiscal year 2013 budget will
    sustain the national immunization program vaccine purchase and
    immunization infrastructure. The budget does not continue funding for
    one-time enhancements planned for fiscal year 2012 to modernize the
    immunization infrastructure through funding to the grantees for
    improving immunization health IT systems and vaccine coverage among
    school-age children and adults; expansion of the evidence base for
    immunization programs and policy; and enhancements to national provider
    education and public awareness activities to support vaccination across
    the lifespan.
        ACA requires new health plans to cover routinely recommended
    vaccines without cost-sharing when provided by an in-network provider.
    As these health insurance reforms expand prevention services to more
    Americans, the size of the population currently served by section 317
    vaccine is expected to decrease in size, specifically underinsured
    children. The Section 317 Immunization Program will continue to have a
    critical role in:
      --providing vaccines to meet the needs of uninsured adults and
            responding to urgent vaccine needs such as outbreak response;
            and
      --ensuring the necessary infrastructure is in place to support the
            Nation's immunization system for both routine vaccination as
            well as managing vaccine shortages and other emergency
            response.
    This critical infrastructure serves both the public (e.g., Vaccines For
    Children Program and Section 317) and private sectors. Insurance
    coverage alone will not provide the immunization infrastructure
    necessary to ensure a strong evidence base for national vaccine
    programs and policy, quality assurance for immunization services, and
    high-vaccination coverage rates across the lifespan.

                                     ______

                    Questions Submitted by Senator Jack Reed
                           section 317 immunizations
        Question. The Centers for Disease Control (CDC), in its fiscal year
    2011 report to the Congress on the Section 317 Immunization Program
    estimated that approximately $1.72 billion is necessary to fulfill the
    goals of adequately immunizing uninsured and underinsured children,
    adolescents, and adults. Indeed, vaccination programs have been proven
    to be one of the most cost-effective approaches to reducing disease and
    future healthcare costs, a critical goal of the Congress. However, the
    fiscal year 2013 budget proposal contains a nearly 10-percent cut to
    this program. While millions more uninsured and underinsured
    individuals will receive free vaccinations beginning in 2014, how does
    this funding level ensure the cost-effective immunization programs
    currently in place are maintained during the intervening years?
        Answer. The fiscal year 2013 budget request includes funds for
    vaccine purchase to continue outreach to the hardest-to-serve
    populations, and critical immunization operations and infrastructure
    that supports national, State, and local efforts to implement an
    evidence-based, comprehensive immunization program. The request also
    specifically directs $25 million toward continuation of the billables
    project, which allows public health departments to vaccinate and bill
    for fully insured individuals in order to maintain section 317 vaccines
    for the most financially vulnerable and respond to time-urgent vaccine
    demands, such as outbreak response. The fiscal year 2013 budget will
    sustain the national immunization program vaccine purchase and
    immunization infrastructure. The budget does not continue funding for
    one-time enhancements planned for fiscal year 2012 to modernize the
    immunization infrastructure through funding to the grantees for
    improving immunization health IT systems and vaccine coverage among
    school-age children and adults; expansion of the evidence base for
    immunization programs and policy; and enhancements to national provider
    education and public awareness activities to support vaccination across
    the lifespan.
                           lead poisoning prevention
        Question. The Advisory Committee on Childhood Lead Poisoning
    Prevention (ACCLPP) recently recommended reducing the blood lead level
    in children from 10ug/dL to 5 ug/dL when greater medical monitoring is
    necessary, along with enhanced lead education for family members and
    more comprehensive investigations of the child's environment. What is
    CDC's plan for implementing this recommendation?
        Answer. The ACCLPP recommendations are currently being reviewed and
    evaluated by U.S. Department of Health and Human Services (HHS). The
    process of carefully reviewing ACCLPP's recommendations and deciding
    whether or not to concur with them may take several months to complete.
        Question. In fiscal year 2012, the Congress requested the CDC and
    Health Resources and Services Administration (HRSA) work together to
    expand healthy housing activities as part of its Home Visiting Programs
    and provide greater incentives for States to implement programs that
    already include these activities. What action has been taken to respond
    to this request?
        Answer. CDC and HRSA are working to identify possible solutions for
    integrating childhood lead poisoning prevention activities into routine
    services of HRSA's early childhood Home Visiting Program.
                    healthy home and community environments
        Question. The fiscal year 2013 budget proposes a consolidation of
    the CDC Healthy Homes and Lead Poisoning Prevention Program and the
    Asthma Control Program even though the two programs are distinctly
    different in their mission and activities. Grantees of the Healthy
    Homes and Lead Poisoning Prevention Program reduce injuries at home,
    make aging in place a real option for our seniors, prevent radon-caused
    lung cancer and carbon monoxide poisoning, and sustain efforts to
    prevent and treat childhood lead poisoning. The Asthma Control Program
    provides grantees with resources to offer workforce and professional
    development for asthma prevention and care and self-management, and
    help improve asthma management in schools, child care centers, and
    homes. Given the distinctions in these activities, how does CDC plan to
    consolidate these programs into one while ensuring we don't lose any
    ground on our lead poisoning prevention and asthma care efforts?
        Answer. The fiscal year 2013 budget proposes a new program--Healthy
    Home and Community Environments--that will incorporate the National
    Asthma Control Program (NACP) and the Healthy Homes/Lead Poisoning
    Prevention Program (HHLPPP). The fiscal year 2013 request for the
    Healthy Homes and Community Environments program is $27.3 million.
        The Healthy Home and Community Environments program is a new,
    multi-faceted approach to address healthy homes and community
    environments through surveillance, partnerships, and implementation of
    science-based interventions to address the health impact of
    environmental exposures in the home and to reduce the burden of disease
    through comprehensive asthma control. This integrated approach aims to
    control asthma and mitigate health hazards in homes and communities
    such as air pollution, lead poisoning hazards, second-hand smoke,
    asthma triggers, radon, mold, unsafe drinking water, and the absence of
    smoke and carbon monoxide detectors.
                          title vii health professions
        Question. The administration's fiscal year 2013 request proposes
    eliminating the Title VII Health Careers Opportunity Program (HCOP),
    and suggests that ``other federally funded health workforce development
    programs will continue to promote training of individuals from
    disadvantaged backgrounds.'' Can you please provide specific examples
    of Federal programs other than HCOP that prepare underrepresented
    minorities to become more competitive applicants to health professions
    schools? If the program is eliminated, where could aspiring health
    professionals find the HCOP-offered academic, financial, and mentorship
    opportunities designed to build a more diverse healthcare workforce
    commensurate with the Nation's needs?
        Answer. The President's budget prioritizes funding activities that
    have a more direct impact on expanding the primary care workforce by
    supporting students who have committed to and are training as health
    professionals. Investments initiated in the fiscal year 2013 budget
    will train an additional 2,800 primary care providers over the next 5
    years.
        Other federally funded health workforce development workforce
    programs will continue to promote training of individuals from
    disadvantaged backgrounds and increase the likelihood that
    disadvantaged students are able to attend health professions programs
    through recruitment activities and scholarship opportunities. For
    example, the fiscal year 2013 budget includes $22.9 million for the
    Centers of Excellence program to recruit, train, and retain
    underrepresented minority students and faculty in healthcare fields to
    increase the supply and quality of underrepresented minorities in the
    health professions. In addition, the fiscal year 2013 budget includes
    $47.5 million for the Scholarships for Disadvantaged Students Program
    which provides grants to health professions and nursing schools for use
    in awarding scholarships to financially needy students from
    disadvantaged backgrounds. This program aims to increase the diversity
    of the health professions workforce as well as to increase the number
    of primary care providers working in medically underserved areas. The
    Affordable Care Act also provided $85 million in funding for
    demonstration projects to address health profession workforce needs.
        Increasing the diversity of the health professions workforce is an
    area of focus for HRSA's health professions programs and for the most
    recent academic year, 58 percent of the graduates from HRSA-funded
    programs were disadvantaged and/or underrepresented minorities (URM).
    Similarly, the proportion of NHSC Scholarship Program participants who
    are underrepresented minorities exceeds the average national enrollment
    rates for URMs in health professions disciplines. Other examples of
    programs that support diversity in the health professions workforce are
    the Primary Care Training and Enhancement and the Nursing Workforce
    Diversity programs. Grantees in the Primary Care Training and
    Enhancement program must put a plan in place to increase the number of
    diverse health professionals and must document their progress. Grantees
    under the Nursing Workforce Diversity program work to increase
    educational opportunities for disadvantaged individuals pursuing
    nursing degrees.
                            state cancer registries
        Question. Given the fact that pediatric cancers are typically fast-
    growing and require prompt treatment, the Committee has provided
    funding to assist States with improving data collection and
    facilitating early case capture of pediatric cancers. This funding has
    enabled researchers in nine States to more rapidly report childhood
    cancer occurrences, reoccurrences, and treatments provided to State
    cancer registries, and 35 States with supplemental registry
    infrastructure funding. What is the range of technology that States
    have implemented designed to improve childhood cancer surveillance and
    facilitate early case capture?
        Answer. Through CDCs National Program of Cancer Registries (NPCR),
    the Caroline Pryce Walker Conquer Childhood Cancer Act supports
    pediatric cancer research, including early case capture. 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.
        CDC received funding to support pediatric cancer research in fiscal
    year 2010 and fiscal year 2011. Fiscal year 2010 resources were used to
    support supplemental grants to 35 cancer registries with existing
    electronic reporting activities to expand their work. During fiscal
    year 2011, CDC allocated funding to specific State projects, where
    resources could be concentrated to develop comprehensive approaches to
    pediatric cancer rapid reporting by healthcare providers. CDC awarded
    funding to seven States.
        The seven States funded by CDC to facilitate early case capture of
    pediatric cancers are building upon existing cancer registry
    infrastructure and implementing a number of innovative technological
    approaches to rapid reporting. Some of these include:
      --Electronic pathology reporting, which provides real-time, automated
            reporting to State central cancer registries from various
            sources, such as hospital pathology laboratories; in-State and
            out-of-State independent pathology laboratories; and large,
            out-of-State children's hospitals.
      --Electronic reporting from State Health Information Exchanges.
      --Using Electronic Health Record data.
      --Using electronic reporting of diagnostic imaging to capture cancer
            cases that do not have a pathology report, such as clinically
            diagnosed brain tumors.
      --Using web-based technology to capture hospital discharge data to
            ensure that reported information is complete.
        As a result of these technological advancements to improve
    reporting speeds and facilitate data access, researchers will be able
    to use more timely cancer data--improving research on pediatric cancer
    trends, risk factors, and treatments. Finally, CDC is working to
    identify technological methods to streamline data access for
    researchers by facilitating data linkages and assisting researchers in
    managing the process to access cancer registry data.

                                     ______

                   Questions Submitted by Senator Mark Pryor
        Question. I appreciate the tough decisions your Department has to
    make as we work to achieve a budget which begins to get our national
    debt under control. However, I am concerned about the cuts recommended
    to the Low-Income Home Energy Assistance Program (LIHEAP). The
    administration's recommendation of $3 billion represents a 40-percent
    cut since fiscal year 2010. Since only $400 million of this will go
    into the Tier 2/Tier 3 formulas, the low-income citizens of warm
    weather and growth States will see a marked decrease in their ability
    to get help.
        Unfortunately, America's most vulnerable citizens are concentrated
    in warm weather States, where they face the growing danger of high
    summer temperatures. Arkansas's poverty rate of 18.8 percent is the
    third highest in the Nation. Under the fiscal year 2013 budget request
    for LIHEAP, it appears that one-third fewer households will be able to
    receive assistance from LIHEAP this year as compared to 2011.
        At a time when LIHEAP is needed the most, I am concerned that this
    program is proposed to be cut again, and that Americans with little
    recourse should be denied access to LIHEAP. How can we work together to
    ensure that the needs of this segment of the population are met?
        Answer. The Department of Health and Human Services (HHS) is
    committed to improving the Nation's health and well-being while
    simultaneously contributing to deficit reduction. To do this, HHS makes
    investments where they will have the greatest impact and lead to
    meaningful gains in health and opportunity for the American people.
        Our fiscal year 2013 budget request includes a number of
    investments which support America's most vulnerable citizens. The
    budget supports critical reforms in Head Start and a Child Care
    Initiative that, when taken together with the Race to the Top Early
    Learning Challenge, are key elements of the administration's broader
    education reform agenda. The budget also includes additional funds to
    provide incentives to States to improve outcomes for children in foster
    care and for children at risk of foster care placement.
        The request for LIHEAP is $3.02 billion, $452 million less than the
    fiscal year 2012 enacted level, but $450 million (17 percent) above
    both fiscal year 2008 and the 2012 request. The fiscal year 2013
    request targets $2.8 billion in base grants using the State allocation
    the Congress enacted for fiscal year 2012. The request also includes
    $200 million in contingency funds, which will be used to target energy
    or weather-related emergencies.
        Questions. It has come to my attention that there are concerns that
    some high-cost, low-volume radiopharmaceuticals may not be receiving
    adequate reimbursement under Medicare in the outpatient setting. It is
    my understanding that today many of these diagnostic drugs are bundled
    into a payment that may only capture a fraction of their cost. Average
    Sales Price (ASP) data submitted on a voluntary basis by companies
    manufacturing radiopharmaceuticals indicates that current Medicare
    reimbursement for these radiopharmaceuticals is likely below hospital
    acquisition costs. Has Centers for Medicare & Medicaid Services (CMS)
    re-evaluated ambulatory payment classifications (APC) payment rates for
    nuclear medicine procedures or its mean cost data for the
    radiopharmaceuticals in relation to ASP data? If the new sales data is
    at odds with CMS calculated costs and the agency believes the
    discrepancy should be addressed in a fiscally responsible manner, does
    CMS have the authority to unbundle and pay separately for diagnostic
    radiopharmaceuticals?
        Answer. The Medicare outpatient prospective payment system (OPPS),
    like other Medicare prospective payment systems, relies on the concept
    of averaging, where the payment may be more or less than the estimated
    cost of providing a service or bundle of services for a particular
    patient, but with the exception of outlier cases, the payment is
    adequate to ensure access to appropriate care. Packaging payment for
    multiple interrelated services into a single payment creates incentives
    for providers to furnish services in the most efficient way by enabling
    hospitals to manage their resources with maximum flexibility, thereby
    encouraging long-term cost containment.
        In the calendar year 2008 OPPS rule, CMS finalized a policy to
    treat diagnostic radiopharmaceuticals differently, for payment
    purposes, than therapeutic radiopharmaceuticals, as part of a broader
    packaging policy under the OPPS. For calendar year 2008 through
    calendar year 2012, we packaged payment for all diagnostic
    radiopharmaceuticals into the major procedure that it was performed
    with, most commonly nuclear medicine scan procedures. We finalized this
    policy because we view diagnostic radiopharmaceuticals as functioning
    effectively as supplies that enable the provision of an independent
    service and are always ancillary and supportive to an independent
    service, rather than serving as a therapeutic modality.
        While we package the cost of diagnostic radiopharmaceuticals into
    payment for the nuclear medicine scan as a single diagnostic modality,
    the OPPS makes separate payment for both therapeutic
    radiopharmaceuticals and brachytherapy sources as a distinct
    therapeutic modality.
        For the calendar year 2012 OPPS, we continue to package payment for
    nonpass-through diagnostic radiopharmaceuticals into payment for their
    associated nuclear medicine procedures. We have established claims
    processing edits (called procedure-to-radiolabeled product edits)
    requiring the presence of a radiopharmaceutical or other radiolabeled
    product HCPCS code, including brachytherapy sources and therapeutic
    radiopharmaceuticals, when a separately payable nuclear medicine
    procedure is present on a claim. This enables hospital's reported
    charges for diagnostic radiopharmaceuticals to be incorporated into the
    annual APC payment rate setting calculations, and provides assurance
    that the claims information we use in rate setting are accurate and
    reflects the associated cost of the single diagnostic modality. We
    evaluate these claims processing edits every quarter to ensure that
    they are up to date.
        We incorporate the line-item estimated cost for diagnostic
    radiopharmaceuticals in our claims data as a reasonable and accurate
    approximation of average acquisition and handling costs for diagnostic
    radiopharmaceuticals. We therefore use these estimated costs to
    establish payment rates for the separately payable product with which
    the diagnostic radiopharmaceutical is packaged. We evaluate and
    establish these APC payment rates on a yearly basis, to reflect changes
    in service costs as well as practice patterns.
        We also note that, in the event that the diagnostic
    radiopharmaceuticals packaged into the primary procedure's payment are
    sufficiently costly, the separately payable major procedure would be
    eligible for an OPPS outlier payment, mitigating any impact from
    extreme costs associated with providing the major procedure.
        While the statute allows us the authority to pay separately for
    these procedures, we believe that the APC payments associated with the
    primary procedures reflect the costs commonly associated with providing
    the procedures as well as support the right incentives in the OPPS
    system for efficiency. Unbundling these procedures would give providers
    no reason to exercise financial prudence when providing the primary
    procedure, along with any associated packaged items. Similarly,
    removing the incentive through packaging, of making cost-efficient
    decisions, could have an adverse effect on the beneficiary, since they
    would pay a 20-percent coinsurance for those items.

                                     ______

                Questions Submitted by Senator Richard C. Shelby
                                obesity funding
        Question. More than one-third of U.S. adults are obese. The Deep
    South has the highest obesity rate in the country, with 6 out of 7
    States having an obese population higher than 30 percent. The two most
    obese States in the Nation, Alabama and Mississippi, both have obesity
    rates more than 32 percent, yet do not receive any obesity prevention
    funding from the Centers of Disease Control (CDC). Why do public health
    dollars not track with burden?
        Answer. In 2008, CDC released a funding opportunity announcement
    for the State-Based Nutrition and Physical Activity Program to Prevent
    Obesity and Other Chronic Diseases. The purpose of this program is to
    improve healthful eating and physical activity to prevent and control
    obesity and other chronic diseases by building and sustaining statewide
    capacity and to implement population-based strategies and
    interventions. The program currently funds 25 States to address the
    problems of obesity and other chronic diseases through statewide
    efforts coordinated with multiple partners.
        State-based nutrition and physical activity (obesity) grants were
    awarded using a competitive process. Applications were reviewed for
    responsiveness to the eligibility criteria in the Funding Opportunity
    Announcement (FOA) and underwent an objective review. Applications were
    scored against the criteria identified and not against one another. For
    each application, objective review comments were presented to a panel
    and a vote took place by the panel to determine if the application was
    approved, disapproved, or deferred. Approved applications were then
    rank ordered by score and funding decisions made based on the
    availability of funding, with preference given for States that had
    higher obesity prevalence rates, provided there was adequate
    justification to fund out of rank order. Neither Alabama nor
    Mississippi met the criteria for funding out of rank order.
        CDC is continuing work to improve the effectiveness of obesity
    related grant programs (nutrition, physical activity and obesity,
    diabetes, heart disease and stroke, cancer and arthritis) by
    strengthening coordination and collaboration across individual
    categorical programs; better defining the range of targeted science-
    based interventions and activities that will accelerate health
    improvements; and working with State grantees to identify efficiencies
    and improve the effectiveness of program investments.
        Regardless of whether a State receives funding or not, CDC provides
    technical assistance to all States.
        CDC continues to develop and disseminate tools and resources for
    funded and nonfunded entities to inform the development and
    implementation of State and local strategies to improve healthful
    eating and physical activity to prevent and control obesity.
     centers for medicare & medicaid services demos/center for medicare &
                              medicaid innovation
        Question. The Center for Medicare & Medicaid Innovation (CMMI) was
    established in the Affordable Care Act to ``test payment and services
    delivery models to reduce program expenditures'' under Medicare and
    Medicaid. The law appropriated $10 billion to fund these new models. At
    a time when the Nation's healthcare entitlement programs are facing
    severe financial strain, I am concerned that funds are being expended
    by CMMI with little to no value provided and further threaten the
    entitlement programs' solvency. Have you received estimates from the
    Centers for Medicare & Medicaid Services (CMS) Office of the Actuary
    that demonstrate that any program developed by CMMI is generating lower
    Medicare spending?
        Answer. During the development of initiatives under the authority
    of section 1115A(f) of the Social Security Act (ACA section 3021), the
    Innovation Center works closely with the CMS Office of the Actuary to
    develop potential models, ensure the potential model will accurately
    test the changes in the delivery of care, and project the expected
    financial implications of the model. The Innovation Center prepares
    estimates of the financial impact of the proposed initiatives, as well
    as an analysis of their potential impact on the quality of health and
    healthcare among beneficiaries, an examination of current costs of the
    targeted healthcare service, an analysis of the potential savings, and
    a review of the prior research that supports testing the initiative.
    The Office of the Actuary has participated in reviewing these savings
    estimates and in some cases produced estimates.
        Question. While the Innovation Center typically works closely with
    the Office of the Actuary during the development of models, the
    statutorily mandated certification of savings by the Chief Actuary does
    not occur in the design phase, but rather in the testing phase to
    determine whether modification or termination of the testing of a model
    is needed and after the conclusion of the demonstration to inform
    whether there should be expansion or wide-scale adoption of the
    initiative. To date, none of the Innovation Center models have been in
    the testing phase long enough to generate sufficient data for the Chief
    Actuary to make such determinations. We believe that the Innovation
    Center's evidence-based approach to innovation will result in reducing
    healthcare costs while improving quality.
        Secretary Sebelius, can you provide specific measures that are
    being used to evaluate the impact of the CMMI initiatives on reducing
    Medicare spending or improving the quality of care?
        Answer. An evaluation of the model's performance is planned for
    each model tested by the Innovation Center. The evaluation is intended
    to determine the model's impact on spending, quality of care delivered,
    and patient health outcomes and experiences. The Innovation Center will
    align its relevant performance measures to those from the Department of
    Health and Human Services National Strategy for Quality Improvement in
    Health Care, as well as measures used for other CMS programs, such as
    those used for the Physician Quality Reporting System and the Medicare
    Shared Savings Program.
        All participating providers will be required to work with an
    independent evaluator to track and provide agreed-upon data as needed
    for the evaluation. As applicable, these data will be merged with
    administrative claims data collected by CMS to allow assessment of
    performance on topics such as clinical quality performance, patient
    functional status, and financial outcomes. The Innovation Center
    anticipates using multiple cycles of data collection due to the
    changing nature of the approaches used by participants in response to
    rapid-cycle feedback. Particular care will be taken to identify the
    effect of each reform in the context of other interventions.
        For example, when evaluating participants in the Comprehensive
    Primary Care initiative, the Innovation Center will review several
    types of quality and patient experience measures. These measures will
    include the following domains:
      --patient and caregiver experience;
      --care coordination and transitions;
      --preventive health;
      --practice transformation; and
      --at-risk populations.
        Question. The Congressional Budget Office (CBO) issued a report in
    January on the ``Lessons from Medicare's Demonstration Projects.'' The
    report found that most programs have not reduced Medicare spending. In
    nearly every program, spending was either unchanged or increased
    relative to the spending that would have occurred in the absence of the
    program. In light of this track record, why should we continue to
    invest billions of dollars into CMMI?
        Answer. We know that reforming our healthcare payment and delivery
    system won't be easy. That doesn't make it any less necessary.
        Before the Innovation Center develops a new model for testing, it
    conducts a thorough review of similar programs' past performance. This
    allows us to build on models that have been successful, while avoiding
    those that have not. When models are in their testing phase, the
    Innovation Center conducts continuous and rigorous evaluation, to
    determine the impact that models are having, both on health
    expenditures and on quality of care. Models that are working will be
    eligible for expansion, while those that are not will be either
    modified or terminated.
        We note that CBO's report also included lessons for the design of
    Medicare demonstrations that may increase a demonstration's odds of
    success. These include the timely collection of clinical data, a focus
    on care transitions, the use of team-based care, and targeted low-cost
    interventions. Much of the Innovation Center's work embodies these
    areas of focus, and all Innovation Center demonstrations emphasize
    rapid evaluation and ongoing data collection.
        The Innovation Center is tasked with testing new and innovative
    payment and delivery models. By definition, such models are unproven.
    While we select models with high potential to improve quality and
    reduce costs, it is likely that some will prove successful, and others
    may not. The only way we can find out is by testing and rigorously
    evaluating them. However, the one thing we cannot afford is to choose
    not try new approaches, simply because they might fail. This would
    ensure that we are left with an outdated and unaffordable healthcare
    system, which misses opportunities to provide patients with high-
    quality, affordable care.
               centers for medicare & medicaid services exchange
        Question. Secretary Sebelius, some States, for example Alabama,
    have decided against setting up a new State-based exchange. If a State
    elects not to establish an exchange, under law, CMS must establish a
    federally facilitated exchange in that State. Is the Federal exchange
    on track to begin January 1, 2014, as advertised?
        Answer. Yes. CMS is currently working to implement a federally
    facilitated Exchange, including important business functions such as
    eligibility and enrollment, plan management, and consumer outreach. In
    addition, contracts have been awarded to build the information
    technology systems essential to exchange operations.
        Question. The budget proposes a significant 50-percent reduction in
    State High-Risk Pool funding with the expectation that States will
    transition to operational exchanges. In light of the fact that some
    States are not setting up an exchange, can you elaborate on how the
    transition from high-risk pools to exchanges is going?
        Answer. The fiscal year 2013 President's budget request provides
    sufficient funding to States as they begin scaling down activities in
    their existing State High-Risk Pools and enrollees are transitioned to
    Affordable Insurance Exchanges in 2014.
        HHS is working diligently with our Federal and State partners to
    ensure exchanges are available to all Americans by January 2014. Much
    of the needed infrastructure work will occur in 2012, and beginning in
    2013, major business processes will become operational in anticipation
    of open enrollment in the exchanges in October 2013. We continue to
    work with States to ensure that they are ready to begin exchange
    operations in 2014 to maintain coverage for State High-Risk Pool
    enrollees.
                 children's hospital graduate medical education
        Question. The Children's Hospitals Graduate Medical Education
    (CHGME) program supports the training of residents and fellows and
    increases the supply of primary care and pediatric medical and surgical
    subspecialties. Nationwide, freestanding children's hospitals have
    trained 49 percent of all pediatric residents and 51 percent of all
    pediatric specialists. The President's budget proposes to decrease
    funding for training pediatric residency positions $177 million less
    than fiscal year 2012. Meanwhile, the budget proposes to begin a new
    Pediatric Specialty Loan Repayment (PSLR) program to repay medical
    school loans. It seems illogical that we would allocate funding to
    repay loans of physicians but reduce the funding to train physicians.
    What is the rationale behind this decision?
        Answer. We recognize the vital role that children's hospitals and
    pediatric providers play in providing quality healthcare to our
    Nation's children. The fiscal year 2013 CHGME funding level continues
    to support direct costs for training pediatric residents at independent
    children's hospitals. This payment provides support for resident
    salaries, expenditures related to stipends and fringe benefits for
    residents, salaries and fringe benefits of supervising faculty, cost
    associated with providing the GME training program, and allocated
    institutional overhead costs.
        The fiscal year 2013 budget retains the incentive to maintain total
    resident levels. The administration recognizes that research has
    indicated that there is a significant shortage of pediatric
    subspecialists, resulting in children with serious illnesses being
    forced to travel long distances--or wait long periods--to see a
    pediatric specialist. In response to these shortages, the fiscal year
    2013 President's budget includes $5 million to implement the PSLR
    program that was authorized in the Affordable Care Act (ACA). Under
    this program, loan repayment agreements will be authorized for
    pediatric specialists who agree to work in underserved areas.
        While both the CHGME payment and the PSLR programs support the
    pediatric medical workforce, the focus of each is different. The CHGME
    Payment Program serves the purpose of providing residency training in
    Children's Hospitals through the payments made to Children's Hospitals,
    while the PSLR program is designed to assist pediatric specialists more
    directly and increase the number of pediatric specialists in
    underserved areas.
                             lobbying restrictions
        Question. Secretary Sebelius, I am concerned about the Department's
    implementation of a longstanding Federal prohibition on lobbying with
    Federal tax dollars. Yesterday you testified before the House Labor,
    Health and Human Services, and Education, and Related Agencies
    Appropriations Subcommittee that you believe it is both legal and
    appropriate for grantees to lobby local governments.
        I believe the interpretation is clear--Federal funds cannot be used
    to change policies at the Federal, State, or local level. However, I
    have several examples of Federal funds being used to secure bill
    sponsors, draft legislation, and lobby for tax increases. How will you
    clarify this misinterpretation by agencies within the Department, and
    what steps will you take to ensure a full investigation occurs
    regarding any Federal tax dollars that were misused for lobbying
    activities?
        Answer. HHS is committed to ensuring the proper use of appropriated
    funds, and to ensuring awardees' compliance with all applicable
    regulations and statutes related to lobbying activities, including
    Office of Management and Budget (OMB) Circular A-122: Cost Principles
    for Non-Profit Organizations; OMB Circular A-87: Cost Principles for
    State, Local, and Indian Tribal Governments; and our own policy
    regarding lobbying activities.
        HHS awardees are informed about the Federal laws relating to use of
    Federal funds, including applicable anti-lobbying provisions. Not only
    are the restrictions noted within HHS funding opportunity
    announcements, the lobbying prohibition is also included within the
    terms and conditions to which each awardee agrees prior to receiving
    Federal funds. In addition, HHS staff monitor the use of Federal funds
    by awardees using tools such as on-site review and risk mitigation
    plans.
        Applicable lobbying restrictions do not prohibit awardees from all
    interactions with policymakers or the public. Federal law allows many
    activities that are not considered lobbying and that community awardees
    may decide to pursue. For example, awardees may use funds to
    disseminate information about public health programs and science-based
    solutions and to implement specific programs, such as evidence-based
    educational materials and media on the health effects of increasing
    physical activity or decreasing exposure to secondhand smoke.
        At HHS, we are committed to fulfilling the mandates from the
    Congress to empower communities to pursue high-quality, science-based
    programs that make a real difference in the health of Americans. We
    take our responsibility as stewards of taxpayer dollars very seriously,
    and we are committed to enabling awardees' success and to ensuring that
    Federal funds are used efficiently and appropriately.
                              healthcare premiums
        Question. Secretary Sebelius, we have repeatedly heard from this
    administration and the President that health insurance premiums will be
    lowered by the end of the President's first term. In February 2008
    President Obama stated: ``We're going to work with you to lower your
    premiums by $2,500 per family per year. And we will not wait 20 years
    from now to do it or 10 years from now to do it. We will do it by the
    end of my first term as President.'' However, yesterday you testified
    before the House Labor, Health and Human Services, and Education, and
    Related Agencies Appropriations Subcommittee that health insurance
    premiums could not be lowered by $2,500 until the exchanges come online
    in 2014. Madam Secretary, is it possible that premiums will be lowered
    by the end of this year or is this an abandoned campaign promise?
        Answer. ACA contains market reforms that will reduce premium costs
    for the same level of benefits. Most of the market reforms that will
    impact premium costs, such as exchanges, will not be in place until
    2014. Until the exchanges are implemented, consumers have limited
    ability to compare across options to get the best value for their
    premium dollars, and health insurance issuers have less incentive to
    compete. We may not realize premium decreases until such time as
    exchanges and other market reforms are fully operational.
                            duplication and overlap
        Question. The Government Accountability Office (GAO) released a
    report in February that stated, ``HHS is collaborating with Labor to
    conduct an evaluation to better understand policies, practices, and
    service delivery strategies that lead to better alignment of the
    Workforce Investment Act (WIA) and Temporary Assistance for Needy
    Families (TANF).'' Can you provide further information on this
    collaboration, including examples of State and local practices that may
    be models for other areas to follow and how WIA-TANF duplication can be
    reduced?
        Answer. The Administration for Children and Families (ACF) remains
    committed to bringing about better alignment of Federal investments in
    job training, improved models for delivering quality services across
    programs at lower costs, and providing relevant information to
    workforce and social service communities. In order to address GAO's
    recommendation for developing and disseminating information on State
    and local efforts and initiatives to increase administrative
    efficiencies, both Departments are exploring a variety of efforts aimed
    at addressing the challenges, strategies, incentives, and results for
    States and localities to undertake such initiatives, including
    developing joint administrative guidance, technical assistance and
    outreach, leveraging research resources and other collaborative
    efforts. Some examples of these efforts include:
      --A partnership between ACF and the Employment and Training
            Administration (ETA) encouraged workforce and human service
            agencies to co-enroll youth in WIA and TANF programs and
            leverage TANF funds to cover subsidized wages for youth, thus
            promoting effective and efficient leveraging of Federal
            resources to expand summer employment opportunities for 2010.
      --For program year 2012, ETA has consulted with multiple
            stakeholders, including ACF and other agencies, to redesign
            ETA's plan guidance related to WIA submissions.
      --The Career Pathways Technical Assistance Initiative grants, led by
            an interagency work group consisting of staff from ACF, ETA and
            the Department of Education's Office for Vocational and Adult
            Education, leverages the latest research and best practices to
            help grantees in the workforce and human services agencies form
            partnerships to improve employment and training outcomes for
            low-skilled individuals.
      --Ongoing monthly meetings of the Departments of Labor, Health and
            Human Services Research Working Group allows for sharing of
            current research, helps to identify gaps and to explore
            additional areas for potential collaboration.
      --To gain a better understanding of the TANF-WIA integration that a
            number of States have implemented, ACF and ETA jointly plan to
            develop an approach to identify existing promising WIA and TANF
            linkages.
        Question. In February, the Government Accountability Office (GAO)
    released a report on duplication, fragmentation, and cost-saving
    opportunities in the Federal Government. The report noted that there
    are several areas where the Department of Health and Human Services
    (HHS) may be duplicating work with other Federal agencies. In
    particular, GAO found that the National Institutes of Health (NIH),
    Department of Defense (DOD), and the Veterans Administration (VA) each
    lack comprehensive information on health research funded by other
    agencies, which means that duplication may sometimes go undetected.
    Secretary Sebelius, what are you doing to ensure that HHS is improving
    the ability of agency officials to identify possibly duplication?
        Answer. HHS continues to work with other Federal agencies and the
    Congress to address areas of duplication identified by GAO. To date,
    HHS has addressed or partially addressed a number of the actions
    recommended by GAO. For example, HHS has been working with the VA and
    HUD to better coordinate the collection, analysis, and reporting of
    homelessness data. HHS is also collaborating with the Department of
    Labor (DOL) to promote administrative efficiencies within employment
    and training programs. In addition, the fiscal year 2013 budget
    proposes to transfer the Senior Community Service Employment Program
    from DOL to HHS to further reduce duplication of efforts.
        NIH efforts to address duplication include resources to examine
    details of existing funding when evaluating overlap such as access to
    an Electronic Research Administration (eRA) module called QVR (for
    Query/View/Report). QVR provides extensive data about funded grant and
    unfunded grant applications. NIH makes the QVR resource available to
    other Federal agencies, contingent upon acceptance of the formal data
    access agreement. In fact, the VA currently uses the NIH eRA system for
    some of their applications. DOD staff may request access to QVR and may
    also obtain training in the use of QVR.
        NIH is also an acceptable grant processing site under the Grants
    Management Line of Business (GMLoB) Initiative and is available to DOD.
    HHS will continue to work with other Federal agencies and the Congress
    to address areas of duplication identified by GAO.
        Question. GAO found the Federal investment in early learning and
    child care is fragmented, with overlapping goals and activities. For
    example, five programs within HHS and the Department of Education (ED)
    provide school readiness services to low-income children. These similar
    programs in different agencies create added administrative costs and
    confusion. What steps are you taking to identify and minimize
    unwarranted overlap in early learning and child care programs?
        Answer. Cross-program coordination to ensure that children have
    access to high-quality early learning and child care programs has been
    a priority and key focus for the administration. Over the last 3 years,
    ACF has developed and implemented an integrated early childhood unit
    under the leadership of the Office of the Deputy Assistant Secretary
    for Early Childhood Development, which has become the focal point
    within HHS for early childhood activities at the Federal level. Within
    this structure, the administration has taken several steps to improve
    coordination between the Office of Child Care (OCC) and Office of Head
    Start (OHS), such establishing the National Center on Child Care
    Professional Systems and Workforce Initiatives funded by both OCC and
    OHS, implementing the Early Head Start for Family Child Care
    Demonstration Project jointly coordinated by OCC and OHS, and issuing
    joint guidance on aligning eligibility policies across Head Start and
    child care programs
        The administration has many interagency and interdepartmental
    efforts to coordinate federally funded early care and education
    programs:
          State Advisory Councils on Early Childhood Education and Care.--
            The Improving Head Start for School Readiness Act of 2007
            required that the Governor of each participating State
            designate or establish a council to serve as the State Advisory
            Council on Early Childhood Education and Care for children from
            birth to school entry. The State Advisory Councils will lead
            the development or enhancement of a high-quality, comprehensive
            system of early childhood education and care that ensures
            statewide coordination and collaboration, while addressing how
            best to prevent duplicative services among the wide range of
            early childhood programs and services in the State, including
            child care, Head Start, Individuals with Disabilities Education
            Act preschool and infants and families programs, and pre-
            kindergarten programs and services. ACF awarded $100 million of
            American Recovery and Reinvestment Act (ARRA) funding for State
            Advisory Councils to 45 States, the District of Columbia,
            Puerto Rico, Virgin Islands, and American Samoa.
          Early Learning Interagency Policy Boar.--The Secretaries of ED
            and HHS established the Early Learning Interagency Policy Board
            to improve the quality of early learning programs and outcomes
            for young children; increase the coordination of research,
            technical assistance and data systems; and advance the
            effectiveness of the early learning workforce among the major
            federally funded early learning programs across ED and HHS.
          Administration for Children and Families/Child and Adult Care
            Food Program Workgroup.--Convened by OMB, the Administration
            for Children and Families (ACF)/Child and Adult Care Food
            Program (CACFP) Workgroup brings together staff from the Food
            and Nutrition Services, OCC, and OHS to discuss possible
            collaboration around the CACFP. The workgroup has identified
            the following areas of collaboration:
        --sharing the National Disqualified List;
        --publishing joint information memorandums on collaboration at the
                State and local level; and
        --improving tribal participation in CACFP.
        In addition, the administration's Race to the Top--Early Learning
    Challenge grants, administered jointly by ED and HHS--are designed to
    foster innovation and integration within early education programs
    within a State. In 2011, nine States were awarded Early Learning
    Challenge Grants and in April 2012, the two departments announced that
    five additional States were eligible for such grants. While each State
    has its own areas of focus, all States are working to improve early
    education in all settings so that more high need children are receiving
    high-quality early education services. States are focusing on workforce
    training, early learning standards, developing data systems to track
    children's progress, and engaging families to promote academic success
    for children. And, all States are working on these areas across all
    types of early learning programs, including public pre-K, Head Start,
    privately funded preschool, and child care (such as child care centers
    and family day care homes).
        Finally, several of the Child Care Development Fund (CCDF)
    principles for reauthorization included in the President's budget
    request would streamline Federal, State, and local early care and
    education programs. For example, the budget proposal supports promoting
    continuity of care for children and quality improvement for child care
    providers.

                                     ______

                  Questions Submitted by Senator Thad Cochran
                  elimination of preventive health block grant
        Question. I am concerned about the elimination of the Preventive
    Health and Health Services Block Grant. The block grant gives States
    the autonomy and flexibility to solve State problems and address
    community level needs, while still being held accountable for
    demonstrating the local, State, and national impact of this investment.
    Eliminating this source of flexible funding would jeopardize important
    public health programs already strained by tightening budgets. I am
    concerned that states without capacity will be disproportionately
    affected by the elimination of this formula grant. Additionally, I am
    concerned that your budget proposes to fill the need for the block
    grant with competitive programs funded by the Affordable Care Act.
    Secretary Sebelius, how are you proposing States address community
    health needs to keep their citizens healthy and safe without the
    Prevent Block Grant?
        Answer. Through Centers for Disease Control and Prevention's (CDC)
    existing and expanding activities, there is substantial funding to
    State health departments to address community health needs. The
    activities currently supported by the Preventive Health and Health
    Services Block Grant may be more effectively and efficiently
    implemented through the new Coordinated Chronic Disease Prevention and
    Health Promotion Grant. The budget includes $379 million, an increase
    of $129 million more than fiscal year 2012, for the Coordinated Chronic
    Disease Prevention and Health Promotion Program. This program
    consolidates disease-specific chronic disease funding into a
    comprehensive program to address the leading chronic disease causes of
    death and disability, including heart disease and stroke, obesity,
    diabetes, arthritis and the primary preventable causes of cancer,
    tobacco use, poor nutrition, and physical inactivity. Because many
    inter-related chronic diseases and conditions share common risk
    factors, this program will improve health outcomes by coordinating
    interventions that benefit multiple chronic diseases. As a result, the
    program will gain efficiencies in cross-cutting areas such as
    epidemiology and surveillance, supporting healthful behaviors and
    chronic disease self-management, and improving effective delivery of
    clinical and other preventive services. At the end of the fiscal year,
    CDC will report on the funding spent on prevention and control of
    specific diseases. At the end of the 5-year program, CDC will report on
    improvements in outcomes specific to each disease as well as cross-
    cutting outcomes.
                           teen pregnancy prevention
        Question. Teen and unplanned pregnancy costs taxpayers billions of
    dollars every year, and contributes to a cycle of poor outcomes that
    affect the long-term strength of our workforce. The Mississippi
    Economic Council released a report in January that the State's high
    teen childbearing rate was a hindrance to having an educated and
    competitive workforce. They recommend reducing teen pregnancy as a part
    of improving economic development. Do you have the resources you need
    to spearhead a successful effort to reduce teen and unplanned
    pregnancy?
        Answer. Teen mothers and their children are more likely to face a
    range of challenges and adverse conditions when it comes to the health
    and economic security of themselves and their children. That is why my
    strategic plan for the Department identifies reducing rates of teen
    pregnancy as a priority.\1\ HHS is making investments in strategies
    that give children and youth a positive start in life and is committed
    to supporting both evidence-based programs and innovative approaches
    for children and youth in order to positively impact a range of
    important social outcomes, such as child maltreatment, school
    readiness, teen pregnancy prevention, sexually transmitted infections,
    and delinquency.
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        \1\ http://www.hhs.gov/secretary/about/priorities/
    youth_futures.html.
    ---------------------------------------------------------------------------
        The budget proposes to use unobligated Abstinence Education funds
    from the Title V State Abstinence Education Grant Program for a new
    initiative to address pregnancy prevention among youth in foster care,
    who have an estimated 50-percent teen pregnancy rate. The new
    initiative will not reduce the amount available to States for
    Abstinence Education. Each year, some States choose not to draw down
    their allotment of Title V Abstinence Education funds. Instead of
    lapsing, these funds will be redirected to help youth in the foster
    care system avoid pregnancy.
        Beginning in fiscal year 2010, under the Teen Pregnancy Prevention
    Program, the Office of Adolescent Health has provided $75 million in
    grant funds to States, non-profit organizations, school districts,
    universities, and other organizations to replicate models that have
    been rigorously evaluated and shown to be effective at reducing teen
    pregnancies, sexually transmitted infections, or other associated
    sexual risk behaviors. An additional $25 million in grant funding also
    supports research and demonstration projects to develop and test
    additional models and innovative strategies to prevent teen pregnancy,
    so that evidence base continues to expand and refine. This program
    supports 102 grant projects in 36 States and the District of Columbia.
        Through the Personal Responsibility Education Program (PREP),
    authorized by the Affordable Care Act, the Administration for Children
    and Families provides $55 million in formula grants to States to
    support evidence-based program models or to substantially incorporate
    elements of effective prevention programs while including three of six
    adult preparation subjects mandated by the Congress. To date, 45 States
    as well as DC, Puerto Rico, the Virgin Islands, and the Federated
    States of Micronesia had accepted PREP funds. In addition, 16 PREP
    grants were awarded to tribes and tribal organizations in the summer of
    2011. The PREP program also includes $10 million in competitive PREP
    Innovative Strategies cooperative agreement research and demonstration
    grants to develop and test additional models and innovative strategies.
    The PREP Innovative Strategies program awarded 13 grants through the
    joint funding announcement with OAH. Both programs target groups with
    high teen pregnancy rates. In addition, the Affordable Care Act gives
    States the option of expanding eligibility for Medicaid family planning
    services without having to go through the Federal waiver process.
    Despite these substantial investments much work remains in reaching
    adolescents given there are an estimated 47 million persons ages 10-19
    of age in the United States. Increased training for the multiple
    professionals who touch the lives of young people, media campaigns, and
    well-coordinated care services at the community level can all help
    ensure healthy, productive and hopeful young persons.

                                     ______

                 Questions Submitted by Senator Lamar Alexander
             patient protection and affordable care act regulations
        Question. Please provide a schedule of when you expect upcoming
    healthcare regulations will be published. Senior administration staff
    previously indicated that many of the interim final rules will be
    reissued as final rules. Is this true? If so, please include the dates
    you expect the interim final rules will be reissued as final rules as
    part of the schedule mentioned above.
        In December, the administration published a ``bulletin'' on
    essential health benefits--the mandates that all new health plans sold
    to individuals and small businesses will be required to provide in 2014
    and beyond. The ``bulletin'' fails to answer basic questions from
    States and employers.
        When will you provide the details regarding benefit mandates and
    the other new insurance rules, so that we can know how much premiums
    will be raised and how much Federal costs will increase?
        The ``bulletin'' tells States they must choose among four options
    before September 2012. Will a rule be finalized before the September
    2012 deadline the ``bulletin'' places on States?
        How can States be expected to implement a ``bulletin'' which has no
    force of law?
        Answer. Centers for Medicare & Medicaid Services (CMS) issued a
    bulletin on December 16, 2011 and has gathered input. CMS will take
    public input into consideration and then issue a Notice of Proposed
    Rulemaking. The bulletin announced CMS's intended regulatory approach
    for defining the essential health benefits, based on a State-selected
    benchmark plan. States will need to make their selection and submit
    their essential health benefits benchmark to U.S. Department of Health
    and Human Services (HHS) in the third quarter of 2012 for coverage year
    2014.
             patient protection and affordable care act accounting
        Question. The new healthcare law appropriates ``such sums as may be
    necessary'' to implement the State-based health insurance exchanges.
    Your budget estimates spending $1.087 billion in mandatory money for
    fiscal year 2013.
        How much will the Department have spent on health insurance
    exchanges since the time the healthcare bill was signed into law until
    2014 when the exchanges are supposed to be fully operational?
        Answer. Our current baseline for Exchange Planning and
    Establishment Grants estimates that we will obligate approximately $2.5
    billion from when the law was enacted until fiscal year 2014 and that
    we will outlay $2 billion during that timeframe.
        Question. In addition to this mandatory money for State-based
    health insurance exchanges, the President's 2013 budget requests an
    additional $864 million for the Federal exchange and other exchange
    activities. How will this money specifically be spent and how will the
    Federal exchange differ in functionality from the web portal HHS has
    already implemented?
        Answer. As with the State-based exchanges, fiscal year 2013 is the
    year many operations of the federally facilitated exchange begin, as
    CMS will need to be prepared for open enrollment on October 1, 2013,
    the first day of fiscal year 2014. The majority of the $864 million
    request for CMS's exchange work is related to operations and management
    of the federally facilitated exchange with some funding to support the
    Secretary's duties on behalf of all exchanges. Specifically, $574.5
    million of the total will be used for exchange operations and
    management including eligibility and enrollment functions, certifying
    health insurance plans as qualified to be sold through the exchange, as
    well as oversight of plans and State-based exchanges. The additional
    $289.5 million will be used for consumer education and outreach
    activities, such as a call center, to help consumers understand their
    new options under the Affordable Care Act (ACA) and to fund navigators
    and in-person enrollment assistance to facilitate the enrollment
    process.
        Healthcare.gov is a useful tool for providing information on
    potential sources of insurance available to individuals today, and HHS
    can leverage its capabilities for presenting information to assist
    consumers in comparing across plans in exchanges. The federally
    facilitated exchange will go beyond what is available through
    Healthcare.gov by certifying that the plans offered meet certain
    standards of quality and benefits. The federally facilitated exchange
    will also perform eligibility determinations, enroll individuals into
    plans, and provide for in-person or call center support to answer
    questions about available coverage.
        The healthcare law included a $1 billion implementation fund. In
    order for the Congress to better evaluate the administration's request
    for additional funds for implementation activities, please provide an
    accounting of how the monies provided pursuant to the new healthcare
    law have been expended. As part of your answer, please include a
    comprehensive breakdown of spending by department and subsidiary
    administrative units, as well as by function.
        Answer. The following table displays the spending from the Health
    Insurance Reform Implementation Fund as of February 29, 2012, by
    agency:

    ------------------------------------------------------------------------
                  Organization                  Obligations       Outlays
    ------------------------------------------------------------------------
    Internal Revenue Service................    $213,264,945    $154,181,697
    Office of Personnel Management..........       2,938,850       1,442,102
    Department of Labor.....................       3,055,102       2,958,880
    Department of Health and Human Services.     251,742,492
                                             --------------------134,917,483
                                             -------------------------------
          Total, Health Reform                   471,001,389     293,500,162
           Implementation Fund..............
    ------------------------------------------------------------------------

        HHS uses these funds to implement Medicare and Medicaid changes
    required in the ACA, including closing the Part D coverage gap and
    developing new value-based purchasing models for Medicare providers.
    HHS has also used these funds to plan and prepare for the establishment
    of State-based and federally facilitated exchanges as required in the
    ACA.
        The Office of Personnel Management (OPM) uses funding to plan for
    implementing and overseeing the establishment of at least two Multi-
    State Plan Options to be offered on each State health insurance
    exchange beginning in 2014, and allowing tribes and tribal
    organizations to purchase Federal health and life insurance for their
    employees.
        The Department of the Treasury uses funding to implement multiple
    tax changes from the ACA, including the Small Business Tax Credit,
    expanded adoption credit, excise tax on indoor tanning services,
    charitable hospital requirements, plan for exchanges, and a number of
    other revenue provisions.
        The Department of Labor uses funds to conduct compliance
    assistance; modify or develop IT systems that support data collection,
    reporting, policy and research; and develop infrastructure for the
    newly required Multiple Entity Welfare Arrangements reporting and
    registration within ACA.
        Of the $251,742,492 obligated by HHS to date, approximately 13
    percent has paid for personnel, 84 percent has supported contractual
    services, and 3 percent has been obligated for rent, supplies, or other
    miscellaneous services.
        Question. The HHS budget calls for 76,341 employees in fiscal year
    2013. This is an increase of nearly 1,400 employees over the fiscal
    year 2012 level. How many of these employees will be hired to implement
    the new healthcare law?
        Answer. At the Centers for Medicare & Medicaid Service (CMS), the
    President's budget requests an increase of 136 full-time equivalents
    more than the fiscal year 2012 appropriated level to enable CMS to
    address the needs of a growing Medicare population, as well as oversee
    expanded responsibilities from legislation passed in recent years.
        Question. How many staff members are currently working at the
    Center for Consumer Information and Insurance Oversight (CCIIO)? Please
    provide numbers for both full-time and part-time staff separately.
        Answer. As of March 10, 2012, CCIIO has approximately 261 employees
    on-board. 258 employees are considered full-time, and 3 employees are
    considered part-time. This staff is supported by a combination of
    discretionary funds and mandatory ACA funding.
        Question. How many staff do you expect will be working at CCIIO at
    the end of fiscal year 2012? How many staff do you expect will be
    working at CCIIO at the end of fiscal year 2013?
        Answer. By the end of fiscal year 2012, CMS expects to use 450 FTEs
    on CCIIO-related activities. This staffing level will grow to a
    projected 710 FTEs by the end of fiscal year 2013 as CMS brings the
    exchanges online and implements consumer protections and other reforms.
                    centers of excellence in early childhood
        Question. In the 2007, the Congress authorized the establishment of
    Centers of Excellence in Early Childhood for the purpose of evaluating
    the success of Head Start and other early childhood programs funded by
    the Federal Government. However, minimal funding has been allocated to
    support these Centers. At the same time, the Federal Government
    continues to fund more and more programs focused on early education.
    The President's fiscal year 2013 budget further requests additional
    funding, through Race to the Top, for an Early Learning Challenge Fund.
        Rather than just adding to the duplicative list of funding silos
    for early education, wouldn't this money be better spent in support of
    the Head Start Centers of Excellence so that we can figure out what is
    working and what is not working?
        Answer. The Departments of Health and Human Services and Education
    have been working collaboratively reduce and prevent silos and
    duplication of efforts between our two Departments, to develop the
    infrastructure and models to maximize the use of Federal dollars at the
    State, and local levels and to build accountability into all Federal
    funds. Both the Race to the Top--Early Learning Challenge and the Head
    Start Centers of Excellence in Early Childhood are examples of our
    efforts. However, these efforts have very different goals. There are 10
    Head Start Centers of Excellence that serve as models for other
    individual programs. This funding has provided an excellent opportunity
    to showcase these Head Start programs so that other early childhood
    programs may benefit from their best practices. In contrast, the Race
    to the Top--Early Learning Challenge provides grants to States that
    target broad systems of reform across all early childhood programs,
    including building the infrastructure in States to better manage
    funding and minimize duplication of efforts. The goal of Race to the
    Top and our other interagency work is to provide greater continuity
    between schools, child care programs, Head Start programs, and State-
    funded pre-kindergarten programs.
                      consumer oriented and operated plans
        Question. The Department of Health and Human Services issued rules
    governing the grants for the Consumer Oriented and Operated Plan (CO-
    OP) program on July 20, 2010. On February 21, 2012, the Department
    released the identities of the first eight grants/loans recipients.\1\
    One of the grant recipients was the Common Ground Healthcare
    Cooperative of Wisconsin, which is an organization affiliated with the
    liberal activist group Industrial Areas Foundation. Common Ground was
    reportedly formed in August 2011, just 3 months prior to applying for
    the taxpayer money, and will receive $56,416,000.
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        \1\ http://www.jsonline.com/business/nonprofit-health-insurer-
    lands-Federal-loan-rm49ho7-139863553.html.
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        What criteria were used to select CO-OP grant recipients?
    Specifically what criteria were used to assess their experience in
    providing health insurance and benefits?
        Answer. CO-OP loan applications are subject to rigorous review and
    vetting by CMS' independent contractors, and by a review committee in
    CMS, which is separate from the CMS group responsible for administering
    the CO-OP program. CMS and these experts evaluate applicants based on
    their financial models and business plan, the applicant's ability to
    meet the regulatory standards and milestones for development, the
    likely long-term sustainability of the plan, adherence to the health
    policy goal of consumer operation and orientation, and the likelihood
    of loan repayment. The awards are also subject to legal review. Each
    CO-OP must be licensed as a health insurance issuer in each State in
    which it offers a health insurance plan. In addition, CO-OPs must meet
    the same requirements that other health insurance issuers must meet in
    each State. All CO-OPs are selected based on their viability and
    potential for success, as evidenced in their detailed business plans,
    financial plans, and actuarial projections.
        Question. Is it true that the HHS rules regarding CO-OPs projected
    a 35-40 percent default rate?
        Answer. The regulatory impact analysis in the CO-OP proposed rule
    (76 FR 43237) included an estimate of a technical default rate but
    incorrectly described it as an estimate of a non-repayment rate.
        The default rate is not an estimate of insolvencies. The rules did
    not estimate insolvencies.
        Because of Federal accounting rules, the default estimate includes
    loan recipients that CMS expects will fully repay the loan and at all
    times will be compliant with their loan agreement and Federal law. For
    example, the Affordable Care Act, in section 1322, requires the
    repayment of loans, but repayment terms ``must take into consideration
    any appropriate State reserve requirements, solvency regulations, and
    requisite surplus note arrangements.'' The statute envisions occasions,
    such as when a loan recipient must keep additional State-mandated
    insurance reserve requirements, when it is in the best interest of the
    consumer, loan recipient, and the State regulator for Department to
    change the loan repayment terms. This is one of many examples in which
    a loan recipient may be considered a default and included in the
    default rate estimated in the rules but is not in financial distress.
        Given the high bar to receiving funds, the detailed monitoring and
    oversight by CMS, and the concurrent oversight by State insurance
    regulators, we expect a high percentage of CO-OP loans to be repaid in
    full.
        All CO-OP loans must be repaid with interest and loans will only be
    made to private, nonprofit entities that demonstrate a high probability
    of becoming financially viable. In addition, as described in the
    Funding Opportunity Announcement, CMS has built in a strong monitoring
    process to ensure that CO-OPs are meeting development milestones
    according to prescribed timetables. Loan recipients are subject to
    strict monitoring, audits, and reporting requirements for the length of
    the loan repayment period plus 10 years. To ensure strong financial
    management, CO-OPs are required to submit quarterly financial
    statements, including cash flow data, receive site visits by CMS staff,
    and undergo annual external audits, in order to promote sustainability
    and capacity to repay loans. This monitoring is concurrent with ongoing
    financial and operational monitoring by State insurance regulators. In
    addition, CMS will use all remedies available in law or equity to
    collect unpaid loans.
                                exchange grants
        Question. Patient Protection and Affordable Care Act (PPACA)
    section 1311(a) enables the Secretary of HHS to make planning and
    establishment grants each year to the States. The law specifies that
    the Secretary shall determine the amount to be made available to
    States, but it does not specify how the Secretary should make the
    determination. So far HHS has spent nearly $1 billion on exchange
    grants, but it is not clear how these monies are being used.
        Please identify all recipients of the planning and establishment
    grants and explain the criteria you used to determine how much to award
    to each grantee. As part of your answer, please include the total
    amounts each grantee received and identify how each grantee has
    indicated they will spend these funds.
        Answer. States are required to submit detailed budgets as part of
    their grant applications. These budgets must outline the costs for each
    of the exchange core areas on which they will be working under the
    grant (e.g., IT systems, outreach and education, etc.) including
    administrative and overhead costs. These budgets are carefully reviewed
    and negotiated with the State before each award is made to ensure they
    represent a valid cost estimate to perform activities required under
    the grant.
        Question. In general, States used Planning Grant funding to perform
    such activities as insurance market analysis and stakeholder outreach
    to provide the information necessary to make initial policy decisions
    about how an exchange could best serve their residents. Many States are
    using Level I Establishment grants to begin work on their eligibility
    systems and other IT systems, to develop consumer assistance functions,
    and to implement the plan management infrastructure necessary to
    certify qualified health plans. The State of Rhode Island has a Level
    II Establishment Grant for work to establish all core functions of a
    State-based exchange. For a complete list of States that have been
    awarded Establishment Grants, the specific activities they are
    performing under those grants, and the amounts that have been awarded,
    please see: http://www.healthcare.gov/news/factsheets/2011/05/
    exchanges05232011a.html.
        Please also describe the process for selecting grantees,
    identifying whether this was a competitive process, and if so, what
    criteria were used to evaluate grant applications.
        Answer. The funding provided under section 1311 of the Affordable
    Care Act is available to fund activities of any State for activities
    necessary to establish an exchange. All grant applications are subject
    to objective review by programmatic experts to ensure that requirements
    outlined in the funding opportunity announcement are satisfied.
                                prevention fund
        Question. Recently enacted legislation to extend unemployment
    insurance, payroll tax provisions and delay a scheduled reduction in
    Medicare payments to physicians was paid for in part by a $5 billion
    reduction in the prevention fund. In addition, the President's budget
    also called for a $5 billion reduction in this fund. In light of the
    bipartisan interest in reducing the monies allocated to this fund, we
    would request that you provide the following information to help us
    assess the effectiveness of the expenditures authorized under the fund.
        Please describe how the programs funded under section 4002 of PPACA
    are being measured to determine their efficacy. As part of your answer,
    please indicate whether and how each program is evaluated to determine
    how it improves health outcomes for identified individuals and reduces
    healthcare expenditures.
        Answer. HHS strives to ensure that programs funded by the
    Prevention and Public Health Fund (PPHF) are making the greatest health
    impacts. Within the programs, the Department assigns a trained project
    officer to monitor and advise each grantee. Project officers provide
    ongoing consultation and oversight to grantees regarding program
    performance.
        Project officers also conduct site visits in order to objectively
    validate information and actively resolve challenges that a grantee is
    facing in order to ensure that the goals of the project are achieved.
        Programmatic performance measures also have been developed for each
    PPHF funded program at three levels:
      --performance milestones for start-up;
      --short-term impact; and
      --long-term objectives.
    All PPHF funded programs report twice a year regarding the status of
    established milestones and measures.
        HHS leaders regularly review these performance data to ensure that
    programs are on track and accountable for the outcomes associated with
    each investment.
                          chronic disease coordination
        Question. Less than 4 cents of every healthcare $1 is spent on
    prevention, yet chronic diseases account for 70 percent of deaths and a
    huge healthcare cost burden. The CDC budget proposes the consolidation
    of several existing categorical programs into a single coordinated
    program. Can you explain what efficiencies you hope to gain from this
    proposal and what assurances you can give to those who are concerned
    about losing the identity of disease specific funding streams?
        Answer. The budget includes $379 million, an increase of $129
    million more than fiscal year 2012, for the Coordinated Chronic Disease
    Prevention and Health Promotion Program. This program consolidates
    disease-specific chronic disease funding into a comprehensive program
    to address the leading chronic disease causes of death and disability,
    including heart disease and stroke, obesity, diabetes, arthritis and
    the primary preventable causes of cancer, tobacco use, poor nutrition,
    and physical inactivity. Because many inter-related chronic diseases
    and conditions share common risk factors, this program will improve
    health outcomes by coordinating interventions that benefit multiple
    chronic diseases. As a result, the program will gain efficiencies in
    cross-cutting areas such as epidemiology and surveillance, supporting
    healthful behaviors and chronic disease self-management, and improving
    effective delivery of clinical and other preventive services. At the
    end of the fiscal year, CDC will report on the funding spent on
    prevention and control of specific diseases. CDC will also report
    annually on improvements in outcomes specific to each disease as well
    as cross-cutting outcomes.
                           environmental health/lead
        Question. While CDC has prevented approximately 100,000 children
    from being poisoned by lead each year through the Healthy Homes and
    Lead Poisoning Prevention Program, in fiscal year 2012 funding was not
    included for the program. The Committee noted that $350 million will be
    spent by HHS to conduct home visiting programs in fiscal year 2012
    through the Maternal, Infant, and Early Childhood Home Visiting
    Program; this funding appropriated by the Patient Protection and
    Affordable Care Act, is $100 million more than the fiscal year 2011
    level. The subcommittee further stated that it intends the Health
    Resources and Services Administration and CDC to work together to
    ensure that activities previously funded through Healthy Homes will be
    fully incorporated into the Home Visiting Program. How has the
    Department worked to support this legislative intent?
        In fiscal year 2013 again the Healthy Homes and Lead Poisoning
    Prevention Program was again consolidated and slated for potential
    elimination. How is the administration going to ensure that the
    Nation's most vulnerable children are tested for lead poisoning and
    ensure that if those children test positive that treatment and
    environmental remediation services are provided?
        Answer. CDC and HRSA are working to identify possible solutions for
    incorporating childhood lead poisoning prevention activities into
    routine services of HRSA's early childhood Home Visiting Program.
        The fiscal year 2013 President's budget proposes a new program--
    Healthy Home and Community Environments--that will incorporate CDC's
    National Asthma Control Program (NACP) and the Healthy Homes/Lead
    Poisoning Prevention Program (HHLPPP). The fiscal year 2013 request for
    the Healthy Home and Community Environments program is $27.3 million.
        The Healthy Home and Community Environments program is a new,
    multi-faceted approach to address healthy homes and community
    environments through surveillance, partnerships, and implementation of
    science-based interventions to address the health impact of
    environmental exposures in the home and to reduce the burden of disease
    through comprehensive asthma control. This integrated approach aims to
    control asthma and mitigate health hazards in homes and communities
    such as air pollution, lead poisoning hazards, second-hand smoke,
    asthma triggers, radon, mold, unsafe drinking water, and the absence of
    smoke and carbon monoxide detectors.
        Question. Given the drastic cuts to CDC's Lead Poisoning Prevention
    Program that could essentially end all State cooperative agreements,
    what are your proposed strategies moving forward to ensure that the
    essential services (emergency response to children with lead poisoning,
    home inspections that include environmental health components,
    surveillance, etc.) provided by State and local health departments to
    vulnerable children are not lost?
        Answer. With fiscal year 2012 funding, CDC's Healthy Homes and Lead
    Poisoning Prevention Program will continue to provide lead expertise
    and analysis at the national level and remain a valuable resource to
    State and local agencies by providing the following:
          Surveillance Support.--Provide software and technical assistance
            to support the Healthy Homes and Lead Poisoning Surveillance
            System (HHLPSS), which gathers information related to lead and
            other health hazards in homes.
          Epidemiological Support.--Maintain staff to provide expertise and
            epidemiological support in response to a lead poisoning
            outbreak.
          Subject-Matter Expert Support.--Maintain the Advisory Committee
            on Childhood Lead Poisoning Prevention (ACCLPP). The ACCLPP
            advises and guides the Secretary and Assistant Secretary of HHS
            and the Director of CDC regarding new scientific knowledge and
            technical developments and their practical implications for
            childhood lead poisoning prevention efforts.
                                  section 317
        Question. CDC takes one of the largest hits in the budget request,
    and especially concerning is the proposed reduction in the section 317
    immunization program. A report from CDC estimates that this program is
    underfunded by hundreds of millions of dollars. Vaccination programs
    have been proven to be some of the most cost-effective approaches to
    preventing disease and reducing healthcare costs, and the children's
    vaccine programs are estimated to be a 10:1 savings as one example. The
    section 317 program provides the infrastructure for the Vaccines for
    Children program, which has been a huge success.
        What is the rationale for cutting this program by $58 million or
    close to 10 percent when we are still 1 to 2 years away from expanded
    coverage? Will this reduction cut purchase grants or operational
    support for health departments?
        Answer. The fiscal year 2013 budget includes funds for vaccine
    purchase to continue outreach to the hardest-to-serve populations, and
    critical immunization operations and infrastructure that supports
    national, State, and local efforts to implement an evidence-based,
    comprehensive immunization program. The request also specifically
    directs $25 million toward continuation of the billables project, which
    allows public health departments to vaccinate and bill for fully
    insured individuals in order to maintain section 317 vaccines for the
    most financially vulnerable and respond to time-urgent vaccine demands,
    such as outbreak response. The fiscal year 2013 budget will sustain the
    national immunization program vaccine purchase and immunization
    infrastructure. The budget does not continue funding for one-time
    enhancements planned for fiscal year 2012 to modernize the immunization
    infrastructure through funding to the grantees for improving
    immunization health IT systems and vaccine coverage among school-age
    children and adults; expansion of the evidence base for immunization
    programs and policy; and enhancements to national provider education
    and public awareness activities to support vaccination across the
    lifespan.
        Question. How do you see the role of the section 317 program
    evolving along with implementation of the Affordable Care Act?
        Answer. The Affordable Care Act requires new health plans to cover
    routinely-recommended vaccines without cost-sharing when provided by an
    in-network provider. As these health insurance reforms expand
    prevention services to more Americans, the size of the population
    currently served by section 317 vaccine is expected to decrease in
    size, specifically underinsured children. The Section 317 Immunization
    Program will continue to have a critical role in providing vaccines to
    meet the needs of uninsured adults and responding to urgent vaccine
    needs such as outbreak response, and ensuring the necessary
    infrastructure is in place to support the Nation's immunization system
    for both routine vaccination as well as managing vaccine shortages and
    other emergency response. This critical infrastructure serves both the
    public (e.g., Vaccines For Children Program and Section 317) and
    private sectors. Insurance coverage alone will not provide the
    immunization infrastructure necessary to ensure a strong evidence base
    for national vaccine programs and policy, quality assurance for
    immunization services, and high vaccination coverage rates across the
    lifespan.
        Question. In 2012, $190 million from the Prevention and Public
    Health Fund will be transferred to the section 317 immunization
    program. How will these funds be used and will those activities
    continue in 2013 at the same level of support?
        Answer. In fiscal year 2012, PPHF will meet the needs of the
    Section 317 Immunization Program, as well as provide one-time resources
    for infrastructure enhancements in health IT, planning and
    implementation of public health billing systems, adult vaccination, and
    capacity for vaccinating school-age children. The fiscal year 2013
    budget directs $25 million toward continued progress in the billables
    project, but eliminates these other one-time enhancements.

                                     ______

                   Questions Submitted by Senator Ron Johnson
        Question. In the Massachusetts Health Insurance Exchange, I
    understand there is a 6-month period between when an employer drops
    coverage and when an employee is eligible for participation in the
    exchange. Is there any similar provision in Obamacare?
        Answer. In Massachusetts, an individual is not eligible for
    subsidized coverage if offered employer-sponsored insurance within the
    last 6 months. The employer offer must meet certain benchmarks and the
    Board can waive the 6-month requirement (956 CMR 3.05). There is no
    similar 6-month waiting period in the Affordable Care Act.
        Question. In the various analyses conducted by the Department of
    Health and Human Services (HHS) or the Centers for Medicare & Medicaid
    Services on employer behavior related to employer sponsored insurance,
    is this significant difference in policy taken into account?
        Answer. The Affordable Care Act does not include the same
    requirements as the Massachusetts law, and the Department has not
    examined the differences. Congressional Budget Office (CBO) and the
    Joint Committee on Taxation recently released updated estimates of the
    potential impact of the Affordable Care Act on coverage. The report
    shows that the Affordable Care Act is estimated to reduce the number of
    nonelderly people without health insurance by 30 million to 33 million
    in 2016 and subsequent years.
        Question. Are other differences in the Massachusetts model taken
    into account? If so, which ones. If not, why not?
        Answer. HHS is charged with implementing the Affordable Care Act
    and not a State law. Estimates of the impact reflect analysis of the
    Federal law only.
        Question. How much will HHS spend on health insurance exchanges, in
    total, from the time the healthcare bill was signed into law until 2014
    when the exchanges are supposed to be fully operational?
        Answer. Our current baseline for Exchange Planning and
    Establishment Grants estimates that we will obligate approximately $2.5
    billion from when the law was enacted until fiscal year 2014 and that
    we will outlay $2 billion during that timeframe.
        Through the end of fiscal year 2011, HHS had obligated
    approximately $100 million to implement the federally facilitated
    exchange as well as carry out the Secretary's responsibilities on
    behalf of all exchanges. The fiscal year 2013 President's budget
    requests an additional $864 million for the Department's exchange-
    related responsibilities to prepare for the opening of exchanges in
    January 2014.
        Question. Please describe a realistic timeline for HHS to establish
    Essential Health Benefits, Health Information Exchanges, and State and
    Federal Insurance Exchanges?
        Answer. The establishment of the exchanges is a complex and
    resource-intensive process. We believe it is realistic to have an
    exchange operating in every State in time for open enrollment beginning
    on October 1, 2013, for plan year 2014. The Department is currently
    working to provide additional information on Essential Health Benefits
    in the coming months, so that States and health insurance issuers have
    information available to prepare for plan year 2014.
        The State Health Information Exchange (HIE) program promotes
    innovative approaches to the secure exchange of health information
    within and across States and ensures that healthcare providers and
    hospitals meet national standards and meaningful use requirements.
    Fifty-six States, eligible territories, and qualified State Designated
    Entities received awards under this program. In fiscal year 2011, all
    recipients received approval of their implementation plans for
    achieving statewide health information exchange. Recipients are
    currently continuing to execute these plans and improve health
    information exchange in their localities.
        Question. How does HHS plan on addressing the low income
    individuals who will frequently alternate between insurance through an
    exchange and Medicaid?
        Answer. HHS recognizes the potential for movement of individuals
    between the exchange and Medicaid. Our goal is to ensure the accuracy
    of eligibility determinations to achieve a seamless transition
    experience for individuals with changes in circumstances that cause
    their program eligibility to change between the exchange and Medicaid.
    To this end, the verification and eligibility determination processes
    for exchanges will be designed to parallel and integrate with those in
    Medicaid and Children's Health Insurance Program (CHIP). The exchange
    will coordinate with Medicaid and CHIP to ensure that an applicant
    experiences a seamless eligibility and enrollment process regardless of
    where he or she submits an application.
        To the extent that individual's circumstances change, section
    155.330 of the exchange proposed rule establishes standards for
    eligibility redeterminations during a benefit year. Exchanges must
    redetermine eligibility if they receive and verify information either
    reported by an enrollee or through electronic data matching. In an
    effort to identify changes quickly, this section proposes to require
    enrollees to report changes in circumstances that affect eligibility
    within 30 days of such a change.
        Question. If HHS does not have a plan for these individuals, why
    not?
        Answer. HHS recognizes the potential for movement of individuals
    between the exchange and Medicaid. Our goal is to ensure the accuracy
    of eligibility determinations to achieve a seamless transition
    experience for individuals with changes in circumstances that cause
    their program eligibility to change between the exchange and Medicaid.
    To this end, the verification and eligibility determination processes
    for exchanges will be designed to parallel and integrate with those in
    Medicaid and CHIP. The exchange will coordinate with Medicaid and CHIP
    to ensure that an applicant experiences a seamless eligibility and
    enrollment process regardless of where he or she submits an
    application.
        To the extent that individual's circumstances change, section
    155.330 of the exchange proposed rule establishes standards for
    eligibility redeterminations during a benefit year. Exchanges must
    redetermine eligibility if they receive and verify information either
    reported by an enrollee or through electronic data matching. In an
    effort to identify changes quickly, this section proposes to require
    enrollees to report changes in circumstances that affect eligibility
    within 30 days of such a change.
        Question. What funding does HHS plan on using to establish State-
    level exchanges for the States that refuse to establish their own
    exchange?
        Answer. In fiscal year 2012, CMS will use a combination of
    administrative funding and the Implementation Fund for Exchanges. In
    fiscal year 2013, the President's budget requests additional funding in
    the CMS Program Management account for programmatic and administrative
    activities necessary to prepare for exchange open enrollment beginning
    October 1, 2013. CMS anticipates collecting user fees in fiscal year
    2014 to begin offsetting some of the operational costs of the federally
    facilitated exchange.
        Question. Please describe the HHS Federal exchange model, also
    describe how will it be different from an inter-State exchange?
        Answer. Specific details about the federally facilitated exchange
    will be released through guidance to States and other stakeholders in
    the coming months. Although there are opportunities for States to
    participate in the federally facilitated exchange, such as through a
    Partnership Exchange, the ultimate responsibility for operations will
    remain with the Federal Government. An inter-State exchange would share
    functions, such as a call center and financial management, across
    states in a manner similar to the federally facilitated exchange, but
    in this case the States involved are responsible for the exchange
    operations.
        Question. In addition to this mandatory money for State-based
    health insurance exchanges, the President's 2013 budget requests an
    additional $864 million for the Federal exchange and other exchange
    activities. How will this money specifically be spent and how will the
    Federal exchange differ in functionality from the web portal HHS has
    already implemented?
        Answer. As with the State-based exchanges, fiscal year 2013 is the
    year many operations of the federally facilitated exchange begin, as
    CMS will need to be prepared for open enrollment on October 1, 2013,
    the first day of fiscal year 2014. The majority of the $864 million
    request for CMS' exchange work is related to operations and management
    of the federally facilitated exchange with some funding to support the
    Secretary's duties on behalf of all exchanges. Specifically, $574.5
    million of the total will be used for exchange operations and
    management including eligibility and enrollment functions, certifying
    health insurance plans as qualified to be sold through the exchange, as
    well as oversight of plans and State-based exchanges. The additional
    $289.5 million will be used for consumer education and outreach
    activities, such as a call center, to help consumers understand their
    new options under the Affordable Care Act and to fund navigators and
    in-person enrollment assistance to facilitate the enrollment process.
        Healthcare.gov is a useful tool for providing information on
    potential sources of insurance available to individuals today, and HHS
    can leverage its capabilities for presenting information to assist
    consumers in comparing across plans in exchanges. The federally
    facilitated exchange will go beyond what is available through
    Healthcare.gov by certifying that the plans offered meet certain
    standards of quality and benefits. The federally facilitated exchange
    will also perform eligibility determinations, enroll individuals into
    plans, and provide for in-person or call center support to answer
    questions about available coverage.
        Question. How does HHS plan on integrating the necessary private
    information needed from the Internal Revenue Service (IRS), HHS,
    Department of Homeland Security (DHS), Social Security, and patient
    medical records while ensuring that the data is up-to-date and remains
    private?
        Answer. Protecting the privacy and confidentiality of personal
    health information is among our highest priorities. The Department has
    a long and successful history of doing so in the Medicare program. The
    minimum functions that an exchange must perform do not require or
    necessitate the collection of medical records of individuals who
    purchase coverage through the exchange. In response to concerns
    regarding privacy of personal health information of individuals
    enrolling in exchanges and Medicaid, the final exchange rule will
    address privacy and security standards for personally identifiable
    information that exchanges must establish and follow in more depth than
    previously discussed.
        Section 1413 of the Affordable Care Act outlines a series of data
    exchanges through secure interfaces that will facilitate eligibility
    determinations for enrollment in a qualified health plan (QHP) in the
    exchange and insurance affordability programs in a timely manner. To
    assist in these operations HHS has contracted for support in building a
    data services hub that will provide critical IT functions to every
    exchange. The hub will act as a single interface point for exchanges to
    Federal agency partners, minimizing the burden on states in exchanging
    information with Federal agencies. The hub will enable a streamlined,
    secure, and interactive customer experience that will maximize
    automation and real-time adjudication to the extent possible while
    protecting privacy and personally identifiable information.
        Question. What database will be established to handle this data?
        Answer. HHS is not establishing a database to facilitate
    eligibility determinations. Data will not be held by HHS. Instead, as
    described above HHS, through the data services hub will facilitate the
    exchange of data between Federal agencies and exchanges necessary to
    determine eligibility for enrollment in a QHP through the exchange and
    for insurance affordability programs.
        Question. What progress has been made and what portion of the
    budget has been allocated to ensure this integration and confidential
    data are protected?
        Answer. Protecting the privacy and confidentiality of data is among
    our highest priorities. In response to concerns regarding privacy of
    personal health information of individuals enrolling in exchanges and
    Medicaid, the final exchange rule will address privacy and security
    standards for personally identifiable information that exchanges must
    establish and follow in more depth than previously discussed.
        As we implement exchanges working with our State partners we will
    use the provisions of the final regulation along with other applicable
    statutes to ensure the privacy and confidentiality of data.
        Question. The healthcare law included a $1 billion implementation
    fund. In order for the Congress to better evaluate the administration's
    request for additional funds for implementation activities, please
    provide an accounting of how the monies provided pursuant to the new
    healthcare law have been expended. As part of your answer, please
    include a comprehensive breakdown of spending by department and
    subsidiary administrative units, as well as by function.
        Answer. The following table displays the spending from the Health
    Insurance Reform Implementation Fund as of February 29, 2012, by
    agency:

    ------------------------------------------------------------------------
                  Organization                  Obligations       Outlays
    ------------------------------------------------------------------------
    Internal Revenue Service................    $213,264,945    $154,181,697
    Office of Personnel Management..........       2,938,850       1,442,102
    Department of Labor.....................       3,055,102       2,958,880
    Department of Health and Human Services.     251,742,492
                                             --------------------134,917,483
                                             -------------------------------
          Total, Health Reform                   471,001,389     293,500,162
           Implementation Fund..............
    ------------------------------------------------------------------------

        HHS uses these funds to implement Medicare and Medicaid changes
    required in the ACA, including closing the Part D coverage gap and
    developing new value-based purchasing models for Medicare providers.
    HHS has also used these funds to plan and prepare for the establishment
    of State-based and federally facilitated exchanges as required in the
    ACA.
        The Office of Personnel Management uses funding to plan for
    implementing and overseeing the establishment of at least two Multi-
    State Plan Options to be offered on each State health insurance
    exchange beginning in 2014, and allowing tribes and tribal
    organizations to purchase Federal health and life insurance for their
    employees.
        The Department of the Treasury uses funding to implement multiple
    tax changes from the Affordable Care Act, including the Small Business
    Tax Credit, expanded adoption credit, W-2 changes for loan forgiveness,
    excise tax on indoor tanning services, charitable hospital
    requirements, and plan for exchanges.
        The Department of Labor uses funds to conduct compliance
    assistance; modify or develop IT systems that support data collection,
    reporting, policy, and research; and develop infrastructure for the
    newly required Multiple Entity Welfare Arrangements reporting and
    registration within the Affordable Care Act.
        Of the $251,742,492 obligated by HHS to date, approximately 13
    percent has paid for personnel, 84 percent has supported contractual
    services, and 3 percent has been obligated for rent, supplies, or other
    miscellaneous services.
        Question. The Department of Health and Human Services Budget (HHS
    budget) calls for 76,341 employees in fiscal year 2013. This is an
    increase of nearly 1,400 employees over the fiscal year 2012 level. How
    many of these employees will have responsibilities covered under the
    new healthcare law?
        Answer. The fiscal year 2013 President's budget requests an
    increase of 136 FTEs more than the fiscal year 2012 appropriated level
    for ACA related activities.
        Question. How many staff members are currently working at the
    Center for Consumer Information and Insurance Oversight (CCIIO)? Please
    provide numbers for both full-time and part-time staff separately. How
    many staff do you expect will be working at CCIIO at the end of fiscal
    year 2012? How many staff do you expect will be working at CCIIO at the
    end of fiscal year 2013?
        Answer. As of March 10, 2012, CCIIO has approximately 261 employees
    on-board. 258 employees are considered full-time, and 3 employees are
    considered part-time. This staff is supported by a combination of
    discretionary funds and mandatory ACA funding. By the end of fiscal
    year 2012, CMS expects to consume 450 FTEs on CCIIO-related activities.
    This staffing level will grow to a projected 710 FTEs by the end of
    fiscal year 2013 as we bring the exchanges online.
        Question. How does HHS account for the $111 billion increase in
    mandatory spending for health insurance exchange tax credit between
    fiscal year 2014-2021? Please provide a full itemized breakdown.
        Answer. Premium tax credits for individuals enrolled in qualified
    health plans are under the jurisdiction of the Department of the
    Treasury, so HHS did not provide the estimates of the tax credits in
    the President's budget referenced in the question.
        HHS understands from the Department of the Treasury that
    approximately one-half of the $111 billion increase for premium tax
    credits related to exchanges results from legislative changes enacted
    in 2011, primarily Public Law 112-56, which changed the definition of
    modified-adjusted gross income to include certain Social Security
    income. This legislative change resulted in shifting individuals
    previously eligible for Medicaid into the exchange premium tax credits.
    The remaining difference is attributable to technical changes to
    Treasury's revenue estimating model that are designed to improve its
    overall accuracy. Those changes impact all income tax modeling and were
    not implemented just for purposes of calculating the cost of the
    premium tax credit. One example of the technical changes involves the
    projection of the distribution of income, which resulted in the
    composition of families projected to claim premium tax credits being
    somewhat older and lower-income than previously projected. These
    changes do not reflect fundamental changes in assumptions regarding
    utilization of premium tax credits or the cost of providing coverage
    for a given person in the exchanges.
        Question. Please describe how the programs funded under section
    4002 of PPACA are being measured to determine their efficacy. As part
    of your answer, please indicate whether and how each program is
    evaluated to determine how it improves health outcomes for identified
    individuals and reduces healthcare expenditures.
        Answer. HHS strives to ensure that programs funded by PPHF are
    making the greatest health impacts. Within the programs, the Department
    assigns a trained project officer to monitor and advise each grantee.
    Project officers provide ongoing consultation and oversight to grantees
    regarding program performance.
        Project officers also conduct site visits in order to objectively
    validate information and actively resolve challenges that a grantee is
    facing in order to ensure that the goals of the project are achieved.
        Programmatic performance measures also have been developed for each
    PPHF funded program at three levels:
      --performance milestones for start-up;
      --short-term impact; and
      --long-term objectives.
    All PPHF-funded programs report twice a year regarding the status of
    established milestones and measures.
        HHS leaders regularly review these performance data to ensure that
    programs are on track and accountable for the outcomes associated with
    each investment.

                                     ______

                   Question Submitted by Senator Jerry Moran
                medicare part d preferred network pharmacy plans
        Question. Last year, Centers for Medicare & Medicaid Services (CMS)
    allowed insurers to partner with large chain drug retailers to launch a
    preferred network Part D pharmacy plan. Similar plans were rolled out
    at the end of 2011. These plans can offer prescription drugs to
    Medicare beneficiaries at significantly reduced prices compared to
    other Part D plans.
        It is important that these preferred network plans, and all Part D
    plans, are accurately marketed to Medicare beneficiaries so they are
    able to fully understand the features of the various plans and the
    benefits and drawbacks of signing up for one plan compared to another.
        Many seniors get their medications and related counsel from a
    trusted pharmacist in their community. The preferred pharmacies in the
    preferred network plans, Part D agents and brokers, and representatives
    of the Senior Health Insurance Information Program should disclose to
    Medicare beneficiaries that the beneficiaries may have to go to a
    specific preferred pharmacy provider to access the most reduced drug
    costs advertised by such plans.
        If Part D plans are not accurately marketed, pharmacy access for
    rural Americans could be jeopardized. If a Part D plan limits Medicare
    beneficiaries to only a small number of pharmacy providers to get the
    most reduced drug prices, it is important that this information be
    clearly disclosed to them. Additionally, it is important that the
    Medicare Plan Finder contain obvious information for beneficiaries
    regarding such pharmacy provider options as well as costs.
        What actions is CMS taking to ensure accurate marketing and full
    disclosure of Part D preferred network plans for the 2013 plan year?
        Answer. An increasing number of Part D plans offer cost-sharing
    differentials between preferred and nonpreferred network pharmacies. It
    is important to ensure that beneficiaries understand whether preferred
    cost sharing is available at individual pharmacies. Specifically,
    confusion may arise if beneficiaries do not select a pharmacy when they
    compare Part D plans using the Medicare Plan Finder. Therefore, we are
    currently working to change the Plan Finder to require each beneficiary
    to select a pharmacy in his/her plan's network for purposes of
    providing cost estimates that reflect the selected pharmacy's preferred
    or nonpreferred status in the plan's network. We believe this change
    will eliminate the possibility that a beneficiary will obtain cost
    estimates and plan selections based on preferred pharmacy cost sharing
    when that beneficiary does not intend to use pharmacies in the
    preferred pharmacy network. The selection of a particular pharmacy in
    Plan Finder for this purpose has no bearing on the beneficiary's
    ability to fill prescriptions at any network pharmacy.

                              SUBCOMMITTEE RECESS

        Senator Harkin.  Thank you, Madam Secretary.
        The record will stay open for 1 week for additional input
    from members of this subcommittee.
        The subcommittee will stand in recess.
        [Whereupon, at 11:45 a.m., Wednesday, March 7, the
    subcommittee was recessed, to reconvene at 10:30 a.m.,
    Wednesday, March 14.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2013

                                  ----------

                           WEDNESDAY, MARCH 14, 2012

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10:30 a.m., in room SD-138, Dirksen
    Senate Office Building, Hon. Tom Harkin (chairman) presiding.
        Present: Senators Harkin, Brown, Shelby, Cochran,
    Alexander, Graham, and Moran.

                              DEPARTMENT OF LABOR

                            Office of the Secretary

    STATEMENT OF HON. HILDA L. SOLIS, SECRETARY

                    OPENING STATEMENT OF SENATOR TOM HARKIN

        Senator Harkin. The Subcommittee on Labor, Health and Human
    Services, and Education, and Related Agencies will come to
    order.
        Welcome back to the subcommittee, Madam Secretary. You are
    joining us today at a critical time for our Nation's workforce.
        The economy is moving in the right direction. U.S.
    employers added 227,000 jobs in February, marking 3 months in a
    row of job gains of more than 200,000. In the private sector,
    we have had 24 straight months of job growth. The outlook for
    manufacturing is particularly encouraging, with 429,000 jobs
    added in the past 2 years.
        But too many people still remain unemployed or
    underemployed. More must be done to ensure that all Americans
    benefit from economic growth, not just the wealthy in our
    country.
        And so I applaud the efforts that you and your Department
    are making to get more Americans back to work, and to keep our
    workers safe, especially in times of budget constraints.

                      FISCAL YEAR 2013 PRESIDENT'S BUDGET

        Under the President's request, funding for the Department
    in fiscal year 2013 would drop slightly below the level for
    fiscal year 2012. Obviously, we are going to ask you to do more
    with less. I am pleased, however, that within the President's
    total, he has proposed increases for efforts to prevent the
    misclassification of workers, to protect whistleblowers, and to
    enhance oversight of the sub-minimum wage program for workers
    with disabilities.
        The President's budget would also continue the disability
    employment initiative that we started in the fiscal year 2010
    appropriations bill. While the overall unemployment rate in
    February was 8.3 percent, the rate for people with disabilities
    was 15.8 percent--almost double. So we must do a better job of
    removing employment barriers for people with disabilities. Your
    Department's disability employment initiative will surely help.

                           JOB CORPS CENTER CLOSURES

        One reduction proposed by the President is to cut funding
    for operating Job Corps centers by $23 million. His plan is to
    close a small number of centers that are chronically low
    performing.
        As you know, I have always been a strong supporter of Job
    Corps. These centers play a crucial role in giving young people
    the training they need to enter the workforce, the military, or
    postsecondary education. And my experience with their work in
    Iowa has been very positive. The center in Denison, Iowa, is 1
    of only 3 in the country to be named a Job Corps Center for
    Excellence by the Department of Labor (DOL).
        A new center in Ottumwa, Iowa, for which you were present
    during the groundbreaking, opened its doors this past October,
    and is taking an innovative approach to training its students.
    The center has a partnership with a nearby community college,
    Indian Hills Community College, that will give its students
    access to higher education at the same time they are enrolled
    in the Job Corps center.
        So I think the Congress should continue to strongly support
    the Job Corps program. But, then again, we also have a
    responsibility to hold centers accountable for their
    performance. If there are centers that fail to serve their
    students year after year, then no one is helped by continuing
    to provide them with taxpayer funding.

                              PREPARED STATEMENTS

        What I will want to understand better is how the Department
    plans to define ``chronically low-performing'', and what
    criteria will be used to determine whether a center should be
    closed. And that is something for an ongoing discussion.
        So, Madam Secretary, I will leave the record open at this
    point for an opening statement by Senator Shelby and Chairman
    Inouye.
        [The statements follow:]
                Prepared Statement of Senator Richard C. Shelby
        Madam Secretary, our Nation continues to face an unemployment rate
    more than 8 percent, the longest stretch of high unemployment in this
    Nation since the Great Depression.
        Moreover, the official unemployment rate of 8.3 percent does not
    adequately illustrate the current employment turmoil. The official rate
    excludes ``discouraged'' workers--those who want to work, but have not
    searched for a job in the last month and those working part-time but
    who would prefer a full-time job.
        If these groups were counted, the real unemployment rate would be
    14.9 percent.
        As more and more Americans are unemployed or underemployed, they
    are looking toward the Department of Labor (DOL) to provide job
    training and employment placement. We need to ensure that DOL is using
    its funds effectively and efficiently and that Americans are receiving
    the training they need to re-enter the labor force.
        DOL's fiscal year 2013 request is for $12 billion. DOL claims that
    the 2013 request reduces spending by $1.2 billion. This is misleading.
        With the transfer of the community service employment for older
    Americans program to another agency and the decrease in the
    unemployment insurance workload, DOL's request is not a decrease of
    $1.2 billion, but less than one-half that amount.
        In this difficult economic environment, limited funding should be
    targeted to programs that are most effective. I have repeatedly
    expressed concern about the Job Corps program. While Job Corps has a
    noble goal and a difficult challenge, it is an expensive program per
    enrollee, it has a number of historically low-performing centers in the
    system, and there are concerns that the program's outcomes may not
    justify the program's costs.
        I appreciate you taking my concerns into consideration and
    proposing a fiscal year 2013 budget that streamlines the program and
    strengthens its accountability.
        However, I do remain concerned that other job training programs
    have not received the rigorous evaluations necessary to determine
    whether their costs are justified by their outcomes. Many of the
    Workforce Investment Act (WIA) programs have not been evaluated since
    2005, and we do not have current data to assess whether they are
    working.
        In this time of record unemployment, I believe DOL should target
    worker training programs to ensure unemployed Americans can return to
    work. Unfortunately, there are several unnecessary initiatives that
    cost hundreds of millions of dollars, such as the Workforce Innovation
    Fund and the One-Stop Rebranding proposal, that will not train a single
    worker.
        The budget submission for the Workforce Innovation Fund requests
    $125 million this year while the Fund has $175 million in the bank. I
    think everyone would agree that we should not add a third year of
    funding to a program that has not awarded a single grant and has
    unknown results.
        In addition, the One-Stop Rebranding initiative allocates $50
    million for a publicity campaign. How will either of these proposals
    help Americans return to work?
        In difficult budgetary times, we need to make tough choices and
    prioritize spending. I look forward to working with the chairman and
    DOL to target funding that puts Americans back to work.
                                     ______

                 Prepared Statement of Senator Daniel K. Inouye
        Mr. Chairman, thank you for chairing this hearing to review the
    President's fiscal year 2013 budget for the Department of Labor.
        I would like to extend a warm aloha to Secretary of Labor, Hilda
    Solis. Madam Secretary, I will continue to do all I can to support your
    vision of good jobs for everyone, because a strong economy depends on a
    strong middle class.

        Senator Harkin. And in the interest of time, since we have
    a series of votes starting at 11:30 a.m., Madam Secretary, I
    have your statement. It will be made a part of the record in
    its entirety.
        Again, welcome back. I will, for the record, say that
    Secretary Hilda L. Solis was sworn in as the 25th Secretary of
    Labor on February 24, 2009. Prior to her confirmation, she was
    one of us, as a Representative of the 32d Congressional
    District in California, holding that position from 2001 to
    2009.
        The Secretary is a graduate of California State Polytechnic
    University, and earned her master of public administration from
    the University of Southern California.
        So, Madam Secretary, again, welcome, and please proceed as
    you so desire.

                      SUMMARY STATEMENT OF HILDA L. SOLIS

        Secretary Solis. Thank you so much, Mr. Chairman, and also
    to the subcommittee members. Senator Brown, it is good to see
    you and other members that I know will be joining us shortly.
        I want to thank you for the invitation to testify before
    you today. And I provided, as you stated, my written testimony
    for the record, but wanted to review a few highlights with you.
    I also want to thank you for all that you did over the past
    year to assure that the Congress adopted an appropriations bill
    that balanced the need of deficit reduction with the real needs
    of American workers.
        DOL's budget request reflects the approach the President
    has taken to make priority investments in areas that we know
    are essential to helping America get back to work. And some of
    the most significant of these proposals are not before this
    subcommittee, but are essential to securing the position as the
    most competitive economy in the world, such as proposals to
    include access to education and job training.
        I am going to concentrate on those items before the
    subcommittee which address the need to invest in our workforce,
    protect workers on the job, and secure Americans' incomes and
    benefits. In some cases, we have made tough decisions on
    finding reductions, as you well stated, Mr. Chairman, in order
    to put America on a more sustainable fiscal course. This is
    part of the administration-wide effort to improve efficiency
    and find savings. My testimony lists these items, which can
    provide you with information to justify the specific actions.

                      INVESTING IN A COMPETITIVE WORKFORCE

        But I want to concentrate on two particular areas this
    morning, first, the need to invest in a competitive workforce.
    And as the President has said, for an economy that is built to
    last, we must get all of our dislocated and low-income workers
    back to work.
        The budget request continues the Department's commitment to
    those who are most vulnerable to the economic distress by
    maintaining and, in some cases, restoring funding for our
    employment and training programs. To support innovation in our
    workforce investment system we are asking for an increase in
    the Workforce Investment Fund that will allow us to test new
    ideas and replicate proven strategies for delivering better
    employment and training results. I like to call the Workforce
    Innovation Fund a reform effort, because we are really looking
    at and testing new types of techniques and coordination that
    actually help to enhance our programs.
        We also know that returning veterans can contribute greatly
    to our economy. This has been a big discussion item with the
    Congress as well as the President. That is why the unemployment
    rate for recent veterans is so troubling to many of us. We will
    bolster our support for newly separated veterans by expanding
    the Transition Assistance Program, known as TAP, and employment
    workshops that are advanced through our State grants for
    veterans' employment services, by other investments necessary
    to implement the recently enacted Veterans Opportunity to Work
    (VOW) to Hire Heroes Act. I want to publicly thank Senator
    Murray, who is not here but has been a champion in particular,
    for her leadership with respect to veterans.

          RE-EMPLOYMENT SERVICES FOR UNEMPLOYMENT INSURANCE CLAIMANTS

        I also would like to state that to help workers continue to
    receive Unemployment Insurance (UI) benefits, they also need
    assistance. And we are proposing a $30 million investment for
    employment service grants to States to fund re-employment
    services for UI claimants, as well as an increase of $15
    million for re-employment and eligibility assessment.
        Eligibility assessment and re-employment services have been
    found to be highly effective at helping UI claimants find
    higher-paying jobs sooner, while at the same time saving money
    for the UI system. You might recall that in the last few years
    people typically get on the phone and call in when they are
    having to register for their employment benefits. We have to do
    a bit more to actually bring the individual in so we can do an
    assessment, get them a program and the assistance that they
    need, diagnostic testing, whatever it takes, to make sure that
    they are successful. And those routes tell us that they are
    more effective, and it is more cost effective.

                            ONE-STOP CAREER CENTERS

        As you know, the system of the one-stop career centers is
    the core delivery mechanism for employment and training
    services. To strengthen our community-based system, the budget
    includes a $50 million allocation to create a uniform and
    recognizable brand for the system. What we are talking about is
    really coordination, and making very clear that the workforce
    systems can be easily identified by users as well as employers.
    As you know, even in your State, you may have a different name
    that doesn't relate directly to the one-stop center, and most
    people are confused about what that means. So we are trying to
    re-brand, and also create more mechanisms to use online tools,
    better technology. Whether you are in rural America or in an
    inner-city, you ought to be able to access same kinds of
    services. So, we are attempting to coordinate that effort.

                           WORKER PROTECTION PROGRAMS

        We are also maintaining our efforts to ensure that persons
    with disabilities have the opportunity to use the system in a
    better way. And we also need to support the worker protection
    programs that are not only there to protect American workers,
    but are crucial to ensuring that all firms are playing by the
    same set of rules. Because, as you know, when wages are not
    provided to employees, as well as into our tax system, overall
    consumers and the public lose. So we think that there is more
    that we can do in that area.
        As we continue to recover from one of the worst economic
    crises in three generations, it is especially important that we
    invest in the enforcement of key laws to protect our workers
    through their wages and benefits. Thus, the budget a requests
    for funding for Wage and Hour Division (WHD), including
    additional funds for the enforcement of the Fair Labor
    Standards Act and the Family Medical Leave Act, along with an
    investment both in wage and hour and in unemployment insurance
    to address the practice of employee misclassification, as you
    stated earlier, Mr. Chairman. I know that that is of particular
    interest to you. I also want to thank you for the increase that
    we were able to provide to WHD, looking at the targeted
    enforcement program of 14c, one that you have been very
    involved in.

             MINE SAFETY AND HEALTH ADMINISTRATION MINE INSPECTIONS

        The budget also includes funding to allow for our Mine
    Safety and Health Administration (MSHA) to meet its statutorily
    mandated inspections, while maintaining our efforts within both
    MSHA and our Office of the Solicitor to continue the progress
    that we have seen already being made to reduce the backlog of
    contested citations. We must continue our efforts in this area
    to ensure that we are holding mine operators accountable if
    they fail to meet their legal and moral responsibility to
    operate safe mines.

                        FISCAL YEAR 2013 REQUEST SUMMARY

        In conclusion, I wish to summarize: DOL's fiscal year 2013
    budget request provides investments to prepare Americans with
    the skills they need, to assist businesses who are looking for
    employable individuals, and to help workers and employers find
    each other in a more efficient manner so that we can enhance
    our workforce system.
        This proposal also ensures that we have fair and safe
    workplaces for our workers. We must continue to foster safe
    workplaces with respect to workers' rights, provide a level
    playing field for businesses, help American workers provide for
    their families and keep the pay and benefits that they earn. We
    will focus on our shared long-term goal of reducing the Federal
    deficit, and I believe it is possible to do so in a way that
    meets these goals and also helps achieve a better and efficient
    system.

                               PREPARED STATEMENT

        I look forward to working with you and this subcommittee in
    the future on this particular area.
        Again, thank you, Mr. Chairman, for inviting me here to
    this hearing. I appreciate that.
        [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 appear before you to discuss the fiscal
    year 2013 budget request for the Department of Labor (DOL).
        To build an economy that is built to last, we have to do more to
    live within our means and restore fiscal accountability and
    responsibility. The President has put forward a plan to make priority
    investments in areas essential to helping America win the race for the
    jobs and industries of the future, while making difficult choices to
    identify cuts and savings that ask for shared sacrifices across the
    board. The budget proposes specific steps to boost growth and secure
    the United States' position as the most competitive economy in the
    world, such as improving access to education and job training, so that
    our workers are the best prepared in the world for the jobs of the 21st
    century.
        The DOL fiscal year 2013 budget request reflects this direction. To
    build on the economic gains we have experienced under this
    administration, we must create good jobs and make investments that will
    boost economic growth. The request makes targeted investments and
    introduces significant reforms to give workers a fair shot to gain
    skills that make them more employable, regain their footing after a job
    loss, find new employment opportunities, maintain workplace safety and
    health, exercise their voice in the workplace, and enjoy critical wage
    and hour protections.
                 targeted investments through difficult choices
        As the President said in the State of the Union Address, we must
    renew our commitment to revitalizing our Nation's economy and to
    building an America that is built to last--where everyone gets a fair
    shot, does their fair share, and plays by the same set of rules.
        DOL's 2013 budget request focuses on how we can help accomplish
    this goal in innovative and cost-effective ways, to ensure we are
    delivering critical services for American workers in everything from
    job training to workplace protection. However, in light of current
    economic realities, and like many families across the country, we had
    to make some tough choices to ensure we are able to:
      --Invest in a competitive workforce;
      --Protect American Workers; and
      --Secure Americans' incomes and benefits.
        In some cases, that meant making tough decisions on funding
    reductions that will put America on a more sustainable fiscal course.
    Consistent with administration-wide efforts to improve efficiency and
    find savings, DOL's budget proposes to streamline operations by:
          Eliminating Overlapping Training Programs.--The missions of the
            Women in Apprenticeship in Non-Traditional Operations and
            Veterans Workforce Investment program will continue to be
            advanced through other Departmental training offices and
            programs.
          Re-proposing the fiscal year 2012 request to transfer the
            Community Service Employment for Older Americans program to the
            Department of Health and Human Services' Administration on
            Aging in recognition of the dual purpose of the program to
            support the economic well-being of seniors, while improving
            coordination with other senior-serving programs with similar
            purposes.
          Closing a Small Number of Chronically Low-Performing Job Corps
            Centers.--While most centers meet program standards, some
            centers have been persistently low-performing based on their
            educational and employment outcomes, and have remained in the
            bottom cohort of center performance rankings for many years.
            Especially in a constrained budget environment, and given the
            resource intensiveness of the Job Corps model, it is neither
            possible nor prudent to continue to invest in centers that have
            historically not served students well. The populations
            previously served by these Job Corps centers will be eligible
            to attend higher-performing centers. Job Corps will also make
            changes to its strategies and approaches based on the findings
            of program evaluations, strengthen the performance measurement
            system, and report center-level performance in a more
            transparent way.
          Reforming the Regional Office Structure of Five Offices Within
            the Department of Labor.--The Occupational Safety and Health
            Administration (OSHA); the Employee Benefits Security
            Administration (EBSA); the Office of the Solicitor (SOL); and
            the Women's Bureau, where the savings are reinvested dollar-
            for-dollar in the Wage and Hour Division (WHD), and the Office
            of Public Affairs. By consolidating or streamlining offices we
            will minimize administrative costs while ensuring that offices
            are strategically placed to perform DOL's functions across the
            country.
          Curbing Nonessential Administrative Spending.--In support of the
            President's message on fiscal discipline and spending
            restraint, DOL has established a plan to reduce the combined
            costs of certain administrative expenses by more than 20
            percent from fiscal year 2010 levels by the end of fiscal year
            2013. Reduction efforts focus on travel, printing, supplies,
            advisory contracts, the executive fleet, extraneous promotional
            items, and employee information technology devices.
          Improving Program Effectiveness and Efficiency.--DOL's fiscal
            year 2013 budget request continues past efforts to enhance
            program effectiveness and improve efficiency. We will invest in
            program evaluations to be overseen by the Chief Evaluation
            Officer and request expanded authority to set aside funds from
            major program accounts for an increased number of evaluations.
            These investments will provide DOL with valuable information
            about strategies and approaches that work and ensure that our
            resources are invested strategically in proven tactics.
                      investing in a competitive workforce
        Particularly during this time of high unemployment, we believe it
    is imperative to provide both a helping hand and a viable path back to
    employment. To get America back to work, DOL will continue critical
    investments in job training and resources for job seekers. Not only do
    these investments provide a lifeline for those who still need critical
    help, but they will also save resources of the Unemployment Insurance
    (UI) system and other programs at DOL by helping people get back to
    work. The budget documents have been provided to the subcommittee and
    are available on our Web site, but for now, I want to share some key
    investments included in our budget request before your subcommittee:
          Training and Employment Services.--For an economy built to last,
            we must get our dislocated and low-income workers back to work.
            The budget request continues DOL's commitment to those who are
            most vulnerable to economic distress by maintaining funding for
            our core training programs while also restoring funding to
            programs that serve some of the most vulnerable populations.
            This includes continued requests for the joint Employment and
            Training Administration and the Office of Disability Employment
            Policy Disability Employment initiative, and our policy work
            aimed at increasing the employment opportunities for persons
            with disabilities, including integrated employment for people
            with severe disabilities.
          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, DOL will invest $100 million in
            the interagency Workforce Innovation Fund, which will test new
            ideas and replicate proven strategies for delivering better
            employment and training results at a lower cost to service
            providers, allowing for more participants to be served at
            static funding levels. This investment will be combined with
            $25 million from the Department of Education for a total fund
            of $125 million in fiscal year 2013. Within the Fund, $10
            million is dedicated to building knowledge of what strategies
            are most effective with disconnected youth.
          Veterans' Employment and Training Service.--We know returning
            veterans can contribute greatly to our economy and that recent
            veterans have particularly high unemployment rates. The
            Department will bolster its support for newly separated
            veterans by delivering effective education, employment, and
            other transition services that enable them to move successfully
            into civilian careers. The recently enacted Veterans
            Opportunity to Work to Hire Heroes Act expands tax credits to
            encourage the hiring of veterans and expands access to the
            Transition Assistance Program (TAP) employment workshops that
            are offered to separating servicemembers. The budget builds on
            these efforts by boosting funding for TAP and grants for
            employment services to veterans by $8 million more than 2012
            levels.
          Employment Service.--The Nation continues to struggle with high
            levels of unemployment and the acute needs of employers seeking
            qualified workers. The employment service fills a critical role
            in helping connect workers with jobs, and serves more than 17
            million participants annually. To help workers receiving UI get
            the assistance they need to find work, the budget proposes an
            additional $30 million for the employment service grants to
            States to fund re-employment services for UI beneficiaries.
            These types of intensive re-employment services and job search
            assistance have been found to be one of the least costly and
            most effective ways to get the unemployed back to work.
          One-Stop Career Centers.--The system of One-Stop Career Centers
            is the core delivery system for employment and training
            services. To strengthen this system, the budget includes $50
            million to create a recognizable and uniform brand for the
            career center system, improve access to workforce services, and
            create on-line tools to reach individuals sooner and more
            frequently while offering personalized services.
        The President's budget request includes additional legislative
    proposals for job training and education resources that we are
    requesting other congressional committees to act upon. These proposals
    include:
          Community College to Career Fund.--An educated and skilled
            workforce is critical for the United States to compete in the
            global economy. To help forge new partnerships between
            community colleges and businesses to train 2 million workers
            for good-paying jobs in high-growth and high-demand industries,
            the Departments of Labor and Education will invest $8 billion
            more than 3 years in this Fund. These investments will give
            more community colleges the resources they need to become
            community career centers where people learn crucial skills that
            local businesses are looking for right now, ensuring that
            employers have the skilled workforce they need and workers are
            gaining industry-recognized credentials and receiving training
            relevant to the local needs of employers to build strong
            careers.
          Pathways Back to Work Fund.--Many Americans of all ages need
            better access to job opportunities and employment-based
            training in order to succeed in today's economy. Building on
            successful American Recovery and Reinvestment Act programs that
            provided employment opportunities for low-income adults and
            youths, the budget also includes a $12.5 billion Pathways Back
            to Work Fund to make it easier for the long-term unemployed and
            low-income workers to remain connected to the workforce and
            gain new skills for long-term employment.
                          protecting american workers
        Worker protection programs are crucial to ensure all firms are
    playing by the same set of rules to keep workers safe. The fiscal year
    2013 budget preserves this administration's recent investments in
    worker protection. Some of the highlights of our worker protection
    request include:
          Mine Safety and Health.--The Mine Safety and Health
            Administration (MSHA) provides miners across the Nation with
            safer and more healthful workplaces through enforcement of mine
            safety and health laws, as well as through technical
            assistance, training, and outreach. The budget request for MSHA
            of $372 million provides funding to allow MSHA to carry out its
            mission, while achieving efficiencies and reallocating
            resources into its highest-priority activities, including
            statutorily mandated inspections in the coal and metal/nonmetal
            enforcement programs.
          Case Backlog Before the Federal Mine Safety and Health Review
            Commission.--The budget includes $16.9 million for MSHA and SOL
            to continue ongoing work to address the backlog of contested
            citations at Federal Mine Safety and Health Review Commission
            (FMSHRC). We must continue our efforts in this area to ensure
            that we are holding mine operators accountable if they fail to
            meet their legal and moral responsibility to operate safe
            mines. If we do not reduce the backlog, some mine operators
            will continue to contest violations as a way of ``gaming the
            system'' to delay payment of civil penalties and avoid scrutiny
            under MSHA's existing pattern of violation regulations. This
            will lead to even higher contest rates and potentially unsafe
            mines.
          Occupational Safety and Health Administration.--Occupational
            Safety and Health Administration (OSHA) uses enforcement and
            compliance assistance activities to ensure that this Nation's
            employees are able to return home safely from work every day.
            The request of $565 million for OSHA includes an additional $5
            million to support OSHA's enforcement of the 21 whistleblower
            protection programs it administers that protect workers and
            others who are retaliated against for reporting unsafe and
            unscrupulous practices.
          International Labor.--DOL must ensure American workers are given
            a fair shot to compete on a level playing field with their
            overseas counterparts. The budget requests $95 million for the
            Bureau of International Labor Affairs (ILAB) to strengthen
            workers' rights and protections in our trading partner
            countries, including an increase of $2.5 million for enhanced
            trade agreement monitoring and enforcement.
                    securing americans' incomes and benefits
        It is essential that we take steps to ensure that America's workers
    are not permanently affected by economic distress. To that end, DOL's
    budget includes resources to help those who have been affected stay
    afloat while they struggle to get back on their feet. Some key
    investments we propose in the fiscal year 2013 budget to ensure
    Americans' income and benefits security are:
          Wage and Hour.--As we continue to recover from one of the worst
            economic crises in three generations, it is especially
            important that we invest in the enforcement of key laws that
            protect our workers' wages and benefits. In fiscal year 2013,
            DOL will continue to protect workers and level the playing
            field for businesses by providing WHD with $238 million,
            including an additional $6.4 million for increased enforcement
            of the Fair Labor Standards Act and the Family and Medical
            Leave Act (FMLA), which ensure that workers receive appropriate
            wages, overtime pay, and the right to take job-protected leave
            for family and medical purposes.
          Employee Misclassification.--When workers are misclassified as
            independent contractors, they are deprived of benefits and
            protections to which they are legally entitled, such as
            overtime and unemployment benefits. At the same time, those
            businesses that play by the rules are placed at a disadvantage
            against employers who violate the law. The fiscal year 2013
            budget proposes $14 million to combat misclassification,
            including $10 million for grants to States to identify
            misclassification and recover unpaid taxes within the
            unemployment insurance system and $3.8 million for the WHD to
            detect and deter the misclassification of employees as
            independent contractors and strengthen and coordinate Federal
            and State efforts to enforce labor violations arising from
            misclassification.
          Unemployment Insurance.--This administration is committed to
            protecting the financial integrity of the UI system and helping
            unemployed workers return to work as swiftly as possible. The
            budget provides full funding for State administration of the UI
            program, as well as an increase of $15 million for re-
            employment and eligibility assessments. Eligibility assessments
            and re-employment services have been found to be highly
            effective at helping UI claimants find higher paying jobs
            sooner, while at the same time saving money for the UI system.
            To help those who have lost their jobs, the President's budget
            also seeks to strengthen the UI safety net. While not before
            this subcommittee, the budget request incorporates the
            Reemployment NOW program originally included as part of the
            American Jobs Act, which includes resources and reforms to help
            UI claimants get back to work quickly. The Reemployment NOW
            program provides funds to introduce programs that allow the
            flexible use of unemployment benefits for short-term employment
            and for individuals who want to start their own businesses,
            some of the elements of which were adopted as part of the
            recently enacted Extended Benefits, Reemployment, and Program
            Integrity Improvement Act (Public Law 112-96). The budget also
            proposes to put the UI system back on the path to solvency and
            financial integrity by providing immediate relief to employers
            to encourage job creation now, reestablishing State fiscal
            responsibility going forward, and working closely with States
            to eliminate improper payments.
          Employee Benefits Security.--To protect health and retirement
            benefits, DOL is requesting $183 million for EBSA for the
            protection of more than 140 million workers, retirees, and
            their dependents who are covered by more than 700,000 private
            retirement plans, 2.5 million health plans, and similar numbers
            of other welfare benefit plans which together hold estimated
            assets of $6 trillion.
          Pension Benefits.--The budget proposes to strengthen the defined
            benefit pension system for the millions of Americans who rely
            on it by giving the board of the Pension Benefit Guaranty
            Corporation (PBGC) authority to adjust premiums and directing
            the board to consider a number of factors, including a plan's
            risk of losses to the PBGC. This action will both encourage
            companies to fully fund their pension benefits and ensure the
            continued financial soundness of the PBGC. It is estimated that
            this proposal will save $16 billion more than the next decade.
          State Paid Leave.--Too many American workers must make the
            painful choice between the care of their families and a
            paycheck they desperately need. While the FMLA allows workers
            to take job-protected, unpaid time off, millions of families
            cannot afford to take advantage of this unpaid leave. DOL's
            budget request includes a $5 million proposal for a State Paid
            Leave Fund to provide technical assistance and support to
            States that are considering paid-leave programs to help workers
            who must take time off to care for a seriously ill family
            member.
                                   conclusion
        To summarize, DOL's fiscal year 2013 budget request provides
    investments to help better connect workers and employers and prepare
    Americans with the skills they need--and that businesses are looking
    for--for the jobs of today and the jobs of the future. It also ensures
    that we have fair and safe workplaces for our workers. An economy built
    to last will require good jobs that pay well and provide security for
    the middle class, and this entails undertaking actions now to support
    and strengthen economic growth and reallocate resources to allow
    targeted investments where they are needed. 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 my 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, Madam Secretary.
        We will begin a round of 5-minute questions here, as soon
    as I figure out who has control of my clock here. Here we go.
    And then I will recognize Ranking Member Shelby.
        Madam Secretary, first of all, I just want to say that last
    evening, I have looked over your entire statement and noted the
    sections where you are bumping up some funding. I absolutely
    cannot find anything that I really disagree with. I think you
    have got the right priorities. I think where you are focusing
    some additional monies is where they ought to be focused, and
    you have my full support in that.
        Again, we will have to see how the whole appropriations
    process works out this year, but I do believe that you have
    done a great job, and your staff has done a great job in making
    sure we have the right priorities funded, and bumped up a
    little bit in those areas that are needed.

               SEQUESTRATION UNDER THE BUDGET CONTROL ACT OF 2011

        One question I just want to ask for the record, and I ask
    it of all the Secretaries that appear before this subcommittee,
    and that is the impact of sequestration. Under the Budget
    Control Act of 2011, funding for almost all programs face a
    possible across-the-board cut in January 2013 if the Congress
    does not enact a plan before then to reduce the national debt
    by $1.2 trillion. In other words, the Congress could approve
    the Departments of Labor, Health and Human Services, and
    Education, and related agencies appropriations bill later this
    year, but find that every budget item is going to be cut by
    sequestration.
        Now, this responsibility rests with the Office of
    Management and Budget (OMB). They have not announced how they
    are going to carry out the process. However the Congressional
    Budget Office (CBO), that is who we rely on, estimated that
    most nondefense discretionary programs would face a cut of up
    to 7.8 percent. Some, such as the Center on Budget and Policy
    Priorities, think the cut could be even larger, about 9.1
    percent. But for the sake of discussion, we will go with CBO.
        I just wonder, have you looked at this question? What would
    the impact be of a 7.8-percent cut to the services and
    activities of your Department? Again, I am particularly
    interested in what that would mean for job training programs
    and worker protection.
        Secretary Solis. Thank you, Mr. Chairman.
        I know that our effort, with the administration, is to work
    with the Congress to see that we can enact a balanced approach
    to deficit reduction. So that is our first priority. We still
    stand very committed to finding some resolution there.
        With respect to the details of sequestration, I cannot get
    into the procedures and how that will be conducted, because I
    know OMB and the administration would like to avoid
    sequestration to begin with. Nevertheless, that is something
    that they will also have to help guide us on.

                   PROGRAMMATIC IMPACTS OF A 7.8-PERCENT CUT

        But I will tell you that, based on overall, your question
    about a reduction of 7.8 percent, in terms of job-training
    programs, we are looking at a hit of about $500 million to our
    workforce system, and also the inability, to reach 1.7
    additional participants. And, of course, you and I know how
    important this 1.7 million individuals that would be cut short
    of our services, and in a time of high unemployment. That is
    not a good sign.
        With respect to veterans, which I know this subcommittee is
    very focused on as well, we are looking at a reduction of about
    $13 million overall in the efforts to try to find employment
    services and provide help for veterans.
        With respect to the Job Corps program--and, in fact, I have
    some students that are visiting us from the Potomac center here
    that have chosen to come and attend this hearing--we are
    looking at a Job Corps program cut, that would be about $122
    million reduction overall. That would mean 3,100 or 3,145 to be
    exact, fewer slots that we would not be able to offer around
    the country. And in a time of high unemployment for youth,
    which is at 16 percent, that obviously would have a devastating
    effect.
        In worker protection, in terms of safety, monitoring, and
    being able to provide technical assistance to businesses, we
    are looking at a worker protection reduction in our agencies of
    $136 million. Again, that would also hurt the safety, well-
    being, and protection of workers in the workforce.
        That is about as best as I can gauge right now, Mr.
    Chairman. But, certainly, we want to work with you and the
    Congress to avoid sequestration.
        Senator Harkin. Well, thank you, I appreciate that. And I
    might be asking for further clarification in written
    correspondence, because I just think people have to know that
    it is not just the defense industry that would be hit. They
    have, of course, been very vocal in their opposition to the
    sequestration, about what it would mean for cuts in aircraft
    and warfighting equipment. But we also have to look at what it
    is going to do to our human infrastructure in this country, if
    we had the sequestration. And a lot of that falls in your
    Department.
        So I think it is important for us to note what is going to
    happen if we have the 7.8-percent sequestration. So I thank you
    very much for outlining them.
        I would yield now to our ranking member.
        Senator Shelby.
        Senator Shelby. Thank you, Mr. Chairman.
        Madam Secretary, we welcome you again here.

             JOB CORPS: DEFINING CHRONICALLY LOW-PERFORMING CENTERS

        In the area of the Job Corps, I have several concerns about
    the cost per student, program performance evaluations, and
    employment outcomes over the life of a Job Corps participant. I
    am pleased to see, however, that the fiscal year 2013 budget
    includes reforms to improve the outcomes and strengthen
    accountability. But we have not seen a lot of the details in
    your request.
        The budget includes, as I understand it, a proposal to
    close chronically low-performing centers. That sounds good. But
    it does not define a chronically low-performing center.
        Can you discuss aspects of your proposal, specifically the
    approximate number of centers that you intend to close, what
    classifies the center as low performing, and how will you use
    those savings from the closure? I think you are going down the
    right road, but I want to hear some specifics, if you can
    discuss them.
        Secretary Solis. Thank you, Senator Shelby. I know that
    this is of concern of other members on the subcommittee. And
    while I strongly believe that the Job Corps program is one of
    our premier programs, I have had the ability to work with many
    of them and probably have a record now as one of the
    secretaries that has visited most of the Job Corps centers in
    the country. And I can tell you that our goal remains to
    continue to try to have at least one Job Corps in each State,
    and we hopefully are continuing to achieve that, which is very
    important with the addition of the New Hampshire site and
    Wyoming site.
        But we need to look at performance, and looking at how well
    we are doing and how well we are not doing. And I certainly
    care about that.
        Senator Shelby. Well, that goes to the durability and the
    reputation of the program, doesn't it?
        Secretary Solis. Exactly. And it is very important that we
    are training individuals for good certificates, and that we
    don't evaluate these Job Corps centers by criteria that they
    have not been introduced to before. So that is one thing that
    we want to make sure of.
        I cannot give you a list right now of the job centers that
    we are looking at, but we will be looking at criteria that we
    have used in the past to look at low-performing centers to see
    what improvements they have made----
        Senator Shelby. Is that how you would define a ``low-
    performing center?''
        Secretary Solis. There would be other aspects, as well, but
    nothing that I think would be out of the ordinary would be
    entirely new. So we would use the best criteria, and also what
    kind of attempt they have made over the past 3 years to correct
    themselves. Since I have been there, we have tried to institute
    better evaluation and technical assistance.
        I think the message is very clear. It isn't just with Job
    Corps but our other programs as well. We think that there
    should be higher standards. In my opinion, I would love to see
    more of our students while obtaining their high school or GED,
    also enrolled at a community college. And some of our centers
    do that, and I want to be able to set a marker so that we can
    enhance the growth and ability so those young people have more
    choices. That is the direction that the Department will take.
        Senator Shelby. But the bottom line is, and you know this
    well, is you have to measure what we are spending money for,
    what is working and what is not working, what centers are
    efficient and which ones aren't. Otherwise, we are just
    throwing money away, aren't we?
        Secretary Solis. And, Senator, I would tell you that before
    anything is made public, we will converse with you----
        Senator Shelby. Will you consult with----
        Secretary Solis. Coordinate----
        Senator Shelby [continuing]. The chairman of the
    subcommittee?
        Secretary Solis. Yes, and we will also make sure that the
    public is fully aware, so we give ample opportunity for
    communities to come forward and also make comments. We will go
    through the Federal Register process.
        Senator Shelby. Sure. Thank you.

                             UPDATES TO H-2B RULES

        I have another area, the H-2B rules. Many industries, as
    you well know, including the seafood and timber industries rely
    on DOL's H-2B visa program to find temporary seasonal workers.
    The seasonal nature of these industries means that these
    businesses routinely face shortages of local workers during
    their peak season.
        The H-2B program not only keeps these businesses open, but
    also contributes to the creation of additional year-round jobs
    for local workers by being open.
        For the second year in a row, it is my understanding that
    the Department has proposed an H-2B rule that would add
    regulatory burdens and costs to American businesses. In
    particular, an H-2B worker would be required to receive a
    minimum of three-quarters of their wages for each 12-week
    period they are employed, even if they do not work three-
    quarters of the time due to weather or other unforeseen
    circumstances. Further, the rule would require, as I understand
    it, employers to pay transportation and subsistence costs to
    and from the workplace for those workers hired under the
    program.
        Many small businesses that use the H-2B program are, you
    know, just simply cannot afford these regulations, and will
    ultimately close, costing us jobs, be more job losses. These
    rules, I believe, are clearly not meant to reform the program
    but, some people believe, to shutter it.
        Do you understand that these rules, as we understand it,
    and they are being implemented, will kill American jobs, not
    create them? And what can we do about this? What is the real
    thrust here?
        What we want to do is create jobs, sustain jobs, isn't it?
        Secretary Solis. The Department has a responsibility, as
    you know, to ensure that the H-2B program works for American
    workers. Yet, one of our priorities is to make sure that we
    strengthen the recruitment requirements for employers, and
    establish an online national job registry because of the high
    rate of unemployment.
        So we also understand that there is a need to at least give
    American workers a chance to apply for these jobs. And what we
    have actually done here is try to minimize abuses that we have
    heard that have occurred.
        Senator Shelby. Sure.
        Secretary Solis. With respect to recruiters that have been
    somewhat unscrupulous----
        Senator Shelby. Sure.
        Secretary Solis. In terms of enticing individuals to come
    through the program.
        Senator Shelby. And you aim to get rid of those people,
    sure.
        Secretary Solis. What we are attempting to do is to hear
    from the employers, and we have heard from those folks that you
    did mention. We did meet with them, and talked about how to
    look at enhancing and improving upon the system as it works
    now. And I know we still have a ways to go. In fact, as a
    result of an appropriations rider, the effective date of the
    wage rule has changed from October 1, 2012.
        The rule changes and the methodology of how H-2B wages are
    calculated will be looked at. And what our attempt here is
    trying to make sure that people are paid adequate wages, that
    foreign workers aren't just drawn here with the belief that
    they are going to have good wages. And then we are
    shortchanging other competitors, businesses that are playing by
    the rules. So we always look to ensure that we can provide
    fairness in those wages.
        Senator Shelby. Well, there should be fairness, and people
    ought to go by the law. And you have to root out fraud and
    everything else.
        But on the other hand, if you put such a burden on these
    small businesses, look at the jobs, the unemployment rate. You
    know, look at the rate of people who have quit looking for a
    job, is 15 percent.
        We shouldn't try to kill and tighten up and over-regulate
    these businesses, should we? I think a lot of the employers
    think that is what you are doing.
        Secretary Solis. Well, we are going to work hard with
    business and try to see how we can better inform them of how
    these programs fully operate. Because the job market has
    changed, and the dynamics of our unemployment situation has
    caused us to look at things a little differently.
        And we will be conducting more outreach, such as, national
    webinars, and making sure that the employer community is
    engaged with us and we are engaged with them. But we have met
    with several Senators on this particular issue, and we are very
    much aware of their comments and concerns.
        Senator Shelby. Don't forget a balanced approach.
        Secretary Solis. Absolutely.
        Senator Shelby. What you do with regulations if you overdo
    it.
        Thank you, Mr. Chairman.
        Senator Harkin. Thank you.
        Senator Brown.
        Senator Brown. Thank you, Mr. Chairman. And welcome, Madam
    Secretary, nice to see you.

                  WORKER TRAINING PROGRAMS AND THE SECTORS ACT

        Early in my term, in 2007, I conducted dozens of
    roundtables around Ohio where I would meet with sort of cross-
    sections of communities, and what was clear to me was that even
    as the economy worsened in 2008, is that employers oftentimes,
    and a wide cross-section of employers, had difficulty finding
    qualified workers. And what we sort of came up with, and I have
    introduced this legislation in three different Congresses now,
    is the Sectors Act, which, as you know, and as you and I have
    talked, Madam Secretary, pretty much empowers local businesses,
    community colleges, workforce investment boards, unions when
    applicable, to right, sort of from the bottom up, to construct,
    well, worker training programs.
        We saw something similar to that, and that the Labor
    Department helped to fund. Just a few weeks ago I was at
    Cincinnati State in southwest Ohio with a group of, in the
    biosciences school, in the school of biosciences, if you will,
    with employers. And they had, in part with this Labor
    Department grant, were seeing a number of people connected that
    way, and employers who need pretty highly skilled workers
    coming out of Cincinnati State finding them.
        The President included $8 million for the Community College
    to Career Fund. I think we have seen quantitative evidence that
    this kind of worker training works.
        And I would like your thoughts on how the Department is
    currently supporting sector partnerships, how does the
    administration plan to move the fiscal year 2013 proposal
    forward? How does, what role does the Labor Department play in
    this?
        Secretary Solis. I want to commend you for having the
    foresight to put forward legislation when you did, because it
    is exactly where we need to go. And we are not going to wait
    for reauthorization of Workforce Investment Act (WIA), because
    we have been in gridlock, even though I know the Senate has
    been very much more forward-thinking about working together.
        We have identified programs that we have funded already
    that are looking at sectors. And we have partnered with other
    agencies like Departments of Energy and Commerce so that we can
    help to fund and provide new initiatives, and support in
    innovation for sectors.
        So, just like Silicon Valley, you see a section of
    California that has taken off with IT over the years, and that
    has been changing. We want to continue to fund those kinds of
    regional sectors that are looking at broad growth in the next
    decade or so, and also looking at places like North Carolina
    and even Florida, where we know that the National Aeronautics
    and Space Administration (NASA) effort is going to be changing
    there. But we should not allow for that brain trust to leave by
    somehow incentivizing businesses and others to come forward.
        And we see it best done with community colleges. We are
    requiring them to do much more. And while this funding has been
    a great opportunity, there is still much more work that we have
    to do because community colleges typically don't always, how
    can I say, go out onto the assembly line and floor and really
    engage with some of the businesses to get the best curriculum,
    and find out exactly what employers want. Some are doing a
    better job than others--but we need to do more. And that is
    why, through the Workforce Innovation Fund, we are continuing
    to fund those efforts.
        Also, through the community college and the Trade
    Adjustment Assistance (TAA) program has just been phenomenal.
    We are already seeing some of the benefits from that. I just
    came off a bus tour with Dr. Jill Biden, and we visited your
    State of Ohio, Columbus State University, and heard from many
    of those businesses that have taken advantage of these programs
    that are now actually thrusting us into new areas of renewable
    energy, manufacturing, and creating a need for businesses to be
    attracted to a particular area because they know they are going
    to have better skilled individuals, and that the communities
    themselves are even offering up tax credit incentives to make
    that happen.
        So I think this is a very good thing that is going on. And
    it is a win-win for all of us, particularly these training
    programs that are finally, I think, reaching the type of folks
    that have been out of work for long periods, and helping to get
    dislocated workers into a new train of thought where if, they
    were doing something for 25 years and their job is no longer
    there, they can now receive upgraded skill certificates. So I
    think certificates, and making it more measurable in that way,
    we are having better results.
        And we are using the dollars more efficiently.
        Senator Brown. Thank you. Let me shift in my last question.

                      YOUTH UNEMPLOYMENT AND JOB TRAINING

        Ohio's unemployment rate is much too high. It is below the
    national average, but still much too high. Even more troubling
    is the unemployment rate among young people, as you know. And
    in Ohio, people aged 16 to 19 have, last year their
    unemployment rate was 19.5 percent.
        I have worked on the Youth Corps Act of 2012, which would
    help to address the need to provide young adults, especially
    those who are in some sense disconnected with more employment
    opportunities. Talk to me about what the Labor Department is
    doing with employment opportunities, especially for young
    adults, especially as summer nears, when the mayors don't have
    the opportunity to put as many young people to work teaching
    them skills, and teaching them work habits, and giving them
    some financial help.
        What are we doing?
        Secretary Solis. Well, Senator, as you know, in the
    Recovery Act we did receive funding to help push out summer
    youth employment around the country. We had close to 400,000
    student participants, which was good because that helped to
    provide them with good work experience and a pay check.
        We continue to work with our youth field programs to assure
    that we are continuing to train individuals. And you can see in
    the audience here today we also have some young students from
    Potomac Job Corps that are entering into areas like
    pharmaceutical assistance and security. We are seeing that we
    are changing our curriculum to make it more amenable and cost
    effective, and really listening to what employers want we can
    make that bridge a lot sooner.
        We also are making investments with students and young
    people that have had trouble with the law, through our
    reintegration of ex-offenders programs. That continues to be a
    high priority, and we are working with the Department of
    Justice to help alleviate some of those issues and barriers
    that continue to be major impediments for people to reintegrate
    into society.
        The President also has now taken up this initiative to
    create summer jobs but on a volunteer basis. Since there is no
    funding for this initiative, we are asking for corporations to
    step forward. We have about 170,000 corporations that have now
    said that they will work with us, set up mentoring programs,
    internship programs, and paid positions. But we need more
    corporations, and more small businesses, and even nonprofits to
    participate. So that is something that the President has
    strongly gotten behind.
        I remain very committed to not only Summer Youth, but to
    all of our youth programs, because I think that we have too
    many young people that are out of work; there is a 16-percent
    underemployment rate and in some areas, as you know, depending
    on the particular ethnic backgrounds, it is much higher. And
    that is unacceptable at a time when we need everybody to be
    working.
        I look forward to working with you on ideas that you might
    have on how we can make our programs a more efficient, and
    hopefully get more of the private sector involved in joining in
    our partnerships.
        Senator Brown. Thank you.
        Senator Harkin. Thank you, Senator Brown.
        Senator Moran.
        Senator Moran. Mr. Chairman, thank you.
        Madam Secretary, I am pleased to have the opportunity
    finally to visit with you this morning. I want to follow up on
    at least the topic that was just raised in your conversation
    with the Senator from Ohio and, in fact, in response to the
    question from the Senator from Alabama about youth. And I
    noticed that you said that we have high unemployment especially
    with youth. And in regard to Senator Brown, you were talking
    about mentoring programs and internships.

                           CHILD LABOR IN AGRICULTURE

        And I am very concerned about the DOL's proposed
    regulations as they deal with youth labor in regard to farms.
    And disappointed--you and I know each other from our days of
    serving in the House of Representatives--and disappointed in
    the Department's effort at outreach and understanding of what I
    think is a very unique way of life. The Department, on its own
    volition, decided to alter, at least propose altering, the
    regulations related to young people working on farms, including
    young people working on their own families' farms. And this is
    an issue that fundamentally alters a historic and familiar
    relationship so important to America, and particularly
    important to rural America.
        And so I am here to engage in a conversation, but to
    criticize not only the process but, at least to date, the
    result that your Department is pursuing in regard to these
    regulations.
        I have asked--again, from our experience in the House I
    consider you to be a conscientious, well-intentioned, open-
    minded person. But I do want you to know that we have reached
    out to you, invited you to meet with me, which was declined,
    invited you to come to Kansas, which was declined. Not to
    necessarily spend time with me, but to be on family farms, to
    meet with Future Farmers of America (FFA) students, see what a
    4-H program is like, to get an experience of something that is
    a pretty common way of life in many places across the country.
        Also, 30 Senators wrote you, the DOL, a letter expressing
    concerns and raising questions. We were told--it was a
    bipartisan letter, we were told that the Department would not
    respond to that letter, but that it would be considered just
    like other comments made by citizens in regard to those rules.
        And so I have the sense that there are those who have the
    ability and desire to have a conversation with you at the DOL
    so that you are fully aware of the consequences of the proposed
    changes that you are making.
        The rules that you are proposing deal, at least in my view,
    in three broad areas. One is a parental exemption, the question
    of whether or not children could work on their own family's
    farm. And the idea that you would even--and I understand that
    you are re-proposing that portion of the rule, and I am worried
    that that sends a message that things are okay. We don't know
    what that re-proposed rule is going to look like, but the fact
    that you would suggest rules that relate to whether a farmer's
    own child at age 15 can work on their own farm suggests that
    input is needed, that this is a major change in the way that we
    live our lives.
        And as you talked about the need for youth employment, it
    is one of the few remaining opportunities for many rural youth
    in small towns across Kansas and around the country to find
    employment in the summer and throughout the school year.
        In addition to that, you want to intrude upon what is
    currently working, in my view, well, related to student learner
    exemptions, and replace 4-H and FFA and county extension
    programs with a DOL program. And you indicate in the proposed
    rules that you believe 4-H and FFA and county extension are,
    quote, too locally driven and lacking Federal direction.
        In my view, those kinds of programs that are locally driven
    by people who have experience, knowledge and a desire to see
    children in their own communities succeed is exactly the kind
    of programs we need.
        And finally, the third component of your proposed rules
    deals with hazardous occupations. And in that regard, the
    regulation is so overly broad, regulations prohibiting a young
    person from working 6 feet off the ground mean that no child,
    no young person is going to be in the cab of a tractor or a
    combine. And, in fact, your rules suggest that a young person
    could not even use a power-driven screwdriver. The language of
    the legislation prohibits anything for a young person to use
    that is not driven by their own power. And so, based upon the
    broad language of this ``hazardous occupation'', do you believe
    that you are prohibiting the use of a power, a battery-powered
    screwdriver?
        The consequences of the things that you put in your
    regulations lack common sense. And, in my view, if the Federal
    Government can regulate the kind of relationship between
    parents and their children on their own family's farm, there is
    almost nothing off limit in which we see the Federal Government
    intruding in a way of life.

                          ADMINISTRATIVE PROCEDURE ACT

        Senator Harkin. Madam Secretary, before you answer that, I
    just want to interject something here.
        I understand the Senator has concerns about this proposal.
    I think we probably all do, those of us from rural areas. I
    still live in my hometown of 150 people. Not too many people
    can say that. And we are all farm-based, and so we all have
    concerns about it.
        However, I just want to state that I and my colleagues need
    to recognize that the DOL must be careful to adhere to the
    Administrative Procedures Act (APA) while it is engaged in this
    rulemaking. Under the APA, the Department is limited in the way
    it is able to discuss a proposed rule, either in meetings or in
    correspondence with interested parties.
        So, you know, this goes back--I've been here a long time.
    Sometimes we all get frustrated with rulemakings. But I
    recognize that whether it is a Democratic or Republican
    administration it doesn't make any difference, they still have
    to adhere to the APA. And so they are limited in what they can
    say, and how they can approach it.
        All the indications I have is that the Secretary takes the
    views and concerns of the agriculture community seriously. They
    are carefully reviewing the more than 10,000 comments it has
    received on this rulemaking. They are consulting with the U.S.
    Department of Agriculture (USDA). And any letters that I write,
    or anybody else writes, will be considered as part of those, as
    part of those comments.
        So I just wanted to state that for the record, under the
    APA.
        Please proceed.
        Secretary Solis. Thank you, Mr. Chairman. And also, Senator
    Moran, I understand your concern, and have taken note of
    comments by other Members of Congress and Senators that have
    communicated with us on this rule. I take very seriously the
    comments that you have made. And I realize that you sent a
    letter to us, but it was at a point where I couldn't respond
    because we were already entering into that gray area where I am
    not allowed to publicly put anything in writing because of the
    comment period.
        But I will tell you that other letters that we received,
    10,000 in fact, had similar subject matters. So it is noted.
        I also want to let you know that, while I wasn't able to
    visit with your local farmers or you in your district, or your
    State, that doesn't mean that my staff isn't available to work
    with you and your subcommittee staff. We have had meetings with
    your staff when you were unable to be there. And we have tried
    to mitigate and at least explain, where there are issues. Some
    of the comments that you make about the use of powered
    screwdrivers and what have you, are taken out of context, and
    they are not what we are proposing. So we do need to do a
    better job of communicating it that is what is being said out
    there.
        I do want to make very clear that it is important for us to
    allow for young people to have the ability to go through
    education programs such as 4-H programs. I don't think this
    rule in any way will hinder that involvement. We are concerned
    when there are fatalities, when we still see the second-largest
    rate of fatalities occurring on farms.
        And while I don't have a problem with children working on
    their parents' or relatives' farms, that is a question that we
    are going to seek comment on. Personally I agree that, those
    are things that should be allowable, quite frankly. But I do
    know that we have to protect and prevent any further injuries
    from young people that are working in settings that are not
    protected.
        We have seen serious fatalities, a record of more than,
    21.3 percent per 100,000. And I just received a report that was
    issued yesterday by the Journal of Pediatrics that also states
    very clearly that we have seen an increase in injury and cost
    to businesses because of fatalities of young people in
    agriculture. Not all of them have been through direct work on
    farms, but many of them in the agricultural industry. So I
    think there is a compelling reason to look at this. We haven't
    upgraded the rule for 40 years. And the way business is done on
    farms has changed a bit.
        We just want to make sure that we get it right, that we get
    the most abundant comments from people that are out in the
    field, that are running these operations, and to do our best to
    try to inform farmers and business owners that we want to work
    with them and provide as much technical assistance and help as
    we can. Certainly we want to clarify those areas that you
    pointed out, that I believe are misinterpreted.
        And we will do what we can to work with you on that.
    Personally, I will see to it that we do that.
        Senator Moran. Madam Secretary, I just would indicate that
    the outreach that, in my view, should have occurred before the
    proposed rules were proposed, was short, fell short. And I am
    troubled by the fact that where you start is so contrary to a
    way of life, to common sense, and to the way that things are
    done.
        I am hopeful that the comment period that you are now in
    will result in significant changes, if not withdrawal, of the
    proposed rule. In fact, we have had pages of folks who have
    contacted us with additional comments, but the comment period
    has expired.
        And it does highlight how the Department's initial
    announcement of proposed rules is so out of touch with farm
    families and youth in rural communities.
        I look forward to the degree that the chairman will allow
    the rules, to have you respond, I would be glad to continue the
    conversation.
        Senator Harkin. Okay, we will start another 5-minute round.
    Thank you.
        As I stated in my letter on this issue, I noted, that
    experts have learned a lot in the 40 years since child labor
    rules in agriculture were first issued. On Monday, the Journal
    of Pediatrics said that more than 26,000 kids and adolescents
    get injured on farms and ranches in the United States every
    year, 26,000. I would just say, Madam Secretary, I would hope
    that you would, in your looking at this, make contact with an
    organization called Farm Safety 4 Just Kids. It was started by
    Marilyn Adams in 1987. It is a wonderful organization. It
    started in Iowa, I am very proud of that. The Web site is
    www.fs4jk.org.
        They have worked with farm families all over the country on
    how to establish safe parameters for kids working on farms,
    working on farms under their parents supervision. I think they
    have really come up with ingenious ways of protecting kids on
    farms and so they could be a great source of information for
    you. My staff could get hold of the staff there for you.

               EMPLOYMENT OPPORTUNITIES FOR DISABLED INDIVIDUALS

        I had one last question, then, and that was dealing with
    the issue of disability. As you know, individuals with
    disabilities have left the workforce at twice the rate of
    people without disabilities, about 7 out of 10.
        Because so many people with disabilities in the recession
    have been laid off, as we begin to re-employ people, I hope
    that we are going to really be looking at, again, not one-for-
    one, but almost two-for-one. For every one person without a
    disability, we have got to hire back two with a disability just
    so we get back to where we were prior to the recession.
        I just, again, would ask you about your disability
    employment initiative. We started that in the fiscal year 2010
    bill from this subcommittee. I know your commitment to
    finalizing section 503 rulemaking by October of this year. I
    appreciate that.
        So, I just wonder if you could just tell us about the
    disability employment initiative. Are there other proposals in
    this budget that I haven't seen to address workforce issues
    related to individuals with disabilities?
        Secretary Solis. Thank you, Mr. Chairman. I know you have
    been a tireless leader on this issue, and something that you
    care and many of us care very deeply about. I do want to say
    that we appreciate your support that you have given us at the
    Department. We have also looked at increasing, through a
    proposed rule, Federal contractors' employment opportunities
    for disabled individuals, which we think is moving in the right
    direction.
        With respect to the disability employment initiative that
    you helped to champion, ETA and our ODEP office, that is the
    Assistant Secretary for ETA, and our Director, Kathy Martinez,
    who you know very well, are working to increase access to
    training, and creating new initiatives. One is the Add Us In
    Initiative. And I think you may be somewhat familiar with that.
    The Add Us In's goal is to get small businesses to better
    understand what the expectations are, and perceptions are, with
    people with disabilities to help create and foster more
    positive outcomes, so that people won't be frightened or afraid
    to hire folks with disabilities, and understand what all that
    means. We are also working with employer associations and other
    sectors to expand that field.
        Senator Harkin. A year ago I met downtown with the U.S.
    Chamber of Commerce, under Mr. Donahue, Tom Donahue. They have
    set as a goal to employ 1--is it 1 million? One million more
    people with disabilities by 2015. I think it is 1 million, it
    may be a little bit more than 1 million. But it is a very
    aggressive goal, and here is someplace where the DOL could work
    with the chamber of commerce in making that happen.
        Secretary Solis. We are attempting to do that with some of
    the various business associations. Kathy Martinez, and our
    Assistant Secretary for ETA who is here, Jane Oates, have been
    working on this, and we know how serious it is. We do have to
    try to level the playing field. So we look forward to working
    with you.
        Senator Harkin. Kathy Martinez does a great job for you.
        Secretary Solis. Thank you.
        Senator Harkin. Senator Alexander.
        Senator Alexander. Thanks, Mr. Chairman. And welcome, Madam
    Secretary.
        Secretary Solis. Thank you.

                               COMPANIONSHIP RULE

        Senator Alexander. I would like to discuss the so-called
    ``companionship exemption'' under the Fair Labor Standards Act
    (FLSA), and the proposed rule of the Department, that I believe
    the comment period may end tonight. So I would like to make a
    comment about it. And then I would like to ask you three
    questions, all of which I believe you could answer yes or no
    without offending anything in the APA.
        Here is my comment. I understand it has not--my worry is
    about changing the way overtime is considered, with the
    companionship exemption. Here we are talking about a situation
    when mostly seniors would hire someone, or some small business,
    to provide a nurse or a helper to live in with that person, or
    to come to that house every day to help someone. And the
    proposals that the proposed rule would seem to have concerning
    overtime suggests to me that the rule would mean that seniors
    in America would have less care, because it would be more
    expensive. There would be fewer jobs for those who are helping,
    and it would likely force a large number of people who are now
    cared for in homes into more expensive institutional settings,
    which would drive up healthcare costs in States which are
    already struggling with healthcare costs, and are about to be
    hit with the new costs that come with the Medicaid mandates on
    the healthcare law.
        So I am concerned that the Department hasn't sufficiently
    evaluated the impact of the rule on what it will do to seniors
    who need care, on people who want jobs, and on Medicaid costs
    to the States.
        The Office of Advocacy at the Small Business Administration
    (SBA) recently sent a letter to you stating the Department's
    economic analysis doesn't fully reflect the fact the majority
    of the in-home companionship services are provided by small
    businesses, and are paid for through the private market. These
    small businesses will have to pass on the higher costs of this
    new overtime to seniors, most of whom are single and living on
    fixed incomes.
        So here are my three questions. One, will the Department
    follow SBA's recommendation to conduct a more thorough economic
    analysis before moving forward with this proposed rule? That is
    number 1.
        Number 2, my office was told by your staff that the
    Department didn't consult with a single Medicaid director when
    developing the rule. Is that true? I am especially interested
    in that because Medicaid is 24 percent of State budgets.
        And, number 3, is the Department willing to withdraw the
    rule to conduct a more comprehensive analysis of the impact on
    State Medicaid and budgets?
        Secretary Solis. Well, Senator, I would first of all tell
    you that in looking at the companionship exemption through FLSA
    that was established back in 1974, it was intended at that time
    to look at other kinds of occupations, like babysitting. It
    didn't really encompass this whole new arena of healthcare, in-
    home healthcare providers. And so it has changed because of
    changing times.
        Senator Alexander. Well, but the change is that we have a
    lot more older people in America who don't have money, who are
    often single. They need help, and they can't a big overtime
    bill.
        Secretary Solis. Senator, I don't disagree, but I also know
    that there is more professionalism that has come about in this
    industry. You have different providers who would like to keep
    people not achieving, say, a better footing, in terms of the
    economy, through these jobs. So they do not want to pay them.
    Many of them have already commented that they are very
    concerned about the overtime pay. But we are looking at an
    industry of about 2 million women, mostly women in this area,
    that are already trying to make ends meet, and are paid very,
    very low wages----
        Senator Alexander. Well, if you put them out of work with
    higher costs caused by your overtime rule, they will really
    have a hard time making ends meet.
        Secretary Solis. Well, I think one of the things that we
    are attempting to do here is also level the playing field.
    Because you do have some good providers, some good folks that
    are playing by the rules.
        Senator Alexander. There is no rule that requires overtime
    pay.
        Secretary Solis. Well, what we are looking at, Sir----
        Senator Alexander. So what you are doing is talking about
    raising the cost of home healthcare to people who can't really
    afford it, and putting people out of work who can't get the
    job. That is what you are really talking about.
        Secretary Solis. Well, we are still taking comments. And I
    know that we have, because of the enormous amount of comment--
    --
        Senator Alexander. Well, what about the answer to my three
    questions? Will you get an SBA report before you move ahead?
    Will you--did you consult with any Medicaid director in any
    State? And, if you didn't, will you before you do the rule?
        Secretary Solis. Well, certainly we have a responsibility
    to always look at economic impact.
        Senator Alexander. Well, the answer can be ``Yes'' or
    ``No'', Madam. Did you, or will you, follow the SBA's
    recommendation? Yes or no?
        Secretary Solis. I will get back to you on that.
        [Clerk's Note.--Additional information is available in
    questions submitted by Senator Alexander under heading
    ``Proposed Companionship Exemption Rule''.]
        Senator Alexander. That is not a ``Yes'' or a ``No''. Did
    you consult with any Medicaid director in any State about the
    increased healthcare costs?
        Secretary Solis. We have consulted with a broad variety of
    appropriate groups.
        Senator Alexander. Did you consult with any Medicaid
    director, which is 24 percent of the costs of a State budget
    about the impact on their healthcare costs?
        Secretary Solis. My staff met with several stakeholder
    groups, yes.
        Senator Alexander. Did you meet with any Medicaid director?
        Secretary Solis. I did not directly.
        Senator Alexander. Did your staff? They told me they
    didn't.
        Secretary Solis. I have to ask my----
        Senator Alexander. So you don't know.
        Secretary Solis [continuing]. Wage and Hour deputy.
        Senator Alexander. You don't know? Whether you met with----
        Secretary Solis. Not offhand. But I know that I have been
    informed fully that they have met with various stakeholder
    groups.
        Senator Alexander. Well, I didn't ask that. I asked whether
    you met with a Medicaid director about this----
        Secretary Solis. I did not personally, Senator.
        Senator Alexander. And if you didn't--well, whether you did
    or not----
        Secretary Solis. No, I did not.
        Senator Alexander. Are you willing to consult with Medicaid
    directors about----
        Secretary Solis. Certainly. Certainly.
        Senator Alexander [continuing]. The effects of the proposed
    rule?
        Secretary Solis. Certainly. Certainly. Certainly.
        Senator Alexander. Thank you.
        Senator Harkin. Senator Graham.
        Senator Graham. Thank you, Mr. Chairman. Thank you, Madam
    Secretary.

                               H-2B VISA PROGRAM

        I want to talk about the H-2B program. And, one, I
    appreciate your staff coming over to meet with several Senators
    that were concerned about this. I thought it was a productive
    meeting. And Senator Mikulski from Maryland was deeply
    involved, so this is a bipartisan issue.
        I think most Americans would be surprised to know, would
    you agree, that apparently there is a labor shortage in
    America, even though we have 8.3-percent unemployment in
    certain areas of our economy?
        Secretary Solis. I know that in certain sectors there is
    that issue does exist.
        Senator Graham. Yes. How can that be?
        Secretary Solis. How can that be?
        Senator Graham. People ask me that. I mean, I just wonder,
    I mean, if we have 8.3 percent unemployment, and maybe 15
    percent of underemployed, and people have stopped working, how
    can it be that we need visa programs for the seafood industry,
    the landscaping industry, and H-1B, the high-tech industry?
        I mean, have you got any ideas on how that happened?
        Secretary Solis. Well, all I can tell you is that for our
    purposes at the DOL, we are trying to assist in providing
    information to American workers about these employment
    opportunities, these openings----
        Senator Graham. And I think you are doing a----
        Secretary Solis. That are available.
        Senator Graham. I think you are doing a good job.
        But, I mean, let me talk about the Kiawah Island Resort,
    they're hosting the PGA, and please come, everybody, in August
    2011. They are having to expand their workforce. That is good
    news. They need some workers, seasonal workers all the time,
    but a plus-up here.
        And they were advertising for service workers, you know,
    maids and other folks to help with the increased capacity
    there, increased business. And they advertised, they needed 150
    workers, and I think we got nine people from the region that
    basically applied. And I can't give you the exact number, but
    about one-third of them couldn't make it because of the drug
    test. So now they have to go to Jamaica and try to bring in
    140-something folks who work hard and do a good job, and that
    was astounding to me. But when you go--have you ever been in a
    chicken processing plant? You know, I know a lot of people from
    the South, it is not a real surprise that American workers have
    moved on from these jobs. It is not because we are lazy, it is
    just because I think the American workforce has higher
    aspirations. And a lot of these jobs that are manual labor
    jobs, like landscaping, and chicken processing, and meat
    processing, employers just cannot find people here at home.
        And I don't think it is an advertising problem. You are
    doing a good job trying to advertise more. And the pay scale,
    because of the rule, is dramatically higher than the minimum
    wage. And the concerns we had is that you were calculating a
    pay scale increase not based on the local community like work
    requirements, but a broader geographic area. You were requiring
    more transportation cost in and out that was making it harder
    for people to afford to get these workers.
        So what I worry about is that we need to give employers
    access to labor, and the first person they should try to hire
    is an American, paying a decent wage. But if you can't hire an
    American, do you agree with me we should have a visa program
    that works for American employers?
        Secretary Solis. Well, I would agree that our purpose is
    to, try to entice American workers to these jobs.
        Senator Graham. Right.
        Secretary Solis. And if they are not able to find them
    after they have gone through a thorough advertisement, beyond
    just the local community paper.
        Senator Graham. Now, we all agree with that.
        Secretary Solis. Because we have abused this program in the
    past.
        Senator Graham. No, we all agree with that. Let us say we
    do it the way that we all agree on, and you just can't find the
    workforce for whatever reason, we want a visa program on the
    high-tech and low-tech end that actually meets employers'
    needs, is that correct?
        Secretary Solis. I would agree with that. And I also would
    think that our priority is to make sure that we don't also
    drive down wages in the past there have been unscrupulous
    employers that have not paid, say, the going rate in certain
    areas.
        Senator Graham. But, in----
        Secretary Solis. And so they have abused the program. We
    are finding that out, and we are trying to clean it up.
        Senator Graham. But the visa program has always had a wage
    calculation requirement. The push-back you got from a lot of
    people from the seafood industry and the landscaping is that
    the cost of this program was getting to be exorbitantly high,
    and it was just not paying what people in South Carolina make.
    You had a broader view of things. The transportation costs
    increased dramatically.
        And as the law, as I understand the law, you can't pay an
    American worker any less than you pay an H-2B visa worker, is
    that correct?
        Secretary Solis. Yes.
        Senator Graham. So you are driving up wages even for the
    local workforce.
        And so I just want to end with this thought: Let us keep
    working together to work on a visa program that meets the needs
    of employers, so they will stay in business, and that American
    workers can go to find a decent paying job, and that the visa
    program doesn't put American workers at risk because we are
    driving up the cost unnecessarily here.
        So, I just want to keep working with you on this. This is a
    big deal to people in my State and, I think, just throughout
    the country. And this is not a Republican issue, this is a
    bipartisan issue. So I look forward to working with you on
    reforming the visa program.
        Secretary Solis. Senator, I agree, and look forward to
    working with you. I agree that we need to work with those
    industries that are growing, the high-tech area in particular,
    and making sure that everyone is using the same reference, in
    terms of bringing individuals here, and they are fully aware of
    what that means--but always giving preference to American
    workers here, that they have first dibs on those jobs. And that
    has been a big game change, I think, in the last few years,
    because of the fiscal crisis that we are in. So we do want to
    do our best.
        And we have worked with Senators, yourself, and we thank
    you for your leadership on this issue and look forward to
    working with.
        Thank you.
        Senator Harkin. Senator Cochran.
        Senator Cochran. Mr. Chairman, thank you.

                     GULFPORT, MISSISSIPPI JOB CORPS CENTER

        Madam Secretary, in 2005, the year 2005, Hurricane Katrina
    struck the Mississippi gulf coast, resulting in huge damages to
    property and businesses and homes all throughout the region.
        Since that time, the Congress has appropriated $14 million
    specifically for the reconstruction of our Gulfport Job Corps
    Center in Gulfport, Mississippi. And I hate to mention this,
    but the center has not been rebuilt yet, and I don't know why.
        But I hope you can help us figure out a way to move forward
    with allocation of previously appropriated funds, or the use of
    funds that we may now appropriate, that can be used under your
    authorities for the construction of facilities for worker
    training and other activities that are appropriate under the
    law for a Job Corps center replacement facility.
        Do you have any plans, specifically, for dealing with this
    need of the Department? Is it considered something that is a
    priority in the DOL?
        Secretary Solis. Senator, I think the last time I was here
    before the subcommittee we had a conversation about this. And I
    do remain committed to continuing to build out that particular
    facility. But I know since that time there have been some local
    issues with respect to the construction of that facility,
    because there are some buildings that are historic in nature,
    that were brought to our attention by the local community
    there. So I know that that has been a challenge for us, in
    terms of figuring out exactly how we go about building and
    starting the construction.
        So I am mindful of that, and want to see how quickly that
    can be resolved, working with you and, of course, taking in
    public comment.
        But while we are waiting, I am responsible for using the
    monies that had been set aside to facilitate other construction
    of other facilities. So I will do that, but I will remain
    committed to working with you, and hopefully see that we can
    get some resolution on a site there that would be amenable to
    the community, as well as to the folks that are involved in
    this process. But we have to do it legitimately. As you know, I
    have to follow procedures, rules, that have been laid down long
    before I arrived as Secretary of Labor.
        Senator Cochran. Well, I appreciate that you have to
    operate under the restraints of law and currently existing
    regulations. But the local community in the Gulfport area, and
    those who would benefit from the training to obtain good-paying
    jobs is still a very serious need in that region.

                              PROPOSED H-2B RULES

        One other question that I have relates to the gulf coast,
    as well. And it involves the seafood community. There have been
    a lot of problems in the Gulf of Mexico that have been
    identified. Many of these are challenging, to say the least.
        But the Department has proposed two H-2B rules that will
    make the process of hiring workers even more cumbersome and
    more challenging to deal with in a positive way.
        Now, I don't know all of the specifics about this, but I am
    told by my staff members in the Gulfport office that we have a
    lot of workers available for H-2B worker's permits. And I
    wonder what is your reaction to the challenge of putting
    together a seasonal workforce under new recruitment timeframes?
    What can we expect?
        Secretary Solis. Senator, we are obviously very concerned
    about this, as well. We have received numerous comments
    regarding this proposal, and know that we are trying, to
    address this as best we can. We want to make sure that we do
    our best to make sure that American workers, have access to
    those jobs, as well--I totally agree with you, because of the
    fact that we have seen such great impacts in the gulf, and want
    to work with you.
        I want to minimize abuses that have occurred in the past. I
    believe that there is more opportunity to have a better, robust
    program that actually helps to give those individuals that are
    engaged in that particular visa program a good quality of life.
        But we want to minimize those unscrupulous businesses that
    take advantage, and drive down costs, and do that deliberately
    because they don't want to pay good wages. So many have been
    able to do that in the past that we are trying to clarify and
    upgrade our rules.
        Our intention is to be very clear and transparent about it.
    But I know that there are folks out in the field that may not
    feel that way, and we want to work with them. That is why we
    are doing more outreach, we are doing more webinars. We are
    consulting with more business, and will do whatever we need to,
    in particular in the gulf. I would love to have my regional
    staff, work with you and your staff, and those appropriate
    individuals, you deem appropriate that we need to work with.
        Senator Cochran. Well, I appreciate the fact that this has
    your personal attention and we thank you for your efforts.
        Secretary Solis. Thank you. Thank you, Senator.
        Senator Harkin. Thank you, Senator.
        Senator Shelby.
        Senator Shelby. Mr. Chairman, Senator Kirk is unable to be
    here. And, Madam Secretary, he has a number of questions, and I
    would submit them to you for the record to answer, if you would
    please.
        Thank you very much.
        Senator Harkin. It looks like our votes are about ready to
    start.
        I just wanted to comment about referring to what Senator
    Alexander was talking about, home care workers and the proposed
    regulation.
        It seems to me that as society has changed, more and more
    people want to receive care in their homes, but we have learned
    some things about this. We know that it is cheaper for society
    as a whole for the elderly to be taken care of in their homes,
    rather than to go to an assisted living place, an institution
    or a nursing home. And, in most cases the quality of life is
    much better for the elderly. They are in their homes, they are
    in their neighborhoods.
        And so this whole thing has built up over the last 30 or 40
    years as we are living longer in our society, I think as
    Senator Alexander alluded to. But it just seems to me that the
    answer to this is not to say that if you are low-income
    elderly, then we need a whole bastion of low-income workers to
    take care of you, who are paid sub-minimum, poverty wages. That
    doesn't seem to help society much, and it doesn't help the
    elderly.
        Some States have already moved ahead. Twenty-one States
    currently offer some protection to home care workers. Sixteen
    States now require overtime for home care workers. So I think
    we are basically moving in the right direction.
        Home care workers need to be better qualified. We know
    instances, case after case, of an elderly person being taken
    care of by someone that is not being paid very well. They are
    not really qualified. The elderly person doesn't take his or
    her medicine. They may fall because they are not supervised
    properly, and maybe don't have the proper barriers in the
    house. They break a hip, they go to the hospital, and the costs
    go up for society because they are covered by Medicare, or
    Medicaid as the case may be. Maybe they are dual-eligible.
        So I think, the time has come to address this issue of home
    care workers, their qualifications and how they are trained, to
    make sure that they are paid to do a job that I think is one of
    the most important jobs in our society. That is to make sure
    that elderly have a good quality of life, that they can
    maintain themselves in their own homes and their own
    communities without being forced to go to an institution.
        So we have to come up with the wherewithal to make sure
    they are paid adequately. As I said, the answer is not to have
    a whole bastion of workers out there that are paid poverty
    wages to take care of the elderly.
        Last, we tried to get a Community Living Assistance
    Services and Supports (CLASS) act into ACA, where people could
    put some money aside for contingencies like this later in life.
    Well, a CLASS Act has got some problems, I know that. But it
    seems to me that we need to have some source of revenues for
    people when they get older to make sure that they can get that
    kind of home care if they so desire.
        The problem, as I have said many times, I have said it
    forthrightly, the only problem with the CLASS Act, it was
    voluntarily. And young people never think they are going to get
    old. They are never going to need that, so they're not going to
    put any money into it.
        But we have seen the value of Social Security, we have seen
    the value of Medicare. We have seen the value of disability
    insurance, all the three components of Social Security, which
    are mandatory, upheld by the Supreme Court numerous times. It
    seems to me we need one more tranche. Because of the longevity
    of people living now, we need another tranche in there, and
    that is a mandatory part that would go toward home care for the
    elderly, and so that we can have a good workforce out there
    that is qualified, trained, paid well, to take care of elderly
    in their own homes.
        So I would just state that for the record, if anybody
    wanted me to go on and on about this!
        Do you have anything else you wanted to add?
        Senator Moran. Mr. Chairman, thank you. I just want to
    follow up.
        I just want the Secretary to know that folks in rural
    America, farm families, care greatly about their kids and their
    safety. Every parent wants to make certain that their child has
    the opportunity to grow up in a safe environment, and have the
    opportunity to earn a living, and learn a trade and a
    profession and pursue the American dream.
        I just want to make certain, absolute certain, that in this
    need to find this safe environment by the Department of Labor,
    that you don't overreact, that you don't overreach, and that we
    don't fundamentally alter the way that rural Americans have
    lived their lives.
        I think teaching, for example, is a noble profession. And
    how do we find good teachers? How does somebody decide they
    want to be a teacher? Well, they experience a great teacher in
    their life, and so they grow up thinking, when I grow up, I
    want to do what this teacher has done for me.
        And your rules as proposed change the way in which we are
    going to have the opportunity for a young person to experience
    working on a farm, their own family's or their neighbor's. And
    we are going to lose that opportunity for that young person to
    say, when I grow up I want to be a farmer, I want to be a
    rancher.
        This is a huge and significant issue for those of us who
    care about rural America. And the rules as proposed are overly
    broad, and overreach, and an involvement in ways that, in my
    view, destroy that opportunity, alter for generations to come
    the chance we have to have farm kids experience that and grow
    up with a dream to farm and ranch in this country.
        We need your help, we need your attention to this proposed
    rule, and would ask again that you alter the plan that you are
    on.
        Thank you, Mr. Chairman.
        Senator Harkin. Thank you.
        Madam Secretary, again, thanks for your appearance here.
    Thanks for your response.
        Secretary Solis. Thank you.

                         ADDITIONAL COMMITTEE QUESTIONS

        Senator Harkin. We may have some further written questions,
    and we will leave the record open for 10 days for such
    questions.
        [The following questions were not submitted at the hearing,
    but were submitted to the Department for response subsequent to
    the hearing:]
                   Questions Submitted by Senator Tom Harkin
                              sequestration impact
        Question. Please elaborate on your response to my question about
    sequestration. I'd like more specific information on the impact of a
    7.8-percent cut on agencies of the Department of Labor (DOL), their
    missions and individuals served by their programs.
        Answer. As I mentioned in the hearing, our effort, with the
    administration, is to work with the Congress to enact a balanced
    approach to deficit reduction. That is our first priority; we remain
    very committed to finding some resolution. By design, the sequester is
    bad policy, bringing about deep cuts in defense and non-defense
    spending and threatening continued economic growth and prosperity. The
    President's 2013 budget presents a balanced plan that contains
    sufficient deficit reduction to avoid a sequester. The budget also
    preserves the Department's core functions and makes important
    investments in areas such as job training and worker protection.
    Although the administration is continuing to analyze the potential
    impact of the sequester, I will tell you that it would be very
    difficult for us to manage cuts of 7.8 percent to our programs and
    still achieve our fundamental mission to prepare and protect American
    workers.
        For example, a 7.8-percent decrease in funding in our employment
    and training programs would result in a reduction of more than $500
    million for our workforce system, meaning that more than 1.7 million
    fewer participants could be trained, retrained, or be helped to find a
    job. For the Workforce Investment Act (WIA) formula grant programs,
    this would mean a reduction of more than $60.1 million for adults,
    resulting in approximately 483,000 fewer job-seekers receiving needed
    services to find sustainable employment; a decrease of $78.6 million
    for dislocated workers, resulting in approximately 63,000 fewer workers
    served; and a reduction of $64.3 million for youth, resulting in 18,600
    fewer disadvantaged youth served. In addition, the Dislocated Workers
    National Reserve would be decreased by $17.5 million, and Community
    Service Employment for Older Americans would be reduced by nearly $35
    million, resulting in approximately 5,500 fewer job-seeking older
    Americans served should this program remain in the Employment and
    Training Administration (ETA) of DOL.
        For the statewide activities funds in each of the three formula-
    funded streams, some States may face a funding deficit to administer
    WIA in program year 2013 if the policy of reducing statewide activities
    funds from 15 percent to 5 percent is continued. If funded at a level
    that is 7.8-percent less than the fiscal year 2012 enacted level,
    approximately eight States (likely Wyoming, North Dakota, South Dakota,
    Vermont, Alaska, Nebraska, New Hampshire, and Delaware given program
    year 2012 formula allotments) would have less than $300,000 available
    to administer their Workforce Investment Act programs.
        In the Job Corps program, a 7.8-percent cut to our current level of
    operations funding would result in a decrease of close to $122.4
    million and would translate into approximately 5,000 fewer student
    enrollments. Funding at this level would also delay the opening of the
    new center in New Hampshire and require us to accelerate plans to close
    Job Corps Centers far beyond the chronically low-performing centers
    that we are committed to addressing, impacting not only the students
    who would not be served, but the communities where centers are located.
    Funding for Construction would be reduced by approximately $8.2
    million, delaying construction and center renovation projects and
    deteriorating center facility conditions, and a reduction of nearly
    $2.3 million to Job Corps Administration would require a cut of 22
    full-time equivalent (FTE) employees, achieved either through attrition
    or a reduction-in-force (RIF).
        For the State Unemployment Insurance and Employment Service
    Operations (SUIESO) appropriation, a reduction of 7.8 percent to the
    fiscal year 2012 funding level translates to a decrease of nearly $56.3
    million for the employment service, resulting in approximately
    1,735,000 fewer job-seekers served. Funding for the One-Stop Career
    Centers would be reduced by nearly $5 million, which would result in
    one or two fewer Disability Employment Initiative grant to States, a
    small reduction in labor market information grants to States, and
    postponement of enhancements to electronic tools.
        A decrease of this magnitude would also require ETA to reduce
    Federal staff by about 51 full-time positions, with severe impacts on
    the oversight, accountability, and efficacy of ETA programs.
        For our worker protection agencies, a 7.8-percent reduction in
    funding would mean a decrease of approximately $136 million. This would
    have a significant impact on our efforts to ensure safe and healthful
    workplaces, and to ensure that workers get the wages and benefits to
    which they are entitled. These reductions would likely impact our most
    vulnerable workers just as we are emerging from an economic recession.
        At this decreased funding level, the Employee Benefits Security
    Administration (EBSA) would be reduced by approximately $14.3 million
    and 100 FTE. This would force EBSA to eliminate nearly 10 percent of
    its workforce and constrain spending in its enforcement, participant
    assistance, and regulatory programs. As a result, EBSA would conduct
    fewer civil and criminal investigations. In addition, effectiveness
    would decline as each Benefit Advisor would have to handle a greater
    percentage of call volume, resulting in less time to analyze and
    resolve participant disputes and inquiries and reducing benefit
    recoveries by an estimated $16 million.
        For the Wage and Hour Division (WHD), a 7.8-percent decrease would
    result in a cut of $17.7 million and 122 FTE, of which 80 would likely
    be investigators. Such a reduction would substantially hamper the
    agency's efforts to level the playing field for all businesses and
    ensure basic fairness in the workplace, particularly affecting the most
    vulnerable low-wage workers in the Nation. A decline of this magnitude
    in WHD investigator staff would result in fewer investigations and less
    money in the hands of workers who purchase basic goods and services in
    this country. More than $17.8 million in back wages would go
    uncollected and more than 21,000 workers would not receive the
    compensation to which they are entitled. In addition, fewer
    investigations could well mean that more children are exposed to
    threatening or hazardous workplace conditions that would otherwise be
    prevented by investigator site visits.
        At a reduced funding level for the Office of Federal Contract
    Compliance Programs (OFCCP), the agency would face a decrease of $8.2
    million and 68 FTE. Any reduction in funding would significantly impact
    the agency's ability to protect workers from discrimination.
    Specifically, OFCCP would reduce the number of supply and service
    investigations, construction evaluations, and Functional Affirmative
    Action Plan (FAAP) reviews such that more than 95,000 employees will be
    affected.
        Reducing funding for the Occupational Safety and Health
    Administration (OSHA) by more than $44 million would put our Nation's
    workers at unnecessary risk by reducing enforcement staffing by 81 FTE,
    60 of which would be Compliance Safety and Health Officers, resulting
    in a decrease of 2,100 inspections. With 2,100 fewer programmed
    inspections targeted to the most dangerous workplaces, fatality and
    injury and illness rates would likely increase. OSHA's whistleblower
    protection program would also be cut by 20 investigator FTE, leading to
    an increase in the already-growing backlog of cases, and making the
    agency unprepared to administer recent whistleblower statutes, such as
    for finance reform and food and safety reform.
        In addition, OSHA's State Plans would be cut by almost $8 million
    at a time when many States are already in difficult financial
    situations due to reductions in funding at the State level. This would
    result in the unemployment of State Plan inspectors, and would lead to
    4,000 fewer inspections of hazardous workplaces. On-site consultation
    programs for small businesses would be reduced by $4.4 million, which
    would lead to the unemployment of staff in these State-based programs
    and an estimated 2,200 fewer consultation visits provided to small
    businesses. Finally, OSHA would be forced to eliminate almost all
    compliance assistance specialists by cutting an additional 31 FTE. The
    agency would be forced to all but eliminate compliance assistance
    efforts for high-demand areas such as residential fall protection and
    severely cut its Voluntary Protection Program.
        For the Mine Safety and Health Administration (MSHA), decreasing
    the agency's funding by more than $29 million could result in delays of
    resolving potentially unsafe conditions and lessen MSHA's ability to
    maintain readiness in the event of a mine emergency. The recent MSHA
    internal review on the Upper Big Branch mine disaster documented the
    effects of imposing resource constraints deep enough to affect MSHA's
    enforcement efforts. At this level, MSHA's ability to maintain staffing
    levels would be impaired. Delays in hiring and training new personnel
    could lead to the staffing and experience shortcoming identified in the
    internal review. A 7.8-percent decrease would also adversely impact the
    ability of the Coal Mine Safety and Health (CMSH) and the Metal and
    Nonmetal Safety and Health programs to conduct all of their required
    inspections and impact MSHA's enhanced enforcement efforts targeting
    the most egregious and persistent violators through the Pattern of
    Violations program and the Special Emphasis dust inspections. It will
    also affect MSHA's ability to support the mine safety and health
    backlog project, and to conduct impact inspections, part 50 audits,
    accountability reviews.
        Additionally, MSHA would have to reduce engineering support to
    enforcement personnel as they encounter difficulties during their
    inspection functions, as well as administrative support for the
    approval of plans, such as dust, ventilation, and roof control. This
    would lengthen the time necessary to review the various plans submitted
    by operators and test equipment destined for use in mines to ensure it
    is intrinsically safe.
        A 7.8-percent reduction would impact MSHA's ability to ensure that
    miners are aware of their rights and responsibilities, impeding MSHA's
    efforts to conduct prompt investigations of miner discrimination
    complaints and investigations of knowing and willful violations of the
    Mine Act, including civil and potential criminal violations. Likewise,
    at the decreased level, MSHA would be forced to reduce efforts such as
    the Small Mine Consultation program and production and distribution of
    training materials to the mining industry, impacting MSHA's ability to
    provide mine operators effective compliance assistance. Many of these
    materials are the primary vehicle for providing safety and health
    awareness to miners. All of these actions have the potential to place
    miners' safety at risk.
        Funding at 7.8-percent less than the fiscal year 2012 enacted level
    for the Office of the Solicitor (SOL) equates to a reduction of $9.8
    million. Because SOL funding largely supports FTE who provide
    litigation and other legal services to the Department in all of its
    enforcement and program areas, a decrease of this magnitude would
    require a reduction of approximately 50 FTE. Based on SOL's major areas
    of work, this would result in approximately 1,100 fewer litigation
    matters opened and concluded compared to SOL's actual litigation
    workload completed in fiscal year 2010 of 14,630 litigation matters
    opened and 14,204 litigation matters concluded. Likewise, SOL would
    have a diminished ability to provide legal opinion and advice, with an
    estimated reduction of 700 fewer opinion matters opened and 400 fewer
    opinion matters concluded, compared to the fiscal year 2010 actual
    results of 8,678 opinion matters opened and 6,198 opinions matter
    concluded.
        For the Bureau of Labor Statistics (BLS), a reduction of 7.8
    percent, or $47.5 million, in fiscal year 2013 would force the Bureau
    to eliminate approximately eight of its survey programs. While the
    administration would have to determine which programs would
    specifically have to be eliminated, this reduction would likely lead to
    cuts in widely used data used to determine the state of the economy and
    for other key purposes.
        At the reduced funding level, the Bureau of International Labor
    Affairs (ILAB) would be cut by nearly $7.2 million. Some key impacts of
    reductions on this scale would be diminishing ILAB's capacity to combat
    child labor and to support projects abroad to ensure that United States
    workers do not suffer unfair competition in today's global labor
    market; reducing ILAB's capacity to monitor and enforce the labor
    commitments of trade partners under Free Trade Agreements, and labor
    obligations under Trade Preference Programs; hampering ILAB's capacity
    to engage in oversight and auditing of projects abroad funded by
    appropriations for specified purposes; and reducing policy engagements
    on job creation and worker protection with key economies such as China,
    India, Brazil, Russia, South Africa, and other G-20 members.
        A 7.8-percent decrease to the Veterans' Employment and Training
    Service (VETS) would reduce funding to this agency by more than $20.6
    million. This includes a reduction of about $13 million to Jobs for
    Veterans State Grants, which would reduce State Disabled Veterans
    Outreach Program and Local Veterans Employment Representative staff by
    approximately 165 positions. This reduction in personnel would result
    in approximately 53,000 fewer veterans receiving specialized services,
    including 7,100 veterans with significant barriers to employment who
    would not receive intensive services and thus continue to have issues
    with obtaining employment.
        With a reduction of $3 million to the Homeless Veterans
    Reintegration Program, VETS projects that approximately 1,500 homeless
    veterans with significant barriers to employment would not receive
    critically needed employment services. Since there are no other Federal
    programs reaching out to homeless veterans with employment services,
    and based on historical placement rates, approximately 889 homeless
    veterans would not be placed into employment and reintegrated back into
    the workforce. With these reductions, the administration's commitment
    to eliminate homelessness amongst veterans by 2015 will not be met.
        At a 7.8-percent funding reduction for the Transition Assistance
    Program, VETS would only be able to provide the mandated Employment
    Workshop to 150,904 transitioning servicemembers and would not be able
    to fulfill the legislative mandates in the VOW Act. This funding level
    would grossly underfund a statutory requirement of the Agency and leave
    approximately 155,084 transitioning servicemembers unserved.
        As you can see through the examples given above, a 7.8-percent
    across-the-board reduction to our programs would have a devastating
    impact on the Department. At a time when we are just starting to see
    strong signs of renewed economic growth, it makes no sense to undermine
    this progress with harmful automatic cuts to Federal discretionary
    spending.
                wage equality for individuals with disabilities
        Question. The fiscal year 2013 budget request for WHD includes
    additional resources and staff for oversight related to the Fair Labor
    Standards Act 14(c) program. How will the WHD and other DOL agencies
    not only improve compliance with the law but also work to improve
    integrated and competitive wage outcomes for individuals with
    disabilities under the budget request?
        Answer. DOL's WHD is working to enhance its investigation actions,
    technical assistance, and certification process on behalf of workers
    with disabilities. In addition, WHD and the Office of Disability
    Employment Policy (ODEP) are working collaboratively to ensure outreach
    efforts include relevant up-to-date information about available
    resources to ensure employers are aware of their obligations and how to
    comply with the law and that workers who have disabilities know and
    understand their rights. For example, WHD is collaborating with ODEP to
    include information about available resources and best practices at
    regional educational events in fiscal years 2012 and 2013 for Community
    Rehabilitation Programs that employ individuals with the most
    significant disabilities. WHD will also examine the Fair Labor
    Standards Act section 14(c) certification program to develop
    subregulatory processes that strengthen safeguards against
    noncompliance and maximize use of adaptive technology to provide
    frontline training to certification seekers. WHD will also collaborate
    with ODEP and other stakeholders to further develop existing programs
    and to identify new avenues of outreach to people with disabilities,
    caregivers, family members, and employers to ensure all stakeholders
    have equal access to information about effective, full employment of
    workers with disabilities. Among other methods, the agency will explore
    how the certification process may be used as a vehicle for
    disseminating new, state-of-the-art employment information and
    resources to affected employers and employees. The Department takes
    very seriously its role in ensuring that the Nation's workers receive
    the full protections afforded under the provisions of the law and will
    provide additional specific training to agency staff to ensure
    investigations and outreach efforts are timely and effective and
    maximize positive impact for workers with disabilities.
                         regional office consolidation
        Question. Please provide more information on the Department's
    proposed consolidation of regional offices, including how the involved
    agencies will continue to meet their goals and objectives under the
    regional reorganization and the specific factors that went into
    identifying the regions proposed for consolidation for each involved
    agency.
        Answer. The budget proposes adopting a leaner, more efficient
    approach for five offices within the DOL:
      --OSHA;
      --SOL;
      --Office of Public Affairs (OPA);
      --the Women's Bureau (WB); and
      --the EBSA.
        In fiscal year 2013, each of these bureaus will consolidate their
    regional offices to ensure that they are strategically placed to
    perform DOL's key functions across the country while eliminating
    unnecessary administrative costs.
        In an effort to streamline agency operations, OSHA proposes to
    reorganize its regional structure and jurisdictional authority from its
    current operation of 10 Regional Offices (ROs) to 7. The reorganization
    will involve the consolidation of OSHA's Regions 1 (Boston) and 2 (New
    York); Regions 7 (Kansas City) and 8 (Denver); and Regions 9 (San
    Francisco) and 10 (Seattle). The estimated savings would come largely
    from the saved compensation from three Regional Administrator positions
    and related benefits. Additional savings would be achieved through
    reduced rent needs and travel expenditures.
        SOL is working on regional office consolidation to better align
    legal offices with the Department's component agency structures, with
    eventual reduction from eight to six SOL regions. As an initial step,
    SOL is planning to reduce one region (Kansas City) in fiscal year 2012.
        OPA consolidation of regional offices includes the closure of
    offices in Denver, Colorado and Seattle, Washington. These offices have
    been essentially closed since fiscal year 2011 due to attrition of
    Federal staff. OPA will continue to meet agency goals and objectives
    continuing to have the workload of the Denver and Seattle locations
    processed and managed by the remaining regional offices in Chicago,
    Dallas, and San Francisco.
        For the WB, the consolidation of regional offices will refocus the
    agency to its policy responsibilities as it works through other DOL
    agencies for its outreach functions. The Department strongly supports
    the work of the WB and believes that increased collaboration with other
    regional DOL agencies will allow the Bureau to more effectively and
    efficiently carry out its mission.
        The WB is developing objective criteria to guide the process for
    consolidation of its regional offices. The goal is to continue to meet
    the Bureau's mission in the most coordinated and efficient manner. We
    anticipate that we will be able to achieve this goal by maintaining
    those WB regional offices in geographical locations where other DOL
    regional offices exist and opportunities for sister agency
    collaboration will be maximized.
        The Department remains committed to the advancement and rights of
    working women, particularly those who are the most vulnerable.
    Consolidating the Bureau's regional offices will result in savings that
    are reinvested, dollar-for-dollar, in the enforcement of the Family and
    Medical Leave Act and Fair Standards Labor Standards Act--two laws that
    have a direct and tangible benefit for women in the workforce.
        As with the WB, EBSA is still developing the details of its effort
    to consolidate regional offices. The objective of EBSA's consolidation
    is to increase the efficiency and effectiveness of the enforcement and
    worker assistance operations. Similar to OSHA's approach, a primary
    guiding principle in the EBSA effort is to not allow a reduction in
    front-line enforcement or other services for the public because of
    consolidation. Some of the specific factors that EBSA is considering in
    identifying the regions proposed for consolidation options include the
    closer alignment of regional offices with financial centers, number of
    plans, participants and beneficiaries, and total plan assets; a better
    alignment of regional workload; the elimination of some split state
    responsibility in regional jurisdictions; and taking advantage of the
    regional locations of other DOL offices such as SOL and the Office of
    Assistant Secretary for Administration and Management.
           occupational safety and health administration enforcement
        Question. The President's fiscal year 2013 budget request includes
    $207 million for Federal OSHA enforcement and $104.2 million for State
    OSHA enforcement. At this funding level, Federal OSHA has approximately
    1,000 workplace inspectors and can inspect workplaces under its
    jurisdiction once every 129 years. This is similar to the number of
    inspectors in fiscal year 2001 and compares to nearly 1,500 Federal
    OSHA inspectors onboard in fiscal year 1980--a time when the workforce
    was significantly smaller.
        With so few inspectors responsible for the safety and health of 140
    million workers, what is the Obama administration's strategy for
    ensuring that there is a strong effective enforcement program to ensure
    that workers safety and health is protected on the job?
        Answer. The agency attempts to shape and focus enforcement
    activities to have an impact on as many workplaces as possible, rather
    than just the workplace which was the target of the inspection. To
    achieve its goal of reducing workplace injuries, illnesses, and
    fatalities through Federal enforcement, OSHA uses strategies that make
    the most-effective use of its limited resources and powers. The agency
    also is working closely with Labor's Chief Evaluation Officer to assess
    its strategies--through current studies involving Site-Specific
    Targeting (SST) and On-site Consultation--and using data and evidence
    to make program changes when needed. OSHA uses the following
    enforcement strategies.
             targeting the most hazardous worksites for inspection
        In addition to inspections that OSHA is required to perform or
    prioritizes, such as imminent danger, fatalities, catastrophes,
    complaints and referrals, OSHA targets inspections through a variety of
    means, including:
      --SST is based on the OSHA Data Initiative and targets establishments
            in general industry with high injury/illness rates.
      --Local and National Emphasis Programs (LEPs/NEPs) target high-hazard
            industries (e.g., shipbreaking), hazards that may lead to
            severe illnesses (e.g., lead and silica), and hazards that may
            lead to severe injuries (e.g., amputations).
      --The Construction Targeting Program (C-Target) is based on a random
            selection of construction projects from a data file provided by
            F.W. Dodge and incorporates a modeling system to predict level
            of activity at a given construction site.
         leveraging enforcement actions to maximize hazard elimination
        The agency has two enforcement strategies designed to leverage
    enforcement action to maximize the elimination of workplace hazards
    that lead to injuries, illnesses, and death:
      --The Severe Violators Enforcement Program (SVEP), which is intended
            to focus enforcement efforts on significant hazards and
            violations by concentrating inspection resources on employers
            who have demonstrated recalcitrance or indifference to their
            OSH Act obligations by committing willful, repeat, or failure-
            to-abate violations in certain circumstances. SVEP actions
            include mandatory follow-up inspections, nationwide inspections
            of related workplaces/worksites, increased company awareness of
            OSHA enforcement, enhanced settlement provisions, and Federal
            court enforcement under section 11(b) of the OSH Act.
      --Corporate or Enterprise Wide Settlement Agreements (CSAs) are made
            with employers that have workplace hazards at multiple sites.
            Through a CSA, OSHA broadens its effect on employers'
            compliance and abatement efforts from one establishment at a
            time to hundreds or even thousands of workplaces at a time.
                   getting the most deterrence from penalties
        Actual and potential penalties deter employers from maintaining
    hazardous workplaces that do not comply with the requirements of the
    OSH Act. However, OSHA's statutory penalty limits are low, compared to
    other Federal agencies. As a result, OSHA must use leveraging
    strategies in order to get the most deterrence from the penalties OSHA
    imposes.
        OSHA implemented a revised penalty system in fiscal year 2011, with
    the goals of increasing deterrence, decreasing noncompliance, and
    reducing workplace injuries, illnesses, and fatalities. Since that
    time, OSHA has been monitoring the effect of the new penalty system and
    has recently adjusted the penalty policy to allow a 60-percent
    reduction in penalty for employers that have between 1 and 25
    employees. These monitoring efforts will continue and the agency will
    modify the system as necessary.
               focusing enforcement on a broader range of hazards
        Under the General Duty Clause (section 5(a)(1)) of the OSH Act,
    employers must provide a workplace ``free from recognized hazards that
    are causing or are likely to cause death or serious physical harm.''
    OSHA is actively using the General Duty Clause to address hazardous
    conditions in areas where there are currently no standards, such as
    heat exposure, workplace violence and combustible dust.
                    increased publicity and direct outreach
        OSHA uses increased publicity and direct outreach to reach many
    more workplaces, supporting its goal of reducing workplace injuries,
    illnesses, and deaths.
        The fear of public disapproval, as a result of being identified as
    a violator of OSHA regulations, motivates employers to abate workplace
    hazards. OSHA has received reports that some employers have abated
    hazards in their workplaces, without any OSHA action directly aimed at
    them, after learning from the media about other employers who have
    received OSHA citations, sizable fines, and public notoriety for unsafe
    workplaces.
        In addition, OSHA continues direct outreach to employers about
    hazards that OSHA believes put workers at particular risk of injury,
    illness, or death. For example, OSHA has continued its campaign on
    distracted driving and will actively work with NIOSH in support of its
    ``Construction Fall Protection Campaign''. OSHA applied this strategy
    in the grain storage industry in fiscal year 2011, following several
    grain entrapment deaths and a study by Purdue University showing that
    the number of grain entrapments in the United States was increasing
    annually. OSHA sent a strong warning letter to more than 1,900 grain
    storage employers in States covered by Federal OSHA and to 350
    employers in State Plan States. Several months later, OSHA sent another
    letter to approximately 10,170 establishments, 6,200 of which were
    covered by Federal OSHA.
          occupational safety and health administration state programs
        OSHA State Plans are responsible for workplace safety and health
    for 40 percent of U.S. workers. Although State Plans develop and
    enforce their own standards, section 18(c)(2) of the OSH Act requires
    these programs to be at least as effective in providing safe and
    healthful employment and places of employment as Federal OSHA programs.
        Federal OSHA conducts annual on-site monitoring visits in each
    State plan to ensure that their standards and enforcement program are
    at least as effective as the Federal program. Federal OSHA is currently
    in the process of concluding an agreement with the state plans
    concerning new effectiveness measures that are scheduled to go into
    effect at the beginning of fiscal year 2013.
                 improving the whistleblower protection program
        Question. Recently OSHA has reorganized their Whistleblower
    Protection Office to make the program more effective and to respond to
    criticism found by the Government Accountability Office (GAO) in
    several reviews. Could you describe what steps DOL/OSHA is taking to
    improve the effectiveness of its Whistleblower Program and how DOL
    intends to use the additional funds and personnel that have been
    requested for this program?
        Answer. In addition to reorganizing and raising the status of the
    Whistleblower Protection office within OSHA, the agency is currently
    undertaking numerous internal improvement efforts in order to improve
    the efficacy of its whistleblower program.
        Due to an increase in the number of whistleblower complaints filed
    with the agency over the past decade, OSHA has steadily accumulated a
    sizeable backlog of whistleblower complaints awaiting investigation. To
    address this issue, the Agency conducted a re-evaluation of its
    investigative processes and is developing numerous strategies for
    streamlining the process, including simplified paperwork requirements,
    new priority-based intake procedures, and a new approach for sharing
    information between parties of a case. Once implemented, these
    strategies will allow OSHA to better manage its whistleblower caseload,
    resulting in higher-quality investigations and better customer service.
        The agency is also developing an alternative dispute resolution
    (ADR) program for whistleblower cases, which will serve as a valuable
    conflict resolution alternative to the resource-intensive and time-
    consuming investigative process. OSHA's ADR program will encourage
    early and fair resolution of whistleblower complaints by providing
    parties with an opportunity to explore resolution options with a
    neutral, third-party mediator.
        OSHA is expanding its audit activities of the whistleblower program
    to promote accountability and ultimately improve the quality of
    whistleblower investigations. Newly developed audits will evaluate how
    closely regional investigators are following the Whistleblower
    Investigations Manual and applicable whistleblower regulations in their
    casework. Planned audit activities include a comprehensive audit of
    regional practices to be performed every 4 years by the National
    Office, as well as self-administered audits for the regions to perform
    during the years that they are not audited by the National Office.
            steps to improve effectiveness of whistleblower program
        Additional OSHA projects aimed at improving the effectiveness of
    the whistleblower program include:
      --Drafting new chapters to the Whistleblower Investigations Manual to
            provide more comprehensive guidance to the investigators in the
            field, and to promote consistency in investigative procedures
            across the regions;
      --Revising OSHA's information database to include a more detailed
            internal control system, which will allow OSHA to identify
            impediments to efficient investigations and better manage
            investigative resources by tracking and monitoring the critical
            phases of on-going investigations;
      --Reconfiguring current training courses for new whistleblower
            investigators to better prepare new hires, and expanding OSHA's
            training offerings to include advanced courses for more senior
            investigators, as well as training for regional supervisors and
            whistleblower managers.
      --Redesigning OSHA's whistleblower program Web site
            (www.whistleblowers.gov) to improve user navigability, and
            developing an online complaint filing system to allow workers
            to initiate the complaint-filing process electronically.
      --Drafting and publishing four Interim Final Rules and four Final
            Rules, and establishing the procedures for the handling of
            retaliation complaints under the whistleblower provisions of
            several statutes recently enacted or amended by the Congress.
                 planned use of additional funds and personnel
        The fiscal year 2013 budget provides an increase of $4.8 million
    and 37 FTE for the whistleblower program. The additional funds and
    staff requested are essential if OSHA's whistleblower program is to
    continue its improvements. Without additional investigator staff, OSHA
    is challenged in meeting the growing demands of its increased statutory
    responsibilities.
        Over the past decade, large increases in the number of
    whistleblower complaints received by OSHA and assignment of new
    whistleblower statutes to OSHA by the Congress have not been matched
    with adequate investigator personnel to handle those complaints. A DOL
    Office of Inspector General (OIG) report (Number 22-12-014-10-105,
    issued January 20, 2012) determined that reducing the caseload to six
    per investigator would require an additional 58 investigators. OSHA's
    fully trained whistleblower investigators currently carry around 30-40
    cases at a time on average. Without more investigators, investigative
    quality and timeliness will continue to suffer. Additionally,
    investigator turnover will remain high as over-worked investigators
    leave OSHA for opportunities elsewhere, compromising training resources
    and depriving the program of experienced whistleblower investigators
    within its ranks.
      reducing employer burden in meeting occupational safety and health
                            administration standards
        Question. Please describe specific actions the OSHA will take to
    meet ``the agency's expanded commitment to reduce the burden on
    employers to the extent possible while still fulfilling its mission.''
        Answer. The increase provided in the fiscal year 2012
    appropriations for the On-site Consultation Program will allow OSHA to
    increase its commitment to assisting small businesses with identifying
    workplace hazards, providing advice on compliance with OSHA standards
    and assisting in the establishment of safety and health management
    systems. The additional funding will provide resources for increasing
    awareness about the On-site Consultation Program's services, training
    for consultants to ensure that their skills are maintained and
    expanded, and promoting and supporting OSHA initiatives through
    outreach, including the planned Fall Prevention Outreach Campaign,
    residential construction initiatives, safety and health in the
    healthcare sector, vulnerable workers and the Injury and Illness
    Prevention Program.
        In addition, OSHA will provide resources to help employers comply
    with new or updated standards. For example, OSHA will issue additional
    compliance assistance resources for its updated Hazard Communication
    Standard. These compliance assistance resources will include small
    entity compliance guides for chemical producers and users and a model
    training program. OSHA will continue to provide employers with
    resources to help them comply with OSHA requirements and protect
    workers from a variety of workplace hazards, including falls and
    working outdoors in the heat.
        Finally, all of OSHA's regulatory activity includes vast
    opportunities for input by stakeholders, including small businesses,
    concerning measures OSHA can take to reduce burdens while providing the
    protection to workers that the OSH Act mandates.
      state involvement in occupational safety and health administration
                                     policy
        Question. How has OSHA involved State plans in development of
    national policy, including national emphasis programs?
        Answer. OSHA recognizes that since States with OSHA-approved State
    plans are expected to participate in OSHA's National Emphasis Programs
    (NEPs), they should have the opportunity to participate in the
    development of these programs. OSHA meets several times every year with
    the Occupational Safety and Health State Plan Association (OSHSPA), an
    organization that represents the 27 States with OSHA-approved safety
    and health programs. When prospective NEPs are discussed at an OSHSPA
    meeting, States are encouraged to raise any concerns or experiences
    that they have on the issue, either during or following the meeting.
        To further improve communication, OSHA implemented a more formal
    system to give the State plans an expanded opportunity, beyond
    discussions at regular OSHSPA meetings, to provide input into the
    development of specific NEPs and other major OSHA policy documents.
    Directives and other policy documents that constitute changes to the
    Federal program which will impact State programs, including NEPs and
    other enforcement policies, are being shared in draft on a special
    limited access Web site for State review in draft and comment prior to
    issuance. Six documents, including five NEPs, have been shared with the
    States in this manner, and conference calls were held between the
    States and the OSHA technical staff involved in developing the
    policies. OSHA has made significant changes in the directives in
    response to written comments submitted by States. OSHA also welcomes
    any State suggestions for hazards or industries that rise to the level
    of a national problem.
                          voluntary protection program
        Question. For the past 5 years with closed data, under the fiscal
    year 2012 budget and fiscal year 2013 request please provide a history
    for the approval of new Voluntary Protection Program (VPP) sites,
    renewal of VPP sites and total number of VPP sites.
        Answer.

                                                        VPP DATA
    ----------------------------------------------------------------------------------------------------------------
                                                                                                       Total active
                               Fiscal year                                  New         Reapprovals    end of fiscal
                                                                                                           year
    ----------------------------------------------------------------------------------------------------------------
    Fiscal year 2007 actual.........................................             256             203           1,902
    Fiscal year 2008 actual.........................................             230             235           2,110
    Fiscal year 2009 actual.........................................             172             239           2,284
    Fiscal year 2010 actual.........................................             175             253           2,446
    Fiscal year 2011 actual.........................................             101             298           2,445
    Fiscal year 2012 operations plan................................             100             280  ..............
    Fiscal year 2013 budget.........................................              60             280  ..............
    ----------------------------------------------------------------------------------------------------------------

        Question. Also, what has the VPP Review Workgroup found in terms
    its review of VPP and recommendations for program improvement?
        Answer. OSHA formed a VPP Review Workgroup in 2011 made up of
    representatives from OSHA's National and Regional Offices. The
    workgroup was responsible for conducting a comprehensive review of the
    VPP and submitting recommendations for improving the program. The
    recommendations of the workgroup are currently under review. OSHA has
    begun evaluating and prioritizing suggested recommendations for changes
    that are determined to be key and that will strengthen the program's
    effectiveness and integrity.
                      one-stop career center system review
        Question. ODEP and ETA are conducting a separate independent survey
    of the physical, programmatic, and communications accessibility of the
    One-Stop Career Center system and review of Workforce Investment Board
    policies and procedures relative to the availability of intensive and
    training services for individuals with disabilities. What are the
    findings from this work? What corrective actions are planned?
        Answer. ODEP, ETA, and the Chief Evaluation Office (CEO) currently
    are planning the accessibility study and review of Workforce Investment
    Board policies and procedures. CEO will provide the funding for
    designing and conducting the accessibility study and currently is in
    the process of developing a Blanket Purchase Agreement (BPA) in order
    to competitively secure services to do so. The DOL's CEO has indicated
    that the BPA contract should be awarded this spring, at which time the
    Task Order for the accessibility study will be the first procurement
    action. The accessibility study is expected to begin in summer 2012,
    with findings projected to be available in late 2013.
                      universal dislocated worker program
        Question. Earlier this month the Obama administration announced a
    proposal to create a Universal Dislocated Worker program. The proposal
    would consolidate the Trade Adjustment Assistance program with the
    Workforce Investment Act's Dislocated Worker program and provide the
    same benefits to all workers. Can you explain how National Emergency
    Grants (NEGs), which are funded through the National Reserve, fit into
    the Universal Displaced Worker program proposal? Would NEGs continue to
    be funded with discretionary funding?
        Answer. NEGs give the Secretary of Labor the ability to provide
    resources in situations where the workforce system is unable to meet an
    unanticipated need for reemployment services, such as a natural
    disaster or a large plant closure. These grants would work in
    conjunction with the Universal Displaced Worker (UDW) program, as they
    do currently with the Workforce Investment Act's (WIA) Dislocated
    Worker formula program. Since NEGs are designed to respond to
    unanticipated events that yield unknown needs for workforce services,
    we believe it appropriate that they continue to be funded with
    discretionary funds out of the WIA appropriation, and accordingly NEGs
    would continue to be funded separately. It is important that the
    Secretary retain this flexibility to respond to events such as natural
    disasters, large plant closures, and other events which temporarily
    create more demand for services than the affected State and local
    workforce systems can address on their own, or which require a unique
    set of services, such as employing dislocated workers in jobs related
    to disaster recovery. We would work with the Congress to ensure that
    the benefits and services NEGs provide complement those provided under
    the UDW program.
                           federal regulation waivers
        Question. The President's budget requests legislative language that
    would allow the Secretaries of Labor and Education to waive statutes
    and regulations relating to the Workforce Investment Act of 1998, the
    Wagner-Peyser Act and title I of the Rehabilitation Act in instances
    when the Secretaries believe waivers would substantially improve
    education and employment outcomes. Additionally, in the Solicitation
    for Grants Announcement for the Workforce Innovation Fund (SGA/DFA PY-
    11-05) you encourage applicants to include information on how waivers
    of Federal laws or regulations, if waived, would enhance the proposed
    innovations. Can you provide examples of which laws and regulations you
    believe are prohibiting successful outcomes for workforce services
    delivery and information? Can you also describe how you would evaluate
    waiver requests? How would you define ``substantial improvement of
    education and employment outcomes''?
        Answer. Waiver authority can be one of the most effective tools the
    Federal Government has to spur experimentation and innovation.
    Particularly in the absence of significant funding to entice States and
    locals to come forward with new ideas, administrative flexibility is a
    powerful tool.
        Because States and local areas are in the best position to identify
    statutory or regulatory barriers that may impede innovation and
    improvements in workforce service delivery, the President's budget
    requests expanded waiver authority for the Workforce Investment Act of
    1998 (WIA), the Wagner-Peyser Act (W-P), and title I of the
    Rehabilitation Act to provide greater opportunity and flexibility to
    States in designing strategies that best fit their needs. Enhanced
    waiver authority would enable States to test innovative structural and
    service delivery approaches in a limited setting to improve participant
    outcomes and the cost-effective delivery of services.
        The Department has exercised its authority under WIA to approve
    hundreds of waivers requested by States during the last decade, and has
    a well-established process for evaluating such requests. The Department
    believes this process can easily be adapted in the context of the
    Workforce Innovation Fund to incorporate a collaborative review of
    waiver requests with the Department of Education that affect programs
    administered by both agencies, including approval of such requests by
    both the Secretaries of Labor and Education or their designees. In
    reviewing applications, we would expect requesters to be able to
    demonstrate how their proposed approach would improve outcomes
    consistent with the purpose of the programs involved. As set forth in
    the fiscal year 2013 budget, waivers would only be provided to projects
    which include:
      --A plan to effectively evaluate the impact of the strategies being
            tested on outcomes for program participants;
      --A strong accountability system, including outcome measures which
            show outcomes for program participants and demonstrate that
            subpopulations with the greatest barriers to employment are
            being appropriately served by the workforce system; and
      --Other required elements, as established by the Secretaries in
            regulation or grant solicitation.
        DOL also requires States to report annually on outcomes achieved by
    waivers in the WIA annual performance report that States are
    statutorily required to submit to the Department, and would continue to
    do so.
                          national apprenticeship act
        Question. DOL is working on regulations for Equal Employment
    Opportunity in the National Apprenticeship Act, which should increase
    nontraditional job opportunities for women and underrepresented
    populations and accomplish the same goals of Women in Apprenticeship
    and Non-Traditional Occupations Act (WANTO). Can you provide an update
    on the timing of the regulations?
        Answer. Since 2010, ETA has consulted stakeholders, including the
    Secretary's Advisory Committee on Apprenticeship, to gather input for
    development of this rule through a variety of methods, including
    virtual Webinars and in-person town hall meetings. The Department is in
    the process of drafting this Notice of Proposed Rule Making, and
    anticipates publishing it in 2012.
                           job corps center closures
        Question. Can you tell me more about how ``chronically low-
    performing'' Job Corps centers will be defined and the process the
    Department will undertake to close a center? Can you tell me more about
    how low-performing centers have been identified in the past and what
    opportunities they have been given to improve?
        Answer. The Department has established a comprehensive performance
    management system to assess program effectiveness across multiple
    components of services and programs offered to Job Corps students. The
    performance management system serves three primary purposes, as
    follows, to:
      --Meet accountability requirements for establishing performance
            measures (also known as metrics) and reporting student outcomes
            for the Job Corps system prescribed in the WIA legislation,
            Common Performance Measures for Federal youth training
            programs, and DOL priorities;
      --Assess centers' and agencies' accomplishments in implementing
            program priorities and serving students effectively; and
      --Have a management tool that provides useful and relevant feedback
            on performance, while encouraging continuous program
            improvement.
        To assess center performance against established goals and
    priorities, the Office of Job Corps' Federal staff conduct on-site
    center assessments and monitoring trips, and electronic desk monitoring
    and contractor performance reporting. Underperforming centers may be
    placed on a corrective action plan or performance improvement plan.
    Such a plan may be targeted to a specific area of performance (e.g.,
    academic attainment) or in cases of significant underperformance, may
    include overall center operations.
        Chronically low-performing centers are those that have consistently
    failed to meet performance standards over the past several program
    years. The Department is using its existing performance measures as the
    key component for developing its methodology for identifying centers
    for closure that will be published in the Federal Register for the
    public and stakeholders to provide feedback, prior to its use in
    selecting centers for closure.
        Further, the Department will ensure that it follows the
    legislatively mandated process for closing a Job Corps Center, per
    section 159 of the WIA, which includes the following:
      --Advance announcement to the general public of the proposed decision
            to close the center, through publication in the Federal
            Register or other appropriate means;
      --Establishment of a reasonable comment period, not to exceed 30
            days, for interested individuals to submit written comments to
            the Secretary; and
      --Notification of the Member of Congress who represents the district
            in which such center is located, within a reasonable period of
            time in advance of any final decision to close the center.
                     rebranding of workforce career centers
        Question. The President's budget includes a proposal to rebrand the
    workforce career centers. Can you provide additional information or
    examples of why the system needs rebranding? What barriers does the
    current branding pose to workers in need of services? And would States
    compete for funding or would the Department work with each State on the
    rebranding process?
        Answer. A 2005 GAO report (``Employers Are Aware of, Using, and
    Satisfied with One-Stop Services, but More Data Could Help Labor Better
    Address Employers' Needs'') found that only about one-half of employers
    are aware of the public workforce investment system. In addition, each
    year, 20 million individuals tap into our existing workforce system
    resources, but there are millions more who could benefit from being
    able to reliably find the services they need to succeed in today's
    economy. Currently, names for One-Stop Career Centers vary from State
    to State, or even from town to town, and online Federal, State, and
    local tools are spread across many Web sites with different names.
    Jobseekers may not understand that these resources are available to
    connect them to training and other supports. Veterans transitioning to
    civilian life might look for a One-Stop Career Center, but cannot find
    anything nearby with that name. Businesses that are well-connected to
    the workforce system in one State may not be aware that the same
    services are available to them elsewhere, under a different name.
        The Department's initiative to establish the American Job Center
    Network is designed to give workers and businesses an easily
    identifiable source for the help and services our workforce system
    provides. While the Department will initiate this effort in fiscal year
    2012, under the President's fiscal year 2013 budget proposal, the
    Department will:
      --Use a significant portion of the funds (approximately 70 percent)
            to support co-location among partner programs, increase the
            number of American Job Centers and service points, and increase
            public awareness and accessibility of workforce services
            through nationwide outreach and education using the American
            Job Center brand. These funds would be distributed to States
            and locals, with a small national reserve for administration
            and technical assistance.
        --To increase the number of service points, funds can be used to
                establish new service points for workforce services in
                local communities, such as computers at a library or
                community-based organization to access online services, or
                expanding access to workforce services within community
                colleges and schools, or even creating kiosks in major
                commercial chains.
        --The recipients may also use these funds to expand workforce
                services during hours convenient for working adults and
                businesses, particularly small businesses. In addition,
                States will use the funds to fully implement the American
                Job Center brand, and funds could support Web site
                adjustments and outreach through multiple media. The
                Department will also seek to create a national outreach and
                education plan to increase awareness and usage of the
                public workforce investment system.
      --The Department will use the remaining funds to expand current
            national electronic tools to provide more interactivity between
            the online customer and the virtual services currently
            available through www.CareerOneStop.org. The new electronic
            tools would include a jobseeker portfolio, an interactive
            resume analysis tool, an interactive knowledge and diagnostic
            database providing automated responses to common questions, and
            virtual chats with career counselors. For jobseekers who lack
            computer skills or Internet access, the Department will also
            expand its telephone contact centers to provide on the phone
            some of the personal interaction offered through staff-assisted
            services at brick and mortar One-Stop Career Centers.
          re-employment services for unemployment insurance claimants
        Question. The President's budget includes increased funding for
    Employment Service Grants to States to carry out more intensive re-
    employment services for Unemployment Insurance (UI) claimants, among
    other activities. Can you provide information on the successful re-
    employment services that the Department will highlight and encourage
    States and local areas to implement?
        Answer. Providing effective re-employment services to unemployed
    (including long-term unemployed) jobseekers and minimizing erroneous
    payments are high priorities for the Department and its partners, the
    State workforce agencies. Re-employment assistance can result in more
    rapid re-employment, shorter claim duration, and fewer erroneous
    payments of UI benefits. For example, in Nevada, a pilot program of Re-
    employment and Eligibility Assessments (REAs) coupled with re-
    employment services reduced weeks claimed by 2.96 weeks and benefits
    received by $805. Further study revealed that REAs in Nevada increased
    re-employment by close to 20 percent initially and by close to 10
    percent into the second year following participation in the program.
    REAs also increased earnings by 25 percent initially and close to 15
    percent into the second year after participation in REAs. Thus,
    eligibility assessment and re-employment services not only shorten UI
    duration, but also persistently boost employment and earnings.
    Effective re-employment services for UI claimants include at the
    minimum the provision of labor market and career information, an
    assessment of the skills of the individual, and orientation to the
    services available through the One-Stop Centers established under title
    I of WIA. Some claimants benefit from additional services such as
    comprehensive and specialized assessments, job search counseling and
    the development or review of an individual re-employment plan,
    individual and group career counseling, and training services. The
    Department encourages States and local One-Stop Centers to consider the
    claimants' individual circumstances and adopt approaches that are most
    likely to effectively speed their return to work.
                                     ______

                Questions Submitted by Senator Daniel K. Inouye
                          compact of free association
        Question. In 1986, the United States entered into Compacts of Free
    Association with the Federated States of Micronesia and the Republic of
    the Marshall Islands. In 1994, the United States entered into a similar
    relationship with the Republic of Palau. The Compacts set forth the
    bilateral terms for government, economic, and security relations
    between the United States and the Freely Associated States (FAS), and
    the laws approving the Compact set forth the U.S. policy context and
    interpretation for the Compacts. Section 141 of the Compact provides
    that certain FAS citizens ``may be admitted to, lawfully engage in
    occupations, and establish residence as a nonimmigrant in the United
    States and its territories.'' However, the Congress also stated, in
    section 104(e)(1), that ``it is not the intent of Congress to cause any
    adverse consequences for an affected jurisdiction.'' It is estimated
    that affected areas of the United States are spending upward of $200
    million annually for healthcare, education, and other services for FAS
    migrants. Although the Compacts allow the FAS migrants to engage in
    work in the United States, employers find that there is a significant
    need for language and cultural education and job training. How best can
    the Department of Labor assist States and territories in preparing
    Compact migrants for employment opportunities?
        Answer. Migrants from the Marshall Islands and Micronesia are
    eligible to receive labor exchange and employment services and
    Workforce Investment Act (WIA) authorized employment and job training
    programs in One-Stop Career Centers across mainland United States and
    outlying areas. There is a wide range of services available through the
    One-Stops that can be tailored to meet the employment and training
    needs of these individuals. Many outlying areas--Guam, American Samoa,
    the Virgin Islands, and Northern Mariana Island, including the Republic
    of Palau--receive annual WIA title I (WIA Adult, Dislocated Worker and
    Youth programs) formula allotments. The availability of WIA title I
    funding to Palau has also been extended through fiscal year 2012 in the
    Consolidated Appropriations Act of 2012 (in the Department of
    Education's General Provisions at section 306, title III, division F,
    Public Law 112-74).
        In addition to the One-Stops, the Department's competitive grants
    to States and outlying areas, such as the recent Trade Adjustment
    Assistance Community College and Career Training Grant program, bolster
    the capacity or the workforce system to provide quality employment and
    training services and programs. Freely Associated States migrants can
    potentially benefit from access and participation in these programs to
    improve their employment outcomes.
        Since 2003, the Marshall Islands and Micronesia no longer receive
    WIA title I funding for employment and training services provided
    through the WIA Adult, Dislocated Worker and Youth programs, but have
    been receiving funds from the Department of Education's appropriation
    (see Compact of Free Association Amendments of 2003, Public Law 108-188
    (December 17, 2003)), codified at 48 U.S.C. 1921d(f)(1)(B)(iii) (the
    ``Compact'').
     aligning hawaii's prepaid health care act and the affordable care act
        Question. Hawaii has traditionally experienced a much lower rate of
    uninsured individuals due to the landmark State law, the Prepaid Health
    Care Act (PHCA), which requires employers to provide healthcare
    coverage to full-time employees. As the State works to implement
    elements of the Affordable Care Act (ACA), questions have arisen
    regarding the ability for Hawaii's law to interact with the ACA in a
    manner that would allow Hawaii residents maximum benefits. Will there
    be further guidance from the Department of Labor (DOL), specific to
    Hawaii's healthcare environment, on how the PHCA can work in
    conjunction with the requirements of the ACA? Is it DOL's desire for
    Hawaii to maintain the requirements of the PHCA?
        Answer. DOL is committed to working with the State of Hawaii
    regarding the coordination of the PHCA and the ACA. DOL also works with
    our Federal partners in ACA implementation, such as the Department of
    the Treasury and the Department of Health and Human Services, on these
    issues, as necessary. Conversations about specific interactions have
    already begun and will continue to ensure the best result for Hawaii
    residents and their health coverage.
                                     ______

                  Questions Submitted by Senator Patty Murray
          government accountability office principles for successful
                 collaboration between employers and employees
        Question. In the January 2012 Government Accountability Office
    (GAO) report, ``Innovative Collaborations between Workforce Boards and
    Employers Helped Meet Urgent Local Workforce Needs'', GAO identified
    six principles for successful collaboration, including leadership,
    leveraging resources, and providing business responsive services by
    examining 14 examples of collaborations between local workforce board,
    employers, community colleges, Manufacturing Extension Partnerships
    (MEPs), economic development and others. How is the Department of Labor
    (DOL) using its resources to ensure that all boards and the entire
    system are putting these principles in place?
        Answer. GAO's report findings validate the Department's
    longstanding position that stronger partnerships between employers and
    the public workforce system improve employment and retention outcomes
    for our Nation's workers. The report also echoes the Department's
    strategic thinking on the importance of linking workforce services to
    meet the needs of regional and local economies, and the need for public
    workforce system reform through the reauthorization of the Workforce
    Investment Act of 1998 (WIA).
        A key area of exploration for the Department is enhancing our dual-
    customer approach to effectively serve both workers and employers. We
    continue to provide technical assistance on business engagement to
    workforce system practitioners. For example, in May 2011, we provided
    in-person and virtual training for business liaisons in local workforce
    areas, and established a set of online resources available for business
    liaisons across the country. In 2012, we are planning to offer a series
    of activities and learning opportunities to promote and enhance
    services to business customers, beginning with a National Job Fair
    Month, scheduled for June 2012. In addition, we want to emphasize that
    while the Department provides policy leadership and guidance to the
    One-Stop delivery system, States have a critical role in making
    business engagement a priority, including tracking data on services to
    employers. The Department's on-line technical assistance platform for
    workforce practitioners contains numerous examples of promising State
    and local practices in business engagement.
        The Department is also working across Federal agencies to
    streamline administrative processes and better align resources and
    programs to ensure effective service delivery. The Departments of
    Labor, Health and Human Services, and Education continue to seek
    opportunities to develop joint guidance to State and local grantees,
    and to implement cross-cutting demonstration projects that encourage
    partnerships and improve models for delivering quality services across
    programs at lower costs.
                  workforce investment act program performance
        Question. The annual performance results for WIA programs this past
    year noted that nearly 8.7 million workers received assistance and more
    than one-half of the people who got help through WIA gained employment,
    despite the fact that there are nationally more than four jobseekers
    for every available job. On top of that, 4 out of 5 job seekers who
    gained employment through WIA were retained in their employment
    according to the Department's data. Additionally, 8 out of 10 employers
    who utilized the workforce system were satisfied by the assistance they
    received from the workforce system. What does this data reveal about
    WIA programs ability to effectively respond during periods of high
    unemployment, such as the country has experienced for the last several
    years?
        Answer. These data illustrate in a statistical manner the value of
    the services provided by WIA programs. The workforce system experienced
    a tremendous increase in demand for its services during recent economic
    downturn. In response, the Department has implemented various
    strategies including:
      --on-the-job training;
      --setting new goals for the increased attainment of industry-
            recognized credentials, including degrees and certificates by
            workforce system participants;
      --issuing guidance on entrepreneurship and self-employment
            activities;
      --emphasizing the importance of longer-term training; and
      --encouraging the development of career pathways, especially for low-
            skilled youth and adults.
        The benefits of these strategies are evidenced by the higher-
    employment outcomes of WIA program completers.
        It is worth noting that according to the latest Job Openings and
    Labor Turnover Survey data provided by the Bureau of Labor Statistics
    (BLS), there are roughly 12.8 million unemployed Americans looking for
    work and 3.5 million job openings. This ratio shows that the average
    job seeker only has a 27-percent chance of obtaining the job they want
    and need due to the high level of competition. However, WIA program
    completers are finding employment at more than twice that rate, further
    showing the value of WIA program services in helping job seekers gain
    skills that employers demand.
        Although the Department is proud of the accomplishments of the
    workforce system, we recognize more must be done to create an economy
    that is built to last. The President's blueprint for growth includes
    new proposals that would allow the Department to pursue additional
    strategies intended to strengthen manufacturing, energy, education, and
    skills training. Additionally, the reauthorization of WIA remains a
    unique opportunity to modernize and position the workforce system to
    help even more workers and employers.
                           job corps center closures
        Question. Please provide a detailed plan regarding the Department's
    plan to identify and close ``low-performing'' Job Corp centers. Please
    include a time line, a description of the selection factors, the
    Department's definition of ``low-performing'' and which centers the
    Department would currently label as ``chronically low-performing.''
    Please also include a description of the cost-effective strategies
    identified in rigorous evaluations that the Department plans to move
    toward as well as the changes in performance measurement and reporting.
    Finally, please describe how the Department will work with the
    Department of Agriculture regarding the evaluation of Civilian
    Conservation Centers.
        Answer. Chronically low-performing centers are those that have
    consistently failed to meet performance goals over the past several
    program years. The Department is using its existing performance
    measures as the key component for developing its methodology for
    identifying centers for closure that will be published in the Federal
    Register for the public and stakeholders to provide feedback, prior to
    its use in selecting centers for closure. A timeline has not yet been
    developed for the closure process.
        The Department will ensure that it follows the legislatively
    mandated process for closing a Job Corps center, per section 159 of the
    WIA, which includes the following:
      --Advance announcement to the general public of the proposed decision
            to close the center, through publication in the Federal
            Register or other appropriate means;
      --Establishment of a reasonable comment period, not to exceed 30
            days, for interested individuals to submit written comments to
            the Secretary; and
      --Notification of the Member of Congress who represents the district
            in which such center is located within a reasonable period of
            time in advance of any final decision to close the center.
        As you may know, the U.S. Department of Agriculture Forest Service
    operates 28 Job Corps centers under an Interagency Agreement with the
    DOL. The performance of these centers is evaluated in the same manner
    as those centers operated by private entities under contract with the
    Department. DOL's Federal staff perform the same on-site and electronic
    monitoring of the operated centers, including the development and
    implementation of performance improvement plans, when necessary. All
    Job Corps centers will be evaluated for closure using the same
    methodology.
        The Department is currently conducting a study to review the
    program's operations and performance management practices. The final
    results of this study will be available in summer 2013 and will be used
    to implement reforms and efficiencies system-wide.
        Regarding changes to performance metrics and reporting, beginning
    in Program Year 2010, the Department began tracking Job Corps student
    attainment of industry-recognized credentials. These credentials, which
    include industry certifications, state licensures, and pre-
    apprenticeship credentials, provide students with geographic and
    economic mobility. They demonstrate to employers that Job Corps
    graduates have attained the skills and knowledge necessary to compete
    in today's workforce.
        The Department is also taking steps to make Job Corps' performance
    measures more transparent and accessible to the public and the
    program's stakeholders. The Office of Job Corps has launched on its Web
    site an interactive map (at http://www.jobcorps.gov/AboutJobCorps/
    performance_planning/omsdata.aspx) that provides information on each
    Job Corps centers' performance. Job Corps will also offer an online
    guide explaining the program's performance management system in
    layperson terms. Later this year, the Department will submit a report
    to the Congress detailing the results of each of the metrics outlined
    in the WIA.
                           job corps center contracts
        Question. Please provide a description of the process the
    Department uses to award contracts for Job Corp centers. Also please
    describe any planned changes to this process, the rationale for any
    changes, and the anticipated impacts of such changes.
        Answer. DOL uses competitive procedures prescribed by the Federal
    Acquisition Regulations (FAR) 6.1 and FAR 6.2. In accordance with FAR
    Part 10 and FAR 19.502-2, DOL reviews the market research conducted by
    the Contracting Officers to determine if a requirement shall be set-
    aside for small business concerns, HUBZone small business concerns,
    8(a) firms, or Service Disabled Veteran Owned Small Business concerns.
    On rare occasions, and only as permitted by the exceptions provided in
    FAR 6.3, DOL uses this authority to award contracts without competitive
    procedures.
        DOL utilizes ``contracting by negotiation'' techniques defined
    under FAR Part 15 and, when doing so, conducts a trade-off analysis
    among evaluation factors to determine which contractor offers the best
    value to the Government. When the Department conducts such a trade-off
    analysis, technical approach (e.g., quality of services provided to the
    students) is the most important evaluation factor.
        Due to pending litigation, the Department cannot comment on any
    planned changes to this process.
                         regional office consolidation
        Question. Please provide a detailed description of the Department's
    regional office closure plan including specific offices and locations.
    In addition, please describe how the services provided by such center
    will be provided under the consolidation plan.
        Answer. The budget proposes adopting a leaner, more efficient
    approach for five offices within the DOL:
      --the Occupational Safety and Health Administration (OSHA);
      --the Office of the Solicitor (SOL);
      --the Office of Public Affairs (OPA);
      --the Women's Bureau (WB); and
      --the Employee Benefits Security Administration (EBSA).
        In fiscal year 2013, each of these Bureaus will consolidate their
    regional offices to ensure that they are strategically placed to
    perform DOL's key functions across the country while eliminating
    unnecessary administrative costs.
        In an effort to streamline agency operations, the OSHA proposes to
    reorganize its regional structure and jurisdictional authority from its
    current operation of 10 Regional Offices (ROs) to 7. The reorganization
    will involve the consolidation of OSHA's Regions 1 (Boston) and 2 (New
    York); Regions 7 (Kansas City) and 8 (Denver); and Regions 9 (San
    Francisco) and 10 (Seattle). The estimated savings would come largely
    from the saved compensation from three Regional Administrator positions
    and related benefits. Additional savings would be achieved through
    reduced rent needs and travel expenditures.
        The Solicitors' Office (SOL) is working on regional office
    consolidation to better align legal offices with the Department's
    component agency structures, with eventual reduction from eight to six
    SOL regions. As an initial step, SOL is planning to reduce one region
    (Kansas City) in fiscal year 2012.
        OPA consolidation of regional offices includes the closure of
    offices in Denver, Colorado and Seattle, Washington. These offices have
    been essentially closed since fiscal year 2011 due to attrition of
    Federal staff. OPA will continue to meet agency goals and objectives
    continuing to have the workload of the Denver and Seattle locations
    processed and managed by the remaining regional offices in Chicago,
    Dallas, and San Francisco.
        For the WB, the consolidation of regional offices will refocus the
    agency to its policy responsibilities as it works through other DOL
    agencies for its outreach functions. The Department strongly supports
    the work of the WB and believes that increased collaboration with other
    regional DOL agencies will allow the Bureau to more effectively and
    efficiently carry out its mission.
        The WB is developing objective criteria to guide the process for
    consolidation of its regional offices. The goal is to continue to serve
    the highest number of women possible in the most coordinated and
    economically efficient manner. We anticipate that we will be able to
    achieve this goal by maintaining those WB regional offices in
    geographical locations where other DOL regional offices exist and
    opportunities for sister agency collaboration will be maximized.
        The Department remains committed to the advancement and rights of
    working women, particularly those who are the most vulnerable.
    Consolidating the Bureau's regional offices will result in savings that
    he budget would reinvest, dollar-for-dollar, in the enforcement of the
    Family and Medical Leave Act and Fair Standards Labor Standards Act--
    two laws that have a direct and tangible benefit for women in the
    workforce.
        As with the WB, the EBSA is still developing the details of its
    effort to consolidate regional offices. The objective of EBSA's
    consolidation is to increase the efficiency and effectiveness of the
    enforcement and worker assistance operations. Similar to OSHA's
    approach, a primary guiding principle in the EBSA effort is to not
    allow a reduction in front-line enforcement or other services for the
    public because of consolidation. Some of the specific factors that EBSA
    is considering in identifying the regions proposed for consolidation
    options include the closer alignment of regional offices with financial
    centers, number of plans, participants and beneficiaries, and total
    plan assets; a better alignment of regional workload; the elimination
    of some split State responsibility in regional jurisdictions; and
    taking advantage of the regional locations of other DOL offices such as
    SOL and the Office of Assistant Secretary for Administration and
    Management.
         consolidation of workforce investment act program evaluations
        Question. Please describe how the Department will sufficiently
    evaluate programs under title I of the WIA should program evaluation
    and research responsibilities be consolidated under the Departmental
    Program Evaluation office as proposed under the budget. What impact, if
    any, would such consolidation have on the gold standard evaluation?
        Answer. The fiscal year 2013 budget proposes the use of a set-aside
    to finance evaluations for DOL's WIA programs, as well as pilots,
    demonstrations, and research considered applied research for employment
    and training programs, building on language that was included in the
    2012 enacted appropriations bill. The 0.5 percent evaluation set-aside,
    which currently applies to the rest of the Department's funding, is
    intended to ensure that sufficient funding is available to carry out
    comprehensive, rigorous, and robust research and evaluations and to
    promote greater stability of funding for these efforts across the
    Department as a whole. Specifically, the Department is requesting that
    up to 0.5 percent of the amounts appropriated for training and
    employment services also be made available to support evaluations under
    the oversight of the Department's Chief Evaluation Officer. The
    projects on Employment and Training Administration (ETA) programs will
    continue to be guided by the current Five-Year Research and Evaluation
    Strategic Plan, which is specified under WIA section 171, and ETA's
    Five Year Learning Agenda developed jointly with the Chief Evaluation
    Office. This set-aside proposal for evaluations is an addition to a
    provision included in the Consolidated Appropriations Act of 2012 that
    authorized the Secretary to ``reserve not more than 0.5 percent from
    each appropriation made available in this Act identified in subsection
    (b) in order to carry out evaluations of any of the programs or
    activities that are funded under such accounts.''
        There will be no effect on the Workforce Investment Act Adult and
    Dislocated Worker Programs Gold Standard Evaluation (WGSE); that
    evaluation is included in the ETA Strategic Plan and in the ETA
    Learning Agenda. Initiated in fiscal year 2010, the WGSE is a random
    assignment evaluation of two major programs under title I of WIA. The
    evaluation measures the postprogram impacts on employment and earnings
    of receiving intensive services and training funded through WIA, as
    compared to receiving core services only and/or services funded through
    other sources. The complete evaluation is being conducted over the
    course of 7 years and represents a major improvement in the specificity
    and quality of previous WIA evaluations. We anticipate the final report
    being available in late 2017.
                   workforce investment act research programs
        Question. How does the Department plan to conduct pilot,
    demonstration, and research projects under WIA should funding for such
    projects be eliminated as proposed under the budget?
        Answer. In fiscal year 2013, the Department requests the use of a
    set-aside funding mechanism to finance evaluations, as well as pilots,
    demonstrations, and research for employment and training programs. The
    new set-aside approach is intended to ensure that sufficient funding is
    available to carry out comprehensive, rigorous, and robust research and
    evaluations and to promote greater stability of funding for these
    efforts across all DOL programs, including the WIA, Job Corps,
    Unemployment Insurance, and the Employment Service. The projects that
    the Department undertakes will continue to be guided by the current
    Five-Year Research and Evaluation Strategic Plan, which is specified
    under WIA section 171, and ETA's Five Year Learning Agenda developed
    jointly with the Chief Evaluation Office. Specifically, the Department
    is requesting that up to 0.5 percent of the amounts appropriated for
    these programs be made available to support this effort. Evaluations
    (which may include demonstration components) and applied research
    projects using these funds will be conducted by DOL's ETA under the
    oversight of the Department's Chief Evaluation Officer. This set-aside
    proposal builds on the provision included in the Consolidated
    Appropriations Act of 2012 that authorized the Secretary to ``reserve
    not more than 0.5 percent from each appropriation made available in
    this Act identified in subsection (b) in order to carry out evaluations
    of any of the programs or activities that are funded under such
    accounts.'' The Department considers pilots and demonstrations
    previously funded under WIA section 171 to be components of evaluations
    designed to test program interventions, services, and models.
        In addition, WIF will support pilot and demonstration activities to
    test innovative approaches to the delivery of employment and training
    services.
             workforce investment act ``pay for success'' projects
        Question. Please provide a detailed description of how ``Pay for
    Success'' projects will be identified for award and implemented under
    the Workforce Investment Fund (WIF).
        Answer. ETA plans to make available approximately $20 million for
    Pay for Success pilot grants, funded out of the fiscal year 2012
    Workforce Innovation Fund (WIF). In piloting the Pay for Success model,
    which is currently being piloted in the United Kingdom, the Department
    will provide funding for projects that will demonstrate the feasibility
    and viability of this innovative financing model. Under the Pay for
    Success grants, third-party investors pay the operating costs of an
    intervention, with the goal of achieving pre-negotiated outcomes. The
    Government repays the principal investment made for funding the
    intervention and a return on investment only if results are achieved.
    In this way, the model is different from how Government agencies
    typically fund services; Government funding is shifted from paying for
    specific processes and services to paying for specific outcomes.
        The Department plans to announce the competition for Pay for
    Success pilot project grants in a Solicitation for Grant Applications
    to be published in spring 2012. Eligible applicants will be State,
    local, or tribal government entities in partnership with a managing
    intermediary organization. This partnership must agree to a common goal
    of achieving specific workforce development-related outcomes. On the
    basis of this partnership, the intermediary will raise operating
    capital from philanthropic, private sector, and/or other social
    investors, manage the delivery of services, and be responsible for
    achieving outcomes and overall cost savings to the public sector as
    negotiated with the Government. The independent investors take on the
    risk of funding the project based on an expectation of an additional
    return on their investment if project outcomes are met. An independent
    entity, procured by the applicant, will verify if outcomes have been
    met for the purposes of repayment. The Department will pay the
    administrative costs of the grantee and the costs of the independent
    validator as they occur. Upon verification of the achievement of
    negotiated outcomes by the independent validator, the Department will
    confirm that the validation methodology was followed and make the
    appropriate payments to the State/local/tribal government grantee,
    which then flows through the intermediary to the investor(s). If the
    outcomes are not achieved, the Department will not release the funds.
    To support grantees' success and workforce system knowledge about Pay
    for Success, the Department will provide technical assistance and
    evaluation of the Pay for Success financing strategy.
        Grants under the Pay for Success financing model will be awarded
    competitively to those highly qualified applicants who best address the
    following key elements in their proposals:
      --a well-defined problem and associated target population;
      --a flexible and adaptive preventative service delivery strategy;
      --a commitment of funds from independent investors to cover all
            operating costs of the intervention;
      --one or more well-defined, achievable target outcomes;
      --a well-defined outcome measurement and verification methodology;
      --a project timeline that clearly indicates the date by which the
            outcome will be achieved and validated;
      --a financial model that shows public sector cost savings or
            efficiency gains; and
      --a payment arrangement between the applicant and the intermediary,
            to be triggered by the verified achievement of the proposed
            outcome(s) within the grant period.
    To the extent funds are not used for PFS grants, they will be allocated
    to fund non-PFS projects under the WIF.
        targeting teen unemployment under the workforce innovation fund
        Question. Please provide a justification for the Department's
    request to target youth younger than the age of 20 within the WIF.
        Answer. The teen unemployment rate continues to be at or near
    historic highs. In March 2012, the seasonally adjusted unemployment
    rate for individuals age 16-19 was 25 percent, nearly three times the
    overall unemployment rate of 8.2 percent. In addition, the Nation's
    high school dropout rate remains too high. It is critical for the
    Department to invest in innovative projects focused on improving
    services for disconnected youth so that they acquire the skills and
    tools necessary to build successful careers. In addition, the goal is
    to focus specifically on younger youth because less is known about what
    interventions are effective for them. However, while the $10 million
    innovation fund set aside is focused on youth ages 16 through 19, the
    Department anticipates other innovation projects may serve the broader
    pool of disconnected youth.
                    workforce innovation fund funding awards
        Question. Please explain how the Department plans to target and
    award WIF funding should funding not be contributed by programs under
    the Department of Education.
        Answer. The Department will coordinate with the Departments of
    Education and Health and Human Services in the administration of the
    WIF to encourage collaboration across program ``silos''. In fiscal year
    2011, the Department consulted with its partner agencies in the
    development of the WIF grant competition and invited partner agency
    staff to help panel applications. We anticipate working with our
    colleagues at the Departments of Education and Health and Human
    Services to provide technical assistance to grantees on cross-program
    alignment as needed.
              rebranding and strengthening one-stop career centers
        Question. Please describe how the Department's plans to distribute
    and administer the additional $50 million in funds requested under the
    Workforce Information-Electronic Tools-System Building line for
    rebranding and strengthening the one-stop career centers, including how
    such funds will be distributed to the States. Please provide a
    description of the activities planned with this funding and the
    timeline for implementation.
        Answer. Under the President's fiscal year 2013 budget proposal, the
    Department will:
      --Use a significant portion of the funds (approximately 70 percent)
            to support co-location among partner programs, increase the
            number of American Job Centers and service points, and increase
            public awareness and accessibility of workforce services
            through nationwide outreach and education using the American
            Job Center brand. These funds would be distributed to states
            and locals, with a small national reserve for administration
            and technical assistance.
        --To increase the number of service points, funds can be used to
                establish new service points for workforce services in
                local communities, such as computers at a library or
                community-based organization to access online services, or
                expanding access to workforce services within community
                colleges and schools, or even creating kiosks in major
                commercial chains.
        --The recipients may also use these funds to expand workforce
                services during hours convenient for working adults and
                businesses, particularly small businesses. In addition,
                States will use the funds to fully implement the American
                Job Center brand, and funds could support Web site
                adjustments and outreach through multiple media. The
                Department will also seek to create a national outreach and
                education plan to increase awareness and usage of the
                public workforce investment system.
      --The Department would begin this initiative within 45 days of
            enactment of an appropriations act, and complete it within a
            year.
      --The Department will use the remaining funds to expand current
            national electronic tools to provide more interactivity between
            the online customer and the virtual services currently
            available through www.CareerOneStop.org. The new electronic
            tools would include a jobseeker portfolio, an interactive
            resume analysis tool, an interactive knowledge and diagnostic
            database providing automated responses to common questions, and
            virtual chats with career counselors. For jobseekers who lack
            computer skills or Internet access, the Department will also
            expand its telephone contact centers to provide on the phone
            some of the personal interaction offered through staff-assisted
            services at brick and mortar One-Stop Career Centers. Within
            120 days of enactment of an appropriations act, the Department
            would begin to offer expanded services through its telephone
            contact centers. Requirements definition and development of the
            new online electronic tools features would begin within 90 days
            of enactment of an appropriations act, and phase one of the new
            Web site features would launch within a year of enactment of an
            appropriations act.
     continuing women in apprenticeship and nontraditional occupations act
                                    mission
        Question. Please describe how the Department will serve the mission
    and intent of the Women in Apprenticeship and Nontraditional
    Occupations (WANTO) program through other activities.
        Answer. The Department remains firmly committed to the goals of the
    WANTO program and will continue to work tirelessly to promote
    opportunities for women to enter Registered Apprenticeship and to
    access to non-traditional occupations.
        The Department will continue to address the goals and objectives of
    WANTO through revisions to the Equal Employment Opportunity regulations
    governing Registered Apprenticeship as well as through technical
    assistance efforts and guidance from ETA, in conjunction with the WB.
    We also believe that the broader workforce investment system can help
    women access the supports and services needed to enter and stay in
    nontraditional jobs. The number of female participants receiving
    services through the various workforce programs has increased in the
    last few years by more than 40 percent, to more than 15.7 million. In
    some American Recovery Act and Reinvestment grants, particularly the
    Pathways Out of Poverty grants, we were encouraged by solid outcomes
    for those projects that trained women in clean energy jobs. The
    Department will utilize these findings to inform new technical
    assistance to the broader workforce system.
        Last, pre-apprenticeship has shown promise in creating a more
    diverse, next generation of apprentices. ETA is developing a national
    framework to establish consistency and quality across pre-
    apprenticeship programs that can help women and other under-represented
    populations gain greater access to apprenticeship and non-traditional
    employment opportunities.
                         community college career fund
        Question. When does the administration plan to provide legislative
    recommendations for the new community college to career fund?
        Answer. On March 20, 2012, H.R. 4227, Workforce Investment Act of
    2012 was introduced, including provisions that would establish a
    Community College to Career Fund. These provisions reflect extensive
    technical assistance that the Departments of Labor and Education
    provided and thus, align with the priorities and activities envisioned
    in the administration's Community College to Career Fund proposal.
                        guidance for h-2a program users
        Question. Secretary Solis, as you know, ensuring a stable workforce
    for our Nation's agriculture producers is critical to keeping food on
    our plates and not rotting in fields. The H-2A program, which is the
    pathway to bringing farmworkers in to meet these needs legally, has
    been the subject of regulatory tweaking during both this administration
    and the prior administration. My farmers are looking for consistency
    across the Department--for all of your employees to be saying the same
    thing, at any given time. I've been working with both the agriculture
    and labor constituencies for many years now trying to find a path
    forward in the form of AgJOBS. Given that legislation is not likely to
    move, it's incumbent on all of us--the Congress, and the agencies
    charged to implement H-2A program--to provide farmers and farmworkers
    with consistent guidelines and recommendations.
        Secretary Solis, my farmers are telling me that the Department
    lacks clear and consistent instruction for H-2A program users. For
    example, one grower is currently awaiting results from a DOL audit
    while simultaneously preparing contracts for the upcoming harvest
    season. However, since the grower has not seen the results of the
    audit, it is unclear how he can properly and accurately write his new
    contracts to avoid another audit. My staff have also intervened in
    several cases when Department requirements and State requirements were
    directly in conflict. Our farmers, your staff and congressional staff
    should not have to spend countless hours ironing out inconsistencies
    within the H-2A program, but should instead spend that time making the
    program work and ensuring the health and safety of our farmworkers.
        Madam Secretary, how will you lead your staff from the top-down to
    ensure that the Department provides consistent guidelines for users of
    the H-2A program?
        Answer. The Department understands the important role that
    agriculture, especially apple and cherry production, plays in the State
    of Washington's economy. The issuance of the 2010 H-2A Final Rule was a
    top management priority for the Department, making it possible for all
    those who are working hard on American soil to receive fair pay while
    at the same time expanding opportunities for U.S. workers. We share
    your concerns about this workforce issue and view the H-2A program as a
    legal means by which growers may obtain foreign labor, but only when
    they have first recruited U.S. workers and given them a fair
    opportunity to secure these jobs.
        We know employers with legitimate needs are successfully using the
    H-2A Program, and I assure you that we are continuing to take steps to
    assist H-2A employers in complying with the program's requirements by
    providing consistent and clear guidance and continuing to process
    applications efficiently. For example, we implemented a number of
    actions designed to clarify program requirements for participating
    employers and improve program performance. Over the past year, the
    Department engaged in extensive outreach and education efforts to
    familiarize program users with regulatory changes implemented through
    the 2010 H-2A Final Rule, including hosting three national stakeholder
    briefings in December 2011. Each of these briefings was designed to
    assist H-2A employers in preparing their agricultural job offers and
    applications for the 2012 planting season.
        The Department continues to meet with employers, including those
    representing Washington State, and other stakeholders to provide
    additional assistance and explanation of the H-2A program's
    requirements. The Department is continuing its efforts to make the
    program more effective and efficient for employers. The following are a
    few examples of resources for the Department has produced and posted on
    its Web site to make the H-2A program most user-friendly for employers:
      --a new employer Handbook;
      --``Filing Tips'' to avoid common mistakes;
      --four rounds of frequently asked questions to provide clear and
            useful guidance to growers; and
      --other technical assistance materials all aimed at providing
            consistent guidelines to farmers participating in the H-2A
            program. All of these resources are available on the H-2A page
            of the Department's foreign labor certification Web site at
            http://www.foreignlaborcert.doleta.gov/h-2a.cfm#.
        We are pleased with these efforts and our actual program
    performance under the new regulations has improved significantly over
    prior years. For fiscal year 2011, the Department certified 93 percent
    of all H-2A applications filed covering more than 74,000 farm worker
    positions with approximately 85 percent of our final decisions issued
    timely. In the first 6 months of fiscal year 2012, the Department
    received more than 3,700 H-2A applications requesting more than 46,000
    farm workers--a 3-percent increase more than the same period a year
    ago. Employers received certifications for approximately 95 percent of
    H-2A applications filed with more than 82 percent of our final
    decisions issued timely. We believe these performance data indicate the
    H-2A Program is being widely used, and we expect that our performance
    will continue to improve.
        The Department will continue to work directly with employers
    participating in the H-2A Program who encounter issues or problems with
    their application. The H-2A Final Rule includes a process for employers
    to correct application or job order deficiencies, rather than having
    the application denied. However, I feel obligated to note that some of
    these required modifications are not the result of changes in the H-2A
    Final Rule, but rather the employer's (or their representative's)
    failure to comply with long-standing program requirements such as
    offering to pay the most current reimbursement to workers for meals
    when traveling or paying the current hourly Adverse Effect Wage Rate
    (AEWR). Requiring that an employer offer and pay the appropriate
    subsistence level and wage rate is essential to meeting our statutory
    mandate to ensure that the employment of H-2A workers will not have an
    adverse effect on the wages and working conditions of similarly
    employed U.S. workers.
        In other instances, the requested modifications are necessary to
    ensure the employer meets the eligibility criteria for participating in
    the H-2A Program only where there is a legitimate temporary need. Based
    on our program experience, we know that a large number of issues or
    deficiencies which affect our timely processing of applications pertain
    to applicant error or oversight and not from policy or regulatory
    disagreements.
        Question. Will you direct your staff to work in partnership with H-
    2A users on issues that arise that are problematic for the Department
    and/or H-2A users?
        Answer. The Department has been and continues to be willing to work
    with H-2A users on issues that arise that are problematic for the
    Department and/or H-2A users. For instance, in an effort to improve
    customer service and provide greater assistance to the employer
    community in complying with program requirements, we recently expanded
    the use of email to quickly communicate and resolve minor deficiencies
    with employer-filed H-2A applications. Once an employer corrects these
    minor deficiencies, the application and job order are accepted for
    processing, and the employer is provided with instructions through
    email for completing the application process. This E-Mail Pilot
    Notification Program has been well received by the grower community
    and, as a result, our deficiency rate has significantly decreased. For
    the first 6 months of fiscal year 2012, the percent of employer-filed
    applications requiring a formal notice of deficiency was 38 percent;
    compared to approximately 66 percent in fiscal year 2011.
        Finally, in an effort to continue the progress in improving
    communications and work in a closer partnership with growers, the
    Office of Foreign Labor Certification recently established an H-2A
    Ombudsman Program whose primary purpose is to facilitate the fair and
    equitable resolution of concerns that arise within the H-2A Program
    community by conducting independent and impartial inquiries into issues
    related to the administration of the program and proposing internal
    recommendations designed to continuously improve the quality of
    services provided to H-2A Program users. A number of growers and worker
    advocacy organizations are already taking advantage of the new
    Ombudsman Program in order to resolve their issues. To get more
    information on the H-2A Ombudsman Program and how your constituents can
    get connected, please visit our Web site at: http://
    www.foreignlaborcert.doleta.gov/h-2a_ombudsman_program.cfm.
                                     ______

                Questions Submitted by Senator Mary L. Landrieu
                                  h-2b rule 2
        Question. American consumers are searching for more ways to ``Buy
    American'' and support their local food producers. According to some
    estimates, the United States already has a severe seafood trade deficit
    with imports accounting for 86 percent of all seafood consumed. Did
    Department of Labor (DOL) review any specific studies on the economic
    impact of the H-2B regulations announced last month (the ``H-2B Rule 2
    Regulations'') on the U.S. seafood industry? Did DOL solicit input from
    the Department of Commerce on the impact of the H-2B Rule 2 Regulations
    on the seafood industry?
        Answer. Although the Department did not specifically solicit input
    from the Department of Commerce, it did provide opportunity for all
    interested parties to provide their views on, and analysis of, the
    proposed rule leading to the Temporary Non-agricultural Employment of
    H-2B Aliens in the United States Final Rule published February 21,
    2012. See 76 FR 15130 for the notice of proposed rulemaking and 77 FR
    10038 for the final rule. Comments in response to the proposed rule
    provided only anecdotal information on the impacts of the proposed rule
    on the seafood processing industry. We reviewed the comments received,
    and based on our review of existing data and the information received
    from the public, there was no indication that the Department overlooked
    or failed to consider economic studies or analysis specific to the
    seafood industry.
        Question. Would the DOL be willing to delay implementation of H-2B
    Rule 2 Regulations (set to go into effect on April 23d) until the Small
    Business Administration (SBA) is able to complete an economic impact
    study of the impact of the final rules on small businesses that
    participate in the H-2B program?
        Answer. The Department has provided ample time and opportunity for
    stakeholders, including the SBA, to provide their views on, and
    analysis of, the Temporary Non-agricultural Employment of H-2B Aliens
    in the United States Final Rule published February 21, 2012 (77 FR
    10038). The Department met with a wide variety of stakeholders,
    including small and seasonal business representatives, during the
    development of the proposed rule published March 18, 2011 (76 FR
    15130), upon which this Final Rule is based. The SBA's Office of
    Advocacy reviewed the proposed rule prior to its publication, during
    clearance required by Executive Order 12866. In addition, the
    Department provided the public 60 days in which to provide comment on
    the rule and during that 60-day public comment period, the Department
    met with stakeholders during a Small Business Roundtable, convened by
    the Office of Advocacy. The Chief Counsel for Advocacy submitted a
    comment on the proposed rule, which the Department addressed in the
    Final Rule, including by identifying a number of changes (e.g., such as
    extending the length of the three-fourths guarantee calculation period
    from 4 weeks to 12 weeks for job orders lasting 120 days or more and 6
    weeks for job orders lasting less than 120 days, adding catastrophic
    man-made events such as oil spills or controlled flooding to the list
    of triggers that employers could use to request cancellation of the job
    orders, send workers home, and relief from the three-fourths guarantee,
    and reducing the period during which employers are required to accept
    State Workforce Agency referrals of U.S. applicants from the later of 3
    days before the date of need or the date of the last H-2B worker's
    departure to 21 days before the date of need) intended to alleviate the
    concerns Advocacy expressed. Finally, the Office of Advocacy also
    reviewed the Final Rule prior to publication under Executive Order
    12866. SBA has had more than a year to complete and provide to the
    Department their analysis of the economic impact of the Temporary Non-
    agricultural Employment of H-2B Aliens in the United States Final Rule
    published February 21, 2012 (77 FR 10038) and has not yet elected to do
    so.
        On April 26, 2012, the court in the U.S. District Court for the
    Northern District of Florida, Pensacola Division, granted a nationwide
    preliminary injunction enjoining the Department of Labor from enforcing
    the Temporary Non-agricultural Employment of H-2B Aliens in the United
    States Final Rule published February 21, 2012 (77 FR 10038).
        Question. The H-2B Rule 2 Regulations require employers guarantee
    both H-2B and ``corresponding'' American workers a total number of work
    hours equal to at least 75 percent of the workdays in every 12-week
    period--regardless of whether unforeseen factors like hurricanes or oil
    spills mean that production may be shut down. Although employers may
    seek relief from the three-quarters guarantee following a serious
    disaster, what guarantee can you provide that DOL will respond in a
    timely manner to these requests so that small businesses participating
    in the program are not penalized by an unforeseen disaster? Given the
    gulf coast's track record with disasters and its dependence on workers
    in the H-2B program, this is a key issue for many seafood businesses
    along our coastline.
        Answer. In the H-2B Notice of Proposed Rulemaking, the Department
    proposed to allow employers to terminate a job order in the event of an
    unforeseeable, catastrophic event (such as a hurricane) in order to
    address circumstances beyond the control of the employer or the worker.
    In response to employer comments on the proposed rule, the Department
    modified the provision in the Final Rule to include acts of man (such
    as an oil spill or controlled flooding) as well as acts of God.
    Termination of the job order under this provision allows employers to
    end a worker's employment and fulfill the three-fourths guarantee
    through the job order termination date, as opposed to fulfilling the
    three-fourths guarantee through the entire period of the job order.
        The Department recognizes that a timely response to an employer's
    request to seek relief under this provision is a key issue for
    businesses, including coastal seafood firms, and is confident in our
    process for responding to employers. The Department's Employment and
    Training Administration (ETA) has established a process for employers
    to electronically submit requests to terminate the job order and ETA
    commits to responding to terminations requests within 2 working days of
    receipt of such requests.
        Please note that on April 26, 2012, the court in the U.S. District
    Court for the Northern District of Florida, Pensacola Division, granted
    a nation-wide preliminary injunction enjoining the DOL from enforcing
    the H-2B Final Rule.
       operating the voluntary protection program with reduced resources
        Question. In the President's fiscal year 2013 budget, DOL has
    proposed reducing Voluntary Protection Program (VPP) budget by more
    than $3 million and reducing the number of full-time equivalents (FTEs)
    by 31. This drop is problematic because Occupational Safety and Health
    Administration's (OSHA) proposed workload for fiscal year 2013 includes
    only 60 approvals for new VPP sites. Currently, there are more than 100
    sites in the VPP in and actively pursuing VPP status in the State of
    Louisiana. Collectively, these sites employ approximately more than
    20,000 workers. How will the proposed shift in the DOL's OSHA resources
    from compliance assistance to enforcement impact these VPP sites in
    terms of their ability to either obtain or retain VPP their ability to
    participate in the VPP in 2012 and 2013?
        Answer. The reduction of $3 million and 31 FTE is proposed for
    OSHA's entire Federal Compliance Assistance budget activity, not solely
    VPP. This reduction would be achieved through the consolidation of
    compliance assistance personnel in geographically dense regions and the
    completion of outreach and training materials development in fiscal
    year 2012, which will not be needed in fiscal year 2013, and will help
    offset the very urgent need for increased resources for OSHA's
    whistleblower protection responsibilities. In addition to taking steps
    to enhance the efficiency of compliance assistance, OSHA will no longer
    offer the Corporate and Merit VPP programs. The agency plans to focus
    on maintaining the number of current VPP sites by recertifying 280
    current sites.
        It is important to note that none of the steps we are taking will
    eliminate the access of small businesses to the VPP program. In
    addition, we are maintaining the increase for our State Consultation
    program, which is the largest source of OSHA assistance to small
    businesses.
        Question. According to Government Accountability Office (GAO)
    report on the VPP published in May 2009, approximately 80 percent of
    VPP worksites have fewer than 500 employees. Has OSHA studied and
    concluded separately on the impact on small businesses of the fiscal
    year 2013 DOL budget proposal to shift OSHA resources from compliance
    assistance to enforcement?
        Answer. In its report, GAO was looking at the size of the worksite
    and not the size of the company owning the worksite. Only 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).
        OSHA's Safety and Health Achievement Recognition Program (SHARP) is
    a recognition program similar to VPP that is focused exclusively on
    small businesses. Employers that have a full On-site Consultation visit
    and meet other requirements may be recognized under SHARP for their
    exemplary safety and health management systems. As of February 29,
    2012, there were 1,568 SHARP sites, of which 154 are new SHARP site
    that were initially recognized in fiscal year 2011.
        In fiscal year 2012, the On-site Consultation Program budget was
    increased, which enabled OSHA to increase its commitment to assisting
    small businesses with identifying workplace hazards, providing advice
    on compliance with OSHA standards and assisting in the establishment of
    safety and health management systems. This increased commitment to
    assisting small businesses will continue in fiscal year 2013.
        Question. What are OSHA's plans to review the impact on small
    businesses that participate in the VPP of implementing a user fee
    system to fund VPP?
        Answer. OSHA has no plans to implement a user fee system to fund
    VPP.
               measuring voluntary protection program performance
        Question. The May 2009 GAO report found merit in the VPP programs
    overall, but that OSHA had not developed goals or measures to assess
    the performance of the VPP, and the agency's efforts to evaluate the
    program's effectiveness had not been adequate. OSHA generally agreed
    with the GAO Report's recommendations to develop procedures and
    measures to assess the performance of the VPP. What is the current
    status of implementing the recommendations from the GAO report for
    assessing the performance of the VPP?
        Answer. OSHA has implemented a number of new policies to improve
    the performance of VPP participants 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, June 29, 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. OSHA continues to provide GAO with
    annual updates on its recommendations to improve administration and
    oversight of VPP.
        OSHA formed a VPP Review Workgroup in 2011 made up of
    representatives from OSHA's National and Regional Offices. The group
    was responsible for conducting a comprehensive review of the VPP and
    submitting recommendations to the Assistant Secretary for improving the
    program and developing goals and measures. The Workgroup reviewed
    extensive documentation and also interviewed Regional and National
    Office managers and staff, VPP participants, and other external
    stakeholders to solicit their views and recommendations for improving
    VPP. OSHA has begun working on suggested recommendations for changes
    that are determined to be key and that will strengthen the program's
    effectiveness and integrity.
                                     ______

                    Questions Submitted by Senator Jack Reed
                                  work sharing
        Question. My work-sharing legislation was recently signed into law.
    Many States are now awaiting guidance from the Department in order to
    implement work sharing or strengthen their existing program.
        When will the Department issue guidance, specifically with respect
    to Federal financing and grants? What are the Department's plans for
    formulating model work-sharing legislation? What are the Department's
    plans for fulfilling the intent and purpose of the legislation--to
    encourage more States to adopt work-sharing, strengthen existing
    programs, and prevent layoffs--and maximize outreach to State work
    force agencies and businesses?
        Answer. The Department has been working as quickly as feasible to
    implement the many reforms to the Unemployment Insurance program
    contained in the Middle Class Tax Relief and Job Creation Act of 2012,
    including the Short Time Compensation (STC) or work-sharing provisions.
    Early priorities were implementation of the complex changes to the
    Emergency Unemployment Compensation program and the requirement that
    states provide re-employment services and re-employment and eligibility
    assessments for Emergency Unemployment Compensation (EUC) claimants,
    since these provisions had to be implemented by States immediately.
        With regard to the STC provisions, to inform our guidance and to
    meet the statutory requirement to consult with stakeholders and program
    experts, the Department held ``listening sessions'' via two Webinars on
    March 19 and 20, 2012. The Department envisions there will be several
    pieces of program guidance. The first guidance will address the new
    program definition, the transition provisions for States currently
    operating STC programs, new program reporting requirements, and the
    process for 100-percent reimbursement of STC benefits for States
    currently operating STC programs. The first guidance will provide
    preliminary information on the new 2-year Federal STC program and the
    grants. Our current target for issuing this guidance is the first week
    of May 2012. Model legislative language is in development and should be
    ready to release by the end of May 2012. As soon thereafter as
    feasible, the Department will issue more comprehensive guidance on the
    new 2 year Federal STC program and the grants, which is already in
    development. Subsequent to each piece of guidance, the Department will
    host Webinars with States to review the guidance and offer technical
    assistance.
        The Department is excited to be implementing the STC provisions in
    the act as a critical lay-off aversion tool for States. We currently
    are developing a robust outreach and technical assistance plan to
    support State take-up and employer engagement, including collection and
    dissemination of best practices. We will be happy to share that plan
    upon completion.
                 libraries and the workforce investment system
        Question. Public libraries are a key access point to our workforce
    investment system. However, they are often connected to the one-stop
    system on an ad hoc basis. What role will public libraries play in the
    American Job Center Network (AJCN) proposal that the administration
    rolled out on March 12, 2012?
        Answer. Libraries will play a key role in the AJCN. The Employment
    and Training Administration (ETA) has met with representatives from the
    Institute of Museum and Library Services (IMLS) and the American
    Library Association (ALA) to brief them on the AJCN proposal. All three
    organizations have agreed to work together to meet the goals of the
    AJCN proposal. ETA representatives have participated at Library events
    sponsored by IMLS and ALA to discuss the administration proposal and
    will provide training to library staff on the Department of Labor (DOL)
    electronic tools designed to assist job seekers.
        Question. Please provide an update on the activities and outcomes
    as a result of the Department's Memorandum of Understanding with IMLS.
        Answer. DOL and the Institute of Museum and Library Services (IMLS)
    entered into a partnership in October 2009 in recognition of the
    important roles that both the public workforce system and libraries
    have in addressing the varied employment-related needs of American
    workers, job seekers, unemployed workers, and employers. IMLS and the
    Department continue to involve their respective strategic partners in
    the workforce and library systems to raise awareness and share examples
    of partnerships at the local level. In June 2010, the Department
    published a Training and Employment Notice announcing the ETA-IMLS
    partnership to the workforce system and highlighting examples of
    partnerships between the workforce system and public libraries at the
    State and local levels.
        Additionally, the Department has:
      --provided information on where to find libraries on the Department's
            CareerOneStop Web site--America's Service Locator;
      --provided electronic training materials on various electronic tools
            (e.g., mySkills myFuture, ReEmployment portal, Workforce3One,
            CareerOneStop electronic tools) for distribution at national
            meetings of the Public Library Association (PLA) and ALA;
      --delivered Webinars to the public workforce system and library staff
            nationwide to promote and identify effective partnerships
            between the public workforce system and libraries, and provided
            training to library staff on ETA electronic tools; and
      --continued to interact with leaders at IMLS and the ALA.
        Most recently, the Department has met with representatives from the
    IMLS and the ALA to brief them on AJCN proposal and has invited their
    input and participation in this initiative.
        Question. How many of the first round applicants for the Workforce
    Innovation Fund (WIF) have included working with public libraries as
    part of their proposal? In the next round of applications, will the
    Department emphasize public libraries as key partners in an innovative
    workforce investment strategy?
        Answer. The WIF grant solicitation closed on March 22, 2012, and
    applications are being paneled. The Department will continue to
    emphasize the importance of a wide range of partners, including
    libraries, as appropriate, in future rounds.
                                   job corps
        Question. The Department has rightly been focused on working with
    Job Corps Centers to strengthen accountability and improve outcomes for
    students. However, the Department's interpretation of the small
    business set-aside requirements may mean that performance is not one of
    the key criteria for awarding or renewing Job Corps contracts.
        What criteria are used in the Department's determination to set
    aside a Job Corps contract? Are factors such as center performance,
    operator past performance, and student outcomes the primary factors in
    set aside determinations?
        Answer. Employment and Training Administration (ETA) supports the
    use of small businesses as part of the economic engine for the economy.
    ETA's determination to set aside Job Corps procurements arises under
    the express terms of Federal Acquisition Regulations (FAR) section
    19.502-2(b), which requires the Contracting Officer to set aside a
    procurement more than $150,000 for small businesses, ``when there is a
    reasonable expectation that: (1) Offers will be obtained from at least
    two responsible small business concerns offering the products of
    different small business concerns; and (2) Award will be made at fair
    market prices.''
        In determining if there is a reasonable expectation that offers
    will be obtained from at least two responsible small business concerns,
    the Contracting Officer performs market research. This market research
    may include an analysis of prior procurement history and recent
    performance of contractors similar in size, scope, and complexity to
    the pending requirement. Thus, contractor quality and performance are
    primary factors in the small business set-aside determinations.
        The Contracting Officers in the ETA use market research, most often
    via a sources sought notice, to arrive at the most suitable approach
    for acquiring services, as discussed in FAR 10.000. ETA uses the
    resulting market research to determine if a there is a reasonable
    expectation that offers will be obtained from at least two responsible
    (i.e., capable) small businesses and that the award will be made at
    fair market prices. ETA's market research allows DOL to identify
    companies that have experience performing services of a similar size
    and scope to that of the contract in question. For example, if a
    contractor has operated one or more Job Corps centers within the recent
    past that were similar in size and scope to the requirement, DOL will
    consider that information in assessing the available sources to compete
    for a potential contract award.
        In addition, the procurement process includes an analysis of
    several evaluation factors in which technical approach (i.e., quality
    of services provided to the students) is the most important. Also,
    companies' past performance is evaluated during the procurement process
    and is considered in this analysis. Past performance is not the most
    important factor, but it is an important factor that is considered in
    the evaluation. Also, the past performance evaluation includes a
    consideration of the student outcomes achieved if the contractor has
    past performance that includes operating a Job Corps center.
        Question. Are there Job Corps centers that have chronically
    underperformed under several different operators? What performance
    criteria has the Department considered in making its estimates of the
    number of centers that could potentially be closed for chronic low
    performance?
        Answer. Yes, there are Job Corps centers that have had more than
    one operator and have continued to underperform. The Department is
    using its existing performance measures as the key component for
    developing its methodology for identifying centers for closure that
    will be published in the Federal Register for the public and
    stakeholders to provide feedback, prior to its use in selecting centers
    for closure. A timeline has not yet been developed for the closure
    process.
                                     ______

                   Questions from Senator Barbara A. Mikulski
                               h-2b program rules
        Question. It is my understanding that the Department of Labor (DOL)
    currently requires that all workers requested on an application be
    brought over on that application's singular date of need. This policy
    has been raised as a concern in the context of the upcoming
    comprehensive rule, which among many provisions, will require that
    employers pay each H-2B employee three-quarters of the hours guaranteed
    in the contract, over a 12-week period.
        Does the Department believe that practical interaction of these two
    policies--that all workers must come over at once, and then be paid
    three-quarters of the hours in the contract--is a realistic expectation
    of employers in the H-2B program?
        Answer. The Immigration and Nationality Act provides for the
    importation of foreign workers in nonagricultural employment through
    the H-2B program. The Department's Employment and Training
    Administration (ETA) approves applications for foreign workers under
    the H-2B program only if no U.S. workers are available for the job. To
    determine the availability of U.S. workers for the job, ETA requires
    employers to test the labor market--that is, to see whether U.S.
    workers are available for the job under the conditions specified in the
    job order and for the period of need specified in the job order. To
    allow employers to recruit for U.S. workers based on an application
    representing a singular date of need when, in fact, the employer has
    multiple dates of need, unfairly discriminates against U.S. workers who
    may be available for some of the later period, but not the entire
    period, indicated on a singular job order. The Department takes very
    seriously its responsibility to ensure that employers are not
    authorized to bring in foreign workers when U.S. workers are available
    for the jobs. In addition, both the 2008 DOL regulations and those from
    the Department of Homeland Security prohibit the practice known as
    ``staggered entry dates'' on a single labor certification. In other
    words, if an employer needs workers at different times (staggered) in
    their DOL-approved period of temporary need, they are required to
    submit separate applications for those ``staggered'' dates of need in
    order to timely test the labor market for domestic workers.
        The three-fourths guarantee is a necessary protection that ensures
    that workers--both United States and H-2B workers--are given a chance
    to evaluate the desirability of the offered job and that their
    commitment to a particular employer results in a real job that meets
    reasonable expectations for the full-time work that is required for an
    employer to participate in the H-2B program during the period requested
    by the employer. The three-fourths guarantee also ensures that
    employers do not overstate their need for workers, thereby using visas
    that could have gone to other employers with legitimate needs.
        Question. If so, does that assessment hold true for small, coastal
    businesses that are dependent on nature, such as the seafood industry?
        Answer. The Department recognizes the impact weather can have on
    seasonal businesses and therefore, included a provision whereby
    employers can seek to have their job orders terminated in the event of
    fire, weather, or other act of God that makes fulfillment of the job
    order impossible. The Department also included catastrophic or man-made
    events, such as controlled flooding or oil spills as reasons for
    termination of the job order. An employer whose contract is terminated
    under this provision would be required to comply with the three-fourths
    guarantee provision through the cancellation of the contract rather
    than through the entire period of the job order.
        Question. Has the Department taken a thorough review to make sure
    that its existing regulations work in harmony with its revised
    regulations in order to make sure that they are imposing requirements
    on small businesses which are readily achievable?
        Answer. The Department carefully reviewed the proposed
    requirements, comments received on the proposed rule, and current
    program operations and sought to achieve a final rule that balances
    important protections for U.S. workers, H-2B workers, and employers who
    seek to play by the rules with the needs of employers using the H-2B
    program.
                                     ______

                Questions Submitted by Senator Richard C. Shelby
                           workforce innovation fund
        Question. Madam Secretary, I remain concerned that as more
    workforce training programs become competitively awarded they will not
    reach those for whom training programs are intended. I also have
    reservations about appropriating a third year of funding for the
    Workforce Innovation Fund (WIF), a competitive program whose first year
    of funding has not been awarded yet. Why is $100 million from the
    Department of Labor (DOL) in fiscal year 2013 necessary for an
    unproven, untested program that already has $175 million in the bank?
        Answer. The purpose of WIF is to support innovative approaches to
    the design and delivery of employment and training services that
    generate long-term improvements in the performance of the workforce
    system, both in terms of employment and training outcomes and cost-
    effectiveness. Each grant awarded under WIF must include an independent
    third-party evaluation; thus, we anticipate that the benefit of WIF
    investments will extend not only to those individuals who receive
    services under the grant, but also to the broader workforce system,
    which will be able to learn about and adopt those practices shown to be
    promising. We believe having this source of funding is critical to
    drive continuous innovation and evolution in the largely formula-funded
    WIA system.
        Fiscal year 2011 WIF resources must be obligated by September 30,
    2012. This extended period of obligation was intentional to provide the
    Department with sufficient time to create a well-designed program in
    consultation with workforce system stakeholders and Federal agency
    partners, including the Departments of Justice and Education. We intend
    to award approximately $118 million of fiscal year 2011 funds and
    approximately $30 million of the fiscal year 2012 funds by September
    30, 2012 under SGA-DFA-PY11-05. The remaining $20 million of fiscal
    year 2012 funds will be used to fund Pay for Success grants under the
    solicitation we anticipate releasing this spring. By the time fiscal
    year 2013 funds become available, the first round of WIF grantees will
    have been operational for at least a year, giving us valuable
    information about the program and which innovations warrant further
    support in the form of additional grants.
                              governor's set aside
        Question. The Governor's Workforce Investment Act (WIA) set-aside
    allows 15 percent of WIA funding to be used by the Governor, at the
    State level, to pursue creative workforce development initiatives. In
    both fiscal years 2011 and 2012 and proposed for 2013, the set-aside is
    reduced to 5 percent.
        The fiscal year 2013 budget proposal states that the funding for
    the WIF will offset the loss of such funds for statewide initiatives by
    providing targeted demonstration projects across the country. However,
    the loss of funds from the reduction in the set-aside is significantly
    more than the WIF request in 2013.
        Are you concerned that the WIF grants will not be awarded to every
    State and that Governors no longer have the flexibility to implement
    innovative statewide projects?
        Answer. WIF will test the most compelling and innovative models
    across the country and build knowledge that can be applied to future
    programming. While there will be an effort to fund high-quality
    applications across the country, we do not expect that will be awarded
    to every State. By the time fiscal year 2013 funds become available,
    approximately $154 million in WIF grants (fiscal year 2011 funds and
    part of fiscal year 2012 funds) will have been operational for at least
    a year. Funding for the fiscal year 2013 WIF will provide States with
    another opportunity to participate in the initiative.
                    veterans--transition assistance program
        Question. In the past several years, the unemployment rate for
    veterans has been significantly higher than the national average. It is
    critical that veterans can transition effectively out of military
    service into civilian life.
        The budget request assumes that 160,000 transitioning
    servicemembers are expected to use the Transition Assistance Program
    (TAP) in fiscal year 2013. However, it is my understanding that with
    the new requirement that all separating servicemembers participate in
    the TAP, combined with the high number of veterans separating from
    service this year, the amount of veterans using the TAP could be as
    high as 290,000. It is critical that adequate funding be provided for
    TAP to ensure our servicemembers receive proper services during their
    transition period.
        Madam Secretary, are you concerned the budget request cannot
    support increased TAP utilization?
        Answer. We are looking at the issue you have highlighted to ensure
    that we have the ability to meet needs of separating servicemembers. In
    fiscal year 2011, Veterans' Employment and Training Service (VETS)
    conducted 4,200 TAP Employment Workshops to more than 144,000
    servicemembers and their spouses at military installations worldwide
    using a combination of State Workforce Agency employees and contract
    facilitators. With the passage of the VOW Act, and based on separation
    projections from Department of Defense (DOD), we anticipate that
    participation in the DOL Employment Workshop will increase by nearly 40
    percent to approximately 201,000 in fiscal year 2013. We are continuing
    to work with DOD to refine those separation estimates and to better
    understand the plans of our DOD and VA partners for delivering their
    components of the TAP workshops.
                              mandatory proposals
        Question. Madam Secretary, I believe it is important to review the
    entire budgetary picture when appropriating funding. Although the
    Senate Appropriations Committee only has jurisdiction over the
    discretionary side of the ledger, it is still critical that we
    understand how much funding programs receive in mandatory dollars so we
    are able to make responsible choices.
        The President has recently announced several large, mandatory
    programs that affect the DOL. In particular, he has announced an $8
    billion Community College Initiative which will be funded by $4 billion
    from the DOL and $4 billion from the Department of Education; $4
    billion for the ``Reemployment Now'' Initiative; and $12.5 billion for
    a ``Pathways Back to Work'' fund.
        Madam Secretary, how will these programs supplement current worker
    training programs?
        Answer. The administration's proposals that you mention will help
    community colleges and businesses train Americans to acquire the
    critical skills that employers need to succeed and help businesses
    succeed and grow. While the DOL has worked closely with local
    businesses and community colleges through various workforce system
    programs, the Community College to Career Fund provides the resources
    and support necessary to enhance the development and improvement of
    educational and career training programs for workers. These investments
    will give more community colleges the resources they need to become
    community career centers where people learn crucial skills that local
    or regional businesses are looking for right now. Through increased
    employer partnerships, this investment will also ensure that employers
    have the skilled workforce they need and that workers are gaining
    industry-recognized credentials and receiving training relevant to the
    local or regional needs of employers to build strong careers.
        This administration is committed to protecting the financial
    integrity of the Unemployment Insurance (UI) system and helping
    unemployed workers return to work as swiftly as possible, and the
    Reemployment NOW Initiative supports that effort. The proposed
    Reemployment NOW program would provide funds for programs that allow
    the flexible use of unemployment benefits for short-term on-the-job
    training or for claimants to start their own businesses. The bipartisan
    Middle Class Tax Relief and Job Creation Act of 2012 adopted a number
    of the reforms the President proposed in the American Jobs Act,
    including some of the initiatives that would be eligible for funding
    under the Reemployment NOW Initiative. This new law, enacted in
    February 2012 extends UI to prevent 6 million long-term unemployed
    Americans looking for work from losing their benefits, while at the
    same time reforming the system to help them build real skills and
    connect to real jobs. For example, as the President proposed last year,
    Reemployment and Eligibility Assessments (REAs) and Reemployment
    Services (RES) are now required for claimants entering the Emergency
    Unemployment Compensation (EUC) program. That initiative is already
    being implemented by the States. REAs and RES have been found to be
    highly effective at helping UI claimants find higher-paying jobs
    sooner, while at the same time saving money for the UI system. The
    Middle Class Tax Relief and Job Creation Act also included the
    President's proposal for making EUC recipients eligible for State Self-
    Employment Assistance programs, which provide support to claimants who
    start their own businesses. Finally, the new law allows for 10 States
    to conduct demonstration programs similar to the proposed Bridge to
    Work program that would help speed claimants' return to work. These
    demonstrations would allow States to use funds from the unemployment
    trust fund, but the programs must be cost neutral.
        Building on successful American Recovery and Reinvestment Act
    programs that provided employment opportunities for low-income adults
    and youths, the Pathways Back to Work Fund makes it easier for the
    long-term unemployed and low-income workers to remain connected to the
    workforce and gain new skills for long-term employment, through
    subsidized employment and other innovative work-based strategies.
    Pathways Back to Work offer a win-win strategy for job seekers and
    employers. It gives job-seekers an opportunity to gain and demonstrate
    in-demand skills for an extended period of time, while earning much
    needed income to support themselves and their families and stimulate
    their local economies. At the same time, it provides employers with a
    low-risk approach to staffing their businesses and building their
    talent pipeline to remain competitive. The ``earn and learn''
    approaches to be supported by Pathways Back to Work are an important
    complement to more traditional, classroom-based occupational training
    currently supported by DOL and enhance the ability of program
    participants, particularly those lacking work experience, to benefit
    from occupational training.
        Question. How can you ensure that such an influx of funding, twice
    the size of the DOL's current discretionary budget, will be efficiently
    and effectively spent?
        Answer. DOL will work to ensure that these requested mandatory
    grant dollars are efficiently and effectively spent through the same
    strong management and oversight processes it uses now for its grants.
    DOL already utilizes comprehensive processes to regularly review and
    monitor all of its grantees, including an electronic grants management
    system, required quarterly reporting from all grantees on their
    financial and technical performance, and on-site grantee monitoring
    visits. DOL reviews grantees' progress against the program performance
    metrics of entered employment, employment retention and average
    earnings, and plans to use this set of common measures as the basis for
    future programs in addition to any program-specific measures. DOL also
    provides technical assistance to help grantees meet the outcomes to
    which they commit in their grant statements of work.
        DOL is also working to leverage its investments to increase their
    impact across the country by coordinating with other Federal agencies
    on a number of initiatives. Examples of inter-agency coordination
    activities include joint guidance on programs serving similar
    populations, jointly funded discretionary grant programs, and efforts
    to identify opportunities for promoting joint strategic planning across
    programs.
                            duplication and overlap
        Question. The Government Accountability Office (GAO) released a
    report in February that stated, ``HHS is collaborating with Labor to
    conduct an evaluation to better understand policies, practices, and
    service delivery strategies that lead to better alignment of the
    Workforce Investment Act and Temporary Assistance for Needy Families.''
        Can you provide further information on this collaboration,
    including examples of State and local practices that may be models for
    other areas to follow and how the Workforce Investment Act (WIA)/
    Temporary Assistance for Needy Families (TANF) duplication can be
    reduced?
        Answer. The Department of Health and Human Services (HHS) is
    working in close collaboration with the DOL to conduct an evaluation to
    better understand policies, practices, and service delivery strategies
    that lead to better alignment of WIA and TANF, including identifying
    promising State and local practices for successful coordination between
    these programs. The Work Participation and TANF/WIA Coordination Study
    will identify strategies to improve the employment outcomes of current
    and former TANF recipients, reduce administrative inefficiencies, and
    remove the structural and policy barriers that inhibit coordination
    between WIA and TANF. Researchers also will document the reasons for
    collaboration and the process for creating and sustaining partnerships.
    A technical workgroup of subject-matter experts is currently working on
    selecting States and local areas for approximately nine site visits, to
    be conducted during summer 2012, to examine governance structures,
    policy coordination, service delivery pathways, shared data systems,
    and funding. We anticipate that the final report will be available for
    dissemination in spring 2013. The Departments will share the results of
    the evaluation with the public workforce system and other stakeholders.
        As another example of DOL-HHS collaboration, a report entitled
    ``Using TANF Funds to Support Subsidized Youth Employment: The 2010
    Summer Youth Employment Initiative'' was published and posted recently
    on both Departments' Web sites. This work is the culmination of the
    Departments' continued collaboration throughout a study to evaluate WIA
    and TANF coordination and the potential benefits and challenges of the
    TANF-funded summer youth employment initiative. Funded through an
    Interagency Agreement between the Departments, this study followed up
    on the 2010 joint DOL-HHS letter that encouraged States to use TANF
    funds for subsidized youth employment and for workforce and human
    service agencies to co-enroll youth in WIA and TANF programs.
        Question. GAO report also noted that the DOL will award competitive
    grants to encourage States to reduce program overlap. Can you describe
    the program overlap that could be eliminated through these grants?
        Answer. By September 30, 2012, DOL intends to award approximately
    $118 million of fiscal year 2011 funds and approximately $30 million of
    the fiscal year 2012 funds provided for competitive grants under WIF.
    The WIF provides States and local areas with an opportunity to pursue a
    variety of innovation strategies, including those that foster stronger
    cooperation across programs and funding streams--such as integrated
    data management information systems, ``braided'' funding, or changes
    that create a more seamless service delivery experience for
    participants who need help from multiple programs.
        DOL also anticipates awarding up to $20 million through a separate
    grant competition for Pay for Success pilot projects to support an
    innovative approach to funding public social service programs, for
    example through leveraged capital from private or philanthropic
    investors. Under the Pay for Success model, the government pays for
    services only after clearly defined outcomes are achieved. This allows
    effective and evidence-based solutions to be identified and implemented
    while maximizing taxpayer dollars by paying only for demonstrated
    results.
        It is our goal that grants awarded under WIF will achieve greater
    efficiency in the delivery of quality services, such as achieving
    positive outcomes for a lower cost or reducing program overlap and
    administrative costs. We expect that successful strategies will be
    sustained beyond the grant period through other funding streams
    currently available to grantees.
        Question. At last year's hearing, we discussed GAO's 2011 report on
    duplication across job training programs. In particular, the report
    stated that 44 of the 47 Federal employment and training programs
    identified overlap with at least one other program. What steps has the
    DOL taken to reduce duplication within job training programs over the
    past year?
        Answer. DOL recognizes that there are opportunities for the further
    alignment and streamlining of employment and training programs, and our
    fiscal year 2013 budget reflects this reality by including several
    proposals. These proposals include expansion of the WIF which will
    support innovative ways of delivering services working across program
    silos; the transfer of the Senior Community Service Employment Programs
    to the HHS, where the program can work more closely with other senior-
    serving programs; developing single access points for job seekers to
    access all available services through a rebranded and improved network
    of American Job Centers; the elimination of the Women in Apprenticeship
    and Nontraditional Occupations and Veterans Workforce Investment grant
    programs, whose missions can be met through other programs and
    activities; and the merging of the Trade Adjustment Assistance and WIA
    Dislocated Worker program into a single program providing a uniform and
    comprehensive suite of services to all displaced workers in fiscal year
    2014.
                                upper big branch
        Question. The recent internal review by the Mine Safety and Health
    Administration (MSHA) regarding the tragic accident at Upper Big Branch
    claimed that much of the managerial and personnel issues in district 4
    stemmed from budget cuts prior to 2006. However, MSHA's budget
    increased from $246.3 million in fiscal year 2001 to $277.7 million in
    fiscal year 2006. Blame can be placed on many factors for the Upper Big
    Branch tragedy, but Secretary Solis, why did DOL choose to place
    culpability mainly on funding levels, especially given that MSHA's
    budget increased $129 million from fiscal year 2000-2010?
        Answer. The internal review is about more than funding levels. The
    internal review team was comprised of career MSHA employees with
    various specialties and expertise who did not have current enforcement
    responsibility in Coal Mine Safety and Health District 4. Their report
    attributes the shortcomings identified to a number of underlying causes
    in addition to resources, including inspector inexperience, management
    turnover, supervisory and managerial oversight, internal communication
    of policies, and training. We are looking at all of these issues to
    ensure they are addressed.
        As Assistant Secretary Main recently noted during testimony before
    the House Education and Workforce Committee:

        ``The internal review team found the number of coal enforcement
    personnel had eroded to 584 by the end of fiscal year 2005, a result of
    attrition and budget constraints. By comparison, there were 653 such
    personnel in fiscal year 2001. Following the 2006 Sago, Darby and
    Aracoma disasters, MSHA received additional funds to hire more
    inspectors. However, despite efforts to re-establish staffing levels,
    by the time of the UBB explosion, the inspection and supervisory staff
    was significantly composed of new inspectors, replacing a number of
    experienced inspectors who retired. For example, from fiscal year 2005
    to fiscal year 2008, MSHA lost 252 coal enforcement personnel from its
    ranks. Some inspectors retired, were recruited by industry, moved to
    new positions within the agency, or left MSHA for other reasons . . .
    The budget constraints and constant loss of experienced personnel due
    to attrition adversely affected the entire agency.''

        I appreciate all of the support that the subcommittee has provided
    to ensure that MSHA obtains the funding needed not only to meet these
    critical inspection activities, but in related activities such as the
    work that MSHA and the Office of the Solicitor are doing to address the
    backlog of cases before the Federal Mine Safety and Health Review
    Commission.
                     pension benefit guarantee corporation
        Question. Secretary Solis, as Chair of Pension Benefit Guaranty
    Corporation (PBGC), how are you addressing the systemic problems
    uncovered in the Inspector General reports on the National Steel and
    United Airlines (UAL) pension plans? What timelines have been set up to
    address the serious issues raised in the report, to include the
    possible reorganization of the Benefits Administration and Payment
    Department office?
        Answer. The PBGC Office of Inspector General (OIG) found long-
    standing systemic failures at the PBGC that resulted in errors in the
    valuations of assets of the terminated UAL and National Steel pension
    plans, as well as other plans trusteed by the PBGC. The OIG uncovered
    serious flaws in the work of the original contractor and the re-
    valuation work prepared by a second contractor. The PBGC board is
    working with the OIG and the PBGC leadership to ensure that appropriate
    steps are taken to remedy deficient asset valuations for terminated
    plans, erroneous benefit determinations for affected participants, and
    any systemic failures.
        PBGC is redoing the asset valuations for the pension plans of UAL
    and National Steel and taking other actions to make corrections where
    necessary. The board and PBGC are committed to finalizing the asset re-
    valuations for UAL and National Steel as quickly as possible without
    sacrificing accuracy or quality. Participants in UAL or National Steel
    plans whose benefits change as a result of the asset re-valuation will
    be notified this summer.
        For other asset valuations, PBGC is using the experience gained
    from the UAL and National Steel reviews to develop a risk-based
    approach to screen the other plans on which the original contractor
    worked, and to identify plans where contractor errors may have affected
    beneficiaries. The PBGC continues to review its actions with the OIG
    and the board.
        By law, the PBGC's Director is responsible for administering the
    PBGC's operations, and the board is responsible for setting policy and
    providing oversight. The Board is committed to holding the PBGC
    management accountable for effectively selecting and monitoring outside
    auditors. This is a core management function of being a good steward
    for the plans the PBGC trustees and for making sure these mistakes do
    not happen again. Over a year ago, PBGC began a strategic review to
    make improvements to the Benefits Administration and Payment
    Department's (BAPD) organizational structure and operations. Based on
    that review, PBGC identified a wide range of actions to address long-
    term systemic failures within BAPD and to ensure that BAPD has
    sufficient expertise to effectively select and monitor outside
    auditors. The agency has already begun to make changes in its
    organization, personnel and processes, including the qualifications and
    training of BAPD staff, improved contractor management, and improved
    quality control overall.
                            wyoming job corps center
        Question. Secretary Solis, can you provide an update on the
    progress of the Wyoming Job Corps Center, including when you anticipate
    publishing a construction bid in the Federal Register and your timeline
    for opening the Center?
        Answer. A new center in Wyoming is planned to open after program
    year 2013.
                          voluntary protection program
        Question. Assistant Secretary Michaels recently stated the
    Voluntary Protection Program (VPP) would be expanded. However, the
    budget request for the Occupational Health and Safety Administration
    (OSHA) decreases compliance assistance in fiscal year 2013. Further,
    OSHA is projected to conduct far fewer VPP site evaluations (down 40
    percent from fiscal year 2011) and will completely halt the corporate
    and merit VPP program at new sites. Can you explain why the Department
    is announcing VPP is expanding, when no budget documents support this
    claim?
        Answer. Assistant Secretary Michaels supports the expansion of VPP
    to additional worksites that meet the criteria for VPP participation.
    To that end, OSHA plans to approve 60 new VPP sites and to recertify
    280 during fiscal year 2013. The VPP program is not being cut. In order
    to achieve efficiencies, OSHA will no longer offer its Corporate and
    Merit VPP programs. It is also important to note that none of the steps
    we are taking will eliminate the access of small businesses to the VPP
    program.
        In May 2004, OSHA created the VPP Corporate Pilot to significantly
    expand participation in VPP by allowing corporations committed to VPP
    and interested in achieving VPP recognition at multiple facilities a
    more efficient means of accomplishing this. Over the years, several of
    the corporate participants have failed to meet their commitments to
    bring in 10 participants within 5 years and others have chosen to drop
    out of the program. In addition, it became clear that the Pilot did not
    produce the expected application and onsite evaluation efficiencies.
    Eliminating VPP Corporate will not adversely affect a company's ability
    to achieve VPP status.
        After evaluating participation in the Merit program, OSHA has
    concluded that its resources could be more effectively used for site
    visits to bring qualified companies directly into VPP rather than
    putting resources into developing new VPP candidates, many of whom
    never qualify for VPP, spend little time in the program after
    qualifying, or would qualify without the Merit program. Resources OSHA
    previously used for site visits and reevaluations for Merit
    participants will be directed towards new VPP sites and
    recertifications of existing sites.
                                   farm labor
        Question. Secretary Solis, the DOL announced it would re-propose a
    regulation on the existing agriculture ``parental exemption'' after the
    original, highly controversial proposed rule was withdrawn. The
    original proposal significantly narrowed the application of the
    parental exemption by limiting it to parents that wholly owned the
    family farm. This change ignored the structure of modern agriculture.
    While I appreciate the rule being withdrawn, I question whether a re-
    proposal is even necessary.
        Why is DOL moving forward with another rule? Will DOL rewrite the
    new rule based on the numerous public comments that were made? Is DOL
    conducting outreach with the agriculture industry to ensure that the
    new rules take into account the current structure of the modern farm?
        Answer. As you may know, DOL announced on April 26, 2012, the
    withdrawal of the proposed rule addressing hired farm workers under the
    age of 16. In the same announcement, DOL committed to working with the
    U.S. Department of Agriculture and with rural stakeholders, such as the
    American Farm Bureau Federation, the National Farmers Union, the Future
    Farmers of America, and 4-H, to develop an educational program to
    reduce accidents to young workers and promote safer agricultural work
    practices.
                                     ______

                   Question Submitted by Senator Thad Cochran
                           gulfport job corps center
        Question. The Gulfport Job Corps Center was destroyed by Hurricane
    Katrina in 2005. Since that time, I worked to appropriate both
    dedicated funding of $14 million, as well as other annual construction
    funds for use towards the rebuilding efforts for that facility. The
    bulk of the dedicated $14 million in funding was used for a temporary
    facility and to construct a dorm, but I understand that $4.5 million in
    dedicated funds remain. I continue to work on behalf of the community
    to ensure that the new facility balances their priorities with the best
    interest of the Job Corps training activities. It is my understanding
    that the Department of Labor (DOL) is continuing to consult with the
    Gulfport community, as well as the State of Mississippi, to resolve
    outstanding issues relating to specific design details. Please discuss
    the path forward for this project as well as your plan to protect the
    money that has been reserved for the Gulfport Job Corps facility's new
    construction. Will the construction phase cost more than the remaining
    dedicated funds? If so, how will you approach securing the balance?
        Answer. I recognize that you have been a tireless champion for the
    Job Corps program and have been very eager to see us move from a
    temporary facility to a permanent one in Gulfport--one that we both
    hoped would serve double the amount of students of the temporary
    center, while creating employment opportunities for the community both
    in the construction and operations phases.
        Several months ago, the redevelopment of the Gulfport Job Corps
    Center was placed on hold as the project proposed the demolition of the
    former 33rd Avenue High School, which was eligible for inclusion in the
    National Registry of Historic Places. Since that time, DOL has been
    engaged in the section 106 process, as outlined in the National
    Historic Preservation Act, to gather feedback and input from interested
    parties before making a determination to move forward with the proposed
    project. In addition to the DOL and the Advisory Council on Historic
    Preservation, this process has included consultation with the
    Mississippi Department of Archives and History (MDAH), the city of
    Gulfport, and Gulfport community members.
        Because a mutually agreeable resolution to move forward with the
    proposed project was not reached, on Friday, March 16, 2012, DOL
    terminated the construction contract to redevelop the Gulfport Job
    Corps Center. This will allow the portion of the project's funding that
    expires on June 30, 2012, to be reallocated prior to its expiration.
    The remaining $4.5 million of funding dedicated to the project does not
    expire and will remain available for future redevelopment efforts.
        DOL is committed to serving the youth of the Gulfport community,
    having operated a center in this gulf coast region for more than 30
    years. The DOL will work with the MDAH, the city of Gulfport, and all
    identified consulting parties to begin a new section 106 process for
    the redevelopment of the Gulfport Job Corps Center, which will inform
    future decisions about the establishment of a permanent center in
    Gulfport, Mississippi.
        As you point out, the cost of a new construction project will
    exceed the remaining amount of dedicated funds. By redistributing the
    funding from the cancelled contract to other shovel-ready projects, our
    intent was to free up future years' construction funding for Gulfport,
    rather than allowing those funds to expire. As you know, the Job Corps
    program receives an annual Construction, Rehabilitation, and
    Acquisition (CRA) appropriation each year, and develops a funding plan
    with priority given to the most critical deficiencies. As with each new
    funding cycle, DOL will review the redesign for a Gulfport Center
    redevelopment project alongside the program's other construction and
    rehabilitation needs before making a final funding determination. We
    will continue to work with the Appropriations Committee and your office
    on this matter and appreciate your support for the Job Corps program.
                                     ______

                 Questions Submitted by Senator Lamar Alexander
                     proposed companionship exemption rule
        Question. At a January 25, 2012 briefing, representatives of the
    Department of Labor's (DOL) Wage and Hour Division and the Centers for
    Medicare & Medicaid Services (CMS) told my staff that they did not meet
    with a single State's Medicaid Director.
        Did DOL directly consult or meet with any State Medicaid Directors
    when promulgating the proposed rules? If yes, please provide details
    regarding which State Medicaid Directors DOL met or consulted with, the
    substance of their recommendations, and how their recommendations were
    incorporated into the proposed rule and accompanying economic impact
    analysis. If no, will DOL be willing to withdraw the rule to meet with
    State Medicaid Directors and conduct a more comprehensive analysis of
    the impact of the rule on State Medicaid programs and budgets that
    incorporates their recommendations before moving forward?
        Answer. In development of the proposed rule, Application of the
    Fair Labor Standards Act to Domestic Service (76 FR 81190, December 27,
    2011), DOL reviewed publicly available data to estimate the impact of
    the proposed revisions, and consulted with the Department of Health and
    Human Services' CMS. A significant number of comments were received on
    the Department's proposed rule, including a few from State Departments
    of Human Services, as well as from the National Association of Medicaid
    Directors representing the Nation's 56 State and territorial Medicaid
    agencies. DOL is currently reviewing the comments received on the
    proposed rule and will continue to consult with the Centers for
    Medicare and Medicaid Services on this important matter. Any final rule
    resulting from this Notice of Proposed Rulemaking will address comments
    received on the proposal, including those expressing concerns about the
    potential impact of the proposal on State Medicaid budgets.
        Question. On March 12, 2012, the Office of Advocacy at the Small
    Business Administration sent a letter to you stating that DOL's
    economic analysis does not fully reflect the information provided by
    small businesses in the companion care industry and recommending that
    DOL consider the impact and regulatory alternatives, as required under
    the Regulatory Flexibility Act, before moving forward. Will the DOL
    withdraw the proposed rule to conduct a more thorough economic impact
    analysis that accurately reflects the nature of the private market for
    companion services, economic impact of the rule on small businesses,
    and alternatives proposed by industry?
        Answer. On December 27, 2011, DOL published a proposed rule:
    Application of the Fair Labor Standards Act to Domestic Service. After
    two extensions of public comment period, the comment period closed on
    March 21, 2012. The preliminary regulatory impact analysis contained in
    the proposed rule is based on the best available data. DOL relied on
    data from: the Bureau of Labor Statistics (BLS) 2009 Occupational
    Employment Survey employment and wages by State for the standard
    occupational codes covering Personal Care Aides and Home Health Aides,
    the workers most likely to be impacted by the proposed rule; BLS
    National Employment Matrix, 2008; BLS Quarterly Census of Employment
    and Wages, 2009, the 2007 Statistics of U.S. Businesses, and the 2007
    Economic Census by State for industries most likely to be impacted by
    the proposed rule, Home Health Care Services, and Services for Elderly
    and Persons with Disabilities. In estimating the number of employees
    potentially impacted, and the average hours worked by home health
    aides, DOL also considered research from Paraprofessional Healthcare
    Institute (PHI) which was based, in part, on the Centers for Disease
    Control and Prevention's (CDC) National Home Health Aide Survey.
        The letter from the Office of Advocacy at the Small Business
    Administration was received during the comment period for the proposed
    rule and is a part of the rulemaking record. See Office of Advocacy,
    Winslow Sargeant, comment id: WHD-2011-0003-7756 available at: http://
    www.regulations.gov/#!documentDetail;D=WHD-2011-0003-7756. In its
    comment letter, the Office of Advocacy referenced the Small Business
    Roundtable it had convened; a summary of the Small Business Roundtable
    meeting as well as materials provided to the Department during that
    meeting are part of the rulemaking record (document id: WHD-2011-0003-
    3235, available at: http://www.regulations.gov/#!documentDetail;D=WHD-
    2011-0003-3235). In addition, the Office of Advocacy's letter mentioned
    comments submitted as part of the rulemaking record, including those
    from the International Franchise Association which submitted, as part
    of its comment, a study it commissioned by IHS Global Insight, and the
    California Association of Health Services at Home. These comments are
    included in the rulemaking record (http://www.regulations.gov/
    #!documentDetail;D=WHD-2011-0003-9590 and http://www.regulations.gov/
    #!documentDetail;D=WHD-2011-0003-0134, respectively).
        DOL is continuing to review the comments received on the proposed
    rule, including the letter from the Office of Advocacy and the comments
    referenced in that letter; however, we note that very little economic
    data was provided by the more than 26,000 individuals who commented on
    the proposal. The comments and other materials are part of the
    rulemaking record, available at: http://www.regulations.gov/
    #!searchResults;rpp=25;po=0;s=WHD-2011-0003.
                    proposed child agricultural safety rule
        Question. Based on the major effects this rule would have on the
    agriculture community do you plan to delay implementation of the rule
    and hold more listening sessions with stakeholder groups to gain a
    better understanding of the complexities in a farming operation?
        Answer. As you may know, the Department announced on April 26,
    2012, the withdrawal of the proposed rule addressing hired farm workers
    under the age of 16. In the same announcement, the Department committed
    to working with the U.S. Department of Agriculture (USDA) and with
    rural stakeholders, such as the American Farm Bureau Federation, the
    National Farmers Union, the Future Farmers of America, and 4-H, to
    develop an educational program to reduce accidents to young workers and
    promote safer agricultural work practices.
        Question. If you cannot commit to delaying the implementations,
    what assurances can you give farmers that this will not limit the
    ability for their children to help out on the family farm?
        Answer. As you may know, the Department announced on April 26,
    2012, the withdrawal of the proposed rule addressing hired farm workers
    under the age of 16. In the same announcement, the Department committed
    to working with USDA and with rural stakeholders, such as the American
    Farm Bureau Federation, the National Farmers Union, the Future Farmers
    of America, and 4-H, to develop an educational program to reduce
    accidents to young workers and promote safer agricultural work
    practices.
                     proposed community college career fund
        Question. The President's fiscal year 2013 budget includes $8
    billion in new spending, over 3 years, to support a new community
    college career fund for the Departments of Labor and Education to
    jointly support new partnerships between States, community colleges and
    businesses that will train 2 million workers for good-paying jobs in
    high-growth and high-demand industries.
        While I appreciate the goals of this proposal, we are continually
    facing significant near and long-term funding gaps in the Pell grant
    program. Based on the March 2012 Congressional Budget Office baseline
    estimates, it is projected that Pell grant funding requirements will
    balloon to $30.7 billion in fiscal year 2014, resulting in a funding
    gap of between $6 billion and $9.7 billion. At the same time, the
    maximum Pell grant award in 2012-2013 is $5,550, while the average
    tuition rate at community colleges in the United States is under $3,000
    per year. Therefore, rather than creating another duplicative program,
    wouldn't the requested $8 billion be better spent in support of Pell
    grants, which would then enable more low-income students to attend the
    university or community college of their choice?
        Answer. The Pell grant program and the Community College to Career
    Fund serve two different purposes and are complementary rather than
    duplicative. DOL supports the Pell grant program's goal of expanding
    low-income students' access to postsecondary education and believes
    this program is a key component for meeting the President's goal of
    every American completing at least 1 year of postsecondary education or
    training. Unlike Pell grants, which are awarded to individual students,
    the Community College to Career Fund will support competitive grants to
    community colleges that have partnered with employers to provide
    individuals with the training and industry-recognized credentials that
    are needed by employers. In addition to providing training to
    individuals, the Community College to Career Fund primarily will be
    used to address the serious capacity shortages of many community
    college training programs in high-growth occupations. In combination,
    the Pell grant program and Community College to Career Fund will
    provide individuals with access to a greater range of education and
    training opportunities.
                                     ______

                    Questions Submitted by Senator Mark Kirk
                            veterans' jobs programs
        Question. I am the co-chair of the Veterans Jobs Caucus in the
    Senate, which is working to ensure that our veterans have access to and
    information about available jobs especially as they return from
    overseas. I was a co-sponsor of the first ``Hiring Our Heroes'' fair
    held in Chicago last spring, sponsored by the U.S. Chamber of Commerce.
    The U.S. Chamber has held numerous similar fairs across the country
    over the last year, with the 100th being in Chicago at the end of this
    month.
        A number of programs and initiatives exist across different
    agencies that are designed to help our veterans enter the civilian
    workforce. While agencies like the Departments of Labor (DOL) and the
    Veterans Affairs and the Office of Personnel Management all have
    something to add to these programs, I am concerned that a lack of
    coordination and duplicative efforts are actually hindering the end
    goal: to get veterans jobs. Especially as the Veterans Opportunity to
    Work (VOW) to Hire Heroes Act, passed last fall by the Congress, comes
    online, I have the following questions: Which is the lead agency
    responsible for coordinating veterans' jobs programs? And who within
    DOL is the point person on interagency coordination?
        Answer. DOL's Veterans' Employment and Training Service (VETS) is
    the lead agency for employment and training programs for veterans.
    Deputy Assistant Secretary Junior Ortiz is the point person, and
    ensures coordinated efforts amongst other Federal agencies in issues
    and initiatives related to veteran employment.
        Question. How is DOL ensuring that you handle initiatives that fall
    within your jurisdiction and expertise, such workforce training?
        Answer. DOL has developed an internal workgroup that leads and
    oversees all efforts related to employment and training for veterans.
    This workgroup is co-chaired by the VETS Deputy Assistant Secretary,
    John Moran, and Employment and Training Administration (ETA) Deputy
    Assistant Secretary, Gerri Fiala. The mission of the workgroup is
    specifically to monitor all initiatives, legislative requirements, and
    ongoing programs that directly benefit our transitioning servicemembers
    and veterans.
        Question. What is DOL doing to ensure that veterans know where to
    go to find jobs that match up the skills they have developed in the
    military with the needs in the civilian workforce?
        Answer. VETS has recently redesigned our Transition Assistance
    Program (TAP) Employment Workshop, which includes a module specifically
    on transferrable skills. During the Employment Workshop, participants
    are educated on the services available through the nearly 3,000
    American Jobs Centers funded through DOL. With the recent passage of
    the VOW to Hire Heroes Act, attendance at our TAP Employment Workshop
    is now mandatory for all separating military personnel with only
    limited exceptions.
        DOL funds several employment programs for job seekers, which are
    operated out of the American Jobs Centers. These centers serve as the
    cornerstone for the Nation's workforce investment system. By law,
    veterans receive priority of service in all DOL-funded programs
    administered through the American Jobs Centers. DOL and the State
    workforce agencies actively outreach to both job seekers and employers
    to raise awareness of the services available at these centers. Outreach
    to job seeking veterans occurs prior to separation for both active duty
    military and members of the Guard and reserves. American Jobs Centers
    staff are often present at the Transition Assistance Program Employment
    Workshop and at demobilization events.
        During job fairs, American Jobs Center staff will make contact with
    participants and ensure they are aware of the services available.
        Disabled Veterans Outreach Program (DVOP) specialists conduct
    targeted outreach to located those veterans that face barriers to
    employment. Typical outreach will include visits to Homeless Veteran
    Reintegration Program grantees, homeless shelters, Vet Centers, and VA
    Medical Centers.
        Further, VETS provides grants to each State to fund two staff
    positions DVOP specialists and Local Veterans' Employment
    Representative staff to provide specialized services to veterans.
        In addition, DOL launched a new suite of on-line tools, My Next
    Move for Veterans (www.MyNextMove.org/vets). On My Next Move for
    Veterans, transitioning servicemembers and veterans can access a simple
    and quick search engine where they enter their military experience
    (branch of service and military occupation code or title) and link to
    the resources they need to explore information on civilian careers and
    related training, including information they can use to write resumes
    that highlight related civilian skills.
                                     ______

                   Question Submitted by Senator Jerry Moran
           addressing the shortage of medical laboratory technicians
        Question. One of the many challenges facing our Nation involves a
    shortage of well-trained allied health professionals to meet the
    increasing medical needs of the aging workforce. Hospitals,
    laboratories, and other employers in my home State of Kansas and across
    the country are having difficulty finding medical laboratory
    technicians (lab techs) who can fill current job openings. As a lab
    tech, an individual with a 2-year degree in laboratory science can earn
    an annual salary of around $35,000-$50,000, but employers are
    struggling to find qualified individuals with the appropriate education
    and training to fill these science and healthcare jobs.
        Does the Department of Labor (DOL) currently direct any Federal
    funding it receives to initiatives that support laboratory education
    programs in community colleges and other educational institutions to
    address this healthcare workforce shortage?
        Answer. Yes, through the American Recovery and Reinvestment Act of
    2009 (ARRA), DOL awarded more than $150 million to projects focused on
    healthcare under the Healthcare and Other High-Growth and Emerging
    Industries grant program. The grants allow community colleges,
    community-based organizations, State workforce agencies, and other
    public entities to deliver training that leads to employment in a range
    of healthcare fields, including laboratory technicians. In addition,
    DOL recently awarded more than $130 million to healthcare-focused
    projects under the H-1B Technical Skills Training grants. This grant
    program is designed to provide education, training, and job placement
    assistance in the occupations and industries for which employers are
    using H-1B visas to hire foreign workers, and the related activities
    necessary to support such training. DOL also funded 18 projects that
    include healthcare as a focus area under the first year of the Trade
    Adjustment Assistance Community College and Career Training (TAACCCT)
    program. The TAACCCT program provides $2 billion over 4 fiscal years to
    institutions of higher education to expand and improve their ability to
    deliver education and career training programs that can be completed in
    2 years or less; result in skills, degrees, and credentials that
    prepare program participants for employment in high-wage, high-skill
    occupations; and are suited for workers who are eligible for training
    under the TAA for Workers program. DOL intends to widely disseminate
    the results, including curricula, of successful grantees from these
    initiatives to the public workforce system and stakeholders.
        Question. The Bureau of Labor Statistics estimates that there will
    be almost 11,000 laboratory professional job openings each year
    annually through 2018. However, our Nation is currently only graduating
    around 5,000 students each year that are capable of filling these job
    openings. What actions is DOL taking to address this workforce
    shortage?
        Answer. DOL will continue to address the education and training
    needs of the healthcare sector through workforce development programs
    that are designed to be responsive to the demands of the labor market,
    especially at the regional level. These programs will continue to
    support training programs for industries and occupations that are high-
    growth, including laboratory professionals. These activities will occur
    through both the formula-funded public workforce investment system, as
    well as discretionary grant programs, such as future years of the
    TAACCCT program previously discussed.
                                   job corps
        Question. As a supporter of Job Corps, it is essential that
    students enrolled in this education and job training program receive
    the best instruction and support. What is the DOL doing to ensure that
    student outcomes and performance remain the foundation of Job Corps'
    procurement policies and practices?
        Answer. As you know, Job Corps provides high-quality services to
    help students acquire the skills and tools they need to be successful
    in good jobs or further education. Thus, all contract statements of
    work, which describe the contractor's expected outcomes, required
    deliverables, and levels of performance, are crafted with the intent of
    ensuring that students receive quality education, training, and support
    services. The program's policies and requirement are either directly
    stated, or incorporated by reference, in Job Corps' Outreach and
    Admissions, Center Operations, and Career Transition Services
    contracts. Contracts are performance-based, providing financial
    incentives and penalties directly tied to student outcomes.
        Question. What is DOL's justification for its current use of the
    ``Rule of Two'' in Job Corps operations contracting?
        Answer. Job Corps procurements are governed by Federal Acquisition
    Regulation (FAR) section 19.502-2(b), which requires the Contracting
    Officer to set aside a procurement more than $150,000 for small
    businesses,

        ``when there is a reasonable expectation that: (1) Offers will be
    obtained from at least two responsible small business concerns offering
    the products of different small business concerns; and (2) Award will
    be made at fair market prices.''

        Due to pending litigation, DOL cannot comment further on its use of
    the ``Rule of Two'' in Job Corps operations contracting.

                              SUBCOMMITTEE RECESS

        Senator Harkin. Thank you very much, Madam Secretary.
        Secretary Solis. Thank you very much.
        [Whereupon, at 11:45 a.m., Wednesday, March 14, the
    subcommittee was recessed, to reconvene subject to the call of
    the Chair.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2013

                                  ----------

                           WEDNESDAY, MARCH 28, 2012

                                           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, Pryor, Mikulski, Brown, Shelby,
    Cochran, and Moran.

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                         National Institutes of Health

    STATEMENT OF FRANCIS S. COLLINS, M.D., Ph.D., DIRECTOR
    ACCOMPANIED BY:
            ANTHONY S. FAUCI, M.D., DIRECTOR, NATIONAL INSTITUTE OF ALLERGY
                AND INFECTIOUS DISEASES
            GRIFFIN P. RODGERS, M.D., M.A.C.P., DIRECTOR, NATIONAL
                INSTITUTE OF DIABETES AND DIGESTIVE AND KIDNEY DISEASES
            HAROLD VARMUS, M.D., DIRECTOR, NATIONAL CANCER INSTITUTE
            RICHARD J. HODES, M.D., DIRECTOR, NATIONAL INSTITUTE ON AGING
            THOMAS R. INSEL, M.D., DIRECTOR, NATIONAL INSTITUTE OF MENTAL
                HEALTH, ACTING DIRECTOR, NATIONAL CENTER FOR ADVANCING
                TRANSLATIONAL SCIENCES

                    OPENING STATEMENT OF SENATOR TOM HARKIN

        Senator Harkin. The Senate Appropriations Subcommittee on
    Labor, Health and Human Services, Education, and Related
    Agencies will come to order.
        Dr. Collins, welcome back to the subcommittee. Welcome
    also, Dr. Harold Varmus, Director of the National Cancer
    Institute (NCI); Dr. Tony Fauci, Director of the National
    Institute of Allergy and Infectious Diseases (NIAID); Dr.
    Griffin Rodgers, Director of the National Institute of Diabetes
    and Digestive and Kidney Diseases (NIDDK); Dr. Richard Hodes--
    again, good to see you again--Director of the National
    Institute on Aging (NIA); and Dr. Thomas Insel, both the
    Director of the National Institute of Mental Health and the
    Acting Director now of the new National Center for Advancing
    Translational Sciences (NCATS).
        Again, my personal and professional thanks to all of you
    and the hundreds of thousands of people who are supported by
    National Institutes of Health (NIH) funding. Because of all of
    you, America is the world leader in biomedical research.
        But how long America can maintain that status is a matter
    of growing concern. The threat of sequestration looms large.
    The Congressional Budget Office (CBO) has estimated that most
    nondefense discretionary programs, such as NIH, will be cut by
    about 7.8 percent next January if the Congress does not enact a
    plan before that time.
        The budget plan proposed by the House Budget Committee
    chairman, which the House will vote on this week, is even more
    worrisome. In fiscal year 2013, the Ryan plan would cut
    nondefense spending by 5 percent. The following year, the plan
    will cut nondefense spending by 19 percent.
        If that cut were applied equally across the Government, the
    number of new NIH grants for promising research projects would
    shrink by more than 1,600 in 2014 and by more than 16,000
    during the next decade. That means 16,000 fewer opportunities
    to gain insights and possibly find cures for cancer and
    Alzheimer's and diabetes, and any number of other diseases.
        Such a cut would be devastating not only for medical
    research but also for our economy. A study released last week
    by United for Medical Research concluded that, in 2011, NIH
    funding supported more than 430,000 jobs across the country.
    The link for this report follows: http://
    www.unitedformedicalresearch.com/wp-content/uploads/2012/07/
    NIHs-Role-in-Sustaining-the-US-Economy-2011.pdf.
        Again, it always amazes me how most people think that all
    of that money goes to Bethesda, Maryland, and that is not so.
    Most is awarded to researchers at academic institutions all
    across the United States.
        This same research also found that NIH research generated
    $62 billion in new economic activity last year. So now imagine
    cutting NIH funding by 19 percent in 2014.
        Again, a classic case of pennywise and pound-foolish
    thinking, especially when China, India, and Europe are spending
    more, not less, on medical research.
        But even under the best-case scenario, the budget for NIH
    is likely to remain tight for the immediate future, so we must
    do everything we can to ensure that NIH makes the most
    effective use of the money that is available.
        That was part of the thinking behind the new NCATS, which
    this subcommittee created in last year's appropriations bill.
        NCATS brings together, under one roof, translational
    activities that were already being funded but scattered
    throughout the NIH. For virtually no additional money, NIH now
    has an opportunity to address translational sciences in ways
    that we've never done before.
        So, I look forward to hearing more about NCATS and other
    topics from our witnesses. And again, I just thank all of you
    for your great leadership of one of the great institutions of
    this country, the NIH.
        And with that, I will yield to Senator Shelby for his
    opening statement.

                     STATEMENT OF SENATOR RICHARD C. SHELBY

        Senator Shelby. Thank you, Mr. Chairman.
        I want to thank, at this time, Dr. Collins and the Center
    Directors who've joined us today to discuss the important role
    the NIH plays in every American's life.
        For the millions of Americans suffering from a serious
    illness, biomedical research is the beginning of hope. NIH-
    funded research investigates ways to prevent disease,
    understand its causes, and develop more effective treatments.
        A continued commitment to NIH is essential to addressing
    our Nation's growing health concerns and to spur medical
    innovation for the next generation of treatment and cures.
        Unfortunately, the NIH budget request for the year 2013
    abandons that commitment. The proposed budget for NIH is $30.86
    billion, which is claimed to be level funding from fiscal year
    2012. However, this amount does not take into account the
    additional funding the Department of Health and Human Services
    (HHS) requested for Departmentwide evaluation activities.
        If this so-called evaluation tap is agreed to, it will
    reduce the NIH budget by $215 million, bringing the budget
    request below the 2012 level.
        Further, the administration's request does not keep pace
    with biomedical research inflation, and as a result, in
    inflationary adjusted dollars, the NIH is 17 percent--that's
    right, 17 percent--below where they were 10 years ago.
        Without sustained support for the NIH, the translation of
    discoveries from bench to bedside will be dramatically slowed,
    and the United States will surrender its role as a world leader
    in scientific research.
        I do not agree with the funding level proposed by the
    administration for the NIH. I believe that the NIH funding
    should be a priority and that its benefits extend well beyond
    its research discoveries.
        In 2011, NIH research funding supported 432,000 jobs
    nationwide. The research carried out by the NIH in this network
    of 325,000 researchers at 3,000 institutions across the country
    serves this Nation with the goal of improving human health.
        However, Dr. Collins, I understand that your request
    attempts to live within the confines of a difficult budget
    environment. That said, I'm concerned about several of the
    proposed changes to awarding grant funding.
        For example, you proposed capping the grant amount that a
    principle investigator can receive at $1.5 million. This
    proposal discourages success by limiting awards to some of the
    most successful scientists who accordingly receive the most
    grant funding.
        NIH awards grants through a highly competitive, two-tiered,
    independent, peer-review process that ensures support of the
    most promising science and the most productive scientists. By
    limiting grant award amounts, you're changing the system from
    one that grants awards based on science, merit, and good ideas,
    to one based on whether an investigator has previously received
    a grant.
        I'm also troubled with the proposals to cap inflationary
    cost and reduce the average award of competing research project
    grants below the fiscal year 2012 level. While I recognize that
    you're trying to keep your success rate high and fund as many
    grants as possible, I question whether this is the right
    approach. We do not want the only results of this change to be
    scientists spending more time chasing grants than making
    discoveries, and I don't believe you do either.
        I understand that constrained budgets lead to tough
    decisions. However, it is critical that the NIH not lose sight
    of its goal to fund the best science in the hope of reducing
    the burden of illness.
        A fundamental part of the NIH success over the years has
    been that scientific need and opportunity have always dictated
    NIH funding priorities.
        Dr. Collins, I would caution you on opening the door to
    targeting particular diseases for funding as proposed in the
    fiscal year 2013 budget. The last thing I imagine you want is
    the President deciding what specific diseases deserve NIH
    research.
        Finally, as we continue to operate in a tough budget
    environment, I think we need more out-of-the-box thinking to
    stimulate the research community in imaginative ways. In
    particular, I want to highlight such an approach at the NCI.
        Dr. Varmus has started a new program to answer the
    provocative questions in cancer research. This project focuses
    scientists on 24 unanswered, perhaps nonobvious, questions as
    defined by the research community.
        With more than 750 research teams submitting proposals,
    this project shows there are innovative ways to energize the
    research community, even when budgets are constrained.
        And as the Congress faces unprecedented challenges to
    reduce Government spending, we must all face the consequences
    of tough choices. Certainly, these are difficult times, but I
    believe biomedical research is a necessary and worthy
    investment in the health of our people and the vitality of our
    communities.

                              PREPARED STATEMENTS

        Funding for the NIH lays the foundation for drug and device
    discoveries over the next 10 years. Biomedical research is an
    answer to lowering, I believe, our Nation's healthcare costs.
    This is not the time to abandon our commitment to the health of
    all Americans and to the NIH.
                Prepared Statement of Senator Richard C. Shelby
        Thank you, Mr. Chairman. I want to thank Dr. Collins and the Center
    Directors who joined us today to discuss the important role the
    National Institutes of Health (NIH) plays in every American's life.
        For the millions of Americans suffering from a serious illness,
    biomedical research is the beginning of hope. NIH-funded research
    investigates ways to prevent disease, understand its causes, and
    develop more effective treatments.
        A continued commitment to NIH is essential to address our Nation's
    growing health concerns and to spur medical innovation for the next
    generation of treatments and cures. Unfortunately, the NIH budget
    request for fiscal year 2013 abandons that commitment.
        The proposed budget for NIH is $30.86 billion, which is claimed to
    be level funding from fiscal year 2012. However, this amount does not
    take into account the additional funding the Department of Health and
    Human Services requested for Departmentwide evaluation activities.
        If this so-called ``evaluation tap'' is agreed to, it will reduce
    the NIH budget by $215 million, bringing the budget request below the
    fiscal year 2012 level.
        Further, the administration's request does not keep pace with
    biomedical research inflation. As a result, in inflationary adjusted
    dollars, the NIH is 17 percent less than where they were 10 years ago.
    Without sustained support for the NIH, the translation of discoveries
    from ``bench to bedside'' will be dramatically slowed and the United
    States will surrender its role as the world leader in scientific
    research.
        I do not agree with the funding level proposed by the
    administration for the NIH. I believe that NIH funding should be a
    priority and that its benefits extend well beyond its research
    discoveries.
        In 2011, NIH research funding supported 432,092 jobs Nationwide.
    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.
        However, Dr. Collins, I understand that your request attempts to
    live within the confines of the difficult budget environment.
        That said, I am concerned about several of the proposed changes to
    awarding grant funding.
        For example, you propose capping the grant amount that a principle
    investigator can receive at $1.5 million. This proposal discourages
    success by limiting awards to some of the most successful scientists
    who, accordingly, receive the most grant funding.
        NIH awards grants through a highly competitive, two-tiered
    independent peer-review process that ensures support of the most
    promising science and the most productive scientists.
        By limiting grant award amounts, you are changing the system from
    one that grants awards based on science, merit, and good ideas to one
    based on whether an investigator has previously received a grant.
        I am also troubled with the proposals to cap inflationary costs and
    reduce the average award of competing research project grants below the
    fiscal year 2012 level. While I recognize that you are trying to keep
    the success rate high and fund as many grants as possible, I question
    whether this is the right approach. We do not want the only result of
    this change to be scientists spending more time chasing grants than
    making discoveries.
        I understand that constrained budgets lead to tough decisions.
    However, it is critical that the NIH not lose sight of its goal to fund
    the best science in the hope of reducing the burden of illness.
        A fundamental part of the NIH's success over the years has been
    that scientific need and opportunity have always dictated NIH funding
    priorities. Dr. Collins, I caution you on opening the door to targeting
    particular diseases for funding as proposed in the fiscal year 2013
    budget. The last thing I imagine you want is the President deciding
    what specific diseases deserve NIH research dollars.
        Finally, as we continue to operate in a tough budget environment, I
    think we need more out-of-the-box thinking to stimulate the research
    community in imaginative ways. In particular, I want to highlight such
    an approach at the National Cancer Institute.
        Dr. Varmus has started a new program to answer the ``provocative
    questions'' in cancer research. This project focuses scientists on 24
    unanswered, perhaps nonobvious, questions as defined by the research
    community. With more than 750 research teams submitting proposals, this
    project shows that there are innovative ways to energize the research
    community, even when budgets are constrained.
        As the Congress faces unprecedented challenges to reduce government
    spending, we must all face the consequences of tough choices.
        Certainly these are difficult times, but I believe biomedical
    research is a necessary and worthy investment in the health of our
    people and the vitality of our communities.
        Funding for the NIH lays the foundation for drug and device
    discoveries over the next decade. Biomedical research is the answer to
    lowering our Nation's healthcare costs. This is not the time to abandon
    our commitment to the health of all Americans and the NIH.

        Senator Shelby. Thank you, Mr. Chairman.
        Senator Harkin. Thank you very much, Senator Shelby.
        Senator Inouye regrets that the could not be present but
    has a statement to be included in the record.
        [The statement follows:]
                 Prepared Statement of Senator Daniel K. Inouye
        Mr. Chairman, thank you for chairing this hearing to review the
    President's fiscal year 2013 budget for the National Institutes of
    Health.
        Mahalo (thank you), Dr. Collins, for joining us today. In this
    challenging fiscal environment, I will do my best to support the
    continued progress of science and U.S. competitiveness.

        Senator Harkin. Now we'll turn to Dr. Francis Collins, the
    16th Director of the National Institutes of Health, a
    physician-geneticist noted for discoveries of disease genes
    and, of course, his leadership of the Human Genome Project.
        Prior to becoming Director, he served as a Director of the
    National Human Genome Research Institute (NHGRI) at NIH.
        Dr. Collins received his B.S. from the University of
    Virginia; M.D. from University of North Carolina at Chapel
    Hill; and Ph.D. from Yale University.
        Dr. Collins, you're no stranger to this subcommittee. We
    welcome all of you here. Your statement of course, as usual,
    will be made part of the record in its entirety.
        And I ask you to please proceed as you so desire. I won't
    put any clock time on it, so take whatever time you desire. If
    it starts going more than 10 minutes, however, we will get a
    little nervous, okay?
        Welcome back. Please proceed.

                  SUMMARY STATEMENT OF DR. FRANCIS S. COLLINS

        Dr. Collins. Thank you and good morning, Mr. Chairman and
    members of the subcommittee. I'm pleased to be here with my
    colleagues to present the President's budget request for the
    NIH for fiscal year 2013.
        And I must begin by thanking you, Mr. Chairman, and the
    subcommittee members, for the ultimate fiscal year 2012
    appropriation, which maintained NIH's budget at the fiscal year
    2011 level. And we're also very grateful for your leadership in
    creating the new National Center for Advancing Translational
    Sciences (NCATS).
        I do want to express my concern, since we're here in front
    of the subcommittee, about the health of Senator Kirk, and
    convey best wishes for a speedy recovery from all of us in the
    NIH community.
        In the next few minutes, I want to offer some details
    associated with our budget request, to discuss the health and
    economic benefits of biomedical research, as you have done in
    your opening statements, and talk about the promise that lies
    at the intersection of the life sciences and technology.
        As you can see here, and I'm going to show you some
    visuals, the President's fiscal year 2013 budget request for
    NIH is $30.86 billion, the same overall program level as in
    fiscal year 2012. This proposed appropriation will enable us to
    invest in areas with extraordinary promise for medical science.
        We will also use these resources wisely to encourage a
    vigorous workforce prepared to tackle major scientific and
    health challenges.
        As in the past, we will continue to support a wide array of
    research mechanisms, from investigator-initiated research to
    larger and more complex team and center efforts.
        In fiscal year 2013, NIH expects to support an estimated
    9,415 new and competing Research Project Grants (RPGs). That's
    an increase of 672 more than the estimate for fiscal year 2012,
    with an average cost of about $431,000. For fiscal year 2013,
    total RPGs are expected to number around 35,888.
        And also, to nurture early career scientists, we will
    continue our efforts to ensure that the success rates for
    investigators submitting new applications are the same, whether
    the applicant is first-time or more experienced.
        To maximize funding for investigator-initiated grants and
    to continue our support of first-time researchers, we've had to
    make some tough choices.
        For example, we propose to reduce budgets for noncompeting
    RPGs by 1 percent from the fiscal year 2012 level and to
    restrain growth in the average size of new awards. In addition,
    we will no longer assume out-year inflationary increases for
    new and continuing grants.
        Other highlights of the fiscal year 2013 request include a
    $40 million ramp up of the Cures Acceleration Network (CAN) and
    additional support for Alzheimer's disease research, $80
    million coming as part of an HHS-wide initiative.
        NIH-funded research has prevented untold human suffering by
    enabling Americans to live longer, healthier, and more
    productive lives, and let me mention a few examples.
        Life expectancy: A child born today can look forward to an
    average lifespan of almost 79 years. That's nearly three
    decades longer than one born in 1900.
        Cardiovascular disease: During the last half-century, our
    Nation's death rates for heart disease and stroke have fallen
    by 70 percent.
        Infant mortality: We've achieved an impressive 40-percent
    reduction in this vital area over the last two decades.
        In cancer, the just released 2012 annual report to the
    Nation on the status of cancer shows a continuing decline in
    death rates for most cancers, along with a drop in the overall
    rate of new cancer diagnoses.
        And today's biomedical research holds much, much more
    promise. For example, I want to show you this picture of a
    recent publication of research on Alzheimer's disease, and this
    represents a new opportunity in translational research through
    what we would call drug repurposing.
        Recently, a team of researchers, some supported by NIH,
    found that a drug called bexarotene, a drug originally
    developed for treating a type of skin cancer, can clear beta-
    amyloid, as you see in the before and after picture, in mouse
    models of Alzheimer's disease in just 72 hours.
        In people with Alzheimer's, beta-amyloid accumulates in the
    brain like this, eventually leading to the death of neurons.
    Hope for bexarotene has gone particularly high because it has
    already been studied in humans, providing a wealth of
    information about dose and toxicity, and providing the
    opportunity to initiate clinical trials.
        And that's not all. Here's a list, Senator and members of
    the subcommittee, of just a few of the many recent examples of
    progress in biomedical research, scrolling by here. I wish I
    could tell you the details of each one, but this opening
    statement would then go on for most of the day.
        I would like, however, to talk something about the U.S.
    economy, as you have touched on, both of you, in your opening
    statements.
        As our Nation struggles to recover from a difficult period,
    it's worth pointing out that Government investments in
    biomedical research are a terrific way to spur economic growth.
    A recent analysis estimated that every $1 of NIH support
    returns $2.21 in goods and services to the local economy in
    just 1 year. And on average, every NIH grant creates seven
    high-quality jobs.
        Furthermore, NIH serves as the foundation for the entire
    U.S. medical innovation sector, a sector that employs 1.42
    million directly and supports an additional 6.6 million jobs in
    the United States, resulting in a total employment impact of
    more than 8 million jobs, generating $84 billion in wages and
    salaries, and exporting $90 billion in goods and services.
        Already referred to, the latest figures from the United for
    Medical Research report paint a similar picture. According to
    their update, NIH recently, directly and indirectly, supported
    more than 432,000 American jobs, spurring more than $62 billion
    in economic activity.
        And here's another thing to consider: NIH funding is the
    foundation for long-term U.S. global competitiveness in
    industries such as biotech, drug development, and medical
    devices. Around the world, many nations are following America's
    success story and ramping up their investments in the life
    sciences.
        Global research and development (R&D) spending across the
    world is expected to grow by about 5.2 percent to more than
    $1.4 trillion in 2012. India has posted double-digit percentage
    increases in R&D for several years. Europe plans to increase
    research spending by 40 percent over the next 7 years. China
    has just announced that it will increase its investment in
    basic research by 26 percent in 2012. And Vladimir Putin has
    voiced his intention to increase support for research in Russia
    by 65 percent during the next 5 years.
        Let me now turn to a few areas that are driving medical
    research. No less a futurist than Steve Jobs once predicted,
    ``I think the biggest innovations of the 21st century will be
    the intersection of biology and technology.'' And he was spot
    on.
        One striking example is the cost of sequencing a human
    genome. Eleven years ago, it cost $100 million. Five years ago,
    $10 million. Today, less than $8,000 and heading down.
        Within the next year or two, in fact, a couple of U.S.
    companies plan to sell machines that can sequence a genome in a
    single day for $1,000 or less, using devices like the one I'm
    holding up here, the size of a postage stamp. That's a
    sequencing machine. It used to be as big as a phone booth or
    bigger. This is a new model.
        This will revolutionize how doctors diagnose and treat
    diseases and will allow researchers to pursue previously
    unimaginable scientific questions.
        So this kind of advance in technology empowers both basic
    and applied research, and NIH is a leading supporter of basic
    biomedical research in the world.
        Slightly more than one-half of NIH's budget is being
    invested to support this kind of fundamental research. In our
    view, there is no competition between basic and applied
    research. They're synergistic. And our support of basic
    research makes possible a wide range of new biological
    discoveries.
        Take the example of induced pluripotent stem cells, stem
    cells derived from patients' own skill cells. This technology
    is now being used to develop exciting new models of disease,
    so-called ``diseases in a dish,'' that are expanding our
    understanding of human biology, as well as opening the door to
    new treatment possibilities.
        But let's be honest. There's much work yet to be done.
    Despite phenomenal progress in basic science, we still lack
    effective treatments for far too many diseases.
        And the translational pipeline is long; 14 years on the
    average. And it's terribly leaky.
        A recent article in the Journal Nature Reviews Drug
    Discovery found that despite huge R&D investments, the number
    of new drugs approved per $1 billion, as you see here, has
    fallen steadily since 1950. Bottlenecks continue to vex this
    process, resulting in long development times, high failure
    rates, and steep costs.
        We need to re-engineer this pipeline, and that's why our
    new center, NCATS, is already working with industry to develop
    innovative ways to speed the flow of new therapies to patients.
        Mr. Chairman, I've described the administration's fiscal
    year 2013 request for NIH, the health and economic benefits of
    biomedical research, and the synergy between basic and
    translational research at NIH that's made possible by today's
    technological advances. But I'd like to close with a story that
    ties these points together.
        As toddlers, the twins Alexis and Noah Beery were diagnosed
    with a rare and devastating movement disorder called dystonia.
    Although they initially responded to standard treatment, their
    symptoms reappeared and worsened.
        Noah developed severe tremors in his hands. And Alexis
    encountered even greater difficulties. As you can see in this
    heartbreaking video clip, she began falling frequently and had
    frightening episodes where she could not breathe.
        Desperate for answers, doctors at Baylor College of
    Medicine sequenced the twins' genomes. The result was the
    discovery of a never-before described genetic mutation
    affecting neurotransmitters in the brain. After being put on a
    new treatment regimen tailored to their unique genetic profile,
    the twins' symptoms began to improve within just 2 weeks.
        In fact, Alexis' breathing is so much better today that she
    has joined the school's track team.
        Tonight in a NOVA special on advances in genetic medicine,
    PBS viewers will be able to witness the twins' progress. And
    here's a sneak peak. That's Noah and Alexis, healthy, happy,
    and enjoying themselves on a trampoline.

                              PREPARED STATEMENTS

        While this study centers on teens with a rare disease, the
    outcome carries a message of hope for all of us. It points
    directly to the promise that NIH research offers the patients
    of today and tomorrow.
        So thank you for this opportunity, Mr. Chairman and members
    of the subcommittee. And my colleagues and I will be glad to
    answer your questions.
        [The statements follow:]
             Prepared Statement of Francis S. Collins, M.D., Ph.D.
                    national institutes of health's mission
        Good morning, Mr. Chairman and distinguished members of the
    subcommittee. I am Francis S. Collins, M.D., Ph.D., and I am the
    Director of the National Institutes of Health (NIH). I have with me
    Anthony S. Fauci, M.D., Director of the National Institute of Allergy
    and Infectious Disease (NIAID); Richard J. Hodes, M.D., Director of the
    National Institute on Aging (NIA); Thomas R. Insel, M.D., Director of
    the National Institute of Mental Health (NIMH), and the Acting Director
    of the new National Center for Advancing Translational Sciences
    (NCATS); Griffin P. Rodgers, M.D., Director of the National Institute
    of Diabetes and Digestive and Kidney Diseases (NIDDK); and Harold E.
    Varmus, M.D., Director of the National Cancer Institute (NCI).
        It is a great honor to appear before you today to present the
    administration's fiscal year 2013 budget request for the NIH.
        First, I would like to thank each of you for your continued support
    of NIH's mission to seek fundamental knowledge about the nature of
    living systems and to apply it in ways that enhance human health,
    lengthen life, and reduce suffering from illness and disability. In
    particular, I want to thank the subcommittee for your support during
    the fiscal year 2012 appropriations process, for the ultimate
    appropriation of $30.62 billion for NIH, and for the provisions that
    established NCATS.
        As the largest supporter of biomedical research in the world, NIH
    has been a driving force behind decades of advances that have improved
    the health of people across the United States and around the world.
        NIH basic research and translational advances have prompted a
    revolution in the diagnosis, treatment, and prevention of disease.
    Biomedical research funded by NIH has prevented immeasurable human
    suffering and has yielded economic benefits as well, thanks to U.S.
    citizens living longer, healthier, and more productive lives. These
    benefits include:
      --nearly 70-percent reduction in the death rate for coronary disease
            and stroke in the last half century;
      --effective interventions for HIV/AIDS prevention and treatment, such
            that an AIDS-free generation may be within our grasp;
      --nearly 30-percent decline during the last three decades in the age-
            standardized prevalence of chronic disability among American
            seniors;
      --40-percent decline in infant mortality during 20 years and better
            treatments for premature and low-weight births that result in
            increased infant survival, the prevention of cerebral palsy,
            and better developmental outcomes; and
      --more than 150 U.S. Food and Drug Administration (FDA)-approved
            drugs and vaccines, or new uses of existing drugs.\1\
    ---------------------------------------------------------------------------
        \1\ Stevens, A.J., et al., The Role of Public-Sector Research in
    the Discovery of Drugs and Vaccines. N. Engl. J. Med., 364: 535-41,
    2011.
    ---------------------------------------------------------------------------
        The administration's fiscal year 2013 budget request for NIH is
    $30.86 billion, which is the same overall program level as fiscal year
    2012. This proposed appropriation will enable us to spark innovation
    and invest in areas of extraordinary promise for medical science. We
    will also invest these resources wisely to encourage a vigorous
    workforce that is prepared to tackle major scientific and health
    challenges.
        Within the administration's fiscal year 2013 budget, we will
    continue to protect and increase Research Project Grants (RPGs), NIH's
    fundamental funding mechanism for investigator-initiated research. NIH
    expects to support an estimated 9,415 new and competing RPGs in fiscal
    year 2013, an increase of 672 more than the estimate for fiscal year
    2012, with an average cost of about $431,000. For fiscal year 2013,
    total RPGs are expected to number around 35,888.
        To maximize funding for investigator-initiated grants, and to
    continue our support of first-time researchers, we propose to reduce
    budgets for noncompeting RPGs by 1 percent from the fiscal year 2012
    level and to restrain growth in the average size of new awards. We will
    also no longer assume out-year inflationary increases for new and
    continuing grants. To nurture early career scientists, we will continue
    our efforts to ensure that the success rates for investigators
    submitting new R01 applications are the same whether the applicant is
    first-time or more experienced.
        In fiscal year 2013, we will also conduct an additional review of
    proposed awards to any principal investigator (PI) who already has NIH
    funding of $1.5 million or more in total annual costs, approximately 6
    percent of PIs. This review will be conducted by each institute's
    advisory council. This is similar to a policy the National Institute of
    General Medical Sciences (NIGMS) has had since 1998, which will serve
    as a model for NIH. We recognize that some types of research, notably
    large complex clinical trials, routinely will trigger this review. We
    also know that some of our most productive investigators are leading
    significant research teams that require more than $1.5 million to be
    sustained. This extra level of review will not be viewed as a cut-off
    point but as an opportunity to apply additional scrutiny to be sure any
    added resources are justified by exceptional scientific promise.
        Another significant change in the fiscal year 2013 request is an
    11-percent increase in the NCATS budget. The proposed budget includes
    an increase of $39.6 million for the Cures Acceleration Network (CAN),
    which received $10 million for start-up funding in fiscal year 2012. As
    you know, Mr. Chairman, CAN will fund initiatives to address scientific
    and technical challenges that impede translational research, and to
    advance the development of ``high-need cures'' by accelerating the pace
    and reducing the time between research discovery and therapeutic
    treatment. In total, nearly one-half of the increase requested for
    NCATS will be used to transition programs from the Common Fund,
    allowing the Common Fund to support additional cross-cutting, trans-NIH
    programs.
        I would also note that the fiscal year 2013 NIGMS budget would
    decrease by $48.3 million (after comparability adjustments), primarily
    due to not continuing the 21 percent increase that the Congress
    provided in fiscal year 2012 for the Institutional Development Awards
    (IDeA) program. The budget of the Office of the Director is also cut by
    1.9 percent from fiscal year 2012 enacted level, reflecting a reduced
    request for the National Children's Study (NCS); we will implement
    alternative sampling approaches that will reduce costs and still
    achieve the ambitious objectives of the study.
        In fiscal year 2013, the President is also proposing to spend $80
    million from the Prevention and Public Health Fund to provide
    additional support for Alzheimer's research as part of the national
    plan to address Alzheimer's disease. As many as 5.1 million Americans
    currently suffer from Alzheimer's disease, more than 280,000 more
    Americans will be diagnosed with the disease this year, and nearly 800
    of our fellow citizens are diagnosed every day. By the year 2030, the
    last baby boomer will turn 65 and 7.7 million Americans older than the
    age of 65 will have Alzheimer's disease.\2\ Today, Alzheimer's and
    other dementias cost the United States economy more than $180 billion a
    year and if no cures and therapies are found, will cost the United
    States $1.1 trillion annually by 2050. The $80 million of new funding
    will support research with a strong focus on the prevention of
    Alzheimer's disease, including research to identify genes that cause
    this disease, to develop tests for high-risk individuals, and to
    identify possible targets for therapeutic development.
    ---------------------------------------------------------------------------
        \2\ Alzheimer's Association, 2011 Alzheimer's Disease Facts and
    Figures, Alzheimer's & Dementia, Volume 7, Issue 2.
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          investing in basic science, applying knowledge to therapies
        NIH's commitment to basic research provides the foundation for
    understanding the underlying causes of diseases which is essential to
    the development of promising treatments and cures for some of our
    Nation's most debilitating diseases and conditions. Apple Computer
    founder, Steve Jobs, has been quoted as saying: ``I think the biggest
    innovations of the 21st century will be the intersection of biology and
    technology.'' \3\ Jobs was absolutely right: today technological
    advances are driving science. We need look no further than the cost of
    DNA sequencing to see this dynamic at work. The cost curve for
    sequencing is dropping at a breathtaking rate; sequencing speed has
    increased even faster than computer processing speed. What's more, the
    average cost of sequencing an entire genome has fallen from about $3
    billion 12 years ago, to $10 million 5 years ago, to about $7,700
    today. Two U.S. companies have recently announced that they are
    manufacturing machines that will sequence an individual's genome in 1
    day for approximately $1,000, and that the first such instruments will
    go on sale before year's end. Lower sequencing costs will likely
    revolutionize how clinicians diagnose and treat diseases and enable the
    research community to pursue previously unimaginable scientific
    questions.
    ---------------------------------------------------------------------------
        \3\  Isaakson, Walter, Steve Jobs (New York: Simon & Schuster,
    2011) 539.
    ---------------------------------------------------------------------------
        NIH is the leading supporter of basic biomedical research in the
    world. Put plainly, if we don't fund basic research, most of this work
    would not get done, and it would be only a matter of time before this
    wellspring of new understanding and new therapies would dry up. NIH's
    funding for basic research is slightly more than one-half (54 percent)
    of research funding, and this balance between basic and applied
    research has remained fairly constant over the past decade.
        I also would like to address what may be a misconception about a
    competitive tension between basic and applied research at NIH. As our
    support of basic research has enabled new discoveries, NIH-funded
    scientists have always worked to turn the most compelling of them into
    medical advances. Basic discovery and the development of therapies go
    hand-in-hand at NIH. The two types of research have--and always will--
    exist together in a continuum. Today, I would like to highlight just a
    few areas in which basic research advances are opening up new
    translational opportunities.
        Human Microbiome Project.--One fascinating area of basic research
    is the Human Microbiome Project, an initiative supported through the
    NIH common fund. This project is giving us wonderful insights into the
    sweeping range of bacteria that live on and in each of us, and is
    expanding our knowledge about the role of these microbial communities
    in health and disease. Recent scientific evidence suggests that changes
    in the composition and activity of the human microbiome may contribute
    to obesity, which may provide us with new ways of addressing this
    serious threat to our Nation's health.
        Undiagnosed Diseases Program.--Another recent example emphasizes
    the ``virtuous cycle'' between basic and clinical research. The NIH
    clinical center has recently established a groundbreaking program that
    seeks to identify the cause of illnesses that have remained unsolved by
    other medical practitioners. Since the program started in 2008 some
    1,700 people with undiagnosed conditions have been referred to Dr.
    William Gahl, and more than 300 have been accepted for an initial week
    of consultations and testing. In the 15 to 20 percent of cases that we
    have successfully diagnosed, it has taken from a week to as long as 2
    years to resolve. For example, a pair of sisters from Kentucky suffered
    from joint pain and mysterious calcification of the arteries in their
    extremities. Full evaluation and DNA sequencing led to the discovery of
    an entirely new genetic condition, where a previously unknown enzyme
    pathway in their arteries was blocked. This has led to a dramatic new
    understanding of how the large arteries in all of us maintain their
    normal health, with immediate research spinoffs in the basic and
    clinical arenas.
        Alzheimer's Disease.--NIH-supported investigators are expanding our
    understanding of Alzheimer's disease in ways that may open doors to new
    therapies. Using mice genetically engineered to make the abnormal human
    tau protein--a protein already identified in the brains of Alzheimer's
    patients--scientists found that Alzheimer's disease appears to spread
    through the brain in much the same way that an infection or cancer
    moves through the body. The abnormal tau protein started in one area of
    the brain in the mice and, over time, spread from cell to cell to other
    areas of the brain in a pattern very similar to the earliest stages of
    human Alzheimer's disease. The discovery of the tau pathway could
    influence the direction of future research and give investigators a
    target for drug development that might arrest Alzheimer's disease
    progression at very early stages when the disease is most amenable to
    treatment.\4\
    ---------------------------------------------------------------------------
        \4\ Liu L, Drouet V, Wu JW, Witter MP, Small SA, et al. (2012)
    Trans-Synaptic Spread of Tau Pathology In Vivo. PLoS ONE 7(2): e31302.
    doi:10.1371/journal.pone.0031302.
    ---------------------------------------------------------------------------
        Alzheimer's disease also stands to benefit from translational
    research by way of drug rescuing and repurposing. Recently, a team that
    included NIH-supported investigators reported that bexarotene, a drug
    compound originally developed for treating T-cell lymphoma (a type of
    skin cancer), was capable of clearing the protein beta-amyloid quickly
    and efficiently after only a short exposure to the compound in
    Alzheimer's disease mouse models. Beta-amyloid accumulates in the brain
    of Alzheimer's patients due to an impaired ability to clear the
    protein, leading to a build-up of beta-amyloid plaques and ultimately
    neuronal death. These findings are exciting because, in time, they
    could benefit patients with Alzheimer's disease. Hopes are particularly
    high because the drug used in the study has already been studied in
    humans, providing a wealth of information about dosage and toxicity.\5\
    ---------------------------------------------------------------------------
        \5\ Cramer PE, Cirrito JR, Wesson DW, Lee CYD, Karlo JC, et al.
    (2012) ApoE-Directed Therapeutics Rapidly Clear b-Amyloid and Reverse
    Deficits in AD Mouse Models. http://www.sciencemag.org/content/early/
    2012/02/08/science.1217697.full.pdf.
    ---------------------------------------------------------------------------
        Cystic Fibrosis.--In a step towards personal medicine, the FDA in
    January approved Kalydeco, the first drug to treat an underlying cause
    of cystic fibrosis (CF). Twenty-three years ago, I co-led the team that
    discovered the gene responsible for CF. Mutations in this gene cause a
    protein to malfunction, resulting in a sticky buildup of mucus in the
    lungs and digestive tract that eventually causes fatal health problems.
    Kalydeco, which was developed by Vertex Pharmaceuticals, counters one
    of these mutations, which affects about 4 percent of people with CF.
    Vertex is now testing the drug in combination with another new compound
    to target a more common mutation found in 90 percent of CF patients.
    clinical research: national center for advancing translational sciences
        The translation of basic biological discoveries into clinical
    applications is a complex process that involves a series of intricate
    steps. These steps range from the discovery of basic information about
    the causes of disease, an assessment of whether that information has
    the potential to lead to a clinical advance, the development and
    optimization of therapeutics to test in human trials, and ultimately,
    the application of the approved therapy, device, or diagnostic in the
    real world. Drugs exist for only about 250 of the more than 4,400
    conditions with defined molecular causes.\6\ And it takes far too long
    and far too much money to get a new drug into our medicine cabinets.
    This is an old problem that cries out for new and creative solutions.
    ---------------------------------------------------------------------------
        \6\ Braun, et al., ``Emergence of orphan drugs in the United
    States: a quantitative assessment of the first 25 years.'' Nature Rev.
    Drug Discov. 9(521), 2010; Online Mendelian Inheritance in Man, http://
    www.ncbi.nlm.nih.gov/omim/.
    ---------------------------------------------------------------------------
        In the past, drug development was based on a short list of a few
    hundred targets, but with advances in technology, we are now able to
    identify thousands of new potential drug targets.\7\ We can also study
    whole pathways, organ systems, or even entire organisms rather than
    limiting the research to a single aspect of cell biology or physiology.
    Technologies such as large-scale sequencing, robotic high-throughput
    screening, and real-time imaging modalities uncover massive amounts of
    data that may one day lead to new therapies to prevent, treat, and
    possibly cure diseases. Many of the NIH institutes are deeply engaged
    in these efforts. But we face serious engineering challenges. To put it
    simply, the current translational science framework pursued in both the
    public and private sectors, largely focused on individual projects on
    specific diseases, has not been fully able to utilize recent scientific
    advances to address the bottlenecks that lead to long development
    times, high failure rates, and high costs. This month's issue of Nature
    Reviews Drug Discovery includes a review that demonstrates that,
    despite huge investments in biomedical science and technology, the
    number of new drugs approved per billion R&D dollars spent has been cut
    in one-half every 9 years since 1950.\8\ NCATS is the catalyst we need
    to reengineer the discovery and development process.
    ---------------------------------------------------------------------------
        \7\ Collins, F.S., ``Reengineering Translational Science: The Time
    is Right.'' Sci. Transl. Med., 3(90):90cm17, 2011.
        \8\  Scannell JW, Blanckley A, Boldon H, & Warrington B. (2012).
    Diagnosing the decline in pharmaceutical R&D efficiency. Nature Reviews
    Drug Discovery 11, 191-200. doi:10.1038/nrd3681.
    ---------------------------------------------------------------------------
        To tackle this problem in a science-driven way, NIH proposed the
    creation of NCATS with the goal to develop and test innovative tools,
    technologies, and approaches that will enhance the development of drugs
    and diagnostics for application in all human diseases. NIH has the
    expertise and enthusiasm to tackle this as a scientific problem. By
    focusing on the development of innovative new methods for conducting
    translational science, as opposed to developing therapeutics
    themselves, NCATS can enable others to bring new medical products to
    patients in a highly efficient, cost-effective manner. In the 4 months
    since it was established, NCATS has already developed three new
    initiatives in partnership with industry, academia, and other
    government agencies.
        In the first initiative, NIH is working closely with several
    pharmaceutical companies to develop model agreements for a new pilot
    program to rescue failed drugs. Pharmaceutical companies have access to
    promising compounds that have been shown to be safe in humans, but that
    did not prove effective in treating the condition for which they were
    intended. Researchers are now learning that a compound that is a
    failure for one condition may help to treat another. To capitalize on
    this, NCATS is developing a pilot program in partnership with industry
    that will seek to crowd source some of the most promising of these
    compounds to the brightest minds in science, an unprecedented
    opportunity for NIH-funded researchers, and a new way to bridge
    academic science with industrial expertise.
        Second, NCATS is partnering with the Defense Advanced Research
    Projects Agency (DARPA) to develop a chip that will mimic how humans
    respond to a drug. Scientists funded by NIH and DARPA will spend 5
    years working closely with each other to place 10 diverse human tissues
    on a chip so that they will interact with drugs the same way that they
    do in living patients. By providing a better model to predict drug
    safety and efficacy, the most promising drug candidates can be
    identified more quickly and moved forward into development. FDA will be
    heavily involved in an advisory capacity to ensure this research aligns
    with regulatory requirements.
        In the third initiative, NCATS is working closely with industry to
    develop systematic ways to identify the most promising drug targets
    from the troves of data pouring out of basic research labs. To turn
    these discoveries into therapies, scientists in academia and industry
    need to be able to sift quickly and accurately through these data to
    identify the best targets. NCATS, along with industry partners, is
    taking the lead on developing a consortium that will strive to come up
    with the most streamlined ways to conduct target validation.
        I want to emphasize that these and other initiatives within NCATS
    will provide resources and expertise to assist the basic research
    community in moving their discoveries to the next phase, as well as
    stimulate the basic research enterprise. For example, the Molecular
    Libraries and Imaging Program, originally implemented through the NIH
    Common Fund, has been successful in the development of chemical probes
    for basic and translational research. Many of these new probes have
    been, or are being, modified for use in the clinic, resulting in patent
    applications, licenses to pharmaceutical companies, and new therapeutic
    strategies.
        In the months before NCATS was created by this subcommittee, NIH
    engaged in an unprecedented outreach campaign to make sure that all
    stakeholders--including industry--had an opportunity to comment on the
    proposed Center. In addition to NIH's scientific management review
    board and advisory council to the Director, NIH consulted with the
    boards of the Pharmaceutical Research and Manufacturers of America and
    the Biotechnology Industry Association, the R&D heads of pharmaceutical
    and biotechnology companies, and the investment banking and venture
    capital communities. In addition, NIH held a series of workshops with
    pharmaceutical and biotech firms to discuss drug rescue and repurposing
    and target validation.
        It is important to note that NCATS' work will assist all of NIH's
    Institutes and Centers in their translational and drug development
    efforts. NCATS will provide NIH Institutes and Centers the tools,
    methodology, and infrastructure necessary to speed new approaches to
    therapeutic treatments. The new Center also will work with other NIH
    Institutes and Centers to convene workshops with industry, nonprofits,
    and other government agencies to explore critical translational areas
    and innovative public-private sector partnerships.
        With the fiscal year 2013 budget, NIH will pursue efforts to
    streamline and shorten the pathway from discovery to health through
    several new and ongoing initiatives and programs.
                  economic returns and global competitiveness
        In our knowledge-based world economy, innovation in medical
    research has been able to generate growth, high-quality jobs, better
    health, and better quality of life for all Americans. Investment in NIH
    continues to bring new ways to cure disease, alleviate suffering, and
    prevent illness. Furthermore, it generates new economic activity and
    employment in the communities that receive its funds. One study
    estimates that every $1 of NIH support returns $2.21 in goods and
    services in just 1 year, and that on average, every NIH grant creates
    seven high-quality jobs.
        Investments in the biomedical infrastructure, in scientists' ideas,
    and in workforce training are essential to drive the innovation that
    will spur America's economic recovery and future growth. NIH serves as
    the foundation for the entire U.S. medical innovation sector that
    employs 1 million United States citizens, generates $84 billion in
    wages and salaries, and exports $90 billion in goods and services.\9\
    United for Medical Research has just released an updated version of
    their report ``An Economic Engine: NIH Research, Employment, and the
    Future of the Medical Innovation Sector.'' According to UMR data, the
    $23.7 billion NIH spent extramurally in the U.S. in 2011 directly and
    indirectly supported 432,092 jobs, enabling 16 States to experience job
    growth of 10,000 jobs or more, and propelling $62.135 billion in new
    economic activity.
    ---------------------------------------------------------------------------
        \9\ Ehrlich, Dr. Everett, An Economic Engine: NIH Research,
    Employment and the Future of the Medical Innovation Sector, 8, United
    for Medical Research (May 2011).
    ---------------------------------------------------------------------------
        Thanks in large part to NIH-funded medical research, Americans are
    living longer, healthier, more rewarding lives. A child born today can
    look forward to an average life span of almost 79 years, an increase of
    nearly three decades over life expectancy in 1900. The economic value
    of these gains in average life expectancy in the United States has been
    estimated at $95 trillion for the period from 1970-2000.\10\
    ---------------------------------------------------------------------------
        \10\  Murphy, K.M., & Topel, R.H. (2006). ``The value of health and
    longevity''. Journal of Political Economy, 114(5), 871-904.
    ---------------------------------------------------------------------------
        NIH funding is the foundation for long-term U.S. global
    competitiveness in industries such as biotechnology, medical devices,
    and pharmaceutical development. Around the world, many nations are
    following suit and beginning to ramp up their own investment in the
    life sciences. Global R&D spending is expected to grow by about 5.2
    percent to more than $1.4 trillion in 2012.\11\ India has posted
    double-digit increases for several years, and Europe plans to increase
    research spending by 40 percent over the next 7 years. Even Vladimir
    Putin has announced the intention to increase support for research in
    Russia by 65 percent over the next 5 years. China has just announced
    that it will increase its investment in basic research by 26 percent in
    2012.\12\ To be sure, the scale of China's effort does not match ours.
    However, Chinese scientists are second only to the United States in the
    number of scientific manuscripts published annually, and China's
    intention to compete with us is obvious.
    ---------------------------------------------------------------------------
        \11\  Grueber, Martin, 2012 Global R&D Funding Forecast, 3, Batelle
    and R&D Magazine (December 2011).
        \12\  Hvistendahl M. (2012). ``A Bumper Year for Chinese Science.''
    Science Vol. 335, No. 6073 p.1156. doi: 10.1126/science.335.6073.1156.
    ---------------------------------------------------------------------------
        The United States must compete in training America's next
    generation to make tomorrow's health discoveries and ensure continued
    scientific leadership.
                                a patient story
        Mr. Chairman, this morning I've described the promise that
    inexpensive whole-genome sequencing holds for future medical practice,
    the synergy between basic and translational research at NIH, and the
    need for NCATS. I'd like to close my testimony by telling you a story--
    a story about real patients--that ties my three points together.
        As toddlers, twins Alexis and Noah Beery were diagnosed with a rare
    and devastating movement disorder, called dystonia. Although they
    initially responded to empirical treatment, their symptoms reappeared
    and worsened as they entered their teenage years. Noah developed severe
    tremors in his hands. Even worse, his sister Alexis began falling
    frequently and had frightening episodes where she couldn't breathe.
        Desperate for answers, doctors at Baylor College of Medicine
    sequenced the twins' genomes. The result? Discovery of a never-before
    described genetic mutation affecting neurotransmitters in the brain.
    After being put on a new treatment regimen tailored to their unique
    genetic profile, the twins' symptoms began to improve within just 2
    weeks. I recently saw a video of the two of them doing tricks on a
    trampoline. In fact, Alexis' breathing is so much better today that
    she's joined her school's track team. While this story centers on two
    teens with a rare disease, the outcome carries a message of hope for
    all of us. It points directly to the promise that NIH research offers
    the patients of today and tomorrow.\13\
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        \13\ Bainbridge MN, et al. (2011). Whole-Genome Sequencing for
    Optimized Patient Management. Science Translational Medicine 3, 87re3.
    doi: 10.1126/scitranslmed.3002243.
    ---------------------------------------------------------------------------
        In conclusion, we have never witnessed a time of greater promise
    for advances in medicine than right now. NIH is prepared to continue
    our long tradition of leading the world in the public support of
    biomedical research. Successful development of prevention strategies,
    diagnostics, and therapeutics will require bold investments in research
    across the spectrum from basic science to clinical trials, as well as
    new partnerships between the public and private sectors. With your
    support, we can promise continuing advances in medicine, creation of
    new economic opportunities, and stimulation of American global
    competitiveness in science, technology, and innovation.
                                     ______

       Prepared Statement of Anthony S. Fauci, M.D., Director, National
                  Institute of Allergy and Infectious Diseases
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2013 budget request for the
    National Institute of Allergy and Infectious Diseases (NIAID) of the
    National Institutes of Health (NIH). The fiscal year 2013 NIAID budget
    of $4,495,307,000 includes an increase of $10,210,000 more than the
    comparable fiscal year 2012 level of $4,485,097,000.
        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 allergic diseases, autoimmune diseases,
    and the rejection of transplanted organs. I appreciate the opportunity
    to highlight our recent scientific advances and to describe some of our
    most promising research aimed at improving public health and quality of
    life.
                          infectious diseases research
        HIV/AIDS.--In the 30 years since AIDS was first recognized in the
    United States, the substantial NIAID investment in basic,
    translational, and clinical HIV/AIDS research supported consistently by
    this subcommittee has resulted in many groundbreaking discoveries. With
    this commitment, we have made significant progress, including
    strengthening HIV prevention efforts and developing nearly 30
    antiretroviral drugs to suppress HIV. Thirty years ago, HIV/AIDS was
    for the most part a death sentence. Today, if a young person enters the
    clinic with early HIV disease and begins appropriate therapy, he or she
    can expect to live a near-normal lifespan, a milestone unimaginable at
    the start of the HIV/AIDS pandemic.
        I am pleased to report landmark advances and opportunities in HIV/
    AIDS research this year. In December 2011, the journal Science named an
    NIAID-funded international HIV prevention study its breakthrough of the
    year, reinforcing that the investment in NIH research continues to pay
    extraordinary dividends for public health. This study, known as HPTN
    052, demonstrated that HIV-infected heterosexual individuals who began
    taking antiretroviral medicines when their immune systems were still
    relatively healthy, rather than later, were 96 percent less likely to
    transmit the virus to their uninfected sexual partners. This study
    convincingly demonstrates that antiretrovirals not only can be life-
    saving to people infected with HIV but also can prevent transmission of
    the virus to their uninfected sexual partners. Other studies have shown
    that medically supervised adult male circumcision has proven to be
    highly effective and durable in preventing the acquisition of HIV
    infection. In addition, pre-exposure prophylaxis of at-risk uninfected
    individuals may be an important means of preventing HIV infection.
        HIV vaccines still represent the best long-term hope for ending the
    HIV pandemic. Building on the promising results of the United States
    Army-NIAID RV144 HIV vaccine clinical trial, which found a ``prime-
    boost'' vaccine candidate to be safe and modestly effective at
    preventing acquisition of HIV, NIAID is working to understand the
    immune mechanisms that explain these results, to optimize the
    protective immune responses elicited by the vaccine candidate, and to
    develop and evaluate new vaccine candidates. We also are encouraged by
    the discovery by NIAID-supported scientists of human antibodies that
    can block a wide range of HIV strains. We are expanding clinical
    testing in this area, and insights gained from these studies will guide
    future HIV vaccine research.
        These research advances taken together with the implementation of
    other evidence-based HIV prevention and treatment strategies make the
    possibility of an ``AIDS-free generation'' in the foreseeable future
    eminently feasible. This July, we will consider strategies to implement
    these important findings during the International AIDS Society
    Conference in Washington, DC.
        Tuberculosis and Malaria.--NIAID continues to invest in basic and
    clinical research and collaborate with global partners, including the
    World Health Organization's Stop Tuberculosis (TB) Partnership, to
    combat the co-infections that often accompany HIV infection, including
    TB and malaria. Building on these efforts, we now have a substantial
    development pipeline of TB treatments and vaccines. NIAID has developed
    a Strategic Blueprint for TB Vaccines that proposes new research
    pathways for achieving a licensed TB vaccine. For malaria, NIAID
    supported early-stage basic research that ultimately led to the
    development by others of the first moderately successful malaria
    vaccine candidate aimed particularly for children, RTS,S/AS01, a
    science runner-up breakthrough of the year in 2011. In addition, the
    NIAID Vaccine Research Center is partnering with a biotechnology firm
    to undertake clinical studies of a novel malaria vaccine candidate,
    PfSPZ. NIAID also plays a leading role in the international Malaria
    Eradication Research Agenda initiative.
        Other Infectious Diseases of Domestic and Global Health
    Importance.--NIAID's longstanding investments in basic and clinical
    research have led to many successes in vaccine development for diseases
    of worldwide public health concern, including gastroenteritis caused by
    rotavirus, pneumonia, hepatitis A, and deadly meningitis caused by
    Haemophilus influenzae type b. These are among the vaccines now being
    delivered to countries around the world; where they have been deployed,
    substantial reductions in morbidity and mortality have been observed.
    NIAID has assumed a major leadership role in the ``Decade of Vaccines''
    initiative, a 10-year collaborative effort coordinated by the Bill &
    Melinda Gates Foundation, to develop and deliver vaccines to the
    world's poorest countries. NIAID will continue research on other
    urgently needed vaccines, including vaccines for Group B streptococci,
    Epstein-Barr virus, and hepatitis C virus.
        Seasonal and pandemic influenzas remain critical global health and
    economic threats. NIAID has made significant progress in the
    development and testing of vaccines to protect people from influenza,
    including the elderly, young children, and those with asthma. Recently,
    NIAID researchers demonstrated that a ``prime-boost'' gene-based
    vaccination strategy could activate the immune system and lead to
    broadly neutralizing antibody responses against influenza viruses. This
    finding and those from other researchers signal that we are closer to
    developing a ``universal'' vaccine that could protect against multiple
    strains of seasonal and pandemic influenza viruses.
        This year, in response to the growing public health issue of
    antimicrobial resistance, NIAID will expand our clinical trials
    networks developed originally for HIV/AIDS to investigate this
    important concern. In addition, NIAID will support research to
    determine how to preserve the effectiveness of current antibiotics.
        NIAID's biodefense research has yielded numerous scientific
    advances as we have moved from a ``one bug-one drug'' approach to a
    more flexible, broad-based product development strategy that utilizes
    sophisticated genomic and proteomic platforms to address infectious
    disease outbreaks, whether they are deliberately introduced or
    naturally occurring. As part of this effort, NIAID has awarded
    contracts for the development of broad-spectrum therapeutics against
    emerging infectious disease and biodefense agents.
              research on immunology and immune-mediated disorders
        NIAID was highly gratified that the 2011 Nobel Prize in Physiology
    or Medicine was awarded to three NIAID grantees:
      --Bruce A. Beutler;
      --Jules A. Hoffmann; and
      --the late Ralph M. Steinman.
        Their research has been pivotal in understanding the human immune
    response, and it is helping to inform the development of new vaccines
    and vaccine adjuvants that may provide better protection against
    infectious diseases.
        NIAID's commitment to basic immunology research has led to advances
    in the treatment of immunological conditions such as the rejection of
    transplanted organs. In 2011, the Journal of the American Medical
    Association published an NIAID Immune Tolerance Network study
    demonstrating that children who receive liver transplants may not need
    lifelong anti-rejection therapy to maintain the transplanted organ.
    Other NIAID-supported investigators demonstrated that some kidney
    transplant recipients who also received bone marrow from the kidney
    donor can maintain their kidney grafts without immunosuppressive drugs.
                                   conclusion
        NIAID basic and clinical research on infectious and immune-mediated
    diseases will continue to promote the development of vaccines,
    therapeutics, and diagnostics to improve health and save millions of
    lives worldwide. NIAID remains committed to supporting highly
    meritorious research with the goal of translating fundamental
    scientific findings into public health advances.
                                     ______

      Prepared Statement of Griffin P. Rodgers, M.D., M.A.C.P., Director,
        National Institute of Diabetes and Digestive and Kidney Diseases
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2013 budget request for the
    National Institute of Diabetes and Digestive and Kidney Diseases
    (NIDDK) of the National Institutes of Health (NIH). The fiscal year
    2013 budget includes $1,792,107,000, which is $2,798,000 less than the
    comparable fiscal year 2012 appropriation of $1,794,905,000.
    Complementing these funds is an additional $150 million also available
    in fiscal year 2013 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.
             building new opportunities: basic research discoveries
        From in-depth exploration of fundamental biologic processes, NIDDK-
    supported scientists are achieving remarkable advances and building the
    foundation for previously unimaginable strategies to improve health and
    quality of life. Among these advances, recent NIDDK-supported research
    into genetic risk factors for diabetes, inflammatory bowel disease,
    obesity, liver disease, and the kidney disease focal segmental
    glomerular sclerosis, along with other studies are providing insights
    into disease development and whether an individual is likely to respond
    to a given therapy. Investigating the different types of bacteria that
    reside in the intestines, researchers have discovered surprising links
    to obesity, inflammatory bowel disease, fatty liver disease, and other
    health conditions. Scientists supported by our institute are also
    designing novel intervention strategies and testing these in pre-
    clinical, laboratory models. For example, pursuing a treatment for
    fecal incontinence, researchers used tissue engineering to build muscle
    implants in mice with promising initial results, providing hope for
    future therapeutic use in people. Other scientists examined a potential
    drug for the rare disease Neimann-Pick type C in experiments with
    isolated human cells, and found encouraging results.
        We will continue support for basic research across the Institute's
    mission, to gain further insights into health and disease and propel
    new ideas for interventions. Examples include research to identify type
    2 diabetes risk genes in minority populations disproportionately
    affected by this disease; to discover environmental factors that
    trigger type 1 diabetes in genetically susceptible individuals; to
    elucidate the causes and consequences of a form of diabetes that can
    strike people with cystic fibrosis; to increase understanding of
    intestinal stem cells, which could benefit a variety of digestive
    diseases; and to augment knowledge of blood cells and hematologic
    diseases.
          preventing and treating disease--in clinics and communities
        Through innovative design and rigorous testing of interventions--
    whether in the operating room, doctor's office, or home or community
    settings--NIDDK-supported researchers are improving lives with new
    approaches to prevent, treat, and reverse diseases and disorders. For
    example, investigators previously showed that intensive blood glucose
    control, beginning soon after diagnosis of type 1 diabetes, reduced
    early signs of complications; now, after an average 22-year follow-up,
    the researchers demonstrated that controlling blood glucose reduced the
    risk of developing kidney disease by 50 percent, preserving kidney
    function for decades. The first cystic fibrosis therapy targeting a
    specific molecular defect gained U.S. Food and Drug Administration
    (FDA) approval. This important advance was a culmination of research
    supported in part by NIDDK, from the historic gene discovery (by the
    NIH Director) to clinical trials of the drug. With cutting-edge tissue
    engineering, researchers have successfully generated urethras to
    replace defective tissue and ameliorate urination difficulties in boys.
    A network of investigators found that vitamin E helps reduce fatty
    liver disease in children. In studies that may alert clinicians to
    patients with heightened need for intervention, scientists found that
    elevated levels of the hormone FGF-23 mark increased risk for heart
    disease and death in people with chronic kidney disease, while high
    levels of certain amino acids in the blood signify increased risk for
    type 2 diabetes.
        Looking forward, NIDDK is committed to continuing funding for
    clinical research. Because many diseases within our mission
    disproportionately affect certain populations, we will also continue to
    seek insights and answers to health disparities. As just a few examples
    of our many clinical studies, Institute-supported scientists will
    conduct trials of approaches to prevent or slow the onset of type 1
    diabetes, and they will press forward in developing technology to
    create an artificial pancreas for people with diabetes. In a new
    effort, the Institute is planning a comparative effectiveness study of
    commonly used drugs for type 2 diabetes. We will also continue a
    promising, long-term clinical trial of a lifestyle intervention
    designed to promote weight loss and improve health in obese people with
    type 2 diabetes. Among multifaceted efforts to meet the challenge of
    obesity will be a consortium studying lifestyle interventions for
    overweight and obese pregnant women, to improve the health of both
    mother and child. The Institute will continue to support clinical
    studies for a range of liver diseases; for example, a multicenter
    research network is planning trials of different treatment strategies
    for hepatitis B, including comparative effectiveness research. Multiple
    efforts will pursue approaches to combat chronic kidney disease,
    polycystic kidney disease, primary glomerular disease, and other forms
    of kidney disease and injury. We have also spearheaded an initiative
    encouraging studies to prevent and treat obesity, diabetes, and kidney
    disease in military populations. NIDDK continues to support a multi-
    disciplinary study in chronic urologic pelvic pain, and will support a
    new research network to improve measurement of the complex symptoms of
    lower urinary tract dysfunction in men and women and to advance
    clinical studies. To maximize the reach and benefits of interventions
    proven successful in clinical trials, we will sustain support for
    translational research, to implement these in real-world medical
    practice and community settings, cost effectively, for diverse
    populations. For example, an NIDDK-funded research project provided the
    first demonstration that YMCAs, now officially called Ys, can deliver a
    group-based version of the lifestyle intervention shown to reduce type
    2 diabetes in the Diabetes Prevention Program clinical trial.
             supporting an innovative, multidisciplinary workforce
        Research breakthroughs happen only through the efforts of a
    creative, well-trained workforce. Thus, NIDDK will continue programs to
    train and support researchers at all stages of their careers, and to
    ensure that we benefit from the best scientific minds. NIDDK supports
    summer research opportunities for underrepresented high school and
    college students, workshops for minority investigators and new
    investigators, a new initiative for professional societies to promote
    diversity in the research workforce, and other efforts. We will
    continue to support investigator-initiated projects, along with
    solicited research that is guided by input from expert researchers and
    the public.
              integrating science-based information into practice
        We will also continue to support education, outreach, and awareness
    programs. These efforts include materials tailored for diverse
    audiences and span the range of diseases within our mission, to bring
    vital, science-based knowledge to healthcare providers, patients and
    their families, and the general public.
        In closing, NIDDK's future research investments will build upon
    findings from past and ongoing studies, pursue promising new
    opportunities, and tackle critical challenges toward innovative and
    more effective prevention and treatment strategies. Our research will
    be guided by five principles:
      --maintain a vigorous investigator-initiated research portfolio;
      --support pivotal clinical studies and trials;
      --preserve a stable pool of new investigators;
      --foster research training and mentoring; and
      --disseminate science-based knowledge through education and outreach
            programs.
                                     ______

     Prepared Statement of Harold Varmus, M.D., Director, National Cancer
                                   Institute
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's budget request for the National Cancer
    Institute (NCI) of the National Institutes of Health (NIH). The fiscal
    year 2013 NCI budget of $5,068,864,000 includes an increase of
    $2,717,000 more than the comparable fiscal year 2012 level of
    $5,066,147,000.
        As many of you will read upon its release later today, the 2012
    annual report to the Nation on the status of cancer offers a generally
    encouraging view of cancer trends. The report documents that death
    rates from all cancers combined for men, women, and children in the
    United States continued to decline between 2004 and 2008, the latest
    year for which we have complete analysis. Age-adjusted mortality rates
    for 11 of the 18 most common cancers among men and for 14 of the 16
    most common cancers in women have declined. The overall rate of new
    cancer diagnoses, also known as incidence, among both men and women
    also declined over similar periods, although for women the decline
    leveled off from 2006-2008.
        These continued declines in death rates for most cancers, as well
    as the overall drop in incidence, are powerful evidence that our
    Nation's investment in many fields of cancer research produces life-
    saving approaches to cancer control. The breadth of the Nation's cancer
    portfolio and our ability to pursue many different approaches to cancer
    research must match the heterogeneity of cancer itself, which we now
    understand to be literally hundreds of genetically distinct diseases
    with many avenues to prevention, screening, diagnosis, and treatment.
                               basic and science
        A large part of the NCI basic research portfolio uses molecular
    biology and genetics to deepen our knowledge about the origins and
    behavior of cancers and to develop drugs and understand drug
    resistance. For example, decades of basic research culminated in
    development of the molecularly targeted drug Gleevec (imatinib). Since
    the U.S. Food and Drug Administration (FDA) approved the drug in 2001,
    it has been the treatment of choice--and a very effective one--for
    chronic myelogenous leukemia (CML) as well as a few other cancers.
    Targeted drugs usually inhibit enzymes--in this case, kinases--that are
    essential to the survival of cancer cells, rather than broadly killing
    all rapidly dividing cells in the body. In CML, the target is the
    abnormal protein made by fused genes, BCR-ABL, in cancerous blood
    cells, where in its activated or ``on'' state the mutant enzyme pushes
    white blood cells into overdrive, causing disease. Gleevec blocks the
    mutant enzyme, kills cancer cells, and returns the blood system and the
    patient to a normal state.
        But despite Gleevec's generally powerful effects, some CML patients
    relapse when new mutations make the BCR-ABL protein resistant to
    Gleevec, allowing the abnormal enzyme to drive white blood cell growth
    again despite treatment. This phenomenon, drug resistance, is now being
    encountered with the several other targeted therapies more recently
    introduced for lung cancer, melanoma, and other cancers. So it is
    encouraging to report that NCI-supported research has identified a
    number of drugs targeting BCR-ABL proteins even after they acquire
    mutations that confer resistance to Gleevec. Two of these, approved a
    few years ago, did not overcome relatively common resistance mutation.
    But a third generation of drugs is able to do that, in an interesting
    new way, by freezing the target protein in an inactive conformation, so
    that its enzyme cannot work. This example illustrates another important
    point. Many different research streams--from genetics to structural
    biology to pharmacology--were required for these advances in treatment.
    The need to bring together multidisciplinary teams to focus on key
    questions like drug resistance in cancers increasingly defines modern
    biomedical research.
        To strengthen NCI's ability to drive similar discoveries, NCI this
    year consolidated a number of its genomics initiatives--including the
    flagship program The Cancer Genome Atlas (TCGA)--into a single Center
    for Cancer Genomics. TCGA's aim is to characterize comprehensively the
    genomic alterations in hundreds of samples of about 20 known tumor
    types. With the project nearing completion on schedule, the vast influx
    of data promises to dramatically alter our knowledge of the genetic
    changes that drive cancer development. The new center will work with
    other components of NCI to ensure that the findings are applied to
    developing new diagnostics and therapeutics and are integrated swiftly
    into medical practice.
                            screening and prevention
        Early detection of cancer can enhance therapy. Last year I briefed
    this subcommittee on the recently concluded National Lung screening
    trial, which had demonstrated that current and former smokers who were
    screened with low-dose helical computed tomography were 20 percent less
    likely to die of lung cancer compared to others who received standard
    chest xrays.
        Recent findings from another long-term study also point to
    screening as an effective way to cut deaths from another common
    cancer--colorectal adenocarcinoma, which kills about 49,000 Americans
    every year. Clinical studies, several funded by NCI, have consistently
    demonstrated that tests for fecal blood and direct observation of the
    colon with endoscopy can effectively reduce the mortality rates
    associated with colorectal cancer--by up to 50 percent, according to
    one recent estimate. NCI also is investing in studies to understand
    behavioral and economic barriers to screening to increase screening
    rates, especially among minority populations.
                            diagnosis and treatment
        One of the most critical aspects of cancer is its remarkable
    heterogeneity--cancer is actually a collection of hundreds of
    genetically distinct diseases, each with its unique vulnerabilities.
    Lung adenocarcinomas, for instance, develop through a variety of
    genetic changes, and each pattern of changes requires a different
    therapeutic approach. Just a few years ago, it was recognized that up
    to 7 percent of lung adenocarcinomas contain a fused chromosome that
    activates the protein made by a gene called ALK to cause cancerous
    growth. FDA last fall approved crizotinib to treat patients with the
    abnormal ALK gene. Crizotinib blocks the activity of the enzyme, again
    a kinase, produced by the fused ALK gene, similar to the action of
    Gleevec in CML. This oral drug has been approved by the FDA and must be
    used with a companion molecular test to make sure it is used to treat
    only tumors with the abnormal ALK gene.
        Another potential treatment recently emerged from academic research
    laboratories, this one for metastatic prostate cancer. MDV-3100 is a
    so-called anti-androgen therapy that prevents male hormones from
    stimulating the growth of prostate cancer cells through androgen
    receptors--preventing testosterone from binding to androgen receptors
    and preventing the androgen receptor from initiating the production of
    proteins that induce tumor growth. Current anti-androgen drugs suppress
    the growth of prostate cancer cells temporarily, but in most patients,
    the cancer ultimately develops resistance to these drugs by increasing
    the amount of receptors. MDV-3100, by contrast, binds so tightly to the
    androgen receptors that it prevents them from functioning even when the
    receptor numbers are very high. The new drug performed so well that the
    clinical trials were halted early, and the drug now awaits approval at
    FDA.
                             provocative questions
        During the past 14 months, NCI has brought together researchers to
    propose, craft, and debate what they consider to be the critical
    questions in cancer research that may fall outside our current sphere
    of focus, but that could lead to important discoveries about the causes
    and behaviors of cancers. NCI convened 17 workshops across the country
    that identified some 24 provocative questions, and NCI has set aside an
    initial $15 million from its fiscal year 2012 budget to fund some of
    the more than 750 applications received under this program. While this
    initiative does not replace NCI's longtime and essential emphasis on
    funding investigator-initiated research, it represents a useful new
    approach to making the greatest impact with our research dollars.
        The Congress's past investments in cancer research are the reason
    we are able to report promising scientific findings each year, and why
    the report to the Nation continues to show steady progress against a
    wide range of cancers. We are now able to define genetic changes that
    cause cancer, use them to control cancer with more precise tools, and
    thereby reduce the Nation's cancer burden. The President's budget for
    2013 for the NCI will provide the support for discoveries in basic
    science, cancer control and prevention, for early detection and
    diagnosis, and for methods to prevent, treat, and in some instances,
    cure cancers.
                                     ______

       Prepared Statement of Richard J. Hodes, M.D., Director, National
                               Institute on Aging
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2013 budget request for the
    National Institute on Aging (NIA) of the National Institutes of Health
    (NIH). The fiscal year 2013 budget includes $1,102,650,000, which is
    $522,000 more than the comparable fiscal year 2012 level of
    $1,102,128,000.
        More than 40 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 by 2040. 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.
        NIA 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
    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.
           building momentum in the fight against alzheimer's disease
        Estimates of how many people in the United States currently have
    Alzheimer's disease (AD) range from 2.7 to 5.1 million, depending on
    how AD dementia is defined and measured. However, scientists agree that
    unless the disease can be effectively treated or prevented, the numbers
    will increase significantly if current population trends continue.
        At the same time, there has never been greater cause for optimism.
    In recent years, we have expanded our understanding of how the disease
    takes hold and progresses, identified promising targets for
    intervention, and developed new models to speed discovery. For example,
    researchers have developed a mouse model that expresses human tau, one
    of AD's pathological hallmarks, and discovered that tau pathology is
    transmitted from cell to cell, beginning in the brain's entorhinal
    cortex and spreading from one brain region to the next. This discovery
    provides insight into AD's earliest development and offers a model for
    testing mechanisms and functional outcomes associated with disease
    progression. In another study, investigators ``reprogrammed'' human
    skin cells into induced pluripotent stem cells, which then
    differentiated into working neurons; this breakthrough will facilitate
    the study of AD in human neurons and provide important insight into the
    etiology of the disease.
        Advances in imaging technology, most notably through the NIH-
    supported Alzheimer's Disease Neuroimaging Initiative (ADNI), have
    expanded our ability to understand the underlying pathology of AD,
    diagnose the disease, track the progress of interventions, and even
    identify individuals at risk. ADNI data were also used last year to
    develop new, more comprehensive diagnostic guidelines at both the
    clinical and pathological levels.
        NIH currently supports more than 35 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; more than 40
    compounds are in preclinical development through the AD Translational
    Initiative. NIA also participates in the NIH Neuroscience Blueprint
    under which investigators developing new compounds will have access to
    drug development services not typically available to the academic
    research community.
        Investigators are also ``re-purposing'' treatments for other
    diseases as treatments for AD, with encouraging results. For example, a
    pilot clinical trial recently demonstrated that a nasal-spray form of
    insulin was able to delay memory loss and preserve cognition in people
    with cognitive deficits ranging from mild cognitive impairment (often a
    precursor condition to AD) to moderate AD. In a separate study, the
    skin cancer drug bexarotene promoted clearance of amyloid-beta and
    reversed cognitive deficits in mice. These preliminary findings offer
    new and exciting possibilities for the effective prevention and
    treatment of AD.
        NIA has been an active participant in the implementation of the
    National Alzheimer's Project Act, including the development of a
    national plan to address AD. A new Presidential initiative to boost
    support for AD research, which will provide an additional $50 million
    in fiscal year 2012 and $80 million in fiscal year 2013 for the
    disease, will stimulate and support important groundbreaking work in a
    number of areas, including AD-extensive whole genome sequencing to
    identify genetic risk and protective factors for AD. Our activities
    will be informed by input from expert advisors participating in the May
    2012 Alzheimer's Disease Research Summit.
                  understanding aging at the most basic level
        NIA initiatives on the molecular mechanisms of aging, from in-depth
    study of single cells to the broad study of organisms at the systems
    level, continue to advance our understanding of the basic underpinnings
    of the aging process. For example, investigators recently found that it
    was possible to delay onset of age-related changes in the skeletal
    muscle, fat, and eye tissues in mice by removing senescent cells--i.e.,
    cells that are alive but no longer functional. The study also found a
    slowing of progression of age-related disorders in the mice. These
    results suggest that cell senescence may be a fundamental mechanism
    that drives aging.
             improving the health and well-being of older americans
        As the American population continues to age, it is imperative that
    we identify the optimal means to address the unique health needs of
    older individuals. For example, the Centers for Disease Control and
    Prevention reports that fully one-half of older Americans have at least
    two chronic health conditions that compromise quality of life. NIA is
    participating in a trans-NIH initiative to develop interventions to
    modify behavior and improve health outcomes among individuals with or
    more chronic conditions.
        Increased adherence to recommended medication regimens promises
    substantial improvements in public health as well as savings in
    healthcare costs. NIA-supported investigators found that simply
    encouraging people to write down the time and date when they plan to
    receive a flu vaccination can significantly increase vaccination rates.
    NIA also participates in an NIH-wide initiative to identify practical
    interventions to improve medication adherence in the primary care
    setting.
        Studies have shown that regular physical activity can improve
    physical performance in older people, but definitive evidence that
    physical activity can prevent mobility disability is lacking. NIA
    supports the Lifestyle Interventions and Independence for Elders Study
    to assess the effects of a structured physical activity program in
    1,600 sedentary older individuals. With the U.S. Surgeon General, NIA
    has also launched its nationwide Go4Life campaign to motivate older
    Americans to engage in physical activity and exercise.
        In the past year, preliminary results were released from the
    ``Oregon Lottery'' study, in which randomly selected low-income Oregon
    residents were able to enroll in the State's Medicaid program. Compared
    to a control group, the new Medicaid enrollees reported improved health
    and well-being, as well as reduced financial strain. Use of important
    types of healthcare services such as preventive care also increased.
              empowering the next generation of aging researchers
        The need for healthcare professionals who specialize in the unique
    needs of older individuals is becoming ever more urgent. We must not
    only increase the number of practicing physicians trained in geriatrics
    and in subspecialty fields related to the health problems of elders but
    also foster the development of the next generation of physician-
    scientists whose clinical 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 promote future leaders in clinical aging research through
    support of physicians who seek to become clinician-scientists in
    geriatric aspects of their subspecialty. NIA has also established a
    program targeting undergraduate students from diverse backgrounds in
    order to advance their interest in and knowledge of aging issues.
                                     ______

    Prepared Statement of Thomas R. Insel, M.D., Acting Director, National
                  Center for Advancing Translational Sciences
        Mr. Chairman and members of the subcommittee: It is a privilege to
    present to you the President's budget request for the newly established
    National Center for Advancing Translational Sciences (NCATS) for fiscal
    year 2013. The fiscal year 2013 budget of $639,033,000 includes
    $64,320,000 more than the comparable fiscal year 2012 level of
    $574,713,000. We are thankful for your support for this new Center and
    look forward to sharing progress with you as the Center evolves.
        Our mission is to catalyze the generation of innovative methods and
    technologies that enhance the development, testing, and implementation
    of diagnostics and therapeutics across a wide range of human diseases
    and conditions. As such, NCATS will focus on addressing scientific and
    technical challenges in order to reduce, remove, or bypass significant
    hurdles across the continuum of translational research. These advances
    will enable others in both the public and private sectors to develop
    drugs and diagnostics more efficiently for any number of human
    diseases--ultimately accelerating the pace in which new therapeutics
    are delivered to the patients who need them.
                             fulfilling our mission
        In achieving its aims, NCATS activities will be guided by three
    important principles:
      --facilitate--not duplicate--other translational research activities
            supported by NIH;
      --complement--not compete with--efforts already underway in the
            private sector; and
      --reinforce--not reduce--NIH's commitment to basic research.
        These guiding principles underscore the role of NCATS as a
    catalytic hub for evidence-based research on the process of translating
    scientific discoveries into new diagnostics and therapeutics.
        Key to the success of the NCATS mission is identifying, studying,
    and reducing significant bottlenecks in the process of translation,
    which will require extensive consultation with experts across
    disciplines and sectors. NIH held numerous workshops for stakeholders
    to solicit ideas for the NCATS research agenda. A working group of
    several NIH Institute and Center Directors, including those most
    involved in translational research, clarified the need for a new effort
    focused on the discipline of translation, providing tools and resources
    that could facilitate research across NIH. A working group of the NIH
    advisory committee to the Director, comprised of experts from industry,
    private equity firms, nonprofits, and academia identified the need for
    NCATS to catalyze, invigorate and streamline translational sciences
    nationally and globally. Many areas of priority were identified,
    including research on biomarkers, predictive toxicity, target
    validation, regulatory science and de-risking the pipeline. The
    perspectives of both of these working groups are reflected in several
    of the NCATS initiatives being pursued, ensuring that NCATS is not
    duplicating other efforts at NIH or competing with efforts in industry.
        NCATS is currently assembling an advisory structure comprising both
    the NCATS advisory council and the Cures Acceleration Network (CAN)
    review board. These individuals will span many sectors, from patient
    advocacy organizations to pharmaceutical industry and private equity
    firms, along with renowned experts in translational science and
    regulatory review.
                   catalyzing innovation in clinical research
        Re-engineering and accelerating the clinical research enterprise is
    a major priority for NCATS. The Clinical and Translational Science
    Awards (CTSAs), which represent nearly three quarters of the proposed
    NCATS budget, will lead our efforts to re-engineer and accelerate
    clinical research. Across the Nation, CTSA institutions have been
    supporting first-in human trials for rare and common diseases;
    developing and testing innovative trial designs; and developing
    postmarketing clinical research. Since the first awards in 2006, the
    CTSAs have transformed clinical research in academic medical centers,
    creating new homes for translational science, integrating communities
    into the research process, and training a new generation of
    interdisciplinary clinical researchers. An external evaluation of the
    CTSA program has been conducted and offers constructive recommendations
    for ensuring that this highly valuable program is optimally leveraged
    and aligned with NCATS as we move forward.
        To accelerate research, the CTSAs have developed innovative
    informatics tools, such as REDcap, a freely available tool for clinical
    study management and capture, and ResearchMatch, a free, secure, Web-
    based registry which now has more than 20,000 volunteers for research
    studies and enables researchers to find the ``right match'' to
    participate in studies.
        In 2013, we will be launching CTSA 2.0, the next phase of this
    program building on the successes of the past 6 years. While CTSA 1.0
    established homes for translational research, CTSA 2.0 can create
    neighborhoods, networks of centers with shared resources to accelerate
    research on rare diseases and new therapeutics. Going forward, the
    CTSAs can have an even broader role on translational science,
    supporting the entire pipeline of development from bench to bedside,
    bedside to practice, and beyond practice to public health policy.
                     catalyzing innovation in therapeutics
        Drug development is expensive, slow, and failure prone.
    Approximately 90 percent of compounds that advance to clinical testing
    fail to reach the market. While NCATS will not create an industrial
    drug development pipeline, it can experiment on the process,
    identifying solutions for specific problems in drug development.
        For instance, of the most common concerns we heard from industry,
    patient groups, and the Food and Drug Administration (FDA), was the
    need for detecting toxicity early in the drug development process.
    Roughly one-third of the failures of new medications can be attributed
    to toxicity not predicted from preclinical (animal or in vitro)
    studies. NCATS is working with the Defense Advanced Research Project
    Agency (DARPA) and the FDA to design a chip composed of diverse human
    cells and tissues with read outs that can detect toxicity. This
    ``tissue chip'' should make drug safety assessments more accurate and
    even make them possible earlier in the translational pipeline. DARPA
    and NIH have committed approximately $70 million each over 5 years and
    FDA will provide guidance. The first applications were received in late
    January 2012 and will be funded this year with partial support from the
    NIH common fund.
        Aside from predicting toxicity, NCATS will be working on another
    innovation to speed medication development. Repositioning drugs that
    have not been approved (drug rescue) and drugs that are already
    approved (drug repurposing) are probably the most rapid and cost
    effective approaches to new therapies. As industry holds many of the
    assets and data required for efficient rescue and repurposing, many
    institutes at NIH have been interested in working with companies to
    access specific compounds. Rather than creating 26 different
    approaches, NCATS is working with industry to provide a single,
    comprehensive mechanism with several companies for drug rescuing. This
    will permit investigators and small businesses to apply for NIH funding
    to conduct research on new indications using compounds from industry-
    provided drug collections.
        NCATS is also innovating the process of drug repurposing. Through
    the NCATS Pharmaceutical Collection, we have developed a comprehensive
    database of 3,800 approved and investigational drugs to permit NCATS to
    screen all existing medications for novel effects that might be
    therapeutic for a new indication. With this approach, we discovered
    that a drug approved for rheumatoid arthritis could be a novel
    treatment for leukemia. Rather than requiring 6-8 years for the usual
    preclinical research and development, we moved this approved compound
    into a leukemia trial (in a CTSA institution) within 9 months.
    Continued funding of this program in fiscal year 2013 will contribute
    to the NIH effort of decreasing the time, cost, and attrition rate in
    therapeutic development, to bring more promising new therapies to the
    public.
                    support for rare and neglected diseases
        There are more than 6,000 rare diseases, affecting an estimated 25
    million Americans. Fewer than 250 of these rare diseases have
    treatments, according to data from the Online Inheritance in Man
    Database, Orphanet, and FDA. It is clear that efforts need to be
    directed to increasing the number of treatments either through new or
    repurposed drugs. The Therapeutics for Rare and Neglected Diseases
    (TRND) program within NCATS develops treatments for rare diseases, with
    20 projects currently underway. But TRND is not a typical drug
    development effort--the projects are selected as experiments on the
    pipeline of drug development. That is, each project is an attempt to
    re-engineer the process in addition to addressing a medical need. For
    instance, a project on sickle cell disease has introduced a new class
    of molecules not previously considered as medications for any disease.
    Moreover, the study of rare diseases, including many single gene
    disorders (Niemann-Pick Type C and Hereditary Inclusion Body Myopathy),
    is also giving us new insights into fundamental biology. This process,
    sometimes called reverse translation because it moves from ``bedside to
    bench,'' is one of the ways that NCATS is reinforcing rather than
    reducing NIH's commitment to basic research.
                              investing in people
        NCATS fosters the training of clinicians and researchers in an
    environment of innovation and collaboration, encouraging the next
    generation of leaders in translational sciences. For example, the CTSAs
    are currently supporting more than 900 trainees across a wide array of
    disciplines. NCATS will promote novel training mechanisms, such as drug
    development apprenticeships for early-stage investigators, and explore
    cross-training of physicians and scientists between industry and
    academia.
                                   conclusion
        The creation of NCATS offers an exciting new opportunity for
    accelerating the development of new and more effective therapeutics and
    diagnostics; namely by approaching the process of translation as a
    scientific challenge. By encouraging biomedical researchers across the
    Nation to experiment with new and innovative ways of improving these
    processes, our best and brightest can meet today's challenges head on.
    Moreover, the development of new tools and methodologies enable all
    sectors to participate in this arena, maximizing the likelihood of
    ensuring much needed products are actually available to those who need
    it the most--patients.
                                     ______

      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 2013 NIDCD budget of
    $417,297,000 includes an increase of $1,519,000 over the comparable
    fiscal year 2012 level of $415,778,000.
        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 addressing communication disorders.
                    early experience shapes salt preference
        Even though we know that too much salt is bad for our health, many
    of us still consume too much of it. In a typical diet, a lot of salt
    comes from starchy foods, such as breads and cereals. Too much salt can
    cause high blood pressure, or hypertension. Although hypertension
    itself usually has no symptoms, it can cause serious health problems
    such as stroke, heart failure, heart attack, and kidney failure. NIDCD-
    supported scientists determined that babies whose diets contain
    starchy, salty foods will develop a preference for salty taste by as
    early as 6 months of age, as compared to babies who have not been given
    salty foods. During a preference test, the babies accustomed to saltier
    diets consumed 55 percent more salt than their unexposed peers. Salt
    preference endures into the preschool years, when children exposed to a
    salty diet as babies are more likely to consume plain salt. This
    research identifies a potential role for early dietary experiences in
    shaping taste preferences that could influence salt consumption in our
    adult years. If these results can be repeated in a larger study
    population, it suggests that we may be able to reduce salt consumption
    in future generations by encouraging parents to restrict salt in their
    babies' early diets. Reducing salt consumption will also reduce the
    incidence of hypertension, thus reducing healthcare costs due to
    hypertension and the serious health problems it can cause.
              identification of major proteins involved in hearing
        According to NIDCD statistics, 2 to 3 out of 1,000 children in the
    United States are born deaf or hard of hearing, with changes in genes
    being a major cause of hearing impairment. NIDCD-supported scientists
    have shown that mutations in the TMC1 and TMC2 genes cause hereditary
    deafness in humans and mice. Further, they discovered that the proteins
    encoded by TMC1 and TMC2 genes may be key components of the long-sought
    after mechanotransduction channel in the inner ear--the place where
    mechanical stimulation of sound waves is transformed into electrical
    signals recognized by the brain as sound. Using mice without the TMC1
    and TMC2 genes, the scientists discovered the mice had a deficit in the
    mechanotransduction channels in their sterocilia, the sound-sensing
    organelles of the inner ear, while the rest of the auditory hair cell's
    structure and function was normal. These genes and the proteins they
    regulate are the strongest candidates yet in the search for the
    transduction channel. If these genes do indeed encode the transduction
    channel, they will be useful tools to screen for drugs or molecules
    that bind to or pass through the channel and could be used to prevent
    damage to hair cells.
                          keep noise down on the farm
        Farming is loud work. Squealing pigs, grinding combines, whirring
    power tools, and roaring vehicles can add up to a lot of noise.
    Prevention and treatment of noise-induced hearing loss (NIHL) is a
    priority for the NIDCD. NIDCD's campaign ``It's a Noisy Planet. Protect
    their Hearing'' promotes early education of elementary and middle-
    school children about NIHL and how to prevent it. The NIDCD has
    introduced new materials for parents of children who live and work on a
    farm to help them develop healthy hearing habits and protect their
    hearing for life. The NIDCD hopes that these materials will help
    protect individuals who live and work on a farm from developing NIHL.
    Preventing NIHL will improve quality of life for the millions exposed
    to noise, and decrease overall healthcare costs.
       saliva is effective in screening for cytomegalovirus infection in
                                    newborns
        In June, NIDCD-supported scientists reported that swabbing a
    newborn's mouth for saliva can be used to quickly and effectively
    screen for cytomegalovirus (CMV) infection, a leading cause of
    progressive hearing loss in children. Scientists at the University of
    Alabama at Birmingham (UAB) determined that saliva correctly identified
    every baby born with the infection when liquid samples were used, and
    97.4 percent of babies when the samples were dried. Most babies
    infected with CMV don't show symptoms at birth. NIDCD has placed a high
    priority on developing diagnostic tools to screen babies for congenital
    CMV infection, so that those who test positive can be monitored for
    possible hearing loss. These children can be provided with appropriate
    intervention as soon as possible. Because of this research, we know
    that testing saliva is an effective way to identify children at risk
    for hearing loss due to CMV.
              hiv-exposed children at high risk of language delay
        Children who do not use language well may not do well in school and
    may also have difficulty communicating with their peers and
    establishing friendships. A recent study funded by the NIDCD and seven
    other NIH Institutes found that 35 percent of a group of school-age
    children born to women with an HIV infection during pregnancy have
    difficulty understanding spoken words and expressing themselves
    verbally. These data should encourage those caring for children exposed
    to HIV in the womb to provide early treatment for language impairments.
                                     ______

       Prepared Statement of Linda S. Birnbaum, Ph.D., D.A.B.T., A.T.S.,
         Director, National Institute of Environmental Health Sciences
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's budget request for the National Institute of
    Environmental Health Sciences (NIEHS) of the National Institutes of
    Health (NIH). The fiscal year 2013 NIEHS budget of $684,030,000
    includes a decrease of $725,000 less than the comparable fiscal year
    2012 level of $684,755,000.
                                  introduction
        As the Dutch philosopher Desiderius Erasmus so succinctly put it:
    Prevention is better than cure. In most instances, disease is a result
    of a combination of age, genetics, and environment. But unlike age and
    genetics, environment is something that we can affect in order to
    prevent illness. As an environmental public health institute, the NIEHS
    is entrusted with the mission to prevent human suffering and illness by
    creating and sharing the knowledge necessary for understanding the role
    of the environment in disease, and thereby enable people to lead
    healthier lives. NIEHS continually strives to lead public health
    prevention efforts by providing research science and translation to
    inform decisions and policies at the individual, community, national,
    and global levels that prevent hazardous environmental exposures and
    thus reduce disease and disability. Many of the most challenging
    diseases--and most costly in terms of both human suffering and economic
    resources--are being shown to have strong environmental components.
    Diseases such as cardiovascular disease and stroke, that cause 1 in 3
    deaths in America each year, have been associated with exposure to
    environmental agents such as air pollution and secondhand smoke. An
    estimated nearly 70 percent of Americans older than the age of 20 are
    overweight or obese; for children the figure is more than 30 percent.
    New research, including studies funded by the NIEHS, shows that obesity
    and its common companion diabetes are complex disorders that are
    affected not just by food consumption and physical exertion but also by
    environmental factors including exposures to environmental contaminants
    during early life. Greater understanding of the role of such exposures
    and concomitant efforts to prevent them could dramatically change the
    trend of this increasing public health epidemic. And the list goes on.
    Strong associations have been shown between exposure of pregnant
    mothers to chemicals, including polybrominated diphenyl ethers added to
    products as flame retardants, and a range of neurodevelopmental
    disorders, learning disabilities, and behavioral effects in their
    children. NIEHS continues to commit significant efforts to increasing
    our understanding of these health effects and how they might be
    prevented. On a global level, the problem of respiratory illnesses
    resulting from exposure to indoor air pollution represents an area ripe
    for intervention. Toxic smoke from burning biofuels in cookstoves kills
    nearly 2 million people each year, largely women and children,
    according to the World Health Organization. NIEHS is part of the Global
    Alliance for Clean Cookstoves, a public-private initiative working to
    eliminate exposure to harmful cookstove smoke. This is a tractable
    prevention problem with a potentially huge payoff in public health.
     national institute of environmental health sciences strategic planning
        Looking at this long list of environmentally related diseases
    raises the question, ``How can one Institute have an impact on research
    and disease prevention in all these areas?'' To answer this question,
    NIEHS is striving to maximize its impact and leadership in the
    environmental health sciences through a comprehensive and inclusive
    strategic planning process focused on identifying key strategic goals
    for the next 5 years. Through this process, NIEHS hopes to achieve its
    vision of providing a catalyst for leading the field of environmental
    health sciences in applying state-of-the-art biomedical research to the
    most important issues surrounding environmental impacts on health.
        Six broad-based themes of this plan have been established, through
    ongoing dialogue with research scientists and stakeholder groups.
    ``Fundamental Research'' investigates basic biological pathways of how
    our bodies function, to set the stage for asking more in-depth
    questions about the effects of the environment on biological systems.
    ``Exposure Research'' focuses on the study of environmental exposures
    themselves, internal and external to the body. And since NIEHS
    recognizes that information is only effective if it can be translated
    into sound decisions, ``Translational Science'' is identified as a key
    theme covering research that moves a basic science observation into a
    public health or medical application. NIEHS also affirms its commitment
    to ``Health Disparities and Global Environmental Health'' in
    recognition of the fact that individuals and communities that are
    socioeconomically disadvantaged also tend to suffer inequalities in
    both health and environmental burdens. Through ``Training and
    Education,'' NIEHS recognizes the need to develop the next generation
    of top-notch, innovative, and dedicated environmental health scientists
    and professionals. Finally, to fulfill its mission and statutory
    mandate to disseminate information, NIEHS is committed to developing a
    full range of research translation and communication tools and creative
    stakeholder partnerships. This ``Communications and Engagement'' theme
    is vital for realizing the Institute's mission to promote public health
    and prevent environmentally related disease and disability. Two
    crosscutting themes, ``Collaborative and Integrative Approaches'' and
    ``Knowledge Management'' will be implemented across the other themes to
    ensure the success of the goals throughout the strategic plan.
                             recent accomplishments
        The NIEHS strategic plan highlights areas of leadership that will
    build on an impressive list of recent research accomplishments. For
    example, NIEHS-funded researchers recently published the first study
    documenting how exposure to perfluorinated compounds (PFCs), widely
    used in manufactured products such as nonstick cookware, was associated
    with lowered immune response to vaccinations in children. Other recent
    research funded by NIEHS has shown that even moderate air pollution, at
    levels generally considered safe under current Federal regulations,
    increases the risk of stroke by 34 percent.
        NIEHS is also committed to helping those impacted by environmental
    exposures. In the aftermath of the Deepwater Horizon disaster, many
    questions remain about the long-term impact on the health of gulf coast
    residents and communities. NIEHS is leading a trans-NIH effort to
    create a network of community and university partnerships that seeks to
    identify personal and community health effects stemming from the
    Deepwater Horizon oil spill and to enhance community resiliency to
    potential disasters. The 5-year, $25.2 million program will support
    population-based and laboratory research, which will ultimately develop
    the scientific evidence base needed to promote health and well-being
    for people living along the gulf coast who are at greatest risk for
    potential adverse physical, psychological, and behavioral health
    effects. In addition, research will seek to develop new strategies to
    enhance capacity to respond to future disasters and prevent or minimize
    adverse health effects arising from them. Once completed, research
    findings from the Deepwater Horizon Research Consortia should
    contribute to the evidence base needed to improve preparedness and
    response aimed at minimizing disaster-related health impacts.
        Ultimately, NIEHS remains committed to its overall mission to
    discover how the environment affects people's health, in order to
    promote healthier lives.
                                     ______

      Prepared Statement of Josephine P. Briggs, M.D., Director, National
               Center for Complementary and Alternative Medicine
        Mr. Chairman and members of the subcommittee: As the Director of
    the National Center for Complementary and Alternative Medicine (NCCAM)
    of the National Institutes of Health (NIH), I am pleased to present the
    President's fiscal year 2013 budget request for NCCAM. The fiscal year
    2013 budget includes $127,930,000, which is $26,000 more than the
    comparable fiscal year 2012 level of $127,904,000.
        The landscape of our healthcare system is changing in many
    important ways. Among them is a clear trend toward incorporation of
    complementary health practices, which often have origins outside of
    conventional medicine, into integrative approaches to care. There are a
    number of factors--including consumer demand and emerging scientific
    evidence--driving these changes. Nonetheless, there are compelling
    needs of the public, healthcare providers, and policymakers for good
    scientific evidence on the safety and potential benefit of these
    complementary and integrative approaches. Using the highest standards
    of scientific rigor, NCCAM is committed to developing evidence about
    practices that are being integrated into healthcare. We are
    particularly interested in those cases where there is scientific
    opportunity and/or important public health need.
               trends in complementary and integrative healthcare
        National surveys conducted by the National Center for Health
    Statistics (NCHS) at the Centers for Disease Control and Prevention
    show that nearly 40 percent of Americans report using one or more
    practices such as acupuncture, massage, yoga, meditation, spinal
    manipulation, dietary supplements, or herbal medicines to help manage
    their health and wellness. Similarly, data show that healthcare systems
    and providers are incorporating such interventions. For example, an
    American Hospital Association survey conducted in 2007 showed that 37
    percent of hospitals offered complementary modalities; and a national
    study reported last year by the NCHS reported widespread availability
    of complementary approaches in hospice settings. Other data from the
    Departments of Defense (DOD) and Veterans Affairs (VA) show increasing
    use of complementary modalities in their populations. According to the
    VA, 89 percent of their facilities offered complementary therapies in
    2011. Both the DOD and VA have integrated complementary modalities into
    the care of patients with post-traumatic stress and sleep disorders,
    and to improve treatment of pain.
                 reducing pain and improving symptom management
        One area of urgent public health need is better strategies for
    managing chronic pain. According to the Institute of Medicine, chronic
    pain affects an estimated 116 million Americans, and costs the Nation
    approximately $635 billion each year. Chronic pain is the most
    frequently cited reason for which Americans use complementary health
    practices. For many individuals suffering from chronic pain,
    conventional approaches provide incomplete relief. Furthermore,
    pharmacological treatment with opioids or anti-inflammatory drugs can
    have significant adverse effects. There is now emerging evidence, much
    of it from NCCAM-supported studies, that some nonpharmacological
    interventions, such as massage, spinal manipulation, yoga, meditation,
    and acupuncture, may be helpful in treating chronic pain. Additional
    scientific evidence is needed to better understand these findings, and
    the optimal use and safety of these integrative approaches.
        To this end, NCCAM is supporting a growing portfolio of studies on
    the use of nonpharmacological interventions for the management of
    chronic pain, including back and neck pain and pain associated with
    osteoarthritis, fibromyalgia, and headaches. In addition, we are
    supporting research to better understand the biological mechanisms by
    which complementary modalities may contribute to management of pain and
    other symptoms. For example, we recently funded Centers of Excellence
    for Research on Complementary and Alternative Medicine that use
    advanced functional and structural neuroimaging technologies to study
    pain. NCCAM is also providing leadership to a working group within the
    trans-NIH Pain Consortium to develop standards for research on chronic
    low back pain. Finally, in the next year, NCCAM plans to focus its
    intramural research program on understanding the role of the brain in
    chronic pain syndromes. The program will be highly collaborative with
    other intramural neuroscience programs on the NIH campus.
                     advancing research on natural products
        NCCAM remains strongly committed to developing better evidence and
    information resources on the safety and efficacy of commonly used
    natural products. The Center is targeting investment in research in
    this arena on understanding the biological mechanisms of these
    products, thus creating the translational foundation for subsequent
    human studies.
        In addition, research examining issues of safety is of great public
    health importance, given the widespread availability and use of these
    products by the public. In this regard, one area of specific need is
    rigorous scientific information about interactions of these products
    with drugs or with other natural products. This spring, NCCAM will lead
    a workshop, cosponsored by the NIH Office of Dietary Supplements and
    the National Cancer Institute, with researchers from a variety of
    fields to discuss ways to improve the methodologies needed to study
    herb-drug interactions. Workshop recommendations will help guide
    NCCAM's research agenda.
                  building and disseminating rigorous evidence
        Researchers studying the effectiveness and safety of healthcare
    approaches already in widespread use face methodological challenges,
    challenges that are not unique to NCCAM's mission. To develop better
    methods of studying health outcomes in real-world settings, NCCAM is
    leading an NIH Common Fund Initiative, the Health Care Systems Research
    Collaboratory. The Collaboratory will develop innovative research
    partnerships with healthcare delivery organizations to maximize the
    potential use of electronic health information. NCCAM is also exploring
    possible collaborations with the DOD and the VA, aiming to leverage the
    data being gathered on the use of complementary and integrative
    practices in their healthcare systems. Additionally, NCCAM is providing
    leadership and support to the trans-NIH Patient-Reported Outcomes
    Measurement Information System (PROMIS), which will provide clinicians
    and researchers with more efficient and reliable means for gathering
    data on a variety of patient-reported measures of health and well-
    being.
        NCCAM continues to provide reliable, objective, and evidence-based
    information on the usefulness and safety of complementary health
    practices to the public and healthcare providers. For example, NCCAM
    publishes the Clinical Digest (nccam.nih.gov/health/providers/digest),
    a monthly e-newsletter that summarizes the state of the science on
    complementary health practices and clinical guidelines. Additionally,
    NCCAM provides an online resource (nccam.nih.gov/health/providers) that
    enables healthcare providers to make informed recommendations.
                                   conclusion
        Strong consumer use of complementary health practices, and growing
    integration of these practices into a variety of conventional
    healthcare settings are important trends in U.S. healthcare. While
    there is emerging evidence of promise for some, there are many
    important unanswered questions about effectiveness and safety. NCCAM
    remains committed to building the scientific evidence needed by
    consumers, providers, and health policy makers to make informed
    decisions about the use of complementary and integrative health
    practices.
                                     ______

     Prepared Statement of Roger I. Glass, M.D., Ph.D., Director, Fogarty
                              International Center
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's budget request for the Fogarty International
    Center (FIC) of the National Institutes of Health (NIH). The fiscal
    year 2013 FIC budget of $69,758,000 includes an increase of $219,000
    more than the comparable fiscal year 2012 level of $69,539,000.
        These are exciting times for global health. New HIV prevention
    strategies and the use of mobile technologies to extend the reach of
    health interventions are just two examples of research into emerging
    opportunities that can transform our efforts to improve health around
    the world. These are also examples of advances that can make a
    significant impact on health here at home as well as abroad. As
    populations in both the developed and developing world are vulnerable
    to existing and emerging infectious agents, as well as the growing
    noncommunicable disease (NCD) epidemic, there is no longer a ``them''
    in global health, only an ``us'' (Global Health Council).
        To most effectively address this shared burden of disease, U.S.
    scientists can only benefit from the unique insights and collaboration
    of skilled research partners around the world. At the NIH and within
    the U.S. Government, FIC plays a unique role by supporting the
    development of global health research expertise in the United States
    and abroad, and by fostering the international partnerships that extend
    the frontiers of science, accelerate discovery, and enable the United
    States to continue to lead in addressing the world's most pressing
    health challenges.
                  strengthening sustainable research capacity
        For over two decades, Fogarty has supported the long-term training
    of thousands of scientists worldwide. These scientists provide unique
    insights and perspectives on how to best combat global health
    challenges, and often contribute to groundbreaking research advances in
    collaboration with U.S. partners.
        As the largest international commitment by any one country to fight
    a specific disease, the President's Emergency Plan for AIDS Relief
    (PEPFAR) relies on trained scientists to provide an evidence base for
    the new and effective strategies that have enabled PEPFAR programs and
    policies to make significant contributions to the progress toward an
    AIDS-free generation. For example, with support from Fogarty's
    longstanding HIV/AIDS research training program, Fogarty-supported
    researchers have provided evidence that a new, simpler, and shorter
    treatment regimen of antibiotics can prevent those infected with the
    tuberculosis (TB) bacterium--particularly those who also have HIV--from
    developing full-blown TB. In addition, Fogarty-supported researchers
    and trainees have also helped demonstrate: the effectiveness of anti-
    retroviral therapies in stopping mother-to-child transmission of the
    HIV virus; that male circumcision reduces HIV transmission to HIV-
    negative female partners; and a reduction in HIV transmission among
    women using microbicides that incorporate anti-retrovirals.
        In response to the increased global burden of NCDs, Fogarty's NCD-
    Lifespan research training program supports partnerships between U.S.
    and low- and middle-income country (LMIC) institutions to build NCDs
    research capacity. By focusing on early childhood exposures and the
    genetic, environmental, and lifestyle risk factors that can contribute
    to later onset of disease, NCD-Lifespan projects are creating a cadre
    of investigators and institutions able to conduct research relevant to
    local and global epidemics in areas such as cancer, stroke, mental
    illness, and metabolic disorders. In Ghana, for example, Fogarty is
    supporting the development of a Cardiovascular Research Training
    Institute as a partnership between New York University and the
    University of Ghana, to train investigators to conduct research on
    preventing and treating hypertension, diabetes, stroke, and chronic
    kidney disease. The resulting cadre of investigators will contribute
    research and expertise to the global effort to reduce cardiovascular
    disease morbidity and mortality.
        With respect to identification of innovative, sustainable, and
    cost-effective strategies to fulfill its mission, Fogarty recognizes
    that information and communication technologies, mobile technologies,
    and distance learning can transform the way in which health and health
    research training can be conducted in the 21st century--particularly in
    resource-poor and remote settings. More than 50 Fogarty-supported
    projects have incorporated distance learning activities, which provide
    an innovative and cost-effective way to connect health research
    students in the developing world with state-of the-art content on the
    other side of the globe.
                          new investigators, new ideas
        Over the last decade, American university campuses have seen a
    soaring interest in global health among students and faculty from
    diverse fields, placing U.S. universities in an excellent position to
    help generate solutions to complex global health challenges. Fogarty's
    International Clinical Research Scholars and Fellows program and
    International Research Scientist Development Awards capitalize on this
    groundswell of interest to invest in future American leaders in global
    health research. These programs are investing in the next generation of
    talented American scientists, who will develop the skills and
    sensitivities to conduct research in international settings, and engage
    talented local researchers who can help to address complex health
    challenges that affect populations in the United States and abroad.
    Former Scholars and Fellows have developed innovative solutions to
    concrete global health problems. For example, in Zambia, Dr. Krista
    Pfaendler developed and implemented an effective and low-cost cervical
    cancer screening program using digital cameras for cervical photography
    and acetic acid (vinegar) for visual inspection.
        In 2010, Fogarty piloted a 1-year program to support postdoctoral
    investigators in U.S. universities to carry out innovative,
    multidisciplinary team research in global health. With support from
    this program, scientists developed point-of-care telemedicine units
    built with $2 microscopes that can be attached to a cell phone,
    enabling diagnosis of infectious diseases, such as malaria and HIV, in
    remote settings. Because of their ease of use, effectiveness, cost-
    effectiveness, and the ability for quick diagnosis, these microscopes
    have the potential to revolutionize care in resource-poor settings. The
    next generation of this program, Framework Innovations, will support
    U.S. and developing country institutions as they develop
    interdisciplinary postdoctoral research training programs in global
    health and enable young investigators to develop and test concrete and
    innovative health products, processes, and policies that respond
    practically and cost-effectively to critical health needs.
                        advancing translational science
        Innovative strategies are needed to translate biomedical
    discoveries into new therapies, diagnostics, and prevention tools.
    Supported by Fogarty's International Cooperative Biodiversity Groups
    Program, United States and international scientists conduct discovery
    research on potential health applications of molecules--from plants,
    animals, and micro-organisms--and initiate partnerships with companies
    interested in developing these molecules for potential new drugs or
    diagnostics. This public-private partnership model has led to four
    active patents in the areas of cancer, parasitic diseases, and malaria.
                                   conclusion
        As the world continues to become more interdependent, international
    scientific partnerships will play a critical role in building bridges
    between countries and scientists in the interest of advancing the
    health of our country and our globe. Fogarty invests in the best and
    brightest minds and catalyzes long-term, productive research
    collaborations. Working in partnership with the rest of the NIH,
    Fogarty's unique programs will continue to push the frontiers of
    science and enable scientists in the United States and abroad to work
    together to successfully tackle the world's most pressing and complex
    health challenges.
                                     ______

      Prepared Statement of Patricia A. Grady, Ph.D., RN, FAAN, Director,
                     National Institute of Nursing Research
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2013 budget request for the
    National Institute of Nursing Research (NINR) of the National
    Institutes of Health (NIH). The fiscal year 2013 NINR budget of
    $144,153,000, includes a decrease of $444,000 less than the comparable
    fiscal year 2012 level of $144,597,000.
                                  introduction
        I appreciate the opportunity to share with you a brief summary of
    some of the recent activities and future scientific directions of NINR.
    NINR supports clinical and basic research to build the scientific
    foundation for clinical practice, prevent disease and disability,
    manage and eliminate symptoms caused by illness, enhance palliative and
    end-of-life care, and train the next generation of scientists. In doing
    so, NINR promotes and improves the health of individuals, families, and
    communities across the lifespan, in a variety of clinical settings and
    within diverse populations. NINR's emphasis on clinical research and
    training places NINR in a position to make major contributions to
    developing the evidence base for science-driven practice through
    innovative treatment and behavioral research.
        Over the past year, we have commemorated NINR's 25th anniversary at
    NIH through a series of scientific outreach events that culminated in
    October 2011 with the release of NINR's new Strategic Plan: Bringing
    Science to Life. As NINR looks ahead to the next 25 years, the
    Institute is well-positioned to continue to advance rigorous science,
    develop and support evidence-based science-driven interventions across
    the lifespan, develop future leaders in nursing science, and contribute
    to improving the Nation's health and national healthcare system.
               advancing the quality of life: symptom management
        With the aging of a major sector of the Nation and advances in
    treatment of formerly fatal diseases, we are faced with a population
    that is living with multiple chronic conditions. The challenge of
    treating and managing these multiple conditions and their associated
    symptoms is one that confronts nearly all health practitioners,
    especially nurses involved with chronic illness management. NINR has
    invested deeply in the area of symptom management, from funding basic
    research on pain in our Intramural Research Program (IRP) to our
    extramural support for psychosocial and nutritional interventions to
    improve symptoms of chronic heart failure. Further, recognizing that
    chronic illness strikes across the lifespan, NINR also supports
    research aimed at helping children and adolescents manage their own
    chronic conditions and their symptoms more effectively to improve their
    quality of life. Finally, NINR initiated a call for research on the
    interconnections of diabetes and asthma, both on the rise in the United
    States; this research is focused on early life exposures that are
    associated with both conditions, as well as interventions that target
    the management of each disease and their synergisms.
                    health promotion and disease prevention
        NINR is also heavily committed to health promotion and disease
    prevention. Nurses are often in unique positions as the health
    providers with the most frequent interactions with individuals and
    their support networks, and are therefore well-poised to help develop
    interventions that promote health and prevent disease. In one example,
    NINR currently supports an innovative community-based program in urban
    Pennsylvania that trains male Latino lay health advisors who provide
    their peers information on community support resources, including
    healthcare resources. NINR also is leading a funding opportunity
    focused on developing healthy habits in children and adolescents that
    lead to lifelong sustainable healthy behaviors that prevent disease and
    disability. Finally, in line with our focus on health promotion and
    disease prevention across the lifespan, NINR supported a research
    project that developed a successful program to guide mothers of very
    preterm infants in correctly feeding their vulnerable infants.
                         investing in nurse scientists
        NINR is strongly committed to the development of future health
    scientists, with a specific focus on the training of nurse scientists.
    Along with extramural research grants and fellowships that support pre-
    and postdoctoral students and junior and senior researchers, NINR
    offers a number of intramural training opportunities to develop nurse
    scientists. This year, we are proud to once again offer the NINR Summer
    Genetics Institute, a month-long, intensive course in genetics for
    nurse scientists at all career levels. The course is designed to
    increase research in genetics among graduate students and faculty in
    nursing, and expand the knowledge base among clinicians for genetics in
    clinical practice. NINR also sponsors the Methodologies Boot Camp, a 1-
    week intensive research training course at NIH that focuses on applying
    state-of-the-art methodologies to studies of symptom management,
    including pain, fatigue, and sleep.
                        end of life and palliative care
        With advances in treatment for chronic diseases and the aging of
    our population, we as a society are facing new challenges in
    understanding the complexities of decisionmaking issues surrounding
    palliative and end-of-life care for those with advanced illness. As the
    lead NIH Institute for end-of-life research, NINR is committed to
    supporting research that leads to science-driven practices in
    palliative care that assists individuals, families, caregivers, and
    healthcare professionals in alleviating symptoms and planning for end-
    of-life decisions. In August 2011, NINR convened a 3-day National
    Summit on, ``The Science of Compassion: Future Directions in End-of-
    Life and Palliative Care.'' The Summit, co-sponsored by partners across
    NIH, examined the state of research and clinical practice in end-of-
    life and palliative care and, with almost 1,000 registrants, provided
    an opportunity for scientists, healthcare professionals, and public
    advocates to come together to catalyze and shape the future research
    agenda for this critical scientific area. NINR also supports, along
    with the NIH Office of the Director, a palliative care research
    cooperative to develop an enhanced evidence base for palliative care by
    facilitating multi-site research studies and clinical trials.
                            investing in innovation
        NINR supports innovations that advance patient care, help lower the
    cost of healthcare, and take advantage of the advances in real-time
    personalized information on patients that guide healthcare today. For
    example, NINR supported two critical phases of the development of a
    novel ``lab-on-a-chip'' device for rapidly detecting HIV. The technique
    has proved highly successful, and the research team has gone on to
    refine and clinically test this microfluid-based lab-on-a-chip--or
    mCHIP--in real-life settings, with studies demonstrating that the mCHIP
    can accurately, rapidly, and cost-effectively detect clinically
    relevant infectious diseases in resource-limited settings. Other NINR-
    supported researchers have developed a novel, automated medication
    dispenser that reminds patients when to take medication, monitors
    dosage, and reduces treatment errors. The new dispenser will be the
    first on the market that can deliver not only all common forms of drugs
    but also biologically derived injectables.
                                   conclusion
        Nursing science has a central role in developing the evidence-base
    for science-driven practices in healthcare. NINR's research agenda has
    guided and will continue to guide the advances in this field of health
    research through the implementation of our new Strategic Plan. NINR
    looks forward to continuing its support of innovative nursing science
    focused on some of the most important health and healthcare related
    issues of today.
                                     ______

     Prepared Statement of Eric D. Green, M.D., Ph.D., Director, National
                        Human Genome Research Institute
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's budget request for the National Human Genome
    Research Institute (NHGRI) of the National Institutes of Health (NIH).
    The fiscal year 2013 NHGRI budget of $511,370,000 includes a decrease
    of $893,000 less than the comparable fiscal year 2012 level of
    $512,263,000.
        It is an extraordinary time for the field of genomics. Through
    recent scientific advances and technological developments, we are
    gaining a deeper understanding for how the human genome plays a central
    role in health and disease, enabling investigators across the
    biomedical research spectrum to pursue new avenues for translating this
    knowledge into clinical applications. NHGRI, guided by an ambitious
    vision for genomics research that the Institute published in February
    2011, is poised to lead a research agenda in fiscal year 2013 that will
    focus not only on basic genome biology and the genomic underpinnings of
    disease but will also seek to develop strategies for applying genomics
    to advance medical science and, ultimately, to improve the
    effectiveness of healthcare.
                          ensuring a strong foundation
        The unprecedented decreases in the cost of DNA sequencing--
    resulting from NHGRI-stimulated technology development coupled with
    myriad innovations by the NHGRI Large-Scale Genome Sequencing Centers--
    have fundamentally changed how genomic data is now generated as part of
    biomedical research. Whereas sequencing that first human genome during
    the Human Genome Project cost upwards of a $1 billion, sequencing a
    human genome using recently developed technologies will soon cost
    $1,000 (or less).
        The recent renewal of the program supporting the NHGRI Large-Scale
    Genome Sequencing Centers ensures the productive continuation of
    flagship initiatives such as The Cancer Genome Atlas (TCGA) in addition
    to special projects with specialists focusing on specific disorders,
    such as Alzheimer's disease. These centers will continue to develop
    innovative methodologies and information management systems, which will
    inevitably lead to further reductions in the cost of genome sequencing.
    With such reductions will come the opportunity to sequence the tens of
    thousands of individual genomes required to understand the small
    genetic differences that cumulatively confer risk for common diseases,
    such as diabetes and heart disease. Furthermore, the accessibility of
    low-cost DNA sequencing technologies will be essential for making
    genome sequencing a routine part of clinical care.
        To facilitate the utilization of genomic tools and information for
    exploring biological questions and ultimately improving clinical care,
    the NHGRI Centers of Excellence in Genomic Science will conduct
    interdisciplinary research and training initiatives focused on the
    production, analysis, and utilization of genomic data. From these
    efforts, new insights into the complexity of human genome function are
    emerging, and these in turn are benefiting the research community at
    large. Similarly, the human-centric ENCyclopedia of DNA Elements
    (ENCODE) project and the companion model organism ENCODE project
    (modENCODE) will continue to build a ``knowledge base'' that details
    the functional genomic elements underlying biological processes in
    humans as well as organisms that serve as important models for studying
    human biology.
        To complement the requisite understanding of normal genome function
    established by these projects, tools for defining the genetic
    contributions to human disease are being developed. NHGRI continues to
    lead efforts within the international 1000 Genomes project to build a
    deep catalog of genomic variants among different human populations; in
    turn, this information will be used to identify the subsets of rare and
    common variants that confer risk for (or protection from) specific
    diseases or adverse drug responses. Fiscal year 2013 will also see the
    key maturation of the Human Heredity and Health in Africa (H3Africa)
    initiative, an NIH Common Fund project managed by NHGRI. The increased
    knowledge generated about genomic variation and the complex
    interactions between environmental and genetic factors in African
    populations will enhance understanding of disease predispositions and
    drug responses for all human populations.
        If genomics is to be a powerful contributor to studies being
    performed across the biomedical research community, researchers must be
    able to process and analyze the massive amounts of genomic data that
    they can now readily produce. NHGRI will pursue the establishment of
    pioneering approaches for data management and analysis via the
    development and refinement of bioinformatic tools, resources, and
    standards.
                           translating the potential
        The Genome Sequencing Program continues to be a prominent and
    vibrant part of the Institute's research portfolio. Looking ahead, it
    will play an increased role in translating genomic-based capabilities
    to understand disease biology. The Program's renewal in fiscal year
    2012 included not only continued support for medical sequencing
    projects but also a charge to conduct collaborative research projects
    with other investigators to broaden the application of genome
    sequencing as a tool for unraveling the genomic basis of human disease.
    The prototype for the latter is TCGA, a collaboration with the National
    Cancer Institute to identify the genomic basis of many different forms
    of human cancer.
        The renewal of NHGRI's Genome Sequencing Program also included
    establishment of new Mendelian Disorders Genome Centers focused on
    rare, single-gene (called Mendelian) diseases. These new centers will
    seek to establish the genetic basis for thousands of rare disorders
    (affecting millions of Americans) for which the genetic defects remain
    unknown. Recent advances in genome sequencing offer the hope that the
    genetic underpinnings for most of these rare diseases can be identified
    through focused research efforts that were not possible or affordable
    with previous genome sequencing technologies.
                         preparing for genomic medicine
        To capitalize on its growing foundation of basic and translational
    research, NHGRI recently launched the Clinical Sequencing Exploratory
    Research projects, a new component of the Institute's Genome Sequencing
    Program. The new projects will investigate how to utilize genomic
    knowledge in medical settings and begin to explore how healthcare
    professionals can routinely use genome sequence information for patient
    care. A related effort, the Electronic Medical Records and Genomics
    (eMERGE) Network, is pursuing how patients' genomic information can be
    linked to disease characteristics and symptoms in their electronic
    medical records, providing the ability to explore associations with
    disease pathologies and eventually to improve patient care.
        Key to the ultimate success in all of these endeavors will be
    continued attention to the societal implications of advancing genomic
    technologies and understanding. Deliberate, ongoing engagement by
    laboratory, clinical, and social scientists and scholars in ethics,
    law, and philosophy with the public must remain a priority.
        Through its portfolio of basic and translational research, the
    Institute is pushing forward the boundaries of our knowledge and
    defining the issues that must be addressed before genomics is routinely
    deployed as a standard element in medical care. NHGRI is leading this
    charge by funding ambitious research programs to understand the
    structure and function of genomes more fully, to use genomics as a
    central tool for understanding the biology of disease, and to establish
    the path for the implementation of genomic medicine. In all of these
    pursuits, the Institute maintains a laser-like focus on its ultimate
    mission--to improve human health through genomics research.
                                     ______

      Prepared Statement of Judith H. Greenberg, Ph.D., Acting Director,
                 National Institute of General Medical Sciences
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's budget for the National Institute of General
    Medical Sciences (NIGMS) of the National Institutes of Health (NIH).
    The fiscal year 2013 budget of $2,378,835,000 includes a decrease of
    $48,354,000 less than the comparable fiscal year 2012 level of
    $2,427,189,000.
        This year, in 2012, the National Institute of General Medical
    Sciences (NIGMS) celebrates its 50-year anniversary as NIH's ``basic
    research institute.'' Since 1962, NIGMS has continuously supported
    highly creative people committed to building a broad and deep
    foundation of discovery. The findings are used and applied by
    scientists everywhere, leading to new diagnostics, new therapies, and
    new ways to prevent a wide range of diseases.
                     model systems illuminate human health
        Laboratory-animal versions of disease are a staple of basic
    biomedical and behavioral research. Because fruit flies, worms, mice,
    and other animals are easy and relatively inexpensive to work with--and
    have most of the same genes and many of the same behaviors as we do--
    they are valuable tools for biomedical discovery. Sometimes, though,
    results with animal models do not hold up in human studies, in part
    because organisms studied in the laboratory lack the genetic diversity
    of people. NIGMS has addressed this problem through its support of the
    Collaborative Cross, a large-scale mouse-breeding project that
    significantly expands the genetic diversity of mice. This project has
    made its resources widely available to scientists everywhere--helping
    to fast-track important discoveries about genetics and human disease.
        Other recent studies with model systems, in this case worms, have
    pointed to new information about a group of neurological diseases that
    have a common molecular defect: the inability of normal cellular
    proteins to fold themselves into their proper three-dimensional shapes.
    Misfolded proteins are implicated in Alzheimer's, Parkinson's, and
    Huntington's diseases, amyotrophic lateral sclerosis, cancer, cystic
    fibrosis, and type 2 diabetes. The recent work identified new genes and
    signaling pathways that keep proteins folded properly and prevent toxic
    clumping. The researchers also extended their findings by identifying
    small molecules that appear to repair misfolded proteins.
                                 all systems go
        While animal models offer key clues to understanding human disease,
    other studies that investigate large, interacting systems are an
    essential avenue for learning about health and disease. Systems biology
    approaches, which promote a more thorough grasp of the intricate and
    dynamic workings of how molecular and cellular parts interact to make a
    whole, is a robust area of NIGMS-funded biomedical research.
        Human behavior is one example of an enormously complicated system--
    not just for an individual but also between individuals and within and
    between populations. Systems biology research employing mathematical
    models can draw connections among a vast number of inputs, uncovering
    new connections and making new predictions. NIGMS has joined forces
    with the NIH Office of Behavioral and Social Sciences Research to
    identify opportunities, challenges, and gaps in knowledge needed to
    develop useful models of social behavior. This past fall, NIGMS issued
    a call for funding research that models social behavior. The new
    program has generated substantial interest in the research community,
    and the Institute is looking forward to the results that are likely to
    have broad application.
        Another scientific area of great complexity, even though the
    subject of study is microscopic, is the interactions between viruses
    and their hosts. For many years, NIGMS has funded the AIDS-Related
    Structural Biology Program to obtain the three-dimensional structures
    of HIV proteins. Representing the culmination of hundreds of studies,
    researchers have just published a map of nearly 500 physical
    interactions between components of HIV and those in human cells. The
    research provides a gold mine for further studies into new drugs and
    vaccines against HIV.
                       accelerating the pace of discovery
        As our world has flattened due to increased human travel and
    expanded commercial trade among many international partners, a number
    of new diseases have emerged and infected people around the world. To
    help the Nation and the world understand and prepare for contagious
    outbreaks, NIGMS funds the 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. In 2011, MIDAS scientists used whole-genome
    sequencing to trace the path of the E. coli outbreak that made
    thousands of people ill and killed more than 50 people in Germany and
    France. The project demonstrates the power of modeling and is one of
    the first uses of genetic detective work to study the dynamics of a
    food-borne outbreak.
        The NIGMS investment accelerates the pace of discovery through its
    support of chemistry projects that enable biologists to study cells and
    organisms using state-of-the-art chemical tools; help clarify the
    chemical reactions that underlie human metabolism; and provide new
    strategies for drug development. NIGMS-supported chemists recently made
    two new discoveries that should enhance the manufacture of key drugs.
    In the first study, scientists made significant progress toward a
    simpler, more efficient way to synthesize Taxol, an important cancer
    drug used routinely to treat ovarian, breast, lung, liver, and other
    cancers. In a second study, NIGMS-funded chemists unveiled the working
    parts of the commonly used anti-fungal medicine amphotericin B,
    nicknamed by physicians ``ampho-terrible'' for its harsh side effects.
    The new work opens up possibilities for designing similar anti-fungal
    medicines that are just as effective but easier on the body.
                      investing in the future of discovery
        The Institute believes that a strong biomedical research workforce
    is essential for the tandem goals of improving health and maintaining
    global competitiveness. In 2011, NIGMS published ``Investing in the
    Future: the NIGMS Strategic Plan for Biomedical and Behavioral Research
    Training.'' Implementation of this plan is now in full swing. Going
    forward, NIGMS has articulated clearly that research training is a
    partnership between the NIH and the academic community and continues to
    engage actively with its full range of stakeholders. Key foci include
    the importance of excellent mentoring, a continuing emphasis on
    diversity, and the need to recognize a full menu of career options
    beyond academic research for newly trained scientists.
        NIGMS has also recently established a new organizational component,
    the Division of Training, Workforce Development, and Diversity, which
    integrates training, diversity, and capacity-building activities across
    Institute programs. This new component also oversees the Institutional
    Development Award (IDeA) program that broadens the geographic
    distribution of NIH funding. A new component of this effort is the IDeA
    Program Infrastructure for Clinical and Translational Research
    initiative, which encourages applications from IDeA States to develop
    infrastructure and capacity to conduct clinical and translational
    research on diseases that affect medically underserved populations and/
    or diseases prevalent in these 23 States and territories traditionally
    underfunded by the NIH.
                     extending the reach of basic research
        Within the clinical realm, NIGMS continues to support the NIH
    Pharmacogenetics Research Network (PGRN), now in its 12th year of
    funding. This endeavor has yielded a bounty of medically relevant
    knowledge, including how genetic information can help predict how heart
    drugs, cancer medicines, nicotine patches, and a range of other
    treatments are likely to work in a particular person. One PGRN project
    is now partnering with the Electronic Medical Records and Genomics
    (eMERGE) Consortium to test samples from people whose electronic
    medical records are also available to the researchers. The goal is to
    demonstrate that DNA differences can be useful for decisionmaking about
    drug type and dosage, and ultimately to improve medication safety and
    efficacy.
                                     ______

       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 subcommittee: I am pleased to
    present the fiscal year 2013 President's budget request for the Eunice
    Kennedy Shriver National Institute of Child Health and Human
    Development (NICHD) of $1,320,600,000. This reflects an increase of
    $775,000 more than the comparable fiscal year 2012 level of
    $1,319,825,000.
                      50 years of contributions to health
        This year marks the 50th anniversary of the founding of the NICHD.
    Thanks to continuing congressional support and the unwavering
    dedication of our scientists and stakeholders, NICHD research has
    changed the lives of women, children, families, and those individuals
    with disabilities worldwide. Since the NICHD was established in the
    early 1960s, research supported by the Institute contributed to a 50
    percent drop in sudden infant death syndrome (SIDS), and a 70-percent
    drop in respiratory distress syndrome, both leading causes of the
    Nation's infant mortality rate. Transmission of HIV from infected
    mother to fetus dropped from 25 percent to less than 1 percent in the
    past 15 years. Discovery of an early biological marker of pregnancy led
    to the development of what is now the standard pregnancy test. The
    incidence of Haemophilus influenzae type b (Hib) meningitis, once the
    leading cause of acquired intellectual disability, has dropped more
    than 90 percent with the development of the Hib vaccine by NICHD
    scientists. Beyond these past contributions to public health, our
    anniversary presents a unique opportunity to catalyze scientific
    advances.
                       new advances continue the momentum
        The NICHD's basic research, conducted on the NIH campus and
    supported at academic institutions nationwide, adds to scientific
    knowledge and enables clinical researchers to develop and test new
    treatments. For example, in type 1 diabetes, the immune system destroys
    the body's insulin-producing cells that help control blood glucose
    levels. Infertility researchers funded by the NICHD found a way to
    convert endometrial stem cells into insulin-producing cells and
    transplant them into mice to control diabetes. These findings suggest
    that ultimately, a woman's own, readily available, endometrial stem
    cells could be used to develop insulin-producing islet cells,
    minimizing the chance of rejection posed by using tissues or cells from
    another person.
        Research shows promise for developing new treatments for uterine
    fibroids. These noncancerous tumors, 3 to 4 times more common in
    African American than white women, are often associated with chronic
    pain, infertility, and preterm labor. Currently, few treatment options
    exist except surgical removal of the uterus (hysterectomy). A recent
    NICHD-sponsored analysis concluded that the economic costs of the poor
    health outcomes, treatment, and management of fibroids in the U.S. may
    reach $34 billion annually. Other NICHD-supported researchers found
    that treatment with vitamin D reduced the size of uterine fibroids in
    laboratory rats predisposed to developing the tumors, suggesting that
    differential rates of vitamin D deficiency could help explain the
    health disparities in fibroid formation. Another approach, using a drug
    to shrink the tumors, has shown promise in preliminary clinical
    studies.
        New technologies and tools are allowing the research community to
    move science along faster than ever. For example, a NICHD-supported
    physiatrist is combining bioengineering with a technique called
    ``targeted muscle reinnervation,'' using nerves that remain after
    amputation to control assistive devices; this has enabled researchers
    to link an individual's brain impulses to a computer in a prosthesis
    that directs motors to move the limb. The NICHD Small Business
    Innovation Research (SBIR) program has supported development of
    emerging technologies to address mounting concerns about the effects of
    concussions. Scientists have created a device mounted inside a football
    helmet to measure the impact of a collision. This new tool has already
    helped to quantify the impact of concussions for college football
    players, determine how head injuries may differ for football players at
    different positions, and can be used to design more protective helmets.
        Scientists at the NIH's Autism Centers of Excellence are taking
    advantage of new insights into brain structure and function in their
    Infant Brain Imaging Study. Using a special imaging technique, they
    tracked the brain development of infants and toddlers who have an older
    sibling with an autism spectrum disorder (ASD), and thus, are at
    increased risk of developing ASD themselves. The researchers found
    distinctly different patterns of brain development in the younger
    siblings who were later diagnosed with ASD compared to those who
    weren't. These findings represent the earliest age (6 to 24 months) at
    which such biomarkers for ASD have been identified.
        It is especially gratifying when scientific advances like these are
    put into practice. Last year, I reported on a major new study supported
    by the NICHD demonstrating that fetal surgery to correct
    myelomeningocele (spina bifida) greatly reduced the risk of death and
    doubled the chances of children being able to walk, compared to the
    standard practice of postnatal surgery. Over the past year, the NICHD
    has convened a series of meetings with numerous leading professional
    societies to ensure sufficient and consistent training and guidelines
    for performing this highly complex procedure as it becomes available in
    various sites around the country.
        In late 2011, an NICHD-supported analysis of more than 5 million
    medical records showed that pregnant women assaulted by an intimate
    partner are at increased risk of giving birth to infants at lower birth
    weights. Babies born at low birth weights are at higher risk for SIDS,
    heart and breathing problems, and learning disabilities. The American
    College of Obstetricians and Gynecologists used this information in
    developing physician training materials for screening patients for
    intimate partner violence.
        Since 2002, the NICHD has led the NIH's implementation of the Best
    Pharmaceuticals for Children Act, supporting pharmacokinetic research
    and new clinical trials on drugs not previously tested for pediatric
    use. Due in large part to the NICHD's Pediatric Trials Network, data on
    pediatric safety, dosing, and efficacy for several common drugs were
    sent to the Food and Drug Administration this year so that the drugs'
    labels can be changed, and the children potentially benefiting from
    these therapeutics can be treated appropriately.
                      looking ahead: scientific visioning
        As exciting as these advances are, we know that the promise of
    improving the Nation's health depends on enlightened management of the
    research enterprise. The NICHD has just concluded a ``visioning''
    process to help us focus over the next 10 years on the best ways to
    achieve scientific goals, enhance prevention, and continue to improve
    the Nation's health. After in-depth consultation with more than 700
    experts from around the country, white papers covering nine major areas
    of our science were made available online (http://www.nichd.nih.gov/
    vision), and a scientific commentary summarizing NICHD's overall vision
    will appear in a major medical journal later this year. Now the NICHD
    looks to the future, where we will work with our research partners to
    detail how genes, the environment, and behaviors interact, starting
    before birth, to affect health outcomes. We plan to determine all the
    causes of preterm birth, devise new treatments to maximize gynecologic
    health, and improve the health and functioning of individuals with
    intellectual, developmental, or physical differences. Collaborative
    efforts to strengthen transdisciplinary research and enhance the ways
    that we conduct science will be essential to this future.
                                   conclusion
        Whether they work at the NIH or receive grants at academic
    institutions across the country, NICHD-supported scientists are an
    invaluable national resource. In the past year alone, two long-time
    NICHD grantees were among only seven researchers named by President
    Obama as recipients of the National Medal of Science. And, to honor her
    work encouraging young women from the inner city to engage in
    scientific research careers, a third NICHD grantee was recently awarded
    the Presidential Award for Excellence in Science, Mathematics, and
    Engineering Mentoring. It is with the help of exceptional individuals
    such as these, and your support, that we will embark on the next 50
    years of the NICHD's ``Research for a Lifetime.''
                                     ______

    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 subcommittee: I am pleased to
    present the President's budget request for the National Institute of
    Arthritis and Musculoskeletal and Skin Diseases (NIAMS) of the National
    Institutes of Health (NIH). The fiscal year 2013 NIAMS budget of
    $535,610,000 includes an increase of $462,000 more than the comparable
    fiscal year 2012 level of $535,148,000.
                                  introduction
        As the primary Federal agency for supporting medical research on
    diseases of the bones, joints, muscles, and skin, NIAMS touches the
    lives of nearly every American. Training the basic and clinical
    scientists who carry out this research, and disseminating information
    on research progress in these diseases, are two other important
    components of the NIAMS mission.
                  using science to inform healthcare decisions
        Over the past two decades, the NIH Study of Osteoporotic Fractures
    (SOF) has provided information that healthcare providers are using to
    assess people's bone health. SOF's finding that bone mineral density
    (BMD) relates closely to fracture risk, for example, contributed to
    Medicare's decision to pay for numerous people to get their BMD
    measured every 2 years. Many started taking bone-preserving drugs
    because of their results, and the rate of hip fractures dropped nearly
    25 percent among female beneficiaries. New, longer-term data from SOF
    could refine the screening guidance: women at the highest risk of
    osteoporosis might benefit from annual exams, while frequent
    measurements may be unnecessary for others. In fact, women with the
    lowest risk could be tested much less frequently unless other aspects
    of their health change.
        As multiple treatments become available for various conditions,
    research is needed to help clinicians decide which options are best for
    their patients. Studies of adults who have rheumatoid arthritis (RA)
    suggest that aggressive treatment is more beneficial than waiting until
    the disease progresses. A group of rheumatologists tested whether a
    similar approach would reduce the disability and healthcare costs of
    juvenile idiopathic arthritis (JIA). They compared two therapies and
    determined that early treatment with either strategy increased the
    likelihood that the joint-destroying processes would stop.
        Many diseases within the NIAMS mission involve pain, fatigue, and
    other difficult-to-measure symptoms. The ability 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 NIH, NIAMS is encouraging researchers to use the
    resource in ongoing clinical studies of rheumatic, musculoskeletal, and
    skin diseases.
        For the past decade, researchers have been monitoring the health of
    people who have low back pain due to intervertebral disk herniation,
    lumbar spinal stenosis, or degenerative spondylolisthesis. Early
    findings showed that, in general, most surgical patients fared better
    than patients who received nonoperative care, although many patients
    got better without surgery. Recent data show that the cost-
    effectiveness of surgery for low back pain due to these disorders--4
    years after an operation--is comparable to that of other common
    treatments for nonmusculoskeletal conditions.
        Community engagement is a key component for translating
    interventions into healthcare and integrating lifestyle changes into
    daily living. To address the well-documented disparities in medical
    knowledge and research participation, NIAMS will continue its
    Multicultural Outreach Initiative to improve access to health
    information for underserved minority populations. Fiscal year 2013
    plans include field testing program materials and creating an
    electronic toolkit to facilitate their dissemination.
                          investing in basic research
        Itch is an often difficult and sometimes debilitating symptom of
    many skin diseases and other disorders within the NIAMS mission. Poor
    knowledge of the mechanisms underlying chronic itch has hampered the
    development of pharmacologic treatments. In fiscal year 2013, NIAMS
    will encourage basic and translational studies in this area.
        NIAMS maintains a considerable investment into the genetic and
    cellular basis of osteoarthritis (OA), with the goal of identifying
    potential targets for therapies that halt tissue degeneration. Even
    after researchers develop treatments to stop or reverse OA progression,
    however, some patients will require total joint replacement. With
    support from the American Recovery and Reinvestment Act of 2009,
    researchers made a surprising discovery about the lubricating layer
    that forms around metal-on-metal hip implants. Instead of cell-based
    fluid made by the patient, the lubricant is a synthetic material
    produced through friction. This finding could lead to longer-lasting
    materials which, in turn, could improve the surgeries' success and
    reduce their long-term costs.
        With the advent of new laboratory and data mining tools,
    investigators are making connections among biologic processes and organ
    systems that previously were viewed independently. For example,
    researchers are learning that inflammation, which plays an important
    role in RA and other autoimmune joint diseases, is involved in OA onset
    and osteoarthritic joint degeneration. Others are exploring how
    normally harmless microorganisms can lead to RA by causing the immune
    system to attack healthy tissue.
        The technologic advances related to genome-wide analyses have
    enabled investigators to identify a genetic mutation that causes a rare
    childhood disease characterized predominantly by inflammation and fat
    loss. The disorder, named chronic atypical neutrophilic dermatosis with
    lipodystrophy and elevated temperature (CANDLE), may actually represent
    a spectrum of diseases that have been described in the literature under
    a variety of names. More importantly, since no treatment for this
    disease exists, the findings may have uncovered a possible target for
    future therapies.
                        advancing translational sciences
        NIAMS supports several large programs to encourage teams of
    translational researchers. In fiscal year 2013, it again will partner
    with other NIH Institutes to fund applications for the Wellstone
    Muscular Dystrophy Cooperative Research Centers program. The Centers
    have facilitated numerous basic discoveries and animal tests since
    their establishment in 2003. A group of investigators that includes
    Wellstone researchers recently published preclinical data about small
    molecules that target the defective RNA that causes myotonic dystrophy
    type 1. The cell-culture and mouse-model findings have the potential to
    benefit people who have myotonic dystrophy type 1; their promise also
    extends to other conditions that might be amenable to RNA-targeted
    therapies.
        NIAMS strengthened its Small Business Innovation Research (SBIR)
    program in recent years by inviting eligible companies to propose
    studies on specific topics that complement the Institute's other
    grants. Results from the targeted efforts include a cell-derived human
    skin substitute for use in consumer product testing, drug discovery,
    and toxicity screening. NIAMS will continue to look for opportunities
    that could benefit from an SBIR focus and will solicit applications as
    areas are identified.
                                   conclusion
        The advances described above are just a few of the contributions
    that NIAMS-funded investigators have made to save and improve millions
    of American lives. Collectively, the Institute's research, training,
    and health information programs have significantly advanced our
    understanding of how to treat or prevent many common, chronic, costly
    diseases. Looking forward, this progress will serve as a strong
    foundation for the future, as the burden that these conditions place on
    individuals and society is reduced and, over time, eliminated.
                                     ______

       Prepared Statement of Story C. Landis, Ph.D., Director, National
                 Institute of Neurological Disorders and Stroke
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's budget request for the National Institute of
    Neurological Disorders and Stroke (NINDS) of the National Institutes of
    Health (NIH). The fiscal year 2013 NINDS budget of $1,624,707,000
    includes an increase of $278,000 more than the comparable fiscal year
    2012 level of $1,624,429,000. The NINDS mission is to reduce the burden
    of neurological diseases through research. NIH research has improved
    the lives of many people with neurological disorders directly and by
    providing the foundation for private sector research. The American
    Heart Association (AHA) reported that the stroke death rate decreased
    by 34.8 percent from 1998 to 2008. Better treatments are available for
    multiple sclerosis, epilepsy, Parkinson's, and other diseases, and
    genetics research has led to tests that significantly reduce the time
    to obtain the correct diagnosis for many rare disorders. Moreover,
    basic science is driving remarkable opportunities for progress.
    Paradoxically, however, industry is significantly reducing their
    investment in research on brain disorders because of the challenges
    brain diseases present. NINDS supports a spectrum of basic,
    translational, and clinical research to complement and encourage
    private sector efforts. Because gaps in basic understanding of the
    normal brain or disease are most often the cause when progress against
    neurological disease is not forthcoming, the Institute continues to
    invest more than one-half of its resources in basic research, for which
    the NIH role is especially crucial.
                             accelerating discovery
        Last year, for the first time, researchers provided a molecular
    diagnosis for a family's inherited disease using whole genome
    sequencing (WGS). The disease was a type of Charcot Marie Tooth
    disease, a disorder that affects the body's nerves. This year WGS
    provided not only a molecular diagnosis but also immediate therapeutic
    benefit. In this study, twin children had been diagnosed with dopa-
    responsive dystonia, a movement disorder that reflects a deficiency of
    the neurotransmitter dopamine. The children's health problems persisted
    despite treatment with the drug l-dopa, which replenishes dopamine and
    is usually effective. Once WGS identified the specific gene defect, it
    became apparent that the neurotransmitter serotonin was also deficient.
    Boosting serotonin with a readily available drug dramatically improved
    the children's health. Dozens of studies are now underway using these
    ``next generation'' sequencing methods in common and rare neurological
    diseases. A new ``Center without Walls,'' for example, is bringing the
    best researchers together, regardless of geography, to apply the new
    genetics technologies to epilepsy.
        Next-generation sequencing is just one of several technologies that
    are transforming basic and clinical neuroscience. Optogenetics allows
    precise control of nerve cells' activity by light. Induced pluripotent
    stem cell (iPSC) methods derive nerve cells from skin cells of patients
    affected by disease, to enable studies of disease and screening of
    drugs in a culture dish. NINDS supports extensive iPSC research,
    including consortia in ALS, Parkinson's, and Huntington's disease.
    Brain imaging now reveals structure, activity, and chemistry of the
    living brain in health and disease. Recently, for example, brain
    imaging provided insights about traumatic brain injuries (TBI) in the
    military, the lingering effects of concussions in young athletes and
    new understanding of autism . The NIH Human Connectome Project is an
    ambitious imaging effort to map the wiring diagram of the entire human
    brain. NIH encourages sharing of data from the Connectome project, gene
    studies, iPSC methods, and other research that is producing
    extraordinary amounts of useful information. A notable recent effort to
    promote data sharing is a TBI database created jointly by the NIH and
    the Department of Defense.
                        translating discovery to health
        NINDS has a long history of translating scientific advances into
    better medicine. Rare disease studies, bold new therapeutic strategies,
    and technology development are examples of translational research in
    which NINDS plays a key role. Several NINDS programs support
    translational research. The Anticonvulsant Screening Program (ASP) has
    contributed to the development of eight epilepsy drugs now on the
    market. Following an external review completed this year, the ASP will
    refocus on what most concerns the epilepsy community today--drugs to
    address treatment-resistant epilepsy and to modify the course and
    development of the underlying disease. Recent activities in the NINDS
    Neural Prosthesis Program, which pioneered this entire field, include
    collaboration with Defense Advanced Research Projects Agency (DARPA) to
    enhance brain control of an advanced prosthetic arm, and development of
    an ultrathin flexible brain implant that could one day be used to treat
    epileptic seizures and other disorders. To exploit opportunities across
    all neurological disorders, the Cooperative Program in Translational
    Research, begun in 2002, supports teams of academic and small business
    investigators to carry out preclinical therapy development. NINDS is
    now funding two Phase II clinical trials of therapies developed in this
    program. NINDS is also leading an NIH Blueprint Grant Challenge to
    develop truly novel drugs that will transform the treatment of nervous
    system diseases.
        Because candidate therapies for many disorders are emerging, in
    2011 NINDS launched the NeuroNext clinical network at 25 sites across
    the United States. NeuroNext will remove roadblocks to the crucial
    early stage clinical testing of novel therapies and reduce from years
    to months the time to move new therapies into testing in patients.
    NeuroNext will test biomarkers for spinal muscular atrophy (SMA) in its
    first clinical study to prepare for trials of candidate therapies for
    SMA.
        NINDS phase III, multi-center clinical trials continue to advance
    public health. The Neurological Emergency Treatment Trials (NETT)
    network completed the Rapid Anticonvulsant Medication Prior to Arrival
    (RAMPART) trial well ahead of schedule, showing that paramedics in the
    field can safely deliver the drug midazolam into muscle using an
    autoinjector (like an EpiPen) and stop continuous seizures faster than
    the usual intravenous treatment. These results inform responses to
    common continuous seizures and seizures caused by industrial accidents
    or nerve agents. NETT trials of stroke and TBI emergency treatments are
    underway. Also this year, the Stenting vs. Aggressive Medical
    Management for Preventing Recurrent Stroke in Intracranial Stenosis
    (SAMPRISS) clinical trial showed that patients at high risk for a
    second stroke who received intensive medical treatment had fewer
    strokes and deaths than patients who received a stent in blood vessels
    that supply the brain in addition to the medical treatment. Follow up
    is continuing to compare longer-term benefits.
        With the concern about dementia as our population ages, it is worth
    noting that stroke is a major contributor to dementia, highlighting the
    complex relationships among various types of dementia. Not only do the
    7 million U.S. stroke survivors have an increased likelihood of
    cognitive problems, and perhaps also 13 million who have had ``silent
    strokes'' but also vascular problems that cause stroke are also
    associated with Alzheimer's disease. Signs that a stroke has occurred
    are often found in the brains of Alzheimer's patients, and beta-
    amyloid, a key protein in Alzheimer's pathology, may stimulate the
    formation of blood clots, which can cause stroke. Furthermore, last
    year the Reasons for Geographic and Racial Differences in Stroke
    (REGARDS) study, which is following more than 30,000 people, reported
    that high blood pressure and other known risk factors for stroke
    increase the risk of cognitive problems, even among people who have
    never had a stroke. Research suggests that there is a dementia spectrum
    from pure vascular dementia to pure Alzheimer's disease, with most
    patients having contributions from both. Recognition of intersections
    not only between Alzheimer's disease and stroke but also Alzheimer's
    disease with TBI, Parkinson's, frontotemporal dementia, and other
    disorders may provide leads toward better prevention and treatment of
    all dementias.
        Hundreds of neurological disorders affect patients, families, and
    society. The aging population, concern about the long lasting effects
    of TBI, and reduced private sector investment are among several factors
    that underscore the importance of NINDS funded research. Although
    neurological disorders present enormous challenges, progress in
    neuroscience and other areas of research provides exceptional
    opportunities for the future.
                                     ______

     Prepared Statement of Donald A.B. Lindberg, M.D., Director, National
                              Library of Medicine
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's budget request for the National Library of
    Medicine (NLM) of the National Institutes of Health (NIH). The fiscal
    year 2013 NLM budget of $372,651,000 includes an increase of $7,608,000
    more than the comparable fiscal year 2012 level of $365,043,000. Funds
    have been included to allow the National Center for Biotechnology
    Information (NCBI) to meet the challenges of collecting, organizing,
    analyzing, and disseminating the deluge of data emanating from research
    in molecular biology and genomics.
        As the world's largest biomedical library and the producer of
    internationally trusted electronic information services, NLM delivers
    trillions of bytes of scientific data and health information to
    millions of users every day. Many searches that begin in Google or a
    mobile ``app'' actually retrieve information from an NLM Web site.
    After 175 years, NLM is a key link in the chain that makes biomedical
    research results--DNA sequences, clinical trials data, toxicology and
    environmental health data, published articles, and consumer health
    information--readily available to scientists, health professionals, and
    the public. A leader in biomedical informatics and information
    technology, NLM also conducts and supports leading-edge research and
    development in electronic health records, clinical decision support,
    information retrieval, imaging, computational biology,
    telecommunications, and disaster response.
        NLM's programs and services directly support NIH's four key
    initiatives in basic research, technology, translational science, and
    research training. The Library organizes and provides access to the
    published medical literature and 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' Web sites, as well as
    connecting to vast collections of scientific data. Through its NCBI,
    NLM is a hub for the international exchange and use of molecular
    biology and genomic information, with many databases 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, the Genetic Testing Registry (GTR)
    and the ClinVar database create a bridge between basic research and
    clinical applications.
        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 most
    comprehensive clinical trials database, including registration data for
    more than 117,000 clinical studies with sites in 178 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 more than 5,000 completed trials of FDA-
    approved drugs, biological products, and devices--providing a new and
    growing source of evidence on efficacy and comparative effectiveness.
    NLM is a primary source for results of comparative effectiveness
    research, providing access to evidence on best practices to improve
    patient safety and healthcare quality. In 2011, the Library greatly
    expanded its collection of full-text guidelines, evidence summaries,
    and systematic reviews from authoritative agencies and organizations
    around the world.
              health data standards and electronic health records
        Electronic health records (EHRs) with advanced decision-support
    capabilities and connections to relevant health information will be
    essential to achieving precision medicine and helping Americans manage
    their own health. For 40 years, NLM has supported seminal research on
    electronic patient records, clinical decision support, and health
    information exchange, including concepts and methods now reflected in
    EHR products and personal health record tools, such as Microsoft Health
    Vault. As the HHS coordinating body for clinical terminology standards,
    NLM works closely with the Office of the National Coordinator for
    Health Information Technology to facilitate adoption and ``meaningful
    use'' of EHRs. NLM supports, develops, and disseminates several key
    data standards now required for U.S. health information exchange. While
    actively engaged in research on Next Generation EHRs, NLM also produces
    tools, frequently used subsets of large terminologies, and mappings to
    help EHR developers and users implement health data standards right
    now. NLM's MedlinePlus Connect is used in multiple EHR products to
    provide high quality health information relevant to a patient's
    specific health conditions, medications, and tests, as present in his
    or her EHR.
                      information services for the public
        This EHR connection builds upon NLM's extensive information
    services for patients, families and the public. The Library's
    MedlinePlus Web site provides integrated access to high quality
    consumer health information produced by all NIH components and HHS
    agencies, other Federal departments, and authoritative private
    organizations. It 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 750,000 visits per day. Mobile MedlinePlus, also in both English
    and Spanish, reaches the large and rapidly growing mobile Internet
    audience.
        The NIH MedlinePlus magazine, in English and Spanish, is an
    outreach effort made possible with support from many parts of NIH and
    the Friends of the NLM. Distributed free to the public via physician
    offices, community health centers, libraries and other locations, the
    magazine reaches a readership of up to 5 million nationwide. Each issue
    focuses on the latest research results, clinical trials and guidelines
    from the 27 NIH Institutes and Centers.
        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
        Through its Disaster Information Management Resource Center, NLM
    builds on proven emergency backup and response mechanisms within the
    NN/LM to promote effective use of libraries and information specialists
    in disaster preparedness and response. NLM 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 works with the Pan American Health
    Organization (PAHO) and the Latin American Network for Disaster and
    Health Information to promote capacity-building in disaster information
    management. In addition, NLM responds to specific disasters worldwide
    with specialized information resources appropriate to the need,
    including a recently launched Disaster Information Apps and Mobile Web
    Sites page.
        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 Roderic I. Pettigrew, Ph.D., M.D., Director,
          National Institute of Biomedical Imaging and Bioengineering
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's budget request for the National Institute of
    Biomedical Imaging and Bioengineering (NIBIB) of the National
    Institutes of Health. The fiscal year 2013 NIBIB budget of $336,896,000
    is $1,058,000 less than the comparable fiscal year 2012 level of
    $337,954,000.
        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 physical, 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 better
    healthcare.
             discovery science and technologies to empower patients
        Neurostimulation Research in Paraplegics: Recovery of Voluntary
    Motion, Bladder, and Sexual Function.--Through the NIBIB Rehabilitation
    Engineering program, researchers from the University of California, Los
    Angeles, have developed a high-density electrode array technology for
    epidural stimulation of the spinal cord. The first patient, the victim
    of a car accident that left him completely paralyzed from the chest
    down, received electrical stimulator implants in his lower back. Over a
    1-year period, he received daily electrode stimulating sessions with
    specific tasks and movements being performed, which is known as
    locomotor training. The procedure resulted in independent standing,
    some voluntary leg control, and regained bladder, bowel, and sexual
    function. It is believed that the epidural stimulation and locomotor
    training have two distinct roles. The stimulation appears to switch on
    intact circuits in the spinal cord, while the training relays specific
    information about body and limb positions. The investigators have
    applied this technology to three patients with complete spinal cord
    injury. All patients are able to stand and voluntarily control both
    legs in the presence of epidural stimulation.
        Wireless Tongue Drive System Could Provide Independence to
    Paralyzed Patients.--Assistive technologies (ATs) have been available
    to control devices used for daily living such as powered wheelchairs
    and computers. However, many of these devices have limited commands,
    cause rapid muscle fatigue, or interfere with the user's basic
    functions. NIBIB-funded researchers from the Georgia Institute of
    Technology have developed a tongue-operated AT called the Tongue Drive
    System (TDS) that is unobtrusive, wearable, wireless, and can
    substitute for many arm and hand functions. The core TDS technology
    exploits the fact that even a person with severe paralysis that impairs
    breathing and speech can still move their tongue and therefore, can
    fully utilize this extraordinary system. The device consists of a
    headset, a compact computer, and a tiny magnet attached to the tongue.
    Tongue movements change the magnetic field around the mouth. These
    changes are detected by magnetic sensors in the headset, relayed to the
    computer, and translated into the commands of the user. The system
    allows users to control various devices and perform numerous tasks such
    as drive their wheelchairs, operate their computers, and generally
    control their environment in an independent fashion. The TDS can be
    linked to currently available technologies such as a smart phone, to
    control household appliances, lights, locks, heating/air conditioning,
    as well as prosthetic arms or legs. This remarkable technology could
    offer paralyzed individuals an unprecedented level of independence for
    leading active, productive lives.
              technologies to accelerate therapeutics development
        Multi-Layered Nanoparticles for Specific Delivery of Drugs to
    Tumors.--An important area of investigation supported by NIBIB is
    targeted drug delivery, e.g., to cancer cells and not the surrounding
    normal tissue. One group of investigators has created multilayered
    nanoparticles that can be delivered systemically (by venous injection)
    but act only at the site of the tumor due to the specific chemical
    properties of each layer and their interaction with the specific
    biochemistry of tumor cells. The properties of the outer surface layer
    were designed to provide a surface that promotes distribution of
    particles throughout the body and shields the drug while preventing
    binding to healthy tissues. This outer ``stealth'' layer is also pH-
    sensitive and is shed in the acidic environment of tumors exposing the
    toxic load of the nanoparticle. At the site of a tumor, the shed
    surface layer reveals a charged nanoparticle layer, which contains the
    anti-cancer agent and is readily taken up by tumor cells. The
    investigators have demonstrated that this concept for tumor targeting
    is applicable to a broad range of cancers and compatible with various
    therapies designed to be triggered by acidic tumor tissue. Because
    particles can be designed with layers that can be shed in specific
    environments, the cancer drug can be exposed and delivered directly to
    the tumor, which makes this emerging technology an extremely promising
    cancer drug delivery technique.
        Nanoscale Theranostics: Delivering Treatment and Monitoring
    Efficacy Simultaneously.--Recent advances in nanoscience have spurred
    new developments in the field of theranostics (the combination of both
    therapeutic and diagnostic functions in a single system). These
    integrated systems have been shown to selectively transport therapeutic
    agents to target tissues while simultaneously monitoring biological
    responses to the delivered therapy. The current challenge is to develop
    systems or ``platforms'' that allow the optimization of the function of
    each of the combined molecular components that target the disease site,
    deliver the therapy, and allow for imaging of the results immediately.
    Researchers recently developed a nanoscale delivery platform known as
    polymer-caged nanobins (PCNs). The surface of PCNs can be chemically
    modified to attach a variety of molecules in order to target specific
    cells or tissues. The platform is liposome based, which allows for a
    simplified loading and encapsulation of a range of therapeutic drugs.
    To allow monitoring of the response to therapy, the PCN shell contains
    magnetic resonance imaging (MRI) contrast agents, which provide images
    of the drug targets as well as real time images of the response to the
    drug, e.g., reduction in tumor size. This type of theranostic can make
    the treatment of numerous diseases safer and more successful because
    the prescribed regimens can be adjusted in real time during treatment.
               accelerating early diagnosis at the point-of-care
        Handheld Nuclear Magnetic Resonance for Rapid Point-of-Care
    Diagnostics.--One of the major challenges in medicine is the rapid and
    accurate measurement of proteins that are biomarkers of a specific
    disease, or pathogens in biological samples. Magnetic particles which
    target biomarkers are attractive candidates for such biosensing
    applications because most biological samples do not have any background
    magnetization that would interfere with detection. A handheld micro-
    nuclear magnetic resonance (NMR) device, which can detect such
    particles, has recently been developed for rapid approximately one-half
    hour analysis of a variety of biologics, from bacteria identification
    in small fluid samples to protein markers of cancer. The device employs
    magnetic particles that bind to targets of interest, creating a signal
    detectable by the micro-NMR. Also known as diagnostic magnetic
    resonance (DMR), this powerful biosensor technology offers unique
    advantages, such as robust signal amplification, broad applicability to
    profile different types of targets (DNA, proteins, metabolites, and
    cells), minimal sample preparation, ability to perform measurements in
    turbid media, and high-throughput capacity. Importantly, the low cost
    and ability to use the device at the point-of-care could make important
    contributions to the battle against serious public health issues such
    as tuberculosis and HIV in underserved populations. In an early study
    of patients with unknown solid masses, the diagnosis of cancer was made
    at the bedside in approximately one-half hour and with higher accuracy
    than with the traditional method of tissue biopsy which requires two
    days for final results.
                          new investigators, new ideas
        National Institute of Biomedical Imaging and Bioengineering Design
    by Biomedical Undergraduate Teams Challenge.--The Design by Biomedical
    Undergraduate Teams (DEBUT) challenge is a new National Institute of
    Biomedical Imaging and Bioengineering (NIBIB) program opened to teams
    of undergraduate students working on projects that develop innovative
    solutions to unmet health and clinical problems. The main goals of the
    challenge are:
      --to provide undergraduate students experience in working in teams to
            identify unmet clinical needs, and design, build and debug
            solutions for open-ended problems;
      --to generate novel, innovative tools to improve healthcare,
            consistent with NIBIB's mission; and
      --to highlight and acknowledge the contributions and accomplishments
            of undergraduate students.
        Entries have been solicited in three categories:
      --Diagnostic devices and methods;
      --Therapeutic devices and methods; and
      --Technologies to aid underserved populations and individuals with
            disabilities.
        The winning student team in each category will receive a $10,000
    prize at the NIBIB DEBUT Award Ceremony during the annual conference of
    the Biomedical Engineering Society.
                                     ______

    Prepared Statement of John Ruffin, Ph.D., Director, National Institute
                   on Minority Health and Health Disparities
        Mr. Chairman and members of the subcommittee: 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. The fiscal year 2013 NIMHD budget of $279,389,000
    includes an increase of $3,278,000 more than the comparable fiscal year
    2012 level of $276,111,000.
                                  introduction
        Millions of Americans from racial and ethnic minority, rural and
    low-income populations continue to be burdened by disparities in health
    status and healthcare, despite recent scientific and medical advances
    to improve the quality of health in this nation. Evidence-based
    research has shown that these disparities result from the interaction
    of multiple chronic influences, such as social, environmental,
    behavioral, and biological factors. Traditionally, research emphasis
    has been on examining the biology of health disparities. In recent
    years, the impact of social factors has become more evident in having a
    strong causal linkage to health disparities. For example, the role of
    the social and physical environment, the effect of poor housing
    circumstances, and the difficulties of accessing transportation to
    obtain timely needed medical care, are all important factors.
    Therefore, the elimination of health disparities requires a coordinated
    and integrated approach across multiple disciplines to understand and
    solve the underlying biological and nonbiological evolution of health
    disparities. NIMHD has been at the forefront leading scientific
    research and building bridges to eliminate health disparities while
    working with public and private sector partners.
                             innovation in research
        NIMHD administers a portfolio of programs aimed at approaching
    health disparities from many angles, embodied in the principal goals of
    research, research capacity building, and outreach. Through research,
    the NIMHD seeks to understand the development and progression of
    diseases and conditions disproportionately affecting underserved
    populations, and to develop evidence-based strategies to improve
    prevention, diagnosis, and treatment methods. The Centers of Excellence
    (CoE) Program continues to be a powerful force for encouraging large-
    scale, transdisciplinary research. CoE researchers have analyzed
    associations between insulin resistance and other markers of disease in
    a sample of Mexican-American adolescents from a severely disadvantaged
    community on the Texas-Mexico border. This study found that
    approximately 50 percent of their sample (mean age, 16 years old) were
    overweight or obese, and more participants were obese than overweight.
    Participants (27 percent) in this sample had insulin resistance, a
    strong predictor of diabetes, and two biomarkers, low high-density
    lipoprotein cholesterol and high waist circumference, were strongly
    linked to insulin resistance. These findings emphasize the need to
    address insulin resistance at least as early as adolescence to prevent
    adverse economic, social, and health consequences. Another group found
    evidence that supports the hypothesis that the loss of function of a
    molecule that promotes cell adhesion contributes to the development of
    the aggressive breast cancer commonly found in African-American women.
    NIMHD COE researchers have also discovered that moral beliefs and lack
    of awareness contribute to low rates of cervical cancer screening in
    young Asian-American women.
                       toward diversity in the workforce
        Building the capacity of individuals, institutions, and communities
    to conduct research and undertake training, with the goal of
    strengthening the diversity of the science and medical workforce, are
    crucial to improving the quality of healthcare of America's underserved
    populations. The Research Endowment, Research Centers in Minority
    Institutions (RCMI), and the Building Research Infrastructure and
    Capacity (BRIC) Programs are the pillar of the NIMHD support for
    building a national enterprise of academic institutions with the
    physical and intellectual capability to be leaders in health
    disparities research. At the University of Texas Brownsville, NIMHD
    funding has helped to leverage resources for the creation of a new
    college, the College of Biomedical Sciences and Health Professions, and
    establish a new degree program in biomedical sciences.
        NIMHD continues to recruit an average of 250 new candidates into
    its Loan Repayment Program annually, adding to the diversity of
    individuals from health disparity populations in the science and health
    professions workforce. Many of these scholars are engaged in
    behavioral, social sciences, prevention, health services, and
    community-oriented research exploring the various social determinants
    of health. Some of the innovative research projects include studying
    text messaging to improve depression treatment adherence in low-income
    patients, creating web-based treatment programs for substance use in
    American Indian and Alaska Natives, and examining how perceived
    discrimination and health system distrust affect behavior and
    decisionmaking related to cervical cancer prevention in rural and
    minority women.
                              engaging communities
        Harnessing the power and insights of diverse communities is another
    important factor because health disparity populations often encounter
    cultural or environmental barriers to improved health. Outreach efforts
    remain at the core of the NIMHD's commitment to engage communities in
    the research process, and equally important, to translate research
    findings into culturally and linguistically appropriate tools and
    programs to educate and empower affected communities and their
    healthcare providers. The Community-Based Participatory Research (CBPR)
    Initiative supports research that engages communities in the research
    process as equal partners with scientists. This engagement is valuable
    in helping communities sustain healthy behaviors over the long-term.
    For example, one project at Wake Forest University trained members of
    Latino soccer teams in North Carolina to discuss HIV-prevention
    behaviors with fellow players. After 18 months, men in the intervention
    group were significantly more likely to report consistent condom use
    and HIV testing than those in a control group. Grantees at Saint Louis
    University are increasing fruit and vegetable consumption by local
    black men by producing community gardens. These plots have provided
    more than 1,800 pounds of fresh produce to 150 families, and residents
    showed decreases in hypertension and body mass index.
                       a future of sustainable commitment
        NIMHD seeks to ensure that the investment and progress that has
    been made toward eliminating health disparities is not lost. It will
    continue to identify opportunities to sustain effective programs and
    initiatives by forging and strengthening partnerships across all
    sectors, while accelerating the pace of research, policy, practice, and
    community interventions to address pervasive barriers and emerging
    issues impeding the elimination of health disparities. It will also be
    imperative to establish an effective system of coordination for these
    inter and intra-agency activities. Enhanced understanding of the social
    determinants of health and how where we live, work, and play influence
    health outcomes are among the priorities that must be aggressively
    advanced through innovative approaches. While the issues are many,
    NIMHD is confident that the infrastructure it has built throughout the
    Nation is up to the challenge, and it is poised to support and create
    sustainable interventions that will move the country closer to
    eliminating health disparities. Ensuring that all Americans have an
    equal chance at healthy life is not an option. NIMHD remains committed
    to achieving health equity for underserved communities.
                                     ______

    Prepared Statement of Susan B. Shurin, M.D., Acting Director, National
                        Heart, Lung, and Blood Institute
        Mr. Chairman and members of the subcommittee: 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 2013 NHLBI budget of $3,076,067,000 includes an
    increase of $709,000 more than the comparable fiscal year 2012 level of
    $3,075,358,000.
        The NHLBI leads research and education programs to discover and
    apply knowledge to improve health by preventing and treating heart,
    lung, and blood diseases. I appreciate the opportunity to highlight
    just a few examples of our success in doing so and some of our most
    promising research programs that will enable further advances.
                         chronic disease risk reduction
        Cardiovascular diseases (CVD) and pulmonary conditions are among
    the leading causes of disability and death around the world. Although
    their prevention and treatment have improved dramatically, without
    further progress they will continue to impose an increasing health
    burden as our population ages. A recent meta-analysis of lifetime risk
    for CVD underscored the availability of lifelong opportunities for CVD
    prevention. The Institute is funding a clinical trial to examine diet
    and exercise interventions to improve neurocognition in patients with
    CVD risk factors who have cognitive impairment. Effective ways to help
    people lose weight and sustain weight loss were identified in an NHLBI-
    supported study reported in November 2011; multiple ongoing projects
    are addressing ways to help children and adults in a wide range of
    circumstances improve their health through weight control and physical
    activity.
        The NHLBI continues to focus upon understanding CVD risk in
    vulnerable populations. The Jackson Heart Study is addressing the
    biological, behavioral, and psychosocial factors that account for the
    high burden of CVD in African Americans. The Hispanic Community Health
    Study--Study of Latinos is addressing the factors involved in the
    prevalence and development of CVD in Hispanic populations in the United
    States. Both studies are expected to be renewed in fiscal year 2013. A
    new program planned for fiscal year 2013 will foster development of
    effective and sustainable public health interventions to reduce CVD
    morbidity and mortality in high-risk rural populations.
              interpreting the human genome in health and disease
        Data from the NHLBI's substantial investment in whole exome
    sequencing of participants in its long-term cohort studies is paying
    off: data are now being deposited in dbGaP, the informatics resource at
    the National Library of Medicine, for use by investigators around the
    world. The return on this investment will provide valuable new
    diagnostics and treatments for the next decade.
        The NHLBI has led multiple global consortia in sharing data and
    encouraging analysis of large genomic data sets linked to phenotype.
    One such consortium identified 16 genetic loci important for control of
    blood pressure that are now being explored by other NHLBI-supported
    investigators as new approaches to control blood pressure. Still other
    NHLBI-supported studies are revealing the genetic and environmental
    causes of chronic obstructive pulmonary disease (COPD), asthma,
    abnormalities of heart rhythm, and factors that affect the severity of
    hemoglobin disorders such as sickle cell disease.
               new therapies for heart, lung, and blood disorders
        The NHLBI supports development of improved therapies for heart
    disease through resources such as the Cardiac Translational Research
    Implementation Program (C-TRIP) and their assessment in clinical trials
    through Institute-initiated programs such as the Pediatric Heart
    Network (now completing a trial in Marfan's syndrome and multiple
    studies of genetics and clinical management of congenital heart
    disease), the Heart Failure Network (conducting studies of cellular and
    drug therapies of heart failure), and the Cardiothoracic Surgical
    Trials Network (conducting comparative studies of surgical approaches).
        Several NHLBI programs are advancing translation of basic
    scientific knowledge into new therapies. The Centers for Advanced
    Diagnostics and Experimental Therapeutics in Lung Diseases (CADET) will
    accelerate the development of agents for diagnosing and treating lung
    diseases. Investigators are partnering with other NIH programs such as
    Therapeutics for Rare and Neglected Diseases (TRND) to do early-stage
    translational work that will be followed by NHLBI-supported clinical
    trials.
                          gene and cellular therapies
        NHLBI-supported scientists recently reported success in treating
    hemophilia B, an inherited bleeding disorder, in several patients with
    a single infusion of a gene therapy that durably boosted the production
    of the missing clotting factor. If confirmed in other patients, this
    approach may allow patients to minimize or discontinue expensive
    treatment with replacement clotting factor.
        Encouraging results from studies that use gene therapies in animal
    models for other diseases offer promise for the treatment of human
    disease. For example, a unique genetic approach of replacing the single
    mutated amino acid in mice cured their sickle cell disease. A new form
    of gene therapy for heart failure improved heart function in pigs
    without apparent toxicity.
        Bone marrow transplantation has been standard clinical therapy for
    certain diseases since the 1960s. The NHLBI is the primary Institute
    supporting the Bone Marrow Transplant (BMT) Clinical Trials Network
    (CTN), with strong support from the NCI. A BMT CTN finding that use of
    mobilized peripheral blood stem cells rather than bone marrow
    substantially lowers the risk of graft-versus-host disease (an often
    fatal complication of BMT) has already affected practice and should
    lessen complications of BMT.
        The NHLBI is supporting resources such as the Production Assistance
    for Cellular Therapies program to facilitate laboratory and clinical
    studies of cellular therapies to enhance healing after tissue damage
    caused by myocardial infarction and some forms of lung disease. Use of
    mesenchymal stem cells to repair tissue without scarring is being
    tested in early-stage human trials, with some very encouraging results.
                                 rare diseases
        The NHLBI supports infrastructures--registries, clinical trial
    networks, and biorepositories--to enable research on rare diseases and
    on risk factors for more common diseases. For example, both sporadic
    and Marfan-associated thoracic aortic disease may have a common
    pathway, and a genetic cause of aortic aneurysms may be more prevalent
    than previously thought. The NHLBI is a leader in conducting clinical
    trials in pulmonary hypertension and idiopathic pulmonary fibrosis.
    Linkage of genetic and clinical data with a biorepository is enabling
    identification of factors influencing the development of congenital
    heart disease.
        Following promising studies in mice, the NHLBI is now completing a
    study of losartan, an FDA-approved antihypertensive drug, in Marfan
    syndrome. The NHLBI supported a clinical trial that showed rapamycin
    (Sirolimus) stabilized lung function, reduced symptoms, and improved
    quality of life in patients with lymphangioleiomyomatosis (LAM), a
    progressive cystic lung disease in women. NHLBI partnerships with
    patient advocacy organizations in the conduct of both trials
    facilitated their rapid enrollment and completion.
        Sickle cell disease remains an area of intensive focus for the
    NHLBI. A trial recently demonstrated that hydroxyurea, known to be an
    effective treatment for adults, is also safe and effective in very
    young children. In fiscal year 2013, the NHLBI plans to initiate
    Excellence in Hemoglobinopathy Research Awards to promote
    multidisciplinary basic and translational research and facilitate
    collaboration with clinical hematologists. The NHLBI has played a major
    role in a Department of Health and Human Services (HHS)-wide initiative
    to coordinate the research and healthcare delivery efforts of six HHS
    components to reduce the health burdens of hemoglobinopathies (sickle
    cell disease and thalassemia). The NHLBI is developing clinical
    practice guidelines to ensure that providers know the components of
    high-quality, evidence-based care for sickle cell disease.
                                 hemovigilance
        The NHLBI supports multiple studies, and works closely with the
    FDA, to ensure appropriate monitoring of the blood supply against
    potential threats. In 2010 and 2011, an NHLBI-led interagency group
    demonstrated that a xenotropic murine retrovirus (XMRV), which had been
    reported to be associated with chronic fatigue syndrome in some
    patients, did not pose a risk to the safety of the blood supply. NHLBI
    leadership ensured that this and other important health questions were
    quickly resolved.
                                     ______

    Prepared Statement of Paul A. Sieving, M.D., Ph.D., Director, National
                                 Eye Institute
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's budget request for the National Eye Institute
    (NEI) of the National Institutes of Health (NIH). The fiscal year 2013
    NEI budget of $693,015,000 includes a decrease of $8,861,000 less than
    the comparable fiscal year 2012 level of $701,876,000. 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.
                        clinical/translational research
        Gene Therapy.--In 2008, NEI-supported investigators reported
    results from a landmark phase I clinical trial of gene therapy in three
    patients with a blinding, early onset retinal disease, Leber congenital
    amaurosis (LCA), which is caused by a defect of the RPE65 gene.
    Treatment, consisting of injecting a viral vector to deliver normal
    copies of the RPE65 gene, was well tolerated, and there was objective
    evidence of modest visual improvement in all three study subjects. To
    date, 15 participants have been treated and all have experienced visual
    improvements. Recently published clinical trial results find that
    increasing the dose with a second injection safely expands the area of
    retina exposed to the treatment (RPE65-AAV). Responsiveness of light-
    sensitive photoreceptor cells near injection sites increased after
    treatment. Younger participants, when compared to older participants,
    did not experience greater visual improvements. In fact, the two
    participants with the greatest visual acuity gains were among the
    oldest in the study. The researchers speculated that the number and
    health of remaining photoreceptors matter more than patient age, as the
    rate of photoreceptor loss varies considerably among people with RPE65-
    deficient LCA. The finding suggests that careful evaluation of
    photoreceptor cell health is important in determining potential
    clinical trial participants. Because safety was the primary outcome of
    this trial, a conservative approach was taken that limited treatment to
    the eye with poorer vision. In the future, the researchers plan to seek
    further visual gains by administering three injections of RPE65-AAV and
    treating the better eye.
        A team of NEI investigators restored vision in a canine model of X-
    linked retinitis pigmentosa (XLRP) using a new gene therapy vector
    capable of transfecting both rod and cone cells. XLRP is a severe
    retinal disease that affects both rod and cone photoreceptor cells.
    Patients with XLRP experience night blindness as children and become
    blind by middle age. A common form of XLRP results from mutations in
    the retinitis pigmentosa GTPase regulator (RPGR) gene. Treatment
    restored lost photoreceptor cell structure and repaired photoreceptor
    cell connections to other retinal neurons that send visual signals to
    the brain. This study provides a clearer path to clinical trials for
    XLRP. In addition, gene therapy trials for age-related macular
    degeneration (AMD), choroideremia, Leber's hereditary optic neuropathy,
    Stargardt macular dystrophy (SMD), and Usher syndrome were launched
    this past year. Clinical trials for juvenile retinoschisis,
    achromatopsia, and retinitis pigmentosa are also planned. All of these
    trials were made possible by sustained NEI support to develop and
    refine gene therapy techniques.
        Stem Cell Therapies.--In January 2012 Advanced Cell Technologies
    published preliminary results of the first-ever clinical trials of a
    product derived from human embryonic stem cells (hESCs). These landmark
    clinical trials are evaluating hESC-derived retinal pigment epithelium
    (RPE) cells for the treatment of Stargardt's macular dystrophy (SMD)
    and age-related macular degeneration (AMD). In the two treated
    patients, there were no adverse events and both had modest but
    objective improvements in vision. The RPE is a highly specialized layer
    of cells adjoining the retina that support photoreceptor cell function.
    SMD and AMD are known to result from a diseased RPE.
                                    genetics
        NEI created the International AMD Genetics Consortium in 2010 to
    identify the remaining genetic risk variants for AMD. To increase the
    statistical power needed to identify genes that have small, yet
    significant contributions to AMD, the consortium is conducting a meta-
    analysis on 15 Genome Wide Association Studies (GWAS) representing more
    than 8,000 patients with AMD and 50,000 controls. In addition to
    verifying known genes, the consortium identified 19 new gene variants.
    The genes identified in these studies function in the immune system,
    cholesterol transport and metabolism, and formation and maintenance of
    connective tissue. This study provides a nearly complete picture of
    genetic heritability for AMD. NEI's effort to unite the international
    research community to share GWAS data sets made it possible to solve a
    common goal in our understanding of this blinding disease.
        In 2009, NEI established the NEI Glaucoma Human Genetics
    Collaboration (NEIGHBOR), a consortium of clinicians and geneticists at
    12 institutions throughout the United States dedicated to identifying
    the genetics of glaucoma. NEIGHBOR collected and sequenced 6,000 DNA
    samples and is the largest genetics study of glaucoma. Thus far,
    NEIGHBOR investigators identified a risk variant in the gene CDKNB2.
    This gene is thought to play a role in the development of the optic
    nerve head, where retinal ganglion cell axons, which degenerate in
    glaucoma, converge to form the optic nerve. NEI will make GWAS data
    from NEIGHBOR available to the vision research community for further
    evaluation in 2012.
                                  neuroscience
        In 2011, NEI awarded a grant to support Project Prakash, which
    combines an extraordinary scientific opportunity with a humanitarian
    mission. Understanding how the human brain learns to perceive objects
    remains a fundamental challenge in neuroscience. Project Prakash seeks
    to treat older children born with congenital cataracts and other eye
    disorders and then study how their visual function develops. Visual
    development normally takes place during infancy before children acquire
    language and can communicate what they are seeing. By treating older
    children who can fully communicate, Project Prakash will permit
    scientists to more directly address the nature of neuroplasticity and
    visual development. This study will also provide important clinical
    insights to inform visual rehabilitation. India accounts for nearly 30
    percent of the world's blindness. Many are poor children with treatable
    congenital eye disorders, but most never receive medical attention
    because they live in rural areas far from urban medical centers.
    Tragically, it is estimated that 60 percent of India's blind children
    die before reaching adulthood. Project Prakash is a unique opportunity
    to offer humanitarian medical aid while advancing the field of
    neuroscience.
                                     ______

      Prepared Statement of Martha J. Somerman, D.D.S., Ph.D., Director,
             National Institute of Dental and Craniofacial Research
        Mr. Chairman and members of the subcommittee: 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 2013 NIDCR budget of $408,212,000
    includes a decrease of $2,010,000 less than the comparable fiscal year
    2012 level of $410,222,000.
        Science long has served as one of the Nation's most essential
    economic engines. From the Human Genome Project to the Internet,
    scientists started with basic research questions that later propelled
    American entrepreneurship into creating previously unimaginable new
    markets. So what types of research now are advancing in the Nation's
    laboratories and clinics that might one day propel American industry
    and public health to new heights? Today, I offer a brief overview of
    NIDCR's investment and progress in a few key areas, and suggest their
    potential to enhance the dental, oral, and craniofacial health of
    millions of Americans.
                              chronic inflammation
        A great place to start is with a promising therapeutic approach
    that mimics the body's own signals to control inflammation and
    inflammatory pain. Inflammation is part of the immune system's normal
    response to infections and tissue injury. Without it, tissues would not
    heal. At some pre-programmed point, when the threat subsides, the
    response turns off and inflammation is resolved. For millions of
    people, however, the immune system's signals get crossed and
    inflammation is dangerously prolonged.
        An NIDCR grantee has developed promising candidate compounds based
    on the body's own inflammation-resolving molecules. The compounds have
    proven potent at reducing inflammation and inflammatory pain in animals
    without the adverse side effects of available analgesics. The plan is
    to move into human studies within the next year to evaluate their
    safety and efficacy in turning off the destructive inflammation
    occurring in periodontal disease. The hope is these compounds one day
    will provide a more effective approach to managing this widespread oral
    condition and, possibly, other chronic inflammatory conditions
    elsewhere in the body.
                                  chronic pain
        The Institute of Medicine reported in 2011 that more than 116
    million Americans suffer from chronic pain, with annual costs of
    approximately $600 million. The profound complexity of the body's
    processes for perceiving and responding to pain is a key factor
    contributing to the current inadequacies of chronic pain control and
    interventions to prevent the transition from acute to chronic pain. For
    the most part, chronic pain conditions and their molecular
    underpinnings remain poorly understood. This is changing. In late 2005,
    NIDCR began supporting the first-ever, large longitudinal clinical
    study of a chronic pain condition. It focuses on temporomandibular
    joint and muscle disorders (TMJDs), a common group of conditions that
    affect the area in and around the jaw joint and often overlap with
    other chronic pain conditions. Preliminary findings, reported in
    December 2011, identified mutations in genes linked to chronic TMJD,
    including genes associated with stress, psychological well-being, and
    inflammation. Building on this work, NIDCR places a high priority on
    supporting research on the genetics of chronic orofacial pain, with a
    focus on identifying gene variants that influence pain perception,
    their interactions with environmental triggers, and behavioral
    responses to pain.
        In other work, NIDCR-supported behavioral scientists are providing
    insight into factors influencing providers' treatment decisions for
    chronic pain. They found that decisions tend to be influenced by
    individual characteristics of patients, such as gender and race or
    ethnicity, which are extraneous to the pain condition itself. These
    results are leading to new ways of training providers, helping to focus
    treatment decisions on more clinically relevant factors.
                                  oral cancer
        Personalized healthcare offers tremendous promise for improving the
    lives of people diagnosed with cancer, as well as other diseases. Among
    new cancer occurrences, oral and pharyngeal cancer (OPC) is the eighth
    most common among U.S. men and seventh among African-American men,
    affecting more than 30,000 people each year. Since 2009, NIDCR has
    invested in the Oral Cancer Genome Project, which aims to define the
    genetic changes driving development of oral and pharyngeal tumors. As
    part of this project, NIDCR-supported researchers employed next-
    generation sequencing technology to yield one of the most comprehensive
    analyses yet of the genetics underlying head and neck squamous cell
    carcinoma (HNSCC), the most common of OPCs. The genomics data provide
    evidence that HNSCC involves dozens of distinct molecular conditions,
    each driven by a unique pattern of gene alterations. NIDCR will support
    work to validate the research findings, which could help identify and
    reclassify these tumors based on their individual specific molecular
    characteristics--a key first step in establishing personalized
    therapies.
        Another important result from the Oral Cancer Genome Project was
    the confirmation that head and neck tumors associated with human
    papillomavirus (HPV) infection have their own distinct genetic profile.
    HPV is associated with a subset of OPCs that increased by 225 percent
    from 1998 to 2004. NIDCR supports research to understand the natural
    history of this growing public health issue.
        The Institute also supports research to improve the survival rate
    for HNSCC. In a significant advance, scientists in NIDCR's laboratories
    demonstrated that metformin, a widely used anti-diabetes drug, prevents
    development and progression of oral squamous cell carcinomas in mice.
    NIDCR is initiating clinical studies to determine its effectiveness in
    humans, opening a new approach to treating this deadly cancer.
                            craniofacial development
        Cleft lip and cleft palate (CLP) are among the most common of all
    birth defects, occurring in 1 of 700 live births in the United States,
    or 7,000 babies per year. Treatment is expensive and difficult,
    requiring multiple surgeries, orthodontics, and speech therapy over a
    period of years. NIDCR takes a multi-pronged approach to these
    devastating conditions, incorporating basic research with prevention,
    treatment, and post-treatment research. The goal is fewer children born
    with CLP, better outcomes for those afflicted with the disorders, and
    less cost and stress for families.
        Through genome-wide studies, NIDCR-supported investigators defined
    several genetic and environmental CLP risk factors. This work set the
    stage for a researcher co-funded by NIDCR and NICHD to develop a mouse
    model that closely mimics CLP. The same researcher demonstrated that
    restoring function in one molecule resulted in complete correction of a
    cleft lip defect in mouse embryos still developing in utero.
        NIDCR-funded investigators have found that many children born with
    CLP have impaired cognitive functioning that goes undetected until the
    child is older and remediation is more difficult. Early screening for
    cognitive deficits in children with CLP may help them reach their full
    potential through timely, tailored instruction. Research on early
    screening technologies is underway. In addition, NIDCR continues to
    fund research to optimize care for children with clefting disorders,
    including clinical studies comparing the cost and effectiveness of
    intervention procedures.
        NIDCR's investment in small business innovation research (SBIR) and
    small business technology transfer (STTR) programs is sparking economic
    activity and improving outcomes for people with craniofacial defects
    such as CLP. An NIDCR grantee developed surgical simulation software to
    help clinicians plan and optimize craniofacial surgery and provide a 3D
    prediction of patients' outcomes. Another grantee leveraged SBIR/STTR
    investments to patent a minimally invasive surgical instrument system
    to aid periodontal surgery, often needed by people with CLP.
                              evidence-based care
        NIDCR efforts to strengthen the knowledge base for dental practice
    will accelerate in April 2012 with the establishment of a National
    Dental Practice-Based Research Network. Building on the success of
    precursor regional networks, the national network will leverage the
    power of large numbers of practitioners to propose and perform clinical
    studies on topics important to dentistry. Because the research is
    conducted in the real-world environment of dental practice, dentists
    are more likely to accept and adopt the findings. The expected result
    is nothing short of a transformation of dental practice--one that will
    result in more individualized and evidence-based treatment and
    prevention, to the benefit of millions of Americans.
                                     ______

       Prepared Statement of Lawrence A. Tabak, D.D.S., Ph.D., Principal
                 Deputy Director, National Institutes of Health
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's budget request for the Office of the Director
    (OD) of the National Institutes of Health (NIH). The fiscal year 2013
    OD budget of $1,429,161,000 includes a decrease of $28,220,000 less
    than the comparable fiscal year 2012 level of $1,457,381,000.
        The OD promotes and fosters NIH research and research training
    efforts in the prevention and treatment of disease through the policy
    oversight of both the extramural grant and contract award functions and
    the Intramural Research program. The OD stimulates specific areas of
    research to complement the ongoing efforts of the Institutes and
    Centers through the activities of several cross-cutting program
    offices. The OD also develops policies in response to emerging
    scientific opportunities employing ethical and legal considerations;
    provides oversight of peer review policies; coordinates information
    technology across the agency; and, coordinates the communication of
    health information to the public and scientific communities.
        The fiscal year 2013 request will also support activities managed
    by the OD's operational offices. OD operations is comprised of several
    OD offices that provide advice to the NIH Director, policy direction
    and oversight to the NIH research community and administer centralized
    support services essential to the NIH mission.
        The functions and initiatives of the OD's research offices, also
    known as Program, Projects and Activities, are described in detail as
    follows:
     division of program coordination, planning, and strategic initiatives
        Division of Program Coordination, Planning, and Strategic
    Initiatives (DPCPSI) is the home for cross-cutting offices that support
    research in areas of emerging scientific opportunity, rising public
    health challenges, or knowledge gaps that deserve special emphasis.
    DPCPSI's scope expanded in fiscal year 2012 with the creation of a new
    Office of Research Infrastructure Programs (ORIP) which supports
    research resources that serve grantees across the NIH. In addition to
    ORIP, there are five offices that are described. The fiscal year 2013
    budget for DPCPSI, Office of the Director and the Office of Strategic
    Coordination is $8,116,000.
                   office of research infrastructure programs
        Office of Research Infrastructure Programs (ORIP) supports research
    infrastructure, research-related programs, and NIH's science education
    efforts. Within ORIP, the Division of Comparative Medicine provides
    scientists with essential resources--including specialized disease-
    model laboratory animals, research facilities, training, and other
    tools--that enable research funded by all NIH ICs. The Shared and High
    End Instrumentation programs provide support for the purchase of
    research equipment, ranging in cost from $100,000 to $2,000,000. The
    Animal Facilities Improvement program provides funds to modernize
    animal facilities that support biomedical and behavioral research. ORIP
    also currently monitors more than 350 construction awards that have not
    yet reached their 20-year milestone and 147 ARRA awards for 10 years.
    The ORIP budget for fiscal year 2013 is $283,698,000. The Science
    Education Partnership Awards (SEPA) program encourages pre K-12
    projects that support diversity in the research workforce as well as
    museum exhibits for students, teachers, and the public. In fiscal year
    2013, the budget for SEPAs is $20,282,000. The Office of Science
    Education (OSE) develops science education programs, instructional
    materials, and career resources that serve our Nation's science
    teachers, their students, and the public. The fiscal year 2013 budget
    for OSE is $3,980,000.
                            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, multidisciplinary, 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 2013 budget for OAR is $63,802,000.
               office of behavioral and social sciences research
        The Office of Behavioral and Social Sciences Research (OBSSR) was
    established by the Congress to stimulate behavioral and social science
    research at NIH and to integrate it more fully into the NIH research
    enterprise. To address the contribution of behavior to health and
    disease, OBSSR 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 2013 budget for OBSSR is $27,001,000.
                      office of research on women's health
        The mission of the Office of Research on Women's Health (ORWH) is
    to advance NIH research on women's health. This is accomplished by
    catalyzing innovative research addressing the gaps in knowledge
    regarding diseases and conditions that affect women and in partnership
    with the ICs through the implementation of the NIH strategic plan for
    women's health and sex differences research which serves as a framework
    for interdisciplinary scientific approaches. ORWH promotes the
    recruitment, retention, reentry, and sustained advancement of women in
    biomedical careers and continues to lead efforts to ensure adherence to
    policies for the inclusion of women and minorities in NIH clinical
    research. The fiscal year 2013 budget for ORWH is $42,324,000.
                          office of disease prevention
        The mission of the Office of Disease Prevention (ODP) is to foster,
    coordinate, and assess research in disease prevention and health
    promotion at the NIH. ODP collaborates with other Federal and
    international organizations, academic institutions, and the private
    sector in formulating new research initiatives and policies to improve
    public health. The fiscal year 2013 budget for ODP is $6,065,000. The
    Office of Dietary Supplements (ODS) is within the ODP organizational
    structure. ODS strengthens knowledge and understanding of dietary
    supplements by evaluating scientific information, stimulating and
    supporting research, disseminating research results, and educating the
    public. The fiscal year 2013 budget for ODS is $27,717,000.
              office of strategic coordination and the common fund
        Office of Strategic Coordination (OSC) leads strategic planning for
    and centrally manages Common Fund (CF)-supported programs. OSC works
    with staff across the NIH in CF program development and implementation.
    The NIH CF was created by the 2006 NIH Reform Act which codified the
    approach of the NIH Roadmap for Medical Research to support cross-
    cutting, trans-NIH programs that require participation by at least two
    NIH ICs or would otherwise benefit from strategic planning and
    coordination. The CF provides limited-term funding for goal-driven,
    coordinated research networks to generate data, solve technological
    problems, and/or pilot resources and tools that will stimulate the
    broader research community. The fiscal year 2013 budget for the Common
    Fund is $544,930,000.
               intramural loan repayment and scholarship programs
        The NIH Intramural Loan Repayment and Scholarship Programs (ILRSP)
    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 Undergraduate Scholarship Programs (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
    2013 budget for ILRSP is $7,393,000.
                                     ______

        Prepared Statement of Nora D. Volkow, M.D., Director, National
                            Institute on Drug Abuse
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's budget request for the National Institute on
    Drug Abuse (NIDA) of the National Institutes of Health (NIH). The
    fiscal year 2013 NIDA budget of $1,054,001,000 includes an increase of
    $1,887,000 more than the comparable fiscal year 2012 level of
    $1,052,114,000.
        The President's budget for fiscal year 2013, which has just been
    released, offers a timely opportunity to review NIDA's research
    priorities for bringing the power of science to bear on drug abuse and
    addiction and reducing their burden on the public's health.
                           a technological revolution
        The technologies of biomedical research are advancing at
    unprecedented rates ushering in scientific breakthroughs that are
    providing a deeper understanding of human genetics, chemistry, and
    brain circuitry. The emerging picture has the potential to transform
    how we prevent and treat drug abuse and addiction and its health
    consequences, and involves new techniques for capturing and analyzing
    vast and diverse datasets on everything from genetics to neuroimaging
    to social networks.
        NIDA is poised to harness complete genome and ``deep'' sequencing
    tools and a growing portfolio of epigenetic initiatives to elucidate
    how biological processes and environmental factors like chronic stress
    and drug exposure can alter the expression of genes that influence
    brain organization and function and the expression (or not) of
    substance use disorders. For example, the recent finding in an animal
    model that nicotine can trigger epigenetic processes that make the
    brain more susceptible to the effects of cocaine could have important
    policy and practice implications, if it occurs also in humans.
        Epigenetic research is also shedding critical new light into the
    mechanisms that govern the disease progression of HIV, the spread of
    which is closely intertwined with injection and noninjection drug-use
    behaviors. A cure for HIV has been elusive because the virus is able to
    ``hide'' in a latent form in resting CD4-T cells. This allows HIV to
    persist for years, even with prolonged exposure to antiretroviral
    drugs. Understanding this ``latency'' effect could enable researchers
    to reactivate the virus and use current or future therapies to rid the
    body of it altogether.
        The overlaying of neuroimaging data will further accelerate
    discovery by linking molecular and cellular data with human behavior.
    For example, a new functional magnetic resonance imaging (fMRI)-based
    approach can probe the resting brain (i.e., one not performing any
    specific task) to illuminate circuit-level functions that may prompt
    behavioral responses, including those related to diseased states or
    vulnerability. Individual differences found in these images could
    provide useful biomarkers (neural signatures) of illness risk, course,
    and treatment response.
        The amount and diversity of data being generated by genetic,
    epigenetic, and imaging studies call for harmonization standards that
    will allow data integration across laboratories. Thus, our continuing
    efforts to train the next generation of addiction researchers must now
    take into account the urgent need for a new cadre of interdisciplinary
    scientists capable of developing modern analytical tools for
    integrating and managing large pooled data sets and for modeling and
    analyzing complexity.
                            therapeutics development
        To help those already suffering from addiction, we need to expand
    the tools available to treat substance use disorders and their health
    consequences. To this end, NIDA will continue to invest in the
    development of addiction medications and to seek public-private
    partnerships with pharmaceutical companies still reluctant to play an
    active role due to perceived stigma and financial disincentives.
    Success demands both adaptable and novel approaches.
        Among the ``low-hanging fruit'' are already-approved drugs, which
    NIDA is seeking to repurpose for addiction indications, saving enormous
    amounts of research and development time and cost. Notable in this
    category are: buspirone, which blocks action at the dopamine (D3)
    receptor (among its other effects) and may be useful in treating
    stimulant addiction, based on well-established findings in the animal
    literature; and cytisine, which acts on nicotinic receptors and has
    recently been shown to be about 3.5 times more effective than placebo
    in a smoking cessation trial.
        NIDA also continues to support research to increase the
    effectiveness of various vaccines being tested against nicotine,
    cocaine, heroin, and methamphetamine. Efforts aim to increase these
    vaccines' immunogenicity--that is, their ability to stimulate the
    production of antibodies capable of blocking a drug's entry into the
    brain.
        Finally, NIDA is actively pursuing a strategy that involves the use
    of medication combinations, an approach that has proven effective for
    treating many diseases (e.g., HIV, 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) has shown promise in treating withdrawal symptoms (which can
    trigger relapse) among marijuana-addicted individuals.
             improving public healthcare: delivery and performance
        NIDA will harness every opportunity to translate scientific
    knowledge to improve strategies for combating drug abuse and addiction.
    This commitment includes engaging physicians as ``frontline''
    responders and providing them with tested tools, including a Web-based
    screening tool that generates specific 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 routine medical care, which will enable
    better healthcare decisions and outcomes.
        NIDA will also capitalize on the Affordable Care Act to study how
    innovations in service delivery, organization, and financing can
    improve access to and use of effective prevention and treatment
    interventions. Because so few people access treatment, coupled with the
    more than $600 billion that drug abuse and addiction cost society each
    year, even a marginal increase in treatment use and retention could
    have a sizeable public health impact--for individuals, families, and
    society as a whole.
        To help get evidence-based treatments to providers in a variety of
    settings, NIDA uses collaborative research infrastructures designed to
    deploy proven strategies rapidly and effectively. For example, NIDA's
    Criminal Justice-Drug Abuse Treatment Studies (CJ-DATS) network
    promotes multilevel collaborations to test proven treatment models in
    the criminal justice system, disproportionately affected by both drug
    abuse and HIV. One example, called ``Seek, Test, Treat, and Retain,''
    expands access to HIV testing and treatment, ultimately reducing HIV
    spread.
                           staying ahead of the curve
        NIDA continues to monitor drug abuse trends across different
    populations. Particularly worrisome are the trends pertaining to
    marijuana use, on the rise after about a decade of decline; the
    emergence of an ever-evolving array of synthetic drugs (e.g., spice and
    bath salts) that are sending users to emergency rooms nationwide; and
    the continued high rates of prescription drug abuse, which have
    resulted in a quadrupling in unintentional overdose deaths in this
    country since 1999. NIDA is addressing all these problems through both
    broad-based prevention efforts and targeted initiatives.
        Prescription drug abuse is one such targeted area that demands a
    multifaceted approach. NIDA's long-term strategy to help reverse this
    trend includes:
      --research to understand the factors that influence an individual's
            risk, treat those already addicted, and develop pain
            medications with reduced abuse potential;
      --physician education to improve pain treatment while minimizing
            prescription drug abuse; and
      --community engagement exemplified by NIDA's leadership of a
            multiagency effort to create a Surgeon General Call to Action
            to reduce prescription drug abuse among youth.
        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 and develop and disseminate more effective
    strategies to prevent and treat drug abuse and addiction.
                                     ______

       Prepared Statement of Kenneth R. Warren, Ph.D., Acting Director,
               National Institute on Alcohol Abuse and Alcoholism
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's budget request for the National Institute on
    Alcohol Abuse and Alcoholism (NIAAA) of the National Institutes of
    Health (NIH). The fiscal year 2013 NIAAA budget of $457,104,000 for the
    NIAAA reflects a decrease of $1,868,000 less than the comparable fiscal
    year 2012 level of $458,972,000.
                              scope of the problem
        The Centers for Disease Control and Prevention (CDC) ranks alcohol
    as the third leading cause of preventable death in the United States,
    and the World Health Organization lists alcohol as one of the top 10
    causes of Disability Adjusted Life Years in the United States. And,
    according to a new study by the CDC, the cost of excessive alcohol
    consumption in the United States reached $223.5 billion in 2006.
        On a more personal level, I would venture that each of you knows
    someone who has experienced an alcohol-related problem. It could be a
    child who has difficulty in school as a result of prenatal alcohol
    exposure. Perhaps you have a relative or colleague who is one of the
    almost 18 million people who suffer from alcohol abuse or dependence.
    Alternatively, your son or daughter may be one of the more than 40
    percent of college students who binge drink, many of whom experience
    blackouts, not remembering where they were, what they did, or with
    whom. You may know one of the 97,000 college students to experience
    alcohol-related sexual assault or heard the frustration of a college
    student trying to study while the alcohol-fueled party raged in the
    room next door. Many of us also have friends that grew up in a
    household where alcohol was a problem; in fact, 1 in 10 children in the
    United States grow up under such circumstances. Clearly, alcohol
    related problems are not reserved for the middle-aged, nor are they
    only experienced by those who drink.
                                    research
        NIAAA supported research is advancing our understanding of alcohol-
    related problems across the lifespan. By translating this research into
    new and better prevention and treatment approaches we have the ability
    to enhance the well-being of individuals, their families, and society-
    at-large.
        Much of what we have learned about alcohol use and alcohol use
    disorders in the U.S. population comes from analyses of NIAAA's
    National Epidemiologic Survey on Alcohol and Related Conditions
    (NESARC). Beginning in 2012, the third wave of NESARC will collect DNA
    samples in addition to detailed information on alcohol use, alcohol use
    disorders, and related physical and mental disabilities from an
    estimated 46,000 participants. This rich resource of genetic and other
    data will enable future studies comparing whole genome sequences to
    identify interactions between environmental and genetic risk factors
    that are associated with harmful alcohol use patterns and their
    associated disabilities. Survey data on the distribution of alcohol-
    related problems and treatment utilization will inform treatment
    delivery systems to better help those in need of services.
        Research on individuals at different stages of life and at
    different points in the trajectory of their alcohol use and related
    problems underscores the importance of early identification and
    intervention in reducing future health problems. This is true for:
      --children exposed to alcohol in utero;
      --children and adolescents using alcohol and/or at high risk for
            alcohol-related problems; and
      --individuals who exceed the low risk drinking guidelines, including
            those with alcohol dependence.
        One of the barriers to intervening early with children with fetal
    alcohol spectrum disorders is identification of affected children given
    the wide range of physical, behavioral, and cognitive effects that may
    result from prenatal alcohol exposure. Ongoing studies are
    demonstrating the utility of fetal ultrasound and 3D facial image
    analysis for earlier and improved recognition of affected children.
    Alcohol has also been implicated in sudden infant death syndrome and
    stillbirth. In collaboration with National Institute of Child Health
    and Human Development and NIDCD, NIAAA is supporting studies to
    investigate this association and the role other environmental and
    maternal factors may play.
        Children and adolescents who drink are also vulnerable to a number
    of adverse outcomes. These range from immediate consequences such as
    academic and social problems, injuries, and death, to longer-term
    consequences including increased risk for alcohol dependence.
    Nevertheless, alcohol use increases dramatically during adolescence.
    Given the range and severity of consequences associated with underage
    drinking and the prevalence of drinking and binge drinking, routine
    screening and intervention for alcohol use in young people is critical.
    Yet many pediatricians and family practitioners cite a lack of time, a
    lack of familiarity with screening tools, and a lack of confidence in
    their alcohol management skills as barriers to screening. NIAAA
    designed Alcohol Screening and Brief Intervention for Youth: A
    Practitioner's Guide to help clinicians conduct fast, effective alcohol
    screens and brief interventions. The guide contains a new two-question
    screen and presents the first youth alcohol risk estimator chart, which
    combines information about a patient's age and drinking frequency to
    give a clinician a broad indication of the patient's chances for having
    alcohol-related problems. Coupled with what a clinician already knows
    about a patient, the risk estimator can help determine the depth and
    content of the clinician's response. The guide outlines different
    levels of intervention and presents an overview of brief motivational
    interviewing, an interactive, youth-friendly intervention that is
    considered to have the best potential effectiveness for the adolescent
    population. Importantly, the guide has been endorsed and promoted by
    the American Academy of Pediatrics.
        In addition to the acute consequences of underage drinking, there
    is increasing evidence that alcohol use during adolescence may result
    in enduring functional and structural changes in the brain. Studies to
    date, however, cannot differentiate between anomalies which resulted
    from adolescent alcohol exposure and those which predated it. NIAAA is
    embarking on a new multi-site initiative enlisting children and young
    adolescents before they begin to use alcohol and following them through
    adolescence. These studies will use advanced neuroimaging technology as
    well as neuropsychological and behavioral measures to assess alcohol's
    effects on brain development and associated cognitive, affective, and
    behavioral processes. NIAAA will continue to support complementary
    basic animal research on the effects of adolescent alcohol exposure on
    subsequent brain function and behavior into adulthood. Collectively
    these studies will provide a more complete picture of alcohol's effects
    on the developing brain and potentially provide insight into the
    association between early alcohol use and later alcohol dependence at
    the molecular and structural levels.
        NIAAA continues to promote screening and brief intervention for
    adults and encourages inclusion of it in electronic health records. The
    primary goal is to identify and address high-risk drinking behavior
    early, including advising individuals who do not meet criteria for
    alcohol dependence. 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.
        For those who continue to drink excessively, especially long term,
    the risk of alcoholic liver disease becomes a significant concern. In
    fact, 40 percent of patients with severe alcoholic hepatitis, a serious
    and potentially treatable form of alcoholic liver disease, die within 6
    months of the onset of the clinical syndrome. NIAAA has launched a new
    initiative to foster close collaboration between basic scientists and
    clinicians expediting the translation of emerging findings into more
    effective treatment strategies. Of particular interest is the
    connection between the gut, liver, and brain and how perturbations to
    one organ may aggravate the disease state in another. NIAAA is
    supporting the integration of research to better understand the basic
    biological mechanisms that underlie the disease and the individual
    factors that contribute to disease susceptibility in clinical studies
    that will test new and improved strategies. The goal is to decrease the
    high mortality and morbidity associated with alcoholic hepatitis.
        Developing effective treatments for alcohol dependence remains a
    high priority for NIAAA. Preliminary studies suggest that the smoking
    cessation drug varenicline (Chantix) could reduce drinking in alcohol-
    dependent smokers. NIAAA is currently conducting a larger clinical
    trial with alcohol dependent smokers and nonsmokers to assess safety
    and determine if varenicline reduces drinking in either group.
                                     ______

      Prepared Statement of Jack Whitescarver, Ph.D., Director, Office of
                                 AIDS Research
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the fiscal year 2013 President's budget request for the trans-
    National Institutes of Health (NIH) AIDS research program, which is
    $3,074,921,000. This amount is the same as the fiscal year 2012 enacted
    level. It includes the total trans-NIH support for intramural and
    extramural research for basic, clinical, behavioral, social science,
    and translational research on HIV/AIDS and the wide spectrum of AIDS-
    associated malignancies, opportunistic infections, co-infections, and
    clinical complications; as well as research management support;
    research centers; and training.
        Within the total, the Office of AIDS Research (OAR) has provided
    increases to high-priority prevention research in the areas of
    microbicides, vaccines, behavioral and social science, and treatment as
    prevention research, as well as to etiology and pathogenesis research
    that provides the essential basic science foundation not only for AIDS-
    related research but for other related diseases and conditions as well.
    In order to provide those increases, OAR has reduced and redirected
    funds from other areas, including natural history and epidemiology,
    therapeutics, and training and infrastructure support.
                               the aids pandemic
        The HIV/AIDS epidemic continues to expand. UNAIDS estimates that in
    2010, more than 34 million people were living with HIV/AIDS; 2.7
    million were newly infected; and 1.8 million people died of AIDS-
    related illnesses. In the United States, the Centers for Disease
    Control and Prevention (CDC) estimates that more than 1.2 million
    people are HIV-infected; and someone is infected with HIV every 9\1/2\
    minutes. AIDS disproportionately affects 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 older than the age of 50. The AIDS
    pandemic has devastating consequences around the world in virtually
    every sector of society. Further research to improve prevention and
    treatment is urgently needed. Advances in prevention and treatment also
    will have extensive economic benefits.
     30 years of extraordinary national institutes of health aids research
                                accomplishments
        HIV, the virus that causes AIDS, is one of the most complex
    pathogens to affect human health and challenge biomedical research. In
    the three decades since AIDS was first recognized, NIH has established
    the world's leading AIDS research program. This investment in HIV
    research has transformed the disease from a mysterious and uniformly
    fatal infection into one that can be accurately diagnosed and
    effectively managed with appropriate treatment. A recent study
    estimated that 14.4 million life-years have been gained among adults
    around the world since 1995 as a result of AIDS therapies developed
    through NIH-funded research.
        NIH research has resulted in landmark advances that have led to:
      --the co-discovery of HIV, the virus that causes AIDS;
      --development of the first blood test for the disease, which has
            allowed diagnosis of infection as well as ensured the safety of
            the blood supply;
      --the critical discovery of key targets to develop Antiretroviral
            Therapies (ART) and multi-drug regimens that have resulted in
            improved life expectancy for those with access to and who can
            tolerate these drugs;
      --the development of treatments for many HIV-associated coinfections,
            comorbidities, malignancies, and clinical manifestations, with
            benefits for patients also suffering from those other diseases;
      --groundbreaking strategies for the prevention of mother-to-child
            transmission, which have resulted in dramatic decreases in
            perinatal HIV in the United States;
      --demonstration that the use of male circumcision can reduce the risk
            of HIV acquisition;
      --the first step in proving the concept that a vaccine to prevent HIV
            infection is feasible; and discovery of two potent human
            antibodies that can stop more than 90 percent of known global
            HIV strains from infecting human cells in the laboratory;
      --demonstration of the first proof of concept for the feasibility of
            a microbicide gel capable of preventing HIV transmission;
      --demonstration that the use of therapy by infected individuals can
            dramatically reduce transmission to an uninfected partner;
      --groundbreaking research regarding Pre-Exposure Prophylaxis (PrEP),
            examining whether the use of antiretroviral treatment regimens
            by some groups of high-risk uninfected individuals could reduce
            the risk of HIV acquisition;
      --discovery that genetic variants may play a role in protecting some
            individuals, known as ``elite controllers,'' who have been
            exposed to HIV over an extended period, from developing
            symptoms and enabling them to control the infection without
            therapy;
      --critical basic science discoveries that continue to provide the
            foundation for novel research; and
      --progress in both basic and treatment research efforts aimed at
            eliminating viral reservoirs in the body, which is, for the
            first time, leading scientists to design and conduct research
            aimed at a cure.
                extraordinary opportunities for fiscal year 2013
        Advances made by NIH investigators have opened doors for new and
    exciting research opportunities to answer key scientific questions that
    remain in the search for strategies to prevent and treat HIV infection
    both in the United States and around the world, and represent the
    building blocks for the development of the OAR Trans-NIH AIDS research
    budget:
          Investing in Basic Research.--OAR will increase support for basic
            research that will underpin further development of critically
            needed vaccines and microbicides.
          Encouraging New Investigators and New Ideas.--OAR will provide
            additional support for innovative multi-disciplinary research
            and international collaborations to develop novel approaches
            and strategies to eliminate viral reservoirs that could lead
            toward a cure for HIV.
          Accelerating Discovery Through Technology.--OAR will increase
            funds to support critical studies in the area of therapeutics
            as a method to prevent infection, including treatment to
            prevent HIV infection after exposure; Pre-Exposure Prophylaxis
            (PrEP); a potential prevention strategy known as ``test and
            treat,'' to determine whether a community-wide testing program
            with treatment can decrease the overall rate of new HIV
            infections; and improved strategies to prevent mother-to-child
            transmission. A key priority is to evaluate prevention
            interventions that can be used in combination in different
            populations, including adolescents and older individuals.
          Improving Disease Outcomes.--OAR will target funding for NIH
            research focused on developing better, less toxic treatments
            and investigating how genetic determinants, sex, gender, race,
            age, nutritional status, treatment during pregnancy, and other
            factors interact to affect treatment success or failure and/or
            disease progression. Studies will address the increased
            incidence of malignancies, cardiovascular and metabolic
            complications, and premature aging associated with long-term
            HIV disease and ART.
          Advancing Translational Sciences.--OAR will ensure adequate
            resources for research on the feasibility, effectiveness, and
            sustainability required to scale-up interventions from a
            structured behavioral or clinical study to a broader ``real
            world'' setting.
          global impact of national institutes of health aids research
        Research to address the global pandemic is essential. AIDS research
    represents the largest component of the total NIH global research
    investment. Since the early days of the epidemic, NIH has maintained a
    strong international AIDS research portfolio that has grown to include
    projects in approximately 100 countries around the world. NIH AIDS
    research studies are designed so that the results are relevant for both
    the host nation and the United States. These research programs also
    enhance research infrastructure, and training of in-country scientists
    and healthcare providers. New collaborations have been designed to
    improve both medical and nursing education as a mechanism to build a
    cadre of global health leaders. Most of these grants and contracts are
    awarded to U.S.-based investigators to conduct research in
    collaboration with in-country scientists; some are awarded directly to
    investigators in international scientific or medical institutions.
                  benefits of aids research to other diseases
        It is essential to point out that AIDS research also pays extensive
    dividends in many other areas of biomedical research, including in the
    prevention, diagnosis and treatment of many other diseases. It deepens
    our understanding of immunology, virology, microbiology, molecular
    biology, and genetics. AIDS research is helping to unravel the
    mysteries surrounding so many other diseases because of the pace of
    discovery and because of the unique nature of HIV, i.e., the way the
    virus enters a cell, causes infection, affects every organ system, and
    unleashes a myriad of opportunistic infections, co-morbidities,
    cancers, and other complications. AIDS research continues to make
    discoveries that can be applied to other infectious, malignant,
    neurologic, autoimmune, and metabolic diseases, as well as complex
    issues of aging and dementia, AIDS treatment research has led to more
    effective drugs for multiple bacterial, mycobacterial, and fungal
    diseases and fostered significant improvements in drug design
    technologies. AIDS research has led to the development of new models to
    test treatments for other diseases in faster, more efficient and more
    inclusive clinical trials. Drugs developed to prevent and treat AIDS-
    associated opportunistic infections also now benefit patients
    undergoing cancer chemotherapy and patients receiving anti-transplant
    rejection therapy. AIDS research also has advanced understanding of the
    relationship between viruses and cancer. New investments in AIDS
    research will continue to fuel biomedical advances and breakthroughs
    that will have profound benefits far beyond the AIDS pandemic.
                                    summary
        Despite these advances, however, AIDS is not over, 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 to search for solutions to
    prevent, treat, and eventually cure AIDS.

        Senator Harkin. Thank you very much again, Dr. Collins, for
    a very provocative statement. I mean ``provocative'' in a good
    way, provoking thinking.

                            IMPACT OF SEQUESTRATION

        Senator Harkin. We'll start a round of 5-minute questions
    now.
        First, Dr. Collins, I'd like to start by asking about the
    threat of sequestration.
        Under the Budget Control Act of 2011, funding for virtually
    all Federal programs face a possible across-the-board cut in
    January. So we could approve our appropriations bill later this
    year, and then find that virtually every program will be cut in
    January 2013.
        Now CBO has estimated, as I said in my opening statement, a
    7.8-percent cut. Other observers, such as the Center on Budget
    and Policy Priorities, think the cuts could be even larger, 9.1
    percent. But for the sake of discussion, we'll go with CBO's
    numbers.
        Could you just give us a thumbnail sketch of what that
    would mean for NIH? I mentioned earlier, I think in my
    statement, about the number of cuts that would come because of
    that it was estimated that the number of grants would shrink by
    more than 1,600 in 2014, by more than 16,000 over a decade.
        Just gives us an idea of what that would mean in terms of
    overall NIH performance.
        Dr. Collins. Senator, I appreciate the question. It is a
    very serious one.
        We also heard this estimate from the CBO, that if the
    sequesters were to kick in on January 2013, that NIH would
    expect to lose 7.8 percent of the budget, about $2.4 billion.
    That would, of course, happen with the fiscal year already 3
    months along. The estimate that has been put forward by an
    analysis would result in roughly 2,300 grants that we would not
    be able to award in fiscal year 2013 that we otherwise would've
    expected to.
        That represents almost a quarter of our new and competing
    grants. That would result in success rates for applicants who
    come in with new applications or competing ones falling to
    historically low levels, and it would be devastating for many
    investigators who are seeking to continue programs that they
    have had funded in the past and are back for their competing
    renewal or who are starting things that are entirely new.
        And I think the burden would hit particularly heavily upon
    first-time investigators who are seeking to get their programs
    up and going. And upon learning of something of this sort, what
    is already a considerable sense of anxiety in that cohort, who
    are our future, would only go up.
        This would have across-the-board implications in terms of
    both basic and clinical science. We would, of course, attempt
    to try to prioritize those things that are most critical. But
    there's no question that such things as an influenza vaccine,
    which Dr. Fauci can tell you much more about, in terms of a
    universal vaccine, would be slowed down; that efforts in cancer
    research would be slowed down; that the common fund, also a
    component of the NIH budget where we have a lot of our venture
    capital space, we would not be able to start new programs, such
    as one focused on how to bring together cellphone technology
    and prevention in health, which is a very exciting new area.
        All of those things would be put at great risk by this kind
    of outcome.

                  NATIONAL CANCER INSTITUTE BUDGET RESTRAINTS

        Senator Harkin. Thank you, Dr. Collins.
        And, Dr. Varmus, even if we can avoid sequestration, the
    budget is likely to remain tight. You've been managing the NCI
    with small or no increase since your return.
        What strategies have you found or do you plan that will
    allow you to continue to make progress against cancer with
    these tight budgets?
        Dr. Varmus. Thank you, Senator.
        Well, we've done several things to try to cope with the
    tight budgets. I can't print money, so that would be the ideal
    solution. But we have been, for example, looking very carefully
    at grants that get lower-priority scores, to see if there are
    grants that meet certain high-priority topics to make sure
    those get funded. We've been reorganizing our clinical trials
    cooperative groups to be sure they operate effectively and are
    answering deep scientific questions.
        As you've heard in Mr. Shelby's opening statement, we have
    started a new program that emphasizes the bringing together of
    the scientific community to help define the great unanswered
    questions in cancer research, the so-called provocative
    questions, the initiative that solicited more than 750
    applications to study these deeper questions and empower the
    scientific community to help us define what needs to be
    answered in the future.
        We have the ability to act on our new conception of what
    the genetic underpinnings of cancer are through the
    collaborative project we undertake with the Genome Institute on
    the cancer genome atlas.
        All of these things are helping us, but, of course, these
    strategies don't solve the underlying problem of having
    adequate resources to support science, which costs real money.
        Senator Harkin. Sure.
        Well, I am about out. Senator Shelby, I want to make sure
    everybody gets at least one round of questions.
        Senator Shelby.

                                OBESITY EPIDEMIC

        Senator Shelby. Thank you, Mr. Chairman.
        More than one-third of U.S. adults, as everybody at the
    table knows, are obese. The Deep South, my area of the country,
    has the highest obesity rate in the country with 6 out of 7
    States having an obese population higher than 30 percent.
        Obesity is most prevalent in racial and ethnic minorities,
    low-income populations, and those who live in rural areas.
    Currently, there's a limited number of the most high-risk
    population involved in clinical trials and other NIH-funded
    research.
        My question to you, Dr. Collins, is how can the NIH ensure
    the involvement of the communities most affected by obesity?
        Dr. Collins. A very appropriate question, Senator, and one
    that we are quite concerned about as we look at those curves
    showing increasing longevity for our population. We worry that
    they might flatten out and actually go the wrong way, if we're
    not able to get control of this epidemic of obesity and
    diabetes.
        NIH is deeply engaged in this effort, and I'm going to ask
    my colleague, Dr. Griffin Rodgers, who codirects the effort in
    obesity research across all of the NIH Institutes, to tell you
    something about that plan.
        Senator Shelby. Thank you, Dr. Rodgers.
        Dr. Rodgers. Thank you, Senator.
        NIH supports really a broad array of activities and basic
    translational and clinical research related to the issue of
    obesity. As you point out, this is really a complex problem,
    and a problem that one solution will clearly not be the issue.
        As a result of this, the NIH engaged in a strategic
    planning exercise and just published, about a year ago, a
    strategic plan directed to obesity, aiming at prevention in
    local communities, the hardest affected. You mentioned the
    disparities in racial and ethnic groups, and physicians'
    offices, bringing into the fold a whole lot of people who were
    previously not--including urban planners and others.
        We've enlisted a number of behaviorists to work on this
    problem, and we have some really healthy relationships both in
    the private sector as well as with foundations to tackle this
    major problem.
        Senator Shelby. How do you get people, and I'm one of them,
    I'm sure, to eat an apple instead of a cheeseburger?
        A cheeseburger, sometimes we crave that. We might not crave
    the apple. But we all know the apple is much healthier for us.
    Is that correct?
        Dr. Rodgers. You're absolutely right. And you raised an
    interesting point, something that people have described as
    ``nudge.''
        Sometimes if you make the default value something that is
    healthy, you can achieve your objective. So instead of, ``Would
    you like fries with that?'' could it be ``Would you like an
    apple with that?''
        And I'm pleased to say that many in the food industry are
    beginning to consider these types of approaches.

                  INSTITUTIONAL DEVELOPMENT AWARDS ELIGIBILITY

        Senator Shelby. Institutional Development Awards (IDeA), in
    its entirety, my State of Alabama is a significant recipient of
    NIH funding, mainly due to research grants received by one
    institution, the University of Alabama (UAB), of course.
        While their success provides significant benefits to both
    the State and the Nation through medical breakthroughs and
    economic investment, I'm concerned that its success puts other
    institutions in Alabama at a competitive disadvantage to
    similar schools in the IDeA area.
        The goal there, I understand, is to broaden the geographic
    distribution of the NIH funding to institutions that have a
    historically low success rate. However, many institutions that
    could benefit are unable to compete for this funding, because
    the State they reside in is ineligible due to the success of
    just one institution.
        The fiscal year 2012 bill included report language in
    support of revising current eligibility criteria. No update was
    provided in the congressional justification for fiscal year
    2013.
        Dr. Collins, my question to you, can you discuss the
    progress you've made in response to this language, if you have
    one?
        Dr. Collins. Senator, I appreciate the question, and we are
    very much supportive of the IDeA program, and you've correctly
    cited it's an effort to try to make sure that institutions that
    are in States that don't have particularly heavy research
    investments are still able to compete for funds to be able to
    do good science.
        As I understand it, Senator, the way in which the IDeA
    program is defined, in terms of which States are eligible, is
    not something that NIH has control over, but that in fact is
    something which is in the hands of the Congress.
        We recognize that the IDeA program is not entirely in sync
    with the Experimental Program to Stimulate Competitive Research
    (EPSCoR) that the National Science Foundation (NSF) supports,
    which has a similar intention but a slightly different
    definition.
        We are happy to continue to explore this, but we are unable
    to do so all on our own.
        Senator Shelby. Thank you.
        Thank you, Mr. Chairman.
        Senator Harkin. Thank you, Senator Shelby.
        Let's see, this will be Senator Brown.

                       STATEMENT OF SENATOR SHERROD BROWN

        Senator Brown. Thank you, Mr. Chairman.
        Thank you all for being here and for your public service.
    All six of you are part of the reason that life expectancy is
    30 years longer than it was a century ago, so thank you for
    that.
        My first question is for Dr. Collins, and then a question
    for Dr. Fauci.

                           NATIONAL CHILDREN'S STUDY

        The National Children's Study (NCS), what you're doing is
    impressive, following children from birth to age 21. In 2008,
    Case Western Reserve University School of Medicine in
    Cleveland, where Dr. Collins recently visited, was awarded two
    study center contracts to research children in Lorain and
    Cuyahoga counties, two urban, industrial counties that have a
    pretty diverse population and pretty widespread poverty.
        Case Western Reserve University has worked with community
    partners, such as Battelle Memorial Institute, the Cuyahoga
    County Board of Health--that's Cleveland--and the Lorain County
    General Health District. They employed some 60 people for
    research and data collectors.
        It's been brought to my attention that NIH found that the
    study's geographic approach is too expensive. It seems to back
    off that, and my understanding is that the seven original sites
    conducting this research are opposed to making that change.
        It seems you're missing a whole cohort of children that are
    coming to the office rather than going to the community.
        Can you explain to me what are your thoughts in reversing
    that direction, that decision?
        Dr. Collins. Certainly, Senator, and thank you for the
    question.
        We are very much invested in the success of the NCS as a
    critical way of assessing environmental and genetic risk
    factors for many disorders that affect individuals, with the
    goal then of ascertaining and following 100,000 kids from even
    prior to pregnancy, through the pregnancy, and on to age 21.
        We've conducted over the last 3 or 4 years a series of
    Vanguard studies to try to assess what is the best way to
    ascertain such a large number of individuals. And what we've
    learned through that process, as well as the evolution of the
    way in which science is being conducted and the way in which
    healthcare is now possible to deliver, is that there may be
    ways to do this study which are actually at least as effective
    and considerably more efficient.
        And as a result of that, and what we've learned from the
    Vanguard study, there is consideration underway that main study
    might be focused in a different way than knocking on doors,
    which had been the original plan.
        Knocking on doors turns out to be very expensive, and it
    turns out also to be quite difficult to ascertain a sufficient
    number of cases, whereas working through providers--and again,
    geographically distributed providers--provides us a better
    opportunity to do this in a fashion which can actually save
    taxpayers' dollars.
        But we're very sensitive to the issues you raise. This
    needs to be a study of children in this Nation that does not
    leave out those who, at the present time, don't have much in
    the way of health coverage.
        And so the main study, which is still in the process of
    having its design worked out, will have some serious attention
    paid to that issue, so that we have a representative group of
    children, not necessarily ascertained in the original way, in
    terms of door-knocking but which does in fact give us the
    information we need to know about genetics, about environment
    in multiple different groups across socioeconomic status.
        And I guess I would just encourage those who are concerned
    about the change to be part of the process that's going forward
    now, including a major meeting in the advisory group next
    month, to be sure that we're getting all the input we need to
    design a study that is going to give the answer that the Nation
    needs.

               TUBERCULOSIS: PREVENTION, DETECTION, AND TREATMENT

        Senator Brown. Thank you.
        One other question, Mr. Chairman.
        Dr. Fauci, thank you for your work on infectious disease.
    As you know, March 24, this last Saturday, was World
    Tuberculosis Day, commemorating the day in 1882 when the cause
    of tuberculosis was discovered, as you know.
        It's not much of a problem in this country. It's still a
    problem, obviously. It's not expensive to cure, as long as
    people take their medicines. You know all of that of course.
        One million children will die of tuberculosis (TB) in the
    next 5 years around the country, as you also know, and more
    than 10 million children were orphaned just, I believe, last
    year alone because of TB.
        Most alarming is the spread of multidrug-resistant (MDR)
    and now extensively drug-resistant TB (XDR-TB). The cures for
    MDR are there. The cure for XDR is significantly more
    difficult.
        What are we doing? What is your Institute doing to foster
    the development of diagnostic drugs? What are we doing,
    especially to prevent, detect, and treat TB? And how do we
    manage the pockets, especially of XDR-TB, around the world and
    particularly in India and in sub-Saharan Africa?
        Dr. Fauci. Thank you for that question, Senator Brown.
        This is truly a very important problem that has slipped off
    the radar screen, because of the victims of our success in the
    developed world, as you mentioned. But there are 1.8 million
    deaths with TB worldwide with an increasing percentage being
    MDR and XDR TB.
        To your question, what we have been doing over the past
    several years, most intensively over the past 5 to 10 years at
    NIH, has been to try and bring the science of tuberculosis into
    the 21st century. All of the advances in molecular biology, in
    sequencing and drug targeting, have really not been applied as
    robustly as it should have been to tuberculosis.
        So, we are engaging in rather intense partnerships, with
    industry and public-private partnerships, for the screening and
    development of drugs for what we call point-of-care
    diagnostics. One of the real tragedies about tuberculosis is
    we're using the same diagnostic test that was used a century
    ago, namely looking into the microscope to look for, in a very
    insensitive way, the tubercle bacillus without even knowing
    just by looking at it whether it's sensitive or resistant to
    the common drugs.
        We've now been involved in developing point-of-care
    diagnosis that can tell you within a couple of hours, for
    example, not only is it TB but is it going to be MDR TB.
        We are now on the way to developing a vaccine. It's curious
    that we have a vaccine for TB that's been around again for a
    century that doesn't work on respiratory TB at all, which is
    the most common form of spread.
        So, these are all the kinds of things that we've
    accelerated intensively over the last several years in both the
    control and, hopefully, it sounds maybe pie in the sky but
    people are starting to think about it now, is major control and
    in some countries even elimination of TB.
        So we're very excited about the efforts, and we will
    continue to make them a high priority.
        Senator Brown. Thank you.
        Thanks, Mr. Chairman.
        Senator Harkin. Senator Moran.
        Senator Moran. Chairman, thank you very much.
        Doctors, welcome. One of the first visits that I made after
    becoming a member of the United States Senate was to the
    University of Kansas, where I saw research, basic research in
    pharmacology, pharmaceutical drugs being developed. And this
    research seems to me to be so beneficial.
        And, particularly, I would highlight an example of
    collaboration between the University of Kansas, NCI, and the
    Leukemia and Lymphoma Society. And it seems to me, if we're
    going to get the best opportunities out of our investment, it
    is this public-private collaboration that's going to make a
    significant difference.

         NATIONAL CENTER FOR ADVANCING TRANSLATIONAL SCIENCES ROLE AND
                                 RESPONSIBILITY

        And I want to talk, at least in this round of questions,
    about the National Center for Advancing Translational Science
    (NCATS).
        How do we turn medical discoveries into life-saving
    treatments and cures? And my assumption is that's the goal of
    this new center. Is there a problem? Does that not occur
    adequately today in the absence of NCATS? So in other words,
    what role will NCATS play in improving the circumstance, if
    there is a problem to overcome?
        What are the impediments toward getting that basic research
    and pharmacology into those drugs that save and cure and treat?
    And is there any incompatibility with what the private sector,
    what drug companies are doing, and with what NCATS is
    attempting to accomplish?
        And then finally, perhaps this is for Dr. Varmus, but what
    will be the relationship between NCI and NCATS in this process?
        Dr. Collins. Thank you, Senator Moran, for a very
    interesting set of questions, and one that is very much on the
    minds of many of us as we try to make sure the deluge of basic
    science discoveries that are pouring out of laboratories move
    as quickly as possible into their translational and clinical
    benefits.
        You mentioned this relationship between Kansas and NCATS,
    and the Leukemia and Lymphoma Society.
        Senator Moran. I did it to give you a heads up as to my
    question, so you could anticipate it.
        Dr. Collins. We're very excited about this particular
    program, because it's already now enrolling patients into a
    clinical trial.
        I'm going to ask Dr. Insel, who is now the Acting Director
    of NCATS, to address some of the questions you've posed about
    what we aim to accomplish with this newest part of NIH.
        Dr. Insel. Thank you. It's an honor to be able to tell you
    a little bit about this.
        I think the first thing to be clear about is that all 27
    Institutes and Centers at the NIH have an investment in this
    kind of translation going from fundamental discoveries to
    making changes in health. That's what we do.
        What this new entity will do, and as the chairman said
    before, this new entity is essentially just putting under one
    roof many programs that were already there.
        But this is an attempt to develop the tools and to develop
    some new procedures that make it easier for the other 26
    Institutes and Centers to succeed.
        So this is a great example. This is a case in which we were
    interested in taking a compound that was already available in
    the pharmaceutical industry but not being used very much, one
    that was developed for rheumatoid arthritis, and developing a
    process by which we could screen all of the drugs that were out
    there, to see whether they might hit new targets that might be
    helpful for a disease that no one had ever considered before.
        In this case, a drug for rheumatoid arthritis turned out to
    be very helpful for a particular form of leukemia. And then we
    could go to our colleagues in Kansas, who have one of the NCATS
    centers, the Clinical and Translational Science Awards, and get
    them to begin to develop this, working with the Leukemia and
    Lymphoma Society to have this partnership to potentially
    develop a new treatment for this form of leukemia.
        Senator Moran. I appreciate that story very much. It was
    very impressive, again, for me to see in the laboratory.
        Why does that research not take place elsewhere? Why is NIH
    such an important component in bringing these, as you say, in
    this case, a drug that existed but not, I assume, thought of to
    be used for another purpose?
        Is it the NCI that is necessary to get us to move in the
    directions of this new thought, these new opportunities?
        Dr. Insel. Well again, I would want to make clear that I
    think the NCI and many other Institutes have a stake in doing
    just this. The question is whether you want to do it 26 times
    or you want to do it once.
        So in the case of developing, for instance, a procedure to
    move compounds from the pharmaceutical industry into academic
    settings, we all do that at all the Institutes to some extent.
    It's a bit of an impediment. It gets complicated.
        There are templates that can be developed that will make
    that much easier doing it once instead of doing it multiple
    times. And there are tools that we need.
        In this case, this was a particular repository that was
    developed by the folks at NCATS that collected in one place all
    the medications that were out there, so we could do a single
    screen instead of having to break it up into many different
    attempts.
        So NCATS is really an enabler, essentially. We sometimes
    call it a catalyst for innovation. It's a way of putting under
    one roof many of the tools that all of us need to get things
    done faster.
        Senator Moran. Thank you very much, Doctor. Thank you.
        Dr. Varmus.
        Dr. Varmus. Well, let me just add one or two words here.
        As you pointed out, Senator, the categorical institutes
    have a deep investment in translational research activities,
    and the NCI is no exception to that, with well more than $1
    billion a year being invested in these topics.
        In the case of chronic lymphocytic leukemia, we have a
    major program to look at the basic genetics. It's a disease
    that is a smoldering disease which becomes acute, and we have
    very few treatments when the disease enters its acute phase.
        The intramural program of the NCI came to the chemical
    genome screening center to help find drugs that might be
    repurposed, drugs that the company might have little interest
    in, because it's off-patent, and we were fortunate to have this
    drug turn up.
        Now this trial we see as emblematic of what NCI might be
    involved in, in working with NCATS. In this case, as you've
    heard, the trial is being sponsored by the Leukemia and
    Lymphoma Society. But I think this is a good example of how the
    interaction between the NCATS and individual institutes like
    ours might be very beneficial.
        Senator Moran. Thank you all very much.
        Senator Harkin. Thank you, Senator Moran.
        Senator Pryor.
        Senator Pryor. Thank you, Mr. Chairman and Ranking Member.
    Thank you for holding this hearing today, and I want to thank
    the panel for being here.
        I'm going to focus my questions with Dr. Collins and Dr.
    Varmus.
        I'm a cancer survivor. I survived clear-cell sarcoma about
    15 years ago. Thank you for all your work and all you do in the
    cancer area, and every other area, for that matter.

                               PANCREATIC CANCER

        I want to ask about pancreatic cancer. As I understand it,
    it's the most lethal of the common cancers. It's the fourth-
    leading cause of cancer death. This year, more than 43,000
    Americans will be diagnosed with pancreatic cancer, most of
    whom will die within 1 year of their diagnosis, because the
    disease is usually too far advanced by the time it's
    discovered.
        And I know in this subcommittee, we're careful to avoid
    trying to tie the hands of scientists by directing too
    precisely the appropriated money, on how it should be spent.
    But I'm troubled that while survival rates of many cancers are
    steadily improving, one of the most lethal forms of cancer,
    pancreatic cancer, remains at about 6 percent.
        And I look at the model for breast cancer. I'm not sure
    that's the best model, but I do look at that model and some of
    the focus there. I'm wondering if NIH would consider using that
    breast-cancer model to try to go after pancreatic cancer.
        Dr. Varmus. Thank you for that, Senator.
        As someone who has lost several friends to this disease
    over the last decade and who has worked in my own laboratory on
    this disease, I appreciate the devastation the disease causes
    and the difficulty of trying to make headway against it.
        Indeed, of the cancers that we work on, I'd say progress
    has been relatively small in the clinical arena, as you point
    out.
        But there is a great deal of reason for optimism in this
    domain.
        First of all, we have a much larger number of investigators
    working on the disease, and we have some scientific
    opportunities that are very dramatic that I'd like to outline
    for you very briefly. As a result of both factors over the
    course of the last decade, the amount of money that the NCI
    spends on this disease, despite the flattening of our budget,
    has gone up 300 percent.
        The model that you alluded to of breast cancer is useful,
    because one of the things that's been a factor in increasing
    our attention and increasing our spending on this disease has
    been the role of advocacy groups, such as the Lustgarten
    Foundation and several others, that have helped to incentivize
    NCI-supported investigators to work on this very difficult
    problem.
        There's been a number of dramatic changes in our view of
    this disease in the last few years, one as a result of being
    able to take DNA from tumors and examine the underlying damage
    in the genomes of those cells, to try to understand the disease
    more profoundly.
        One of the consequences of that analysis has been to
    perceive that pancreatic cancer does not arise in a matter of
    months. It rises over the course of one or two decades. And
    that's an important fact, because we know now that there is
    quite a large window of opportunity for detecting the disease
    earlier than we have seen heretofore. And that's, of course, a
    major factor in this disease, the symptoms appear very late
    when the disease has often spread. And unlike certain other
    cancers that manifest themselves on the skin or with symptoms
    at an early stage, it's been difficult to diagnose this disease
    at an early phase.
        Second, we've been able to understand the relationship
    between the tumor itself and the cells that surround it that
    make the disease somewhat impermeable to some of the therapies
    that have been used for other cancers. And there are new ways
    to try to make the surrounding material more permeable to
    cancers.
        Furthermore, there's been a number of mouse models of the
    disease that were previously difficult to create that are now
    being used to try to understand the physiology of the disease
    and to test treatments in animal models.
        All those things give me considerable optimism for the
    future.

                          PRIORITIZING CANCER FUNDING

        Senator Pryor. Well, does that mean, though, that you're
    going to prioritize it in terms of funding and try to invest
    more there?
        Dr. Varmus. It is prioritized, Senator. And I mentioned
    earlier that, in this period of budgetary constraint, the NCI
    has been paying special attention to grants that might in the
    past have been unfunded because they fell below what we used to
    call a pay line. And now we examine quite a number of grants
    that get priority scores that are perhaps less high and look at
    them for the diseases that fall in certain categories where we
    made less progress in therapeutics, neuroblastoma, lung cancer,
    pancreatic cancer, ovarian cancer, and others. And we
    frequently fund grants that scores may have been a little less
    than others but nevertheless represent high-priority areas for
    us.
        Senator Pryor. Thank you, Mr. Chairman.
        Senator Harkin. Thank you, Senator Pryor.
        Senator Cochran.

                INSTITUTIONAL DEVELOPMENT AWARD PROGRAM FUNDING

        Senator Cochran. Mr. Chairman, thank you very much.
        Let me ask about a program that is designed to help ensure
    a broader base of financial support to research institutions
    and those who are in university settings, and who are engaged
    in research that has unique applications and importance to the
    medical community and the life of the citizens of our country.
        This is done through a program called the Institutional
    Development Award (IDeA), and the whole point is to broaden the
    geographic distribution of NIH funding in biomedical and
    behavioral research programs.
        In my State, we have seen some very important strides made
    in these programs. There are 23 other States in the same boat
    as my State of Mississippi.
        The bill that we have provided funding in directed that
    certain areas be undertaken for research and review. The
    Centers of Biomedical Research Excellence (COBRE), which is a
    Competitive Grant Program, received an increase of $45.9
    million through this program. But NIH said that they're not
    going to be able to use the funds, and so this year's bill
    reduces funding by about $50 million.
        I'm asking, what do we need to do, use different wording,
    put a star by the provision in the bill that these are funds
    that are intended to be used and for the purposes that the
    Congress stated? Who wants to take that on and explain what's
    going on to me?
        Dr. Collins. Senator, I appreciate that question and
    clearly the IDeA program is one that NIH is proud of. And
    before you came in, Senator Shelby was asking whether Alabama
    could be added to the club, because, clearly, the 23 States
    that are eligible for this program depend on the opportunity to
    be able to compete for NIH dollars, and lots of good science
    gets done as a result.
        I want to reassure you that the dollars that were allocated
    to the IDeA program in fiscal year 2012, the year that we're
    currently in, are going to be utilized and are going to be
    utilized, I think, quite effectively. We are going to follow
    the Congress's instructions here in terms of how to make the
    most of this additional allocate of almost $50 million, which
    for the IDeA programs represents a 22-percent increase in that
    program in fiscal year 2012 compared to fiscal year 2011.
        So, we will be funding both COBRE program that you referred
    to. Also, as we were asked to do, the new Center for Clinical
    and Translational Science is part of the IDeA program, and that
    process is already very much underway, and we will make sure
    that we do everything you would want us to, in terms of
    reviewing and choosing the very most competitive programs to
    award those dollars to.
        Going forward in fiscal year 2013, you will notice that the
    dollars do not stay at that same level. We are certainly very
    enthusiastic about IDeA, but at the same time, we have so many
    pressures on so many other parts of the program that the
    President's budget reflects that, in terms of decisions that
    were made in putting together that fiscal year 2013 budget.
        But again, I do want to reassure you, as far as fiscal year
    2012, we are going to spend those dollars in a very, I think,
    aggressively innovative way and to the benefit of the IDeA
    States.
        Senator Cochran. Thank you very much.
        And thank you, Mr. Chairman.
        Senator Harkin. Thank you, Senator Cochran.
        I just might add on that IDeA program, I was not one of
    those States either. But I'm not clamoring for Iowa to be one,
    because while I understand the interest of States to find
    funding for a lot of different things, I think Senator Shelby
    said it in his opening statement: We want the best science
    rewarded.
        If it's not in Iowa, then it's someplace else. But it's got
    to be the best science.
        We're not in the business of just spreading money around.
    We're in the business of trying to take the limited budget that
    we have and reward the best science that's out there. And we
    count of all of you and your advisory boards and others to tell
    us what that best science is. I just want to make that
    statement.
        Senator Cochran. Could I have the opportunity of asking the
    witness whether they think this is wisely invested money or
    not? I think the suggestion of the question that the chairman
    has asked suggests that they may be funding in this program
    just because a Senator on this subcommittee, vice chairman of
    the full committee, asked for it.
        Senator Harkin. No, I just want to----
        Senator Cochran. That's not the purpose of the question.
    The question was on the merits of the program, if it was
    justified and if the funding level and the language and all was
    consistent with what the department and the witnesses here
    thought would be an appropriate investment.

                                 H5N1 RESEARCH

        Senator Harkin. Well, I sure hope so. I hope that is what
    they will do.
        Dr. Fauci, over the past few months, there has been quite a
    controversy regarding NIH-funded researched related to H5N1 flu
    virus. You remember, you've been here before in the past on
    this?
        Dr. Fauci. Yes.
        Senator Harkin. A great flare up a few years ago from
    Southeast Asia, concerned about what was going to happen when
    it got here.
        Fortunately, we found out that it wasn't very transmissible
    to humans. But recent research has shown that it's possible to
    genetically alter the virus so that it could spread from human
    to human.
        In December, the National Science Advisory Board on
    Biosecurity said that this research was a ``grave concern to
    public health.'' It asked two journals, ``Nature'' and
    ``Science'', to withhold some parts of the research results to
    reduce the risk that bioterrorists and others could misuse this
    information.
        On the other side, however, many leading flu researchers
    disagree and believe the full results should be published.
        As of now, a final decision on publication is still
    pending. There's also a voluntary moratorium among flu experts
    on some of the research.
        You have said that you support this research. I want to
    know why, and what did NIH hope to learn? Is it worth the
    danger that a lab-made virus could be released into the world,
    either intentionally or by accident? And do you think the full
    results of this research should be published?
        Dr. Fauci. Okay. Thank you for that question, Mr. Chairman.
        First of all, the issue of H5N1 and why we do the research,
    there is no question that influenza, in general, the potential
    for pandemic influenza and, in this case, specifically, the
    H5N1, is a clear and present danger because we still have
    smoldering infections with major outbreaks in chickenpox and,
    occasionally, a jump from a chicken species to the human
    species.
        As you said correctly, this is not easily transmissible
    from human to human, and certainly not transmissible easily
    from chicken to human. The problem is that, as you look in the
    wild, you see that viruses, as they always do, evolve. And the
    critical question that really spurs this research is what are
    those factors that go into the evolution of a virus to what we
    call ``species adapt.'' In this case, adapt to the human in a
    way that would make it transmissible. This is an absolutely,
    unequivocal, critically important question to ask.
        So in that case, the research is really very important. We
    have a major program for decades that studies what we call
    transmissibility in species adaptability that has made us much
    better prepared from year to year and on the rare occasion
    where you get a pandemic to be able to predict and be prepared
    for, to respond to a pandemic. That's issue number one.
        The papers in question, we're doing something that is an
    important approach toward understanding this phenomenon that is
    a real and present danger in the wild. And what they did is
    that they tried to characterize exactly how a virus would look
    if it did develop the capability of, in this case, mammal.
        You use the words human transmissibility. I want to
    underscore that this was transmissibility from ferret-to-
    ferret, which is a good but imperfect model for human
    influenza. So there is a misperception there that this is now
    transmissible in human.
        There was also a misperception in the information that was
    given out to the public that when you made a virus
    transmissible from a ferret to a ferret by aerosol
    transmission, which is the way humans transmit virus from one
    to another, that actually those ferrets died with high degree
    of mortality. And that turns out to be not the case.
        So where we are now, today, is that we had a determination.
    We are very careful about the balance between the scientific
    need to know for the public health good and safety and
    security. We take that very, very seriously.
        When it became clear that this could be what we dual-use
    research of concern that could possibly be used for nefarious
    purposes, we put it before an advisory committee that made the
    recommendation on the basis of the information that they had
    that the research was important to perform, but that perhaps
    parts of it, the details, might not be readily available to
    everyone.
        WHO called a meeting, and when they looked at the data and
    some additional data, and some clarification, they came to a
    conclusion that was a little bit different. They said, in the
    big picture of things, the real and present danger of this
    happening in the wild really outweighs the possible risks of
    there being bioterrorists.
        So, we have a disparity now of recommendations.
        Tomorrow, the NIH/HHS is reconvening the National Science
    Advisory Board for Biosecurity, which is a nongovernment,
    outside group that would advise the Government, and we are the
    ones that originally said that we should hold back.
        So we're looking forward to tomorrow and Friday when this
    group will reconvene and look at additional data, because there
    has been considerably more information that has been gathered
    since the original determination to hold back some of the data.
        Senator Harkin. Well, I'll look forward to that, too. In
    the next couple of days?
        Link for Recommendations follows: http://oba.od.nih.gov/
    oba/biosecurity/PDF/03302012_NSABB_Recommendations.pdf.
        Dr. Fauci. Yes, Sir.
        Senator Harkin. That's very timely.
        I have a follow-up on that, on H5N1, in my next round, but
    my time is up.
        Senator Shelby.

                                 DOWN SYNDROME

        Senator Shelby. In the area Down syndrome, Dr. Collins, I
    support the goal of the NCATS to invest in research that moves
    a potential therapy from development to market as you do. As
    you continue to develop aspects of the new center, this may be
    an opportunity to focus on conditions where comorbidities are
    so pervasive that research will help both the population in
    question and those suffering from such comorbidities.
        For example, 50 percent of those born with Down syndrome,
    also are born with a congenital heart defect, and more than 50
    percent of those with Down syndrome will suffer from the early
    onset of Alzheimer's disease. Yet it's extremely rare for a
    person with Down syndrome to suffer from a solid tumor cancer,
    heart attack, or stroke.
        Can you discuss how NCATS will focus on diseases, such as
    Down syndrome, whose research could benefit many in
    populations?
        Dr. Collins. Thank you for the question, Senator. I'm
    trained as a medical geneticist, and so Down syndrome is
    certainly one of the conditions that, in my clinical years, I
    spent a lot of time wrestling with, in terms of trying to give
    the best advice to children and their parents about this
    disorder.
        As you know, this is caused by an extra copy of an entire
    chromosome, chromosome 21, which means that genes that are
    normally present in two copies are present in three. Even
    though it's one of the smaller chromosomes, there's still a lot
    of genes on that chromosome.
        And it's been a big question for research to figure out
    which of those are the ones that are so dose-sensitive, because
    most of the time, if you have 50 percent more of something,
    it's not going to cause a lot of trouble. But, apparently, on
    that chromosome are some genes that do have that potential.
        It's the National Institute of Child Health and Human
    Development (NICHD), whose Director, Dr. Alan Guttmacher, is
    here, who has the lead in Down syndrome research. They have put
    together a research protocol and a plan over the course of the
    last few years, and now formed a consortium bringing together
    NIH and other organizations to be sure we are looking at what
    the opportunities and gaps are.
        There is some exciting research going on in terms of the
    mouse model of Down syndrome and even some therapeutic
    interventions using neuropeptides that seem to show promise in
    that mouse model.
        In terms of the role of NCATS, again, as you heard from Dr.
    Insel, NCATS does not have as its goal to focus on specific
    disorders. That's the role of the other 26 Institutes.
        NCATS aims to provide resources and to attack those
    bottlenecks that are slowing down everybody, and to try to see
    whether we could do better in terms of, when you have an idea
    about a therapeutic, how do you get it to the point of a
    clinical approval in less than 14 years and with a failure rate
    that's less than 99 percent? That's really what NCATS is all
    about.
        So, NCATS should be an important addition to the landscape.
    But again, I think the lead efforts in Down syndrome will
    continue to be at NICHD.

                 INTERAGENCY COLLABORATIONS AND CYSTIC FIBROSIS

        Senator Shelby. Thank you.
        Dr. Collins, this is a very important time, as you said, in
    the history of drug development. We continue to see the
    benefits from mapping the human genome when specific treatments
    for genetic diseases are being developed to target smaller and
    smaller populations.
        This aspect of personalized medicine holds promise to treat
    or to cure rare diseases that plague millions of Americans.
        In January, the Food and Drug Administration (FDA) approved
    a groundbreaking new drug for cystic fibrosis. This drug treats
    the underlying genetic cause of cystic fibrosis in the 1,200
    people who are affected by a particular genetic mutation. This
    breakthrough treatment has led to tremendous health gains for
    those who take the drug, and may lead to the development of an
    innovative new class of drugs for a much larger portion of the
    cystic fibrosis population.
        Collaboration between the NIH and the FDA has the
    potential, I believe, to move genetic breakthroughs more
    quickly through the development process and into the hands of
    patients by ensuring that the FDA has the tools it needs to
    review and to regulate the genetic treatment.
        What are your thoughts on this?
        Dr. Collins. Well, Senator, I think what you've pointed to
    is a really exciting development for cystic fibrosis but also a
    very important point you're making about the need for close
    collaboration between NIH and FDA, the private sector, and
    advocacy organizations, such as the Cystic Fibrosis Foundation,
    who played a big role in this recent advance in cystic
    fibrosis.
        And if you'll permit me, I will tell you what a personal
    delight it was, having been part of the team that discovered
    that gene in 1989, to see at this point the use of that
    information coming forward with the drug Kalydeco.
        Senator Shelby. What can that mean to the people with
    cystic fibrosis?
        Dr. Collins. So for the roughly 1,300 individuals in the
    country who have this specific mutation in the cystic fibrosis
    gene called G551D, which is unfortunately only about 4 percent
    of cystic fibrosis sufferers, this drug causes that defective
    protein to rev itself up. And the clinical results, as
    published in the New England Journal last year, are truly
    dramatic in terms of improvement in lung function, gain in
    weight, because cystic fibrosis is often associated with weight
    loss. And also, you can see the biomarker for cystic fibrosis,
    the sweat chloride, returning to normal in kids who are taking
    this drug.
        Again, this special this evening that NOVA is putting on
    will give you a couple of examples of how that has played out.
        So that is really gratifying. But you're right. We need to
    be sure that we can replicate that many times over.
        Dr. Margaret A. Hamburg, the Commissioner of the FDA, and I
    have formed a joint leadership council between our senior
    leaders, and many of the NIH representatives who are sitting
    here at the table are on that council. She has also brought her
    Center Directors into that same place.
        We have resolved together to identify the areas that are
    most in need of this kind of collaboration and are working
    quite intensively to try to do that.
        Senator Harkin. Thank you very much, Senator Shelby.
        Senator Mikulski.
        Senator Mikulski. Good morning, everybody. I'm so sorry I
    couldn't be here for all of your testimony. I was at the DOD on
    military medicine, and of course, as you know, a lot of that is
    right across the street from NIH, and we won't talk about the
    traffic jam.
        Senator Harkin. But thank you for helping with that, too.

                    NATIONAL INSTITUTES OF HEALTH PRIORITIES

        Senator Mikulski. And I was effusive with Senator Inouye.
        But, Dr. Collins, and to all of you, I've known you for so
    many years, and I just want to welcome you and let you know how
    glad I am to see you and how much you are appreciated. We ask
    you to do a lot. We hope that we have the adequate resources,
    and at the same time, we are deeply troubled that, as Federal
    employees are under attack, they seem to forget that you are
    the Federal employees we need and we turn to in the national
    interest.
        I'll come back to that, because I wonder how all of that
    harassment, hazing, the cute one-liners in town hall meetings
    against Federal employees are affecting morale, recruitment,
    and retention, because, I think, from what I hear, standing in
    a bagel line or something, or a broccoli line, in Rockville,
    that I hear it.
        But let me get right to my question. Many of you we have
    turned to at a time of national emergency, and I think of Dr.
    Fauci, when an obscure virus was beginning to kill young men in
    our community and escalated in our country and even into a
    global crisis, AIDS; when we had the anthrax scare here, et
    cetera.
        We came together, and we really moved on a national agenda,
    and this then goes to, picking up on Senator Shelby, the
    acceleration of drugs.
        Now, Dr. Varmus, you and I have talked about these things.
    We don't want industrial policy visits at NIH. We don't want to
    pick winners and losers, et cetera.
        But we have compelling needs. We have the orphan drug, you
    know, the rare disease constellation and then we have those
    areas that relate to chronic illness or the impending or
    arriving epidemic of Alzheimer's.
        And my question to you is looking at both your Center for
    Translational Medicine and so on, how can we look at what are
    compelling national needs, those that we know will impact
    significant parts of our population, use a significant amount
    of our cost for the treatment of these, some so long range,
    like Alzheimer's, some immediate, like diabetes, Dr. Rodgers?
        One, do you think it is a valid thing to do? How can we
    work with you to do that? What are the right resources? And how
    do we avoid the industrial policy syndrome, which we certainly
    don't want to get into, because you do need lots of latitude
    for discovery.
        Dr. Collins. Well, thank you, Senator, and by the way,
    congratulations to the Senator from NIH on this recent
    milestone of recently being recognized as the longest-serving
    woman in Congress. We were all cheering for that.
        Senator Mikulski. Thank you. It was moving from the bagel
    line to the broccoli line.
        Dr. Collins. Your question is a very important one. How do
    we in fact decide how to set priorities is what I think you're
    asking, and of course that's not only----
        Senator Mikulski. And also how to accelerate?
        Dr. Collins. And how do we speed up the process of going
    from basic science to therapeutics?
        Maybe just as an example, because it is timely, I would
    mention what you just mentioned, the situation with Alzheimer's
    disease. So talk about a public health circumstance of enormous
    concern. Here we have a diagram showing the prevalence of
    Alzheimer's disease currently at 5.1 million, expected to rise
    almost to 12 million over the course of the next few years, if
    nothing is done about it, and with the cost going through the
    roof. So here is an area of potential, very serious
    significance.
        And also, I'm happy to say, a situation where the science
    of Alzheimer's disease has come across quite quickly in just
    the last year or two, putting us in a position to be able to
    push that therapeutic agenda harder. And yet for many
    companies, diseases affecting the CNS are not seen at the
    present time as being particularly commercially attractive.
        Senator Mikulski. Do you want to say what CNS means?
        Dr. Collins. CNS, central nervous system. I'm sorry. Brain
    diseases.
        I'm going to ask Dr. Hodes, who is the head of the National
    Institute of Aging, to just say a word about the science that
    propels us to be particularly excited about Alzheimer's, again
    as an example of the exhortation you're providing us about what
    we need to pay attention to.
        Dr. Hodes. Thank you. I'd be happy to do so.
        As we've seen emphasized, the byproduct of the extended
    longevity in the American and world population has really been
    the increased threat posed by diseases of late life, and
    Alzheimer's is certainly prominent among them.
        So there's no question, as there has been for a number of
    years, about the public health importance and imperative. As
    Dr. Collins notes, what is most exciting to us all is the
    advance in science that really creates an opportunity,
    justification for optimism, that didn't exist before.
        Earlier, Dr. Collins presented an example of a drug through
    repurposing, in this case Bexarotene, a drug that had been used
    to treat a kind of skin cancer, which when tested for its
    effect on some of the underlying processes of Alzheimer's
    disease in a mouse model showed absolutely dramatic effects.
        Another kind of advance that has been featured, just in the
    past few months, has been the use of induced pluripotent stem
    cells and particularly the translation from a skin fibroblast
    from an individual with or without Alzheimer's disease into
    neuronal cells in a tissue culture dish, which reflect many of
    the underlying biochemical abnormalities of Alzheimer's
    disease.
        The potential here for screening now in cells and tissue
    culture tens, hundreds, thousands of compounds, to see whether
    they will have an effect that provides a suggestion of which
    might ultimately be translated, is just one of the many
    examples that we are poised to capitalize upon at this time.
        Senator Mikulski. Dr. Hodes, if I could jump in?
        This is so exciting to hear. But I held a hearing 3 years
    ago on the issues of Alzheimer's, with my colleague Senator
    Bond, who was tremendously interested in this as well as
    arthritis. And we heard then, 3 years ago, well, we are on the
    brink of big breakthroughs.
        So I had a legislative framework to take a look at that. I
    was stymied in this institution, okay? I was stymied in this
    institution on taking a look at this. And I won't go through my
    legislation. This is not about me. It's about people, which is
    why we're all in this.
        And my question is, 3 years later, I've given up on
    legislation. I mean, I'm going to move my legislation. Maybe
    it'll happen; maybe it won't.
        But I'm asking, administratively, and through the executive
    branch, where we have a body of knowledge and a variety of
    studies that are breakthrough possibilities that meet
    compelling human need and big budget busters, how can we move
    these through this process and get them into the hands of
    clinicians?
        I've now heard about promising science, and I'm going to
    continue to support it, but the promise of science needs to
    have deliverables.
        Dr. Hodes. If I may, Mr. Chairman? I know we're over time.
        Senator Mikulski. Do you mind, Mr. Chairman?
        Senator Harkin. We're over time, but go ahead and respond,
    please.
        Dr. Hodes. So with regard to Alzheimer's, recognizing the
    exceptional scientific opportunity and public health need, in
    the fiscal year 2013 budget, the President's budget proposes an
    additional $80 million for Alzheimer's disease research, over
    and above the regular NIH appropriation, as a recognition of
    that exceptional opportunity.
        But I think your question is broader than that.
        Senator Mikulski. It's much broader.
        Dr. Hodes. And that is how do we, at a time where resources
    are in fact constrained, make decisions about how to set the
    priorities to the way that benefits the public in the greatest
    way? That is our toughest challenge. That's what we sit around
    the table with the Institute Directors on Thursdays and try to
    wrestle it. That's what all 27 of the Institute and Center
    Directors are charged with, in terms of surveying the
    landscape, trying to see where the gaps are. What we don't want
    to do is be overly top down.
        Senator Mikulski. You haven't answered my question.
        Dr. Hodes. I thought I was getting there, but maybe I----
        Senator Mikulski. I feel the pressures of time, Doctor. And
    I don't mean to be interruptive or whatever. But I know you're
    working hard on it. But do you have an answer to my question?
        And if not, it's not a hostile or aggressive question. I
    just feel the demands of time on our population, the
    frustrations that families and patients have. You meet with
    advocacy groups. You're well-known for your accessibility.
        Do you have an answer on how we can do this without
    industrial policy?
        Dr. Hodes. Senator, I share your frustration and your
    passion, believe me. The reason I went into research was
    because of the concerns that we weren't going fast enough in
    finding answers for people who need them desperately.
        I think what NIH is trying to do, in answer to your
    question, is to be sure we are looking at every possible means
    of promoting science rapidly. We are trying to figure out how
    to work with the private sector in circumstances where we can
    do things together.
        But for circumstances where clearly things are hung up,
    like the bottlenecks we're now trying to tackle with this new
    NCATS, we are jumping out there in a fairly aggressive way, in
    fact, in a way that some have said was too aggressive.
        But we accept that concern, because of our impatience, just
    like yours, to take this science that's happening right now and
    turn it into treatments and cures for those millions of people
    who are waiting for those hopes to come true.
        Senator Mikulski. I know my time is up. Well, I want to
    thank you for your science. I want to thank you for your
    dedication and for your compassion and your humanitarianism.
        Senator Harkin. Thank you.

                               NEW INVESTIGATORS

        Senator Moran.
        Senator Moran. Mr. Chairman, thank you. Doctors, let me
    just join, perhaps, the Senator from Maryland, and I was
    thinking about the--I think most of us spend our lives trying
    to create hope for other people. I hope that you take great
    satisfaction in the noble calling that you're pursuing in your
    lives and know that you are providing hope. In my view, it's
    the mission of the NIH to provide hope for Americans and really
    for people around the world that we find cures and treatments.
        And so I commend you for choosing a profession, a career, a
    path, that I think matters so much in changing the world.
        Somewhat in that regard, obviously bringing new talent and
    professionalism, scientists, researchers, and medical
    practitioners to the arena to provide that hope, I've said
    numerous times that one of the problems with reduced funding at
    NIH, or flat-funding that results in less actual money
    available for research, one of the reasons that that's so
    troublesome to me is that we're sending a message to the next
    generation, the potential researchers, scientists, physicians,
    that the certainty of their career path or the value of what
    they do is not recognized.
        And while I say that, I don't have any basis other than
    perhaps common sense to say that that would be the case, and I
    would be interested in knowing if you can, either anecdotally
    or scientifically, tell me that that's a valid point to make to
    the American taxpayer, the merit of making certain that funding
    continues in a stable manner.
        And one perhaps less philosophical question, I would like
    to hear, Dr. Insel, if there is a--this is a question that
    comes to me just knowing of your center. What's going on that
    will be helpful to our returning veterans related to mental
    health? And is there a relationship between what you do and the
    Department of Veterans Affairs (VA)?
        Dr. Collins. I'll take the first part of your question, and
    then ask Dr. Insel to jump right in.
        Certainly, for a new investigator who has recently gone
    through extensive research training and is now starting up
    their own independent research program in one of our Nation's
    great universities or institutes, this is a somewhat scary
    time. They can see what's happened in terms of the likelihood
    of being funded if you send your best ideas to NIH, which
    traditionally during the last 40 years has been in the range of
    25 to 35 percent, and which last year, the last year we have
    full numbers for, fell to 17 percent.
        That means that an awful lot of that effort comes away
    without support. And, therefore, those investigators spend even
    more of their time writing, revising, resubmitting, hoping that
    they will actually make that cut and be able to get started.
        And certainly, if I had to pick one thing that I would say
    would be most healthy for the American biomedical research
    future, it would be stability. The feast or famine just doesn't
    work in this circumstance. You want to give investigators the
    confidence that if they have good ideas, and if they work hard,
    and if they produce publications that change the direction of a
    particular field, they make insights, they make breakthroughs,
    they take risks, that there is a career there. And it's
    difficult when things are bouncing around, as they currently
    are, for particularly early stage investigators to have the
    confidence that there's a pathway for them.
        That trickles down, and others who are sort of earlier in
    their decisionmaking hear about it and begin to wonder whether
    this is a career that they want to invest themselves in.
        That's not happening in other countries, but that's
    happening, certainly, in the United States.

                           RECRUITMENT OF SCIENTISTS

        Senator Moran. Is there an opportunity for that talent that
    we're trying to retain in the United States? Is there a
    movement abroad? Would research scientists in the United States
    conduct their research elsewhere or pursue--are we competing, I
    guess is the word, in a global economy, for the best talent?
        Dr. Collins. We are, and, of course, we have greatly
    benefited over the years in being able to recruit talent from
    other countries, and we continue to.
        In many instances, those individuals would come and be
    trained in our country and then would stay and become part of
    this remarkable innovative community.
        It is less likely now that those individuals will stay.
    It's easier, in many ways, to go back to their countries, where
    there's more support now plus perhaps they see the environment
    here as not as friendly.
        So, yes, that dynamics have certainly changed.

                         POST-TRAUMATIC STRESS DISORDER

        Dr. Insel. So very quickly, with my day job hat on, from
    NIMH, we're particularly concerned about the needs of returning
    veterans. Estimates are somewhere north of 300,000 who will
    develop post-traumatic stress disorder (PTSD) or a related
    disorder that will require some kind of care in the community
    or potentially through the VA.
        We work closely with the VA, but our largest single project
    currently is actually with the DOD, working with the Pentagon
    on a massive project now with more than 30,000 soldiers
    involved, to look at soldiers, with active-duty soldiers, and
    following them through their service to figure out what we can
    do to make sure that they don't develop PTSD, traumatic brain
    injury, or other problems.
        That was really generated by the increase in suicide that
    was reported by the Army, and we've been charged with trying to
    turn those numbers around.
        Senator Harkin. Thank you, Senator Moran.
        Dr. Fauci, I said I have a follow up on H5N1, and that's
    not true. I have a follow-up question but not necessarily on
    H5N1, except to say I just wonder if we've been kind of lulled
    into a state of complacency on this. And we know viruses mutate
    all the time. If this does mutate into a form that is
    transmissible, it could be devastating.
        Dr. Fauci. Right.
        Senator Harkin. And hopefully, we're prepared for that.
        Dr. Fauci. Right.

                           IMMUNOTHERAPY ADVANCEMENTS

        Senator Harkin. But what I want to ask you about was a
    question that you've responded to previously before this
    subcommittee and it has to do with food allergies. We talked
    about this a lot in the past.
        I've been told that small trials involving immunotherapy
    have been very encouraging in treating children who have
    peanut, egg, and/or milk allergies. As I understand what
    happens, these kids are given small amounts, and then larger
    and larger amounts.
        Again, I guess for some children with very severe cases,
    this isn't enough, so they're given both that plus a drug.
        From what I understand, what's needed now are phase II
    trials for these treatments, as well as studies that could
    explain how they're working.
        So, again, what's happening in this area? Why does
    immunotherapy work for some and not for others? And how are you
    proceeding with the phase II trials?
        Dr. Fauci. Okay. Thank you for that question.
        We have, as I've told you and this subcommittee before,
    over the last several years, dramatically increased the
    resources that we have put in on food allergy. Having said
    that, we started off at a low number. So at a time when the NIH
    budget has been flat, we have been progressively increasing by
    a considerable number of factors.
        We still are not where we want to be, but within that
    realm, answer to one of your specific questions, it is unclear
    at present why some people respond to this early
    desensitization by giving small amounts of what would
    ultimately be desensitizing antigen--in this case, it would be
    peanut or chocolate or something like that.
        Phase II trials are, as you know, the next stage after you
    show that a particular intervention is safe in a phase I to go
    in and get more information from a phase II. We are very much
    right now involved in making that next step to go to phase II
    trials and some of those interventions. But it is not in a
    situation where we are having a large enough trial to
    definitively answer the questions, but that is the next stage
    that we're going.
        So we're right at the point and we are working with a
    number of the societies. In fact, I just met less than 2 weeks
    ago with our food allergy constituency groups to discuss how we
    might continue in an arena of constrained resources to push
    this agenda, particularly in the arena of clinical trials.
        Senator Harkin. If you don't have the figure now, maybe you
    could just transmit it to us later on, just how much is this
    going to cost.
        Dr. Fauci. Right. Okay. I don't have the exact number now,
    but clinical trials in general, particularly when you get to
    phase II and phase IIB, which involves several hundreds of
    people, it costs a considerable amount of money.
        And that's really been one of the constraints that we have,
    because the total budget for food allergy, although it's
    accelerated greatly over the last few years, is still,
    relatively speaking, when you compare it to other things,
    rather small, which we're trying to do something about.

                              ALZHEIMER'S RESEARCH

        Senator Harkin. Thank you, Dr. Fauci.
        I still have a minute and a half. I want to get Dr. Hodes
    into this area of Alzheimer's research. The President, as Dr.
    Collins has said a couple of times in his opening statement,
    again, has proposed $80 million for NIH research specific on
    Alzheimer's.
        And where he's getting the money? He's taking it from the
    Prevention and Public Health Fund (PPHF), Senator, that we put
    into the Affordable Care Act.
        I just, again, in a friendly atmosphere, want you to know
    that that won't happen. That is not going to happen. I will
    make absolutely certain that not one more nickel is taken out
    of the PPHF for anything outside than what it was intended for.
    Just as I will not go after NIH to get money for the PPHF,
    we're not going to take money out of that fund and put it into
    NIH.
        Now, again, if you're wondering why I'm so upset about
    this, it's because this President put in his budget to take
    $4.5 billion out of that fund. And the Congress, in extending
    the unemployment insurance to the end of the year and that tax
    cut on Social Security, while they pay for it, they took the
    money out of the PPHF.
        So I'm very upset about that. I'm very upset with the
    President and his people at the Office of Management and Budget
    (OMB) for what they did on that, and then to come and say, now
    we're going to take another $80 million. I know that sounds
    like a small amount but, still, after you've taken $5 billion
    out, and now they're just going to start nickel and diming us?
        So, I just want you to know, I'm a strong supporter of
    Alzheimer's research, but this $80 million isn't happening. NIH
    has the flexibility to direct a larger share of its funding to
    Alzheimer's research within its own budget, assuming two
    things. One, there are enough scientific opportunities to
    warrant an increase, and, second, researchers submit enough
    high-quality applications.
        So, again, I know all of the data and statistics on what's
    happening on Alzheimer's in the future. It's something we have
    to pay more attention to. We need more research into that area.
    How much more, I don't know. That's up to you. You're the
    experts in this area.
        But this subcommittee will be more than supportive of
    efforts by the NIH to focus more on this, given those two
    conditions that I mentioned, into Alzheimer's research.
        And I don't know if you have a response to that, Dr. Hodes
    or not, I'm not asking for a response. I just want you to know
    what's happening here.
        Senator Shelby.

                NATIONAL INSTITUTES OF HEALTH MERITOCRACY MODEL

        Senator Shelby. Thank you, Senator Harkin.
        The NIH has a highly competitive, two-tiered, independent
    peer-review process that ensures support of the most promising
    science and the most productive scientists. The fiscal year
    2013 budget proposes to alter this system by capping the amount
    of awards one principle investigator can receive at $1.5
    million.
        And while I suspect you will state this proposal will only
    scrutinize large guarantees and not mandate a strict dollar-
    level cap, I'm concerned that there's a larger issue with this
    proposal; that is, a disincentive to success.
        This proposal limits the amount of rewards one investigator
    can receive through the peer-review process and does not let
    science dictate funding decisions.
        Dr. Collins, what will make a researcher strive for the
    next discovery when they're limited in the awards that they can
    receive? Could you explain?
        Dr. Collins. Senator, I appreciate the question very much,
    and we are, at NIH, proud of being what we would call ourselves
    a meritocracy; that is, you get supported by NIH because of the
    strength of your science.
        Senator Shelby. Right. Well, that's a strength of NIH,
    isn't it?
        Dr. Collins. It is. And we aim to maintain that.
        This circumstance is born of the particularly difficult
    constraints that we now see in front of us, where there is no
    magical solution to the several pressures.
        I mentioned earlier that the ability of early stage
    investigators who are just getting started to get funded is
    clearly putting them under considerable stress.
        We debated over many months whether in fact there were
    levers that NIH might be willing to try to pull in this
    circumstance to be sure that we were supporting the best
    science in a way that might require a little bit more scrutiny
    in certain circumstances.
        And you're right in your comment. What we are not proposing
    is a cap on an individual investigator's support at $1.5
    million, not at all. It is just that if an investigator has
    already achieved that amount of funding and comes in asking for
    more, that particular grant is going to get a little bit more
    scrutiny to be sure that this is in fact the best use of the
    taxpayers' dollars.
        That's what we're aiming to try to do. This has been, in
    some ways, piloted by National Institute of General Medical
    Sciences (NIGMS). They have been doing this already for several
    years, and even at a lower cap, at $750,000.
        And most of the time, when they look at the application,
    they said, this is great science, we should fund it. We've
    looked at it a little bit more closely now. We want to be sure
    that this investigator can actually manage three or four
    projects as opposed to one, and we think they can, and let's go
    ahead and see what they can do.
        Senator Shelby. So you're not saying you're going to cap
    it?
        Dr. Collins. No.
        Senator Shelby. You're going to measure it and see what
    happens.
        Dr. Collins. We're going to look at it a little more
    closely and see what happens.
        Now only about 6 percent of our investigators are at that
    level, so this is not going to clog the system. And it will be
    the decision of our advisory councils, who are themselves very
    invested in the meritocracy model, who will decide whether, in
    fact, this is the right place to go.

                              REPLICATING RESULTS

        Senator Shelby. In December, the Wall Street Journal ran a
    front-page article entitled, ``Scientists' Elusive Goal:
    Reproducing Study Results.'' I'm sure you saw that.
        The article described a phenomenon in which most biomedical
    study results, including those funded by the NIH, that appear
    in top peer-reviewed journals cannot be reproduced or
    replicated.
        The article cited a Bayer study, describing how it had
    halted 64 percent of its early drug target projects because in-
    house experiments failed to match claims made in the
    publications.
        This is a great concern, Dr. Collins. I don't want to ever
    discourage scientific inquiry, and I know you don't, or basic
    biomedical research. But I think we on this subcommittee, we
    need to know why so many published results in peer-reviewed
    publications are unable to be successfully reproduced.
        When the NIH requests $30 billion or more in taxpayer
    dollars for biomedical research, which I think is not enough,
    shouldn't reproducibility, replication of these studies, be a
    part of the foundation by which the research is judged? And how
    can NIH address this problem? Is that a concern to you?
        Dr. Collins. It certainly is, Senator. And that Wall Street
    Journal article also I think raised many ripples of concern,
    because of the numbers that Bayer was citing.
        Well, first of all, we know that investigators who are
    doing cutting-edge science are working in areas where you're at
    the edge of what's possible.
        Senator Shelby. We know you're experimenting and you're
    hoping. I understand.
        Dr. Collins. Exactly. And so it is not surprising that in
    that circumstance you may come up occasionally with results
    that others can't seem to replicate but----
        Senator Shelby. What about that kind of percentage?
        Dr. Collins. Well, the percentages quoted by Bayer were
    certainly deeply troubling.
        Senator Shelby. What about at NIH? What kind of percentages
    do you have there?
        Dr. Collins. I think it would depend on exactly how the
    question was phrased. So certainly----
        Senator Shelby. What do you mean by that?
        Dr. Collins. Well, when somebody is publishing a paper
    saying that we have determined that it is exactly 24.3 percent
    of individuals who have a particular problem when it turns out
    it's really 31 percent or 17 percent. Well, was that a
    confirmation or not? You see the issue in terms of the
    precision.
        Bayer as a company is trying to make drugs. They want to
    tolerate no imprecision before they invest hundreds of millions
    of dollars. So, some of this is along those lines.
        Senator Shelby. Okay.
        Dr. Collins. Some of it is, frankly, the fact that when you
    try to repeat an experiment, you may not do it exactly the same
    way. And both answers could be right, the original investigator
    and the person who tries to reproduce it, but they actually
    didn't quite do the same experiment. And that is always a
    possibility when you look at a conflict of this sort.
        But you know what the good news is? It's that science is
    self-correcting, that over the course of time, any result that
    matters is going to be looked at by other investigators, in the
    private sector, in the public sector. And if it is not correct,
    you will discover that relatively soon. And if it is correct,
    others will know that and will build upon it.
        So despite the concerns here, which I think are quite real,
    I think we can be confident that our overall scientific
    foundation is strong.
        Senator Shelby. Thank you. Thank you, Mr. Chairman.
        Senator Harkin. Great response.
        Senator Mikulski.

                  FEDERAL EMPLOYEES: RECRUITMENT AND RETENTION

        Senator Mikulski. I know the hour is growing late, and I
    want to note Senator Harkin's concern about prevention.
        And when we did the Affordable Care Act, this was going to
    be one of the lynchpins of our bill, both prevention and
    quality initiatives, so that we can both save lives, improve
    lives, as well as save money.
        That is why we looked at chronic conditions. That is why
    you'll hear me talk so much about them. The epidemic that we
    know is a chronic condition. Hopefully, one day we can manage
    Alzheimer's the way we manage diabetes, that we know that it is
    there, but we can handle it.
        Unfortunately, the prevention money has been used as a bank
    to fund other things, and this is what has Senator Harkin so
    concerned and, quite frankly, myself.
        And I think we need to look at the Alzheimer's funding. We
    need to talk about where else we can look to that, because it
    would be a sad day in our country where one important need and
    one important paradigm shift and focus is pitted against each
    other. So we look forward to working together to solve this
    problem and to move ahead.
        But I want to talk about Federal employees in your NIH. Of
    course, I am deeply concerned about the continual attack. Not
    only do we have to look at how we are going to fund Federal
    employees, their pay, their pensions, the pay freeze but also
    this ongoing hazing, harassment, snarky comments, throwaway
    one-liners, and so on.
        Now that's how I feel. Could you tell me, Dr. Collins, how
    that impacts your recruitment and retention? Or have I just got
    a soft heart towards Federal employees?
        Dr. Collins. We thank you for your soft heart, Senator. It
    means a lot.
        But this is a very serious issue in terms of morale. For
    individuals like the 18,000 who work at NIH, to read about
    themselves in the comments of individuals who've never met
    anybody who works at NIH and who talk about these being
    employees who are simply overpaid and contributing little is
    deeply hurtful.
        I am so proud to stand at the helm of an organization with
    such incredibly dedicated people, some of whom you see here at
    this table with me, and all of those, in terms of senior
    scientific positions, who could easily be employed at much
    better financial rates in other parts of the public and private
    sectors, and who are doing this work because of their hopes of
    making a difference, because of their public spirit, because of
    their determination to make the world a better place.
        To have that kind of dedication characterized in the way
    that seems to be done in a sweeping way by people talking about
    Federal employees as if they are somehow a parasite upon the
    public is really deeply hurtful.
        And of course, that is translated into decisions in terms
    of ways in which Federal employees are being treated in terms
    of financial aspects, which I think our employees are ready to
    actually tighten their belts and take whatever needs to be done
    in an honorable fair-minded way, as far as helping out with the
    difficulties our Government faces.
        But why gang up on them? Why try to single them out?
        Senator Mikulski. Here is my question in line with that.
    Since all of the activities that have been going on,
    particularly around pensions, extended pay freezes, and so on,
    do you see an upsurge in requests for retirement?
        Dr. Collins. I don't know if I have statistics on exactly--
    --
        Senator Mikulski. I am not only talking about the Ph.D.'s,
    but we're talking about the lab people, the ones who run that
    fire department. I mean, there is a lot of support staff that
    goes on to enable the scientist to be the scientist.
        Dr. Collins. Indeed. And we depend on those people
    critically or we couldn't do our work. I don't know whether
    there is an actual statistical indication of an upsurge in
    retirements, but certainly as an indicator of general morale, I
    would not be surprised if that is the case.
        And when it comes to your other question about hiring
    people, the kinds of hires that I am trying to be involved in
    generally are the high-level senior scientists, and this
    question comes up, ``Is this a good time to come and work for
    the Federal Government? All the things we are reading about in
    the paper makes it sounds as if we're not going to be
    considered as the leaders we hoped to be.'' It is a serious
    issue.
        Senator Mikulski. So my colleague from the other side asked
    excellent questions about, you know, the issues about the
    availability of scientists, are they going elsewhere to do
    research, should we change our immigration policy, give every
    new Ph.D. a green card? Those are subjects of debate. But we
    are losing out on ourselves, aren't we?
        Dr. Collins. We are. Even for the people that grew up here
    and want to stay here. They are not necessarily being well-
    received, as they should be for their dedicated service.
        Senator Mikulski. Right. And as I look at the table, I note
    the longevity and the incredible service, Dr. Hodes, we've
    known. Dr. Fauci I have known from more than 25 years--20
    years.
        Dr. Collins. I bet its 25 or 30 years.
        Senator Mikulski. I bet that.
        And Dr. Varmus was at NIH, left for Memorial Sloan-
    Kettering Cancer Center, came back to head a new Institute.
    This says something about mission-driven. But I think we need
    to correct it.
        Now, I want to be clear, I don't have my coat on as
    symbolic defiance of the pay freeze.
        But I think we need to not only look at how we can manage
    our Government in a more frugal way, but I think we need to
    stop this bashing of our Federal employees, and, like you said,
    take note of what we ask them to do. Everybody is against the
    Federal employees until they want them and need them.
        Dr. Collins. Thank you, Senator.
        Senator Mikulski. Thank you very much.

                     NATIONAL INSTITUTES OF HEALTH FUNDING

        Senator Harkin. Thank you, Senator Mikulski.
        I just want to clear up--maybe I misspoke or I may have
    left a wrong impression when I said that we won't take money
    from the prevention fund for NIH; we won't take from the NIH
    for the prevention fund.
        That is not necessarily true. It depends on what it is
    being used for.
        For example, Dr. Rodgers, we have the NIH fund for the
    diabetes prevention program. In fact, I included $10 million
    from the PPHF for that, because that is a proven intervention.
    It has been proven to prevent and to delay the onset of type 2
    diabetes.
        The research for that, however, was funded both by NIH and
    CDC collaboratively. So once they have funded the adequate
    research, and they have proven interventions, that is where
    we're more than willing--I am more than happy to get money out
    for the prevention aspects of that.
        What I was talking about on Alzheimer's is that the
    research for Alzheimer's should not come from the PPHF. If your
    research leads to some proven preventative measures, which we
    hope it does, then that is the point at which then we step in
    with the PPHF. Do you see what I'm saying?
        So I just want to kind of clear that up. That's why the $80
    million is not going to happen from us. If you've got a proven
    prevention strategy that has been proven through research,
    fine. That's what the Prevention and Public Health Fund is for.
    I just want to clear that up.

                                BIOLOGY OF AGING

        But one other question, Dr. Hodes, on Alzheimer's. As to
    the question about the biology of aging, when we think of
    Alzheimer's, cancer, congestive heart failure as distinct
    diseases, one thing they have in common, it comes with aging.
    And so if we can learn more about the aging process, we think
    that might give us more insight into this.
        The NIA took the lead in establishing a group to coordinate
    efforts across the NIH on understanding the role aging plays in
    susceptibility to age-related diseases.
        Can you just tell us a little bit more about the current
    activities of this interest group and why is it important?
        Dr. Hodes. Thank you for that question, and I would be
    happy to.
        Just as you described, aging is clearly a risk factor for
    many of the changes, diseases, conditions that occur as the
    years go by. And there is increasing evidence that there are
    identifiable, underlying biological processes that occur with
    aging that may be of interest not only in their own purely
    scientific right, but because they give clues as to points of
    intervention to affect many of the conditions with aging.
        With this in mind, with increasing evidence, exciting
    studies such as a recent demonstration that in experimental
    animals, small numbers of cells which can be identified as
    senescent--they behave abnormally; they secrete abnormal
    proteins; but they are in very small numbers--went through very
    ingenious genetic manipulations. They are removed from a live
    animal, a mouse model. The mouse does better. The mouse has
    reversed many of the conditions that occur with aging, as an
    example of the way that intervening at this basic level may
    have broad implications.
        Based on this kind of conviction, there has been over the
    past several months discussions beginning with a number of us
    at the table here as Institute Directors, a support of an
    interest group that brings together those who may have primary
    affiliations with various disease organ-centered Institutes and
    Centers, but in common have reason to believe that the
    underlying aging process is relevant to all of us.
        This interest group now has sponsored and will continue a
    series of lectures, of journal clubs. But most importantly, it
    creates a new forum for looking at ways in which common support
    from across the NIH toward problems that are appropriately
    targeted for the benefit of all us based on the condition of
    aging will benefit--and it is truly an exciting time and a
    revolutionary kind of expansion in the way this consciousness
    now has progressed across NIH.
        So we're very excited by it. We think it has great promise
    for making our research more efficient, more targeted to serve
    all.
        Senator Harkin. Very good.
        I have agreed to permit this room to be used by the
    National Alliance on Aging after this hearing for a press
    conference on that subject.
        There was one other thing I wanted to bring up here. I have
    a lot of things I would like to bring up here, as a matter of
    fact.
         I am down to 15 seconds. Do you have another question that
    you want to ask?
        Senator Mikulski.
        Senator Mikulski. I think that's it.
        Senator Harkin. Do you want anything else?
        I'll tell you what, I'll submit it in writing. It is a
    longer question. I'll submit it in writing. We're getting close
    to the noon hour anyway. It has to do with the tension between
    more grants for less money, fewer grants for more money. We
    kind of touched on that in the beginning. I would like to delve
    into that a little bit more, and I'll do it with a written
    question, just how you're looking at that tension that is going
    on, because we want to increase the grants but decreasing the
    amount of money, what does that do?
        Anyway, I am conflicted by it. I don't know what the right
    answer is. So I'll write it to you.
        Anything else that anybody wanted to bring up for the
    record that we not have asked or you wanted to follow up for
    any clarification purposes or anything like that? Anyone at
    all?

                         ADDITIONAL COMMITTEE QUESTIONS

        Well, listen, our thanks to all of you for your great
    leadership at the NIH, and we're going to do our best to make
    sure that our budget is not only not decreased, but we
    hopefully increase it a little bit, but things are tight around
    here, as you know.
        Senator Shelby. Especially in the area of biomedical
    research.
        [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
                              number of new grants
        Question. Dr. Collins, you noted in your opening statement that the
    number of new and competing research grants in the President's budget
    would rise from 8,743 in fiscal year 2012 to 9,415 in fiscal year 2013,
    an increase of 672. That's encouraging. But to achieve this increase,
    the value of individual grants would drop slightly. As you explained,
    noncompeting grants would be cut by 1 percent.
        This raises a fundamental dilemma for National Institutes of Health
    (NIH), one that is likely to persist as long as budgets remain tight.
    And that is: Is it better to award more grants for less money or fewer
    grants for the same (or more) money?
        The President's budget seems to have opted for the former approach.
    More grants mean a higher success rate, plus more opportunities for
    young researchers to win their first award. But of course there are
    also disadvantages when the average value of each grant drops. Some
    argue that it makes more sense to simply fund the best science, and if
    that means fewer grants, then so be it.
        Please comment on this tension and why the President's budget puts
    an emphasis on increasing the number of grants.
        Answer. NIH uses its Research Project Grants (RPG) to support the
    most meritorious research applications identified by a rigorous peer-
    review process to have the highest potential for advancing biomedical
    knowledge and public health. The total number of competing RPG
    estimated in the President's fiscal year 2013 budget request is
    expected to increase to 9,415 compared to the 8,743 funded by the
    fiscal year 2012 enacted level. A tight budget environment prompts a
    delicate balancing of needs to fund adequately new individual projects,
    support the maximum number of new research opportunities, and sustain
    existing grants. In order to maximize resources for investigator-
    initiated grants, NIH plans to follow grants management policies in
    fiscal year 2013 that discontinue outyear inflationary allowances for
    most grants. In the short term, NIH plans to reduce noncompeting
    continuation grants by 1 percent less than the fiscal year 2012 level,
    and negotiate the budgets of competing grants to avoid growth in the
    average award size. In the future, sound fiscal management requires
    that we continue to carefully consider the number, cost, and duration
    of new RPGs in order to minimize negative impact on existing programs.
        Accompanying these policies for maximizing resources in fiscal year
    2013 for new investigator-initiated grants is our continued commitment
    to award grants to new investigators at rates equal to those of
    established investigators. Also, NIH will establish a new process for
    additional scrutiny of awards to any principal investigator with
    existing grants of $1.5 million or more in total costs by an Institute
    or Center's Advisory Council. The purpose of this policy is to promote
    the award of NIH research grants to as many distinct principal
    investigators as possible.
        These policies will work in concert to ensure that pursuit of new
    research questions, the lifeblood for cutting-edge science, is
    maintained. Science advancement includes both the production of new
    knowledge and new scientists. New scientists, however, must have a
    reasonable expectation that they will be able to successfully compete
    for their own research grants at the end of their prolonged period of
    training if they are to be retained as members of the biomedical
    research workforce. NIH has strategically chosen in fiscal year 2013 to
    support a larger number of new research project grants by sustaining
    support for noncompeting continuations at 99 percent of their competing
    levels. This approach balances NIH's commitment to its ongoing research
    portfolio with the need to stimulate new research ideas and priorities
    in this time of limited resources.
                           national children's study
        Question. Dr. Collins, NIH, Centers for Disease Control and the
    Environmental Protection Agency spent a combined $54.7 million on the
    National Children's Study (NCS) from fiscal year 2000 through fiscal
    year 2006. From fiscal year 2007 through fiscal year 2012, the Congress
    appropriated another $937 million for the NCS, bringing the total to
    almost $1 billion. What has this nearly $1 billion achieved so far?
        Answer. NIH has shown the feasibility of performing an NCS by
    designing and testing varied scientific approaches and demonstrating
    how to conduct a study of this size and scientific and logistical
    complexity in a fiscally sound manner.
        In addition to comparing different enrollment strategies to develop
    a scientifically valid and fiscally responsible methodology to enroll
    100,000 children in the Main Study, the NCS has enrolled more than
    3,000 children to date in the Vanguard Study. In addition, we have
    developed innovative approaches to research methodology and developed
    broadly useful research tools.
        Examples include:
      --New informatics approaches including:
        --The capacity to capture systematically the operational,
                logistical, and cost data for an ongoing study;
        --A comprehensive approach to harmonize the terminology for
                neonatal medicine, including the deposition of hundreds of
                terms that researchers around the world can use into the
                National Cancer Institute Enterprise Vocabulary Services;
        --Development of nonproprietary data collection, case management,
                and data archiving tools that conform to international data
                standards and can be used in many types of research;
        --Development of a system of tagging data to allow rapid analysis
                and data pooling for research data;
        --Simulation strategies for comparing complex recruitment
                strategies; and
        --New methods for implementing and analyzing recruitment in large
                studies and an analytic approach to examine rates,
                kinetics, and efficiencies to allow selection of optimal
                recruitment strategies;
      --A research portfolio of approximately 300 individual studies, most
            of which were multicenter, to establish and validate methods to
            support the Study;
      --In conjunction with the U.S. Department of Health and Human
            Services Office for Human Research Protections, a national
            network of Institutional Review Boards using a Federated Model
            that covers all 36 National Children's Study Centers, which
            saves time and costs for administrative review for human
            research protections;
      --A biobank repository for human biological specimens and
            environmental samples that is modular and scalable. The
            repository has collected about 125,000 specimens and has
            already distributed thousands of specimens for analysis and
            additional scientific projects;
      --A research workflow process in 40 locations that is flexible and
            cost effective that can be used by many other types of
            research, as well as the NCS. For example, the Clinical and
            Translational Science Awards (CTSA) Consortium is adapting the
            same processes in many of the 28 NCS locations that are also
            CTSA locations;
      --Collaborations with longitudinal birth cohort studies around the
            globe to harmonize practices and leverage resources; and
      --In collaboration with other statistical agencies, new statistical
            methods for analysis for combining data from multiple types of
            research.
        Question. The President's budget for fiscal year 2013 would add
    another $165 million. What do you estimate the cost of the NCS will be
    in fiscal year 2014, when recruitment is expected to begin?
        Answer. Pilot testing conducted through the NCS Vanguard sites
    showed that a study design based on recruiting participants through
    healthcare providers was most efficient. Other large Federal studies
    have also effectively employed this provider-based approach. Also,
    while the revised approach may use healthcare provider networks as the
    primary source for recruitment, the NCS could see additional
    participants through secondary sources (such as title V clinics, Indian
    Health Service clinics, or contract research organizations) to assure
    inclusion of all appropriate population groups. The President's budget
    request for fiscal year 2013, which shows a reduction of approximately
    15 percent to $165 million for the NCS, appropriately reflects these
    proposed design changes. While future funding needs for the outyears
    will be determined by early data gathered by the Main Study, we
    anticipate that the budget for fiscal year 2014 will be the same as for
    fiscal year 2013.
        Question. How long will the recruitment phase take, and do you
    expect the annual cost will remain fairly constant during that period?
        Answer. We expect to issue the Request for Proposals for the Main
    Study in the fall of 2012, with awards made in 2013 and recruitment
    beginning in 2014. The recruitment phase is expected to continue for
    approximately 3 to 3\1/2\ years. We anticipate annual costs will remain
    flat in unadjusted dollars during the recruitment phase.
        The NCS is able to reduce overhead costs through greater
    operational efficiencies and redistribution of tasks and
    responsibilities. Examples include the use of nonproprietary software
    to eliminate license fees and proprietary support; use of a federated
    model for human subject protection to reduce redundancy and speed
    approvals through elimination of duplicate administrative resources;
    use of the NCS Program Office as a coordinating center to develop study
    instruments and protocol documents, to perform data analysis, and to
    manage field operations and general consolidation of overlapping field
    operations.
        With the reduction in overhead, we anticipate that for fiscal year
    2013 we need approximately $35 million for support services and $130
    million for ongoing Vanguard operations and Main Study initiation. Main
    Study initiation includes:
      --community outreach and advertising;
      --memoranda of understanding with cooperating facilities;
      --establishment and testing of informatics platforms, including data
            security and regulatory compliance;
      --establishment and testing of biospecimen and environmental sample
            collection and shipping from study locations;
      --training of field personnel;
      --regulatory approvals for information collection from participants;
            and
      --establishment of data collection and transmission quality assurance
            and quality control processes.
        Question. Is the annual cost expected to rise or decline after the
    recruitment phase? If so, by approximately how much (e.g., 25 percent)?
        Answer. Once the more labor-intensive recruitment phase has been
    completed, funding requirements for the NCS over the life of the study
    are expected to remain stable. While the number of participant visits
    each year may decrease to once per year, some subgroups in the Study
    may receive additional questionnaires on specific topics. In addition,
    as the number of biospecimens and other data collected from Study
    participants increases, the fiscal needs of the biobank and data
    warehouse rise, as these data and samples are both stored and made
    ready for analysis by other scientists.
        Question. Do you expect the annual cost will remain fairly constant
    during the Main Study, once recruitment has been completed?
        Answer. Annual unadjusted costs are expected to remain constant in
    unadjusted dollars following the recruitment phase of the Main Study.
    The prenatal and infant development phases are of critical importance
    because of the potentially long-term effects of various environmental
    exposures; consequently, the NCS plans to ``frontload'' the Study,
    conducting more participant visits and sample collections in those
    years. However, as the frequency and intensity of study visits
    decreases, the costs associated with biospecimen and environmental
    sample processing, storage, and analysis and with data processing,
    storage, analysis, and security will increase.
                                 pain research
        Question. Dr. Collins, I understand that National Institute of
    Neurological Disorders and Stroke plans to establish a new trans-NIH
    working group on overlapping chronic pain conditions. Please provide
    some more details on this effort and what it is intended to accomplish.
        In addition, what mechanisms will the NIH employ to:
      --expedite scientific understanding of the factors that predispose,
            trigger, and perpetuate chronic pain;
      --advance our knowledge of the diverse underlying mechanisms
            responsible for chronic pain (including individual differences
            and sensitivity to pain);
      --identify promising effective therapeutic drugs (and other
            approaches) for pain control; and
      --expedite the translation of these findings to those suffering,
            especially the most at-risk populations such as women?
        Answer. In 2011, NIH hosted a number of meetings and workshops
    focusing on overlapping chronic pain conditions that disproportionately
    affect women. These workshops included discussions of possible common
    pathways underlying these conditions as well as the need for improved
    research diagnostic criteria for overlapping pain conditions. To
    address these issues further, a new trans-NIH overlapping chronic pain
    conditions working group was formed in fall 2011. The group is led by
    the National Institute of Neurological Disorders and Stroke (NINDS) and
    the National Institute of Dental and Craniofacial Research and brings
    together staff from 13 Institutes and Centers involved in pain research
    as well as a representative from the patient advocacy community. The
    working group will help coordinate research efforts across the NIH on
    overlapping chronic pain conditions and is planning a trans-NIH
    conference in August 2012 that aims to:
      --evaluate and summarize current knowledge on the causes and
            progression of overlapping pain conditions;
      --identify critical research needs, such as improved research
            diagnostic criteria for this group of conditions; and
      --enhance interdisciplinary collaboration and cooperation in this
            area of research.
        NIH utilizes a number of mechanisms to fund research on
    understanding the factors that predispose, trigger, and perpetuate
    chronic pain and the underlying mechanisms responsible for individual
    differences and sensitivity to pain. Sixteen NIH Institutes and offices
    supported the NIH Blueprint for Neuroscience Grand Challenge on Pain,
    whose goal was to facilitate highly collaborative, multidisciplinary
    research to better understand the mechanisms that underlie the
    transition from acute to chronic pain. Research supported by this
    initiative aims to understand the important role of neuroplasticity--or
    changes in the nervous system--in transitioning to chronic pain and the
    need to reverse these maladaptive changes, to allow recovery. Other
    projects funded through this initiative are focused on the
    identification and modulation of genetic changes that predispose
    individuals to and contribute to the onset of chronic pain. NIH
    continues to accept competitive revisions that propose a collaborative,
    1-year pilot study or new specific aim associated with an active NIH
    grant as part of this initiative. The Mechanisms, Models, Measurement
    and Management in Pain Research Initiative supported by 11 NIH
    Institutes is another example of a trans-NIH solicitation that
    encourages a wide range of basic, translational, and clinical research
    on pain including sex differences in the pain experience and genetic
    contributions to individual variability and response to treatment.
        The pain portfolios at a number of NIH Institutes include research
    focused on risk factors for chronic pain and individual differences in
    pain perception. For instance, brain imaging studies (fMRI and resting
    state fMRI) supported by NIH have compared structural and functional
    brain changes with pain states, supporting the notion that central
    nervous plasticity is a characteristic of chronic pain. A cutting-edge
    study used cortical imaging to detect changes in the brain to
    distinguish which patients transition from acute to chronic back pain
    and which recover. Extensive use of imaging tools have also shown that
    differences in patient reported pain sensitivity are correlated to
    activation of brain regions associated with pain and are linked to sex,
    race, genetic makeup, and environmental stress levels. Environmental
    factors such as hormones and stress have been shown to contribute to
    differences in pain sensitivity and analgesic response, while genetic
    variants determine individual sensitivity to certain analgesics,
    ability to sense pain, and risk for chronic pain. Preliminary results
    from the NIH-supported Orofacial Pain: Prospective Evaluation and Risk
    Assessment (OPPERA) study have helped identify several genetic markers
    associated with risk for orofacial pain and related to different
    patterns of self-reported pain. NIH is also funding the ongoing
    Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP)
    studies to study pain characteristics that contribute to risk for
    transition to chronic pelvic pain and a 10-year study on overlapping
    pain conditions that disproportionately affect women, including
    episodic migraines.
        In addition to funding basic research on underlying mechanisms and
    causes for chronic pain, NIH supports a number of activities to advance
    the development of therapies to control and alleviate pain, including
    multiple activities in partnership with the FDA. Members of the NIH
    Pain Consortium--a joint undertaking across 25 NIH Institutes, Centers,
    and offices that facilitates collaborative pain research--currently
    participate in an advisory committee for the Analgesic Clinical Trial
    Translations, Innovations, Opportunities, and Networks (ACTTION)
    Initiative, a public-private partnership program sponsored by FDA to
    streamline the discovery and development of analgesics. In May 2012,
    NIH and the Federal Drug Administration plan to hold a state of the
    science workshop on assessing opioid efficacy and analgesic treatment
    in conjunction with the seventh annual NIH Pain Consortium Symposium
    focusing on advancing pain therapies. More broadly, senior leadership
    from the NIH and FDA are involved in an NIH-FDA leadership council that
    is exploring better coordination of NIH and FDA efforts to improve
    regulatory science and overcome hurdles in the drug development
    pipeline for common and rare diseases.
        The NIH Small Business Innovation Research (SBIR)/Small Business
    Technology Transfer (STTR) program supports research on developing pain
    therapies including projects focused on:
      --the development of small molecules as anti-inflammatory, analgesic
            agents;
      --neural stimulation to relieve phantom limb pain;
      --Internet tools for self-management as an adjunct to chronic pain
            care;
      --improved opioid formulations with fewer side effects; and
      --selectively targeting pain nerve fibers for gene delivery.
        NIH continues to encourage applications through the SBIR program,
    Institute-specific translational programs, and other mechanisms
    including trans-NIH initiatives. For example, the NIH Blueprint for
    Neuroscience Research currently supports a Grand Challenge for
    Neurotherapeutics to address the lack of effective treatments for
    disorders of the nervous system, including chronic pain. Additionally,
    the newly established National Center for Advancing Translational
    Sciences (NCATS) at NIH will catalyze the generation of innovative
    methods and technologies to enhance therapy development for a wide
    range of human diseases and conditions.
        NIH is currently involved in diverse dissemination efforts to
    inform the public about pain research findings. NIH is a member of the
    new Interagency Pain Research Coordinating Committee (IPRCC) which was
    recently created under the Affordable Care Act to enhance pain research
    efforts and promote collaboration across the government, with the
    ultimate goals of advancing fundamental understanding of pain and
    improving pain-related treatment strategies.
        The subcommittee has been specifically charged with making
    recommendations on how to best disseminate information on pain care,
    and NIH is working together with other member Federal agencies to
    collect information on current dissemination efforts in order to inform
    these recommendations.
        The NIH Pain Consortium is encouraging medical, dental, nursing,
    and pharmacy schools to respond to a new funding opportunity to develop
    Centers of Excellence in Pain Education (CoEPEs). The CoEPEs will act
    as hubs to develop and disseminate pain management curriculum resources
    for healthcare professionals and provide leadership for change in pain
    management education. Additionally, NIH provides online informational
    material on numerous chronic pain disorders that specifically reference
    overlapping pain conditions, and funds grants testing methods to teach
    patients how to access high-quality web-based health information for
    self-management of pain.
                                 food allergies
        Question. Dr. Fauci, life-threatening food allergy conditions
    affect millions of America's children. Trials in a small number of
    patients have demonstrated that oral immunotherapy (OIT) is safe and
    effective in a significant percentage of patients. Many researchers
    believe the next step is to determine the most effective dosage and
    timeframe for treatment through larger and more complex clinical
    trials. As we both know, however, these trials are expensive. While
    there are indications of substantial private philanthropic support,
    Federal money will also be required. One private research group has
    estimated that the cost of phase II trials for the eight major food
    allergens (peanut, tree nut, milk, egg, soy, wheat, fish, and
    shellfish), along with mechanism and longitudinal studies, would total
    about $90 million over 6 years.
        Answer. The National Institute of Allergy and Infectious Diseases
    (NIAID) is conducting Phase I and II clinical trials to evaluate OIT or
    sublingual immunotherapy (SLIT) to treat or prevent food allergy. These
    clinical trials include studies of various immunologic parameters to
    understand factors that relate to the development or natural resolution
    of food allergy and/or response to therapy. Recent and ongoing NIAID-
    sponsored OIT and SLIT trials include:
      --phase II clinical trial that showed that egg OIT is safe and
            effective in children 5 to 18 years old with egg allergy (in
            press, New England Journal of Medicine);
      --phase I/II clinical trial to determine whether peanut extract
            placed under the tongue (SLIT) is a safe and effective
            treatment for adolescents and adults with peanut allergy;
      --phase II clinical trial of milk OIT combined with anti-
            immunoglobulin E (omalizumab) for the treatment of children
            with milk allergy;
      --phase II clinical trial to determine if regular consumption of
            baked foods containing milk will enable children with milk
            allergy to drink milk and consume milk-containing foods; and
      --phase I/II prevention trial in which infants and young children at
            high risk for peanut allergy regularly consume peanut-
            containing snacks to determine if this will prevent the
            development of peanut allergy by age 5-6 years.
        Several OIT trials also are in development for children (1-4 years
    of age) and adults with peanut allergy.
        A few additional studies, conducted without NIH sponsorship, have
    recently been published. Similar in size to the NIH-sponsored studies,
    these phase I/II clinical trials (typically 20-60 children per study)
    have focused on milk, egg, and peanut and lead to similar conclusions,
    i.e., approximately 60-90 percent of those subjects who remain on OIT
    for 1-2 years can tolerate modest amounts of the food.
        Question. Are you in general agreement that the scientific studies
    already completed on OIT indicate that moving ahead with larger trials
    on key allergens is appropriate at this time?
        Answer. NIAID is enthusiastic about recent results of OIT for milk,
    egg, and peanut and agree that it will be important to proceed with
    larger phase II trials for these and other food allergens. While we
    anticipate many similarities in study design, the most promising
    approaches will likely differ based on the particular allergen and
    study populations (e.g., children vs. adults; mild vs. severe disease;
    treatment vs. prevention design; and single vs. multiple food
    sensitivities).
        Although OIT is currently the most promising approach for treating
    food allergy, a small number of patients appear not to respond to OIT
    and others (10-20 percent) are unable to tolerate OIT because of
    recurrent allergic reactions. Furthermore, patients with a history of
    severe anaphylaxis, who are most in need of new treatment strategies,
    have not been enrolled in these early-stage OIT clinical trials due to
    safety concerns. Further research is necessary to develop and test
    treatment strategies that will benefit these patients. Novel treatment
    strategies may also provide improved safety and efficacy for food
    allergic individuals in general. For example, the addition to OIT of an
    anti-immunoglobulin E or similar molecule may reduce adverse effects of
    OIT and allow for larger doses of OIT that might be more effective.
    Other routes of allergen administration, e.g., via a cutaneous patch,
    should also be explored.
        Question. What is your professional judgment as to the cost and
    appropriate timing of such a system of trials?
        Answer. For OIT that involves administration of a food alone (e.g.,
    milk, egg, and peanut), large phase II studies may be sufficient to
    change clinical practice (foods are not licensed by the FDA as
    therapeutics). Nonetheless, many such studies would be comparable in
    scope, complexity and cost to modest size phase III clinical trials
    required for drug licensure. In contrast, full phase III licensure
    studies will be required if OIT is combined with pharmaceuticals or
    allergen immunotherapy is administered through devices such as a
    cutaneous patch.
        In our professional judgment, a prioritized set of clinical trials
    would include:
      --a series of larger phase II studies to confirm the promising
            results of the studies on egg, milk, and peanut outlined
            previously (estimated cohort sizes of 100-300 subjects);
      --phase II/III studies of OIT for the same allergens with the
            addition of pharmaceuticals (e.g., anti-immunoglobulin E) to
            diminish adverse events in OIT and improve efficacy of OIT;
      --phase I-III studies of peanut (and perhaps other food allergens)
            delivered by cutaneous patch;
      --phase I/II pilot studies exploring OIT for the other major food
            allergens (tree nut, soy, wheat, fish, and shellfish) followed
            by larger phase II studies (100-300 subjects) to confirm any
            promising results; and
      --various food allergy prevention trials in high-risk infants and
            young children. We anticipate that the minimum duration of most
            phase II-III trials would be 3-4 years and most prevention
            trials would take 6-7 years.
        To ensure that the highest-priority studies are conducted
    ethically, rigorously, and safely, such studies should be phased in
    over a period of years. A phased process will allow knowledge gained
    from the initial studies to inform the design of future studies,
    improve safety, and enable cost efficiencies.
        Factors that contribute to total costs include cohort size, study
    duration, complexity of treatment regimens and clinical outcomes, the
    number of protocol-required blinded food challenges, costs of allergen
    preparation and distribution under Good Manufacturing Practices, costs
    of additional pharmaceuticals (e.g., biologics, such as monoclonal
    anti-immunoglobulin E or cutaneous patch delivery devices), and the
    type and number of immunologic parameters to be studied. Thus, in our
    professional judgment, an integrated set of a prioritized set of
    clinical trials could cost $150-$250 million over many years.
    Additional constraints on implementation of such a highly ambitious set
    of clinical trials include the limited capacity of academic research
    centers and the relatively small existing cadre of highly trained and
    experienced adult and pediatric specialists in food allergy research.
        Question. How much money would be required in the first year to
    initiate a full set of OIT trials?
        Answer. NIAID would recommend that a full prioritized set of OIT
    clinical trials as outlined above not be initiated in a single year. We
    estimate a first-year total cost of $20-$25 million to fund four of the
    highest priority OIT clinical trials for peanut, egg, and/or milk
    allergens.
                                     ______

                Questions Submitted by Senator Daniel K. Inouye
                    institutional development award program
        Question. Over the past 13 years, the Congress has supported the
    National Institutes of Health (NIH) Institutional Development Award
    (IDeA) program. In IDeA States like Hawaii, our biomedical communities
    have seen great improvement in our scientists' ability to garner NIH
    support as well as our capacity to recruit and retain biomedical
    scientists, physician-scientists, teachers, graduate students, and
    postdoctoral fellows. With the dissolution of the National Center for
    Research Resources (NCRR), which administered IDeA, and the proposed
    budget reduction of IDeA by $50 million (representing an 18-percent
    cut), there is concern that NIH is not fully committed to the IDeA
    program even though the Congress has been supplementing the IDeA budget
    for the purpose of expanding clinical translation research efforts in
    IDeA States. What assurances can you provide that NIH supports the IDeA
    program and will continue to sustain research infrastructure support
    targeting the chronically underfunded IDeA States?
        Answer. Following the dissolution of NCRR, the IDeA program was
    transferred to the National Institute of General Medical Sciences
    (NIGMS), a logical home in view of NIGMS' long-standing commitment to
    research training and capacity building. Nearly all the NCRR staff who
    managed the IDeA program also moved to NIGMS, enabling the
    administration of the IDeA grants to proceed seamlessly.
        NIGMS is strongly supportive of the IDeA program. NIGMS appreciates
    its value to States that do not receive high levels of support from
    NIH's traditional grant mechanisms, as well as its importance in
    enabling excellent research, training, and career development that
    benefit the entire Nation. NIGMS intends to essentially maintain the
    level of support for the Centers of Biomedical Research Excellence
    (COBRE) and IDeA Networks of Biomedical Research Excellence (INBRE)
    programs and the new Clinical and Translational Research program.
                               health disparities
        Question. Given the continuing disparities in health outcomes and
    NIH's acknowledgement of the low numbers of underrepresented minority
    researchers, please describe efforts to address disparities in health
    outcomes and the representation of minority investigators in NIH
    support research programs.
        Answer. While the overall health of the U.S. population has
    improved, certain populations continue to have a higher risk of adverse
    health outcomes. These health disparities are the result of
    multifactorial biologic and nonbiologic influences. The NIH Health
    Disparities Strategic Research Plan and Budget, a 5-year plan, provides
    a blueprint for addressing health disparities and fostering access of
    racial/ethnic minorities to the clinical benefits of NIH research. The
    Plan focuses on three major goals each NIH Institute and Center must
    strive to achieve:
      --conduct and support research on the factors underlying health
            disparities;
      --expand and enhance research capacity to create a culturally
            competent workforce; and
      --engage in proactive community outreach, information dissemination,
            and public health education.
        The pace of translation is a recognized barrier to racial/ethnic
    minorities reaping the benefits of clinical research. NIH is committed
    to accelerating the pace of research translation by reducing the time
    it takes for scientific discoveries to reach patients in the form of
    treatments or health information. Several ongoing research programs and
    studies contribute to the NIH efforts to translate research findings to
    racial/ethnic communities and increase their access to the benefits of
    NIH-funded research, including the following:
    Development and Translation of Medical Technologies That Reduce Health
            Disparities Initiative
        National Institute on Minority Health and Health Disparities
    (NIMHD) and the National Institute of Biomedical Imaging and
    Bioengineering established a partnership through the Small Business
    Innovation Research program to support the development and translation
    of medical technologies aimed at reducing disparities in healthcare
    access and health outcomes. Potential technologies targeted are
    telehealth for remote diagnosis and monitoring, sensors for point-of-
    care diagnosis, devices for in-home monitoring, mobile, portable
    diagnostic and therapeutic systems, devices which integrate diagnosis
    and treatment, diagnostics or treatments that do not require special
    training, devices that can operate in low-resource environments, non-
    invasive technologies for diagnosis and treatment, and integrated,
    automated system to assess or monitor a specific condition.
    National Institute on Minority Health and Health Disparities Community-
            Based Participatory Research Initiative
        This 11-year initiative is designed to facilitate the translation
    of scientific discoveries arising from laboratory, clinical, or
    population studies into clinical applications to reduce health
    disparities and to disseminate scientific information. These Community-
    Based Participatory Research (CBPR)-supported intervention studies are
    expected to enhance clinical practice and improve the health of racial/
    ethnic populations by actively engaging the community in all phases of
    research including design, implementation, and dissemination of the
    research results.
    National Institute on Minority Health and Health Disparities Centers of
            Excellence Program
        The Centers of Excellence (COE) program advances scientific
    knowledge on the biological and nonbiological factors contributing to
    health disparities and develops interventions to address some of the
    most prevalent diseases, and health conditions that disproportionately
    affect racial/ethnic minority populations. Since 2002, NIMHD has
    supported 91 COE sites in 35 States, the District of Columbia, Puerto
    Rico, and the U.S. Virgin Islands. Awardees represent all types of
    institutions including Historically Black Colleges and Universities,
    Hispanic Serving Institutions, Tribal Colleges and Universities, and
    Alaska Native and Native Hawaiian Serving Institutions.
        Although NIH recognizes a unique and compelling need to promote
    diversity in the biomedical, clinical, behavioral, and social sciences
    research workforce; sufficient representation has been to date elusive.
    Advancing diversity through NIH training support is expected to produce
    a number of tangible and overlapping benefits including:
      --enhancing the overall capacity to address health disparities;
      --improving patient satisfaction in ways that enhance participation
            in clinical research setting; and
      --creating and preparing a culturally competent workforce that
            enhances communication.
    Research Supplements To Promote Diversity in Health-Related Research
        This NIH-wide program provides supplemental support to existing
    NIH-funded institutions to encourage the participation of individuals
    from groups currently underrepresented in biomedical, clinical,
    behavioral, and social sciences throughout the continuum from high
    school to the faculty level. There is some evidence that individuals
    who have participated in the NIH administrative supplement program
    preferentially conduct research in areas related to minority health or
    health disparities.
    National Institute on Minority Health and Health Disparities Extramural
            Loan Repayment Program for Health Disparities Research
        The Loan Repayment Program for Health Disparities Research (LRP-
    HDR) recruits, trains, and retains highly qualified health
    professionals through repayment of educational loans in exchange for
    conducting minority health or health disparities research. More than 60
    percent of LRP-HDR scholars are from racial/ethnic minority
    populations. Since its inception, more than 2,200 awards to individuals
    representing multiple disciplines including internal medicine, mental
    health, behavioral science, anthropology, pharmacology, cardiology,
    epidemiology, health sciences, oncology, psychology, and
    gastroenterology have been made through this program.
        Question. Does the Research Center in Minority Institutions (RCMI)
    plan to dedicate funding that would further enhance research
    infrastructure and training opportunities at RCMI institutions that
    have been dedicated to addressing these concerns? Also, given the
    importance of science networking within minority serving institutions,
    are there plans for the RCMI Clinical Translational Research program to
    work with the RCMI Translational Research Network to promote more
    multi-site clinical trials to address health disparities in minority/
    underserved communities?
        Answer. An environment that is conducive to health-related research
    at academic institutions, including minority institutions, is a
    priority for the NIH. The NIMHD RCMI program supports the basic
    underpinning of research to further, biomedical, clinical, behavioral,
    and social sciences research activities. Enhancement of infrastructure
    and research capacity includes renovation/alteration of new research
    facilities, creating shared resources that result in economies of scale
    for research projects, and developing a diverse scientific workforce.
    This investment has been instrumental in the engagement of racial/
    ethnic minority populations in research and in the translation of
    research advances into culturally competent, measurable, and sustained
    improvements in health outcomes.
        The RCMI Infrastructure for Clinical and Translational Research
    (RCTR) awards support the development of infrastructure required to
    conduct clinical and translational science in RCMI institutions. This
    infrastructure enhancement may include outpatient clinical research
    resources, biostatistical support, core laboratories, or facilities to
    support patient-oriented investigations such as community-based
    research. Multi-site investigations on those diseases that
    disproportionately impact health disparity populations are an integral
    component of the RCTR program. As the Data and Technology Coordinating
    Center for RCMI, the RCMI Translational Research Network will continue
    working with RCTR to promote scientifically sound, clinical trials
    involving multiple academic institutions, clinical sites, and community
    health providers.
                                     ______

                    Questions Submitted by Senator Herb Kohl
                           national children's study
        Question. The National Institutes of Health (NIH) has announced a
    change in the National Children's Study (NCS) Vanguard contracts from
    academic centers to a national research firm. How do these changes in
    contracts affect the scientific integrity of the study?
        Answer. The change in Vanguard Study operations, to have primary
    data collection performed by another contractor, affects 7 of the 40
    Vanguard locations for a period of 6 months, from July to December
    2012. That contractor, Research Triangle Institute, was selected
    through a full and open competition in 2010 for the purpose of
    providing additional data collection capacity for the Vanguard Study.
    During this 6-month period, the seven locations will participate in a
    pilot project to optimize the transition process and maintain the
    scientific quality and integrity of the Study.
        Prior to July 2012, new funding opportunities to provide data
    collection for all of the Vanguard locations will be announced. These
    new contracts will also be awarded through a full and open competition.
    All current contractors are eligible to compete for these new
    contracts. Following award of those contracts, all Vanguard Study
    centers, including the seven locations in the transition pilot, will
    transition to the new contractors.
        Question. What is NIH's plan for transitioning from a
    decentralized, academic center based recruitment strategy to a
    recruitment strategy with a centralized, national research firm?
        Answer. The NIH is currently planning recruitment for the NCS Main
    Study, which is a separate activity from the Vanguard Study. Based on
    data from the Vanguard Study and consultation with the NCS Federal
    Advisory Committee and other experts, primary recruitment for the Main
    Study will be conducted through healthcare providers. We are currently
    asking for input and gathering additional data on implementation of a
    healthcare provider approach. New solicitations for recruitment and
    data collection for the Main Study will be made through a full and open
    competition. We anticipate that multiple contracts will be awarded. We
    also intend to award new contracts for supplemental recruitment to
    target populations that, on the basis of demographics or potential
    environmental exposures, may be under-represented if one used only a
    provider based approach.
        Question. What is NIH's plan, if any, to collaborate with the
    current Vanguard centers to maintain those children who have already
    enrolled in the studies? What are the logistical challenges to this
    transition?
        Answer. Current NCS Vanguard Study contracts expire over the next
    17 months; new contracts will be awarded following full and open
    competitions. The NCS is working with current contractors to ensure the
    orderly transition of data collection services and of relationships
    with participants, communities, and other local institutions. As is
    usual with longitudinal studies that extend across many years,
    individual contractors may continue to change during the course of the
    study, and it is important for the NCS to have procedures in place to
    ensure smooth transitions that may occur in the future.
        The Vanguard Study will continue to pilot study methods in its
    current 40 locations, several years in advance of the Main Study,
    following the children already recruited by the Vanguard Study until
    they turn 21. In this follow-up phase, it will use a smaller number of
    contractors than in its earlier recruitment phase, thus following
    recommendations in the Institute of Medicine report from 2008 and
    realizing cost savings, while improving scientific quality by achieving
    greater consistency in data and specimen collection among study sites.
        Question. What, if any, role will the current Vanguard sites have
    within the NCS after the NIH ends their contracts?
        Answer. The Vanguard Study will continue in the same sites for the
    next two decades, although it may not be carried out by the same
    contractors. All Requests for Proposals for both the Vanguard and Main
    Studies will have full and open competitions. All current contractors
    can offer proposals for new contracts and also have other options to
    participate in the NCS, including partnering with a primary data
    collector, conducting ancillary studies using NCS infrastructure, and
    doing their own research analyses using NCS data as they become
    available.
                                     ______

                Questions Submitted by Senator Mary L. Landrieu
     national institutes of health institutional development award program
        Question. The National Center for Research Resources (NCRR), an
    Institute within the National Institutes of Health (NIH), houses a
    program called the Institutional Development Award (IDeA program). The
    IDeA program funds research in States that are traditionally
    underrepresented within the NIH, including Louisiana.
        In the fiscal year 2012 U.S. Department of Health and Human
    Services budget, the Congress increased the funding for the IDeA
    program by $46 million. However, for the fiscal year 2013 budget year,
    the President proposes a $48 million decrease. It appears that this
    money is being taken away in order to help fund the new National Center
    for Advancing Translational Sciences (NCATS).
        At a time when NIH budgets are flat, and when the most heavily
    funded States will continue to be funded as they always have, why would
    the administration propose reducing the one pot of money that is
    specifically designed for States that have traditionally been
    underfunded?
        Answer. For fiscal year 2012, the IDeA program was provided with a
    21-percent increase in the congressional appropriation, or
    approximately $50 million, in funding over fiscal year 2011, while most
    other NIH programs were held relatively flat. For fiscal year 2013, the
    budget proposes $225 million for the IDeA program, about the same as
    the fiscal year 2011 level, and approximately $50 million below fiscal
    year 2012. The IDeA program is valued by NIH and gives many
    investigators at less research-intensive institutions an opportunity to
    contribute to biomedical research. Within a constrained budget
    environment, NIH believes that the IDeA program should not be treated
    differently than most other programs in the fiscal year 2013 NIH budget
    which are flat with fiscal year 2011. With regard to NCATS, the fiscal
    year 2013 budget requests an increase because of the need for
    innovative solutions to the bottlenecks currently in the development
    pipeline that hinder the movement of basic research findings into new
    diagnostics and therapeutics for patients. The request for IDeA is made
    in the context of the total NIH budget and not as a particular offset
    to any one program or line item.
       national institute of diabetes and digestive and kidney diseases
                                 funding levels
        Question. The National Institute of Diabetes and Digestive and
    Kidney Diseases (NIDDK) continues to conduct and support innovative
    diabetes research that will move the Nation forward in treatment,
    enhanced detection, and prevention of diabetes.
        In the proposed fiscal year 2013 HHS budget, the NIDDK received a
    slight decrease in funding of $2 million compared with the fiscal year
    2012 funding level. I am concerned that this decrease in funding will
    affect NIDDK's ability to continue to make progress on promising
    diabetes research.
        Would you please share with us the percentage of grants that NIDDK
    has been able to fund over the past 2 years and how this cut will
    affect grants/research going forward?
        Answer. In fiscal year 2010 and fiscal year 2011, the success rates
    for NIDDK-funded Research Project Grants (RPGs) were 26 percent and 21
    percent, respectively; the estimate for fiscal year 2012 is 20 percent.
    In the fiscal year 2013 President's budget request, there is an overall
    reduction of 1 percent in the average cost of both competing and
    noncompeting RPGs. NIDDK also expects to have fewer non-competing
    grants that require funding in fiscal year 2013. As a result, the
    number of new or competing RPGs would increase by 43, resulting in an
    estimated success rate of 21 percent in fiscal year 2013. The slight
    net decrease in funding of $2.798 million, or -0.1 percent, in the
    President's budget request, compared with the fiscal year 2012 funding
    level, is due primarily to a reduction in NIDDK HIV/AIDS research that
    results from $30.951 to $27.635 million or $3.316 million in AIDS
    research. The AIDS reduction is a result of the annual AIDS priority
    level review of all expiring grants in fiscal year 2012 that would be
    competitively submitted for funding in fiscal year 2013. These projects
    are no longer considered to be aligned with the fiscal year 2013
    priorities for trans-NIH AIDS research. The overall non-AIDS total is
    increased by $518,000 resulting from the increased funding in R&D
    Contracts and National Research Service Award Research Training. The
    AIDS reduction plus a non-AIDS increase results in a $2.798 million
    reduction in the total NIDDK.
                              gestational diabetes
        Question. Currently, gestational diabetes is a disease affecting up
    to 18 percent of all pregnant women. Long-term health consequences face
    women and children who have gestational diabetes, such as
    susceptibility to type 2 diabetes.
        Would you please provide a list of the specific research
    initiatives or projects NIDDK or other Institutes at NIH are currently
    funding to address this issue?
        Answer. The NIDDK and National Institute of Child Health and Human
    Development are vigorously supporting research and other efforts to
    address gestational diabetes mellitus (GDM) and its immediate and long-
    term health consequences for women and their children. While complete
    data for fiscal year 2012 are not yet available, we are pleased to
    provide examples of a number of current efforts. The NIDDK, under its
    ``Healthy Pregnancy Program,'' is supporting three major GDM-related
    initiatives:
      --A multi-center research consortium testing interventions in diverse
            groups of overweight and obese pregnant women to improve weight
            and metabolic outcomes in both the women and their offspring.
            This effort is co-supported by NICHD, National Heart, Lung, and
            Blood Institute (NHLBI), and the NIH Office of Research on
            Women's Health.
      --The Hyperglycemia and Adverse Pregnancy Outcomes Follow-up Study,
            which will examine whether elevated blood sugar levels less
            severe than GDM carry similar long-term health risks for women
            and their offspring.
      --An educational component, led by the National Diabetes Education
            Program (NDEP), that targets women with a history of GDM, their
            families, and their healthcare providers to raise awareness of
            health risks and the steps that women and their children can
            take to avert health problems. The NDEP is a joint program of
            the NIDDK and the Centers for Disease Control and Prevention
            (CDC).
        NIDDK and NICHD also support basic and clinical research to better
    understand GDM, as well as to identify ways to prevent or treat it and
    its long-term health risks. For example, several studies focus on
    understanding how maternal diet and metabolism affect fetal development
    and incur long-term risks for obesity and other health problems.
    Researchers are also continuing to study women at risk for type 2
    diabetes due to GDM history who participated in NIH's landmark Diabetes
    Prevention Program clinical trial. Researchers are also:
      --following a large population of women with a history of GDM to
            understand how the frequency and duration of their
            breastfeeding may prevent their later development of type 2
            diabetes;
      --screening women for GDM in the first months of pregnancy, to
            understand whether early-emerging and later-emerging forms of
            GDM differentially affect maternal and child outcomes. Other
            goals of the research are to refine GDM tests and to determine,
            at a systems level, whether routine screening for early GDM in
            obese women improves outcomes in the women and their children;
      --searching for abnormalities in fetal development of heart function
            and other factors that could eventually cause adult heart
            disease in offspring of pregnant laboratory animals with GDM;
            and
      --analyzing post-partum maternal and infant cord blood samples to
            determine whether specialized types of human fat and immune
            cells could be novel biochemical markers to help predict future
            GDM.
                    national cancer institute funding level
        Question. The funding for NIH, and in turn, National Cancer
    Institute (NCI), has eroded since fiscal year 2010, not only due to
    lost purchasing power as a result of biomedical inflation but also due
    to outright cuts in fiscal year 2011.
        How has the eroded funding affected the Institute in terms of the
    number of new grants funded and harm to existing grants? What decisions
    have you had to make as a result? If we could restore funding to fiscal
    year 2010 levels, or even better, increase funding above those levels,
    what could you do with the new money?
        Answer. As a result of the decrease to the NCI budget in fiscal
    year 2011, we funded 1,106 competing grants, 147 fewer than in 2010.
    For the 3,769 existing grants that received continuation funding in
    2011, the amount was reduced by 3 percent from the fiscal year 2010
    level. Principal investigators could have used a number of strategies
    to accommodate lower funding levels, including reducing staff,
    deferring the purchase of equipment or supplies, or scaling back their
    projects in some way.
        In fiscal year 2011, NCI applied reductions of 2 to 5 percent in
    most budgets for our many activities--including the intramural
    programs, contracts at NCI-Frederick and elsewhere, the NCI-designated
    cancer centers, and the operating budgets of all NCI components. NCI's
    leadership made choices to achieve the necessary savings while
    preserving core elements needed to sustain the pace of discovery. NCI
    leadership has carefully assessed the overall research portfolio and
    determined the areas where, in our professional judgment, increased
    funding could have additional impact over time in reducing cancer
    incidence and mortality. Any increase in funding would be used in part
    to increase support for new research grants, especially grants to new
    investigators to support new ideas. Other critical areas that could
    receive additional support include cancer genomics and transformation
    of NCI's clinical trials to increase efficiency and reflect the state
    of the science. An increase to our appropriation could also allow NCI
    to fund additional grants through the new Provocative Questions project
    by augmenting the $15 million that was dedicated to the project.
    Additional resources could support more research toward solving some of
    the enduring paradoxes in cancer research.
                   national cancer institute--drug resistance
        Question. We've heard reports of some targeted treatments achieving
    incredible results, but then cancers stop responding to those drugs.
    What is the NCI doing to understand and overcome this drug resistance?
        Answer. One of the most disappointing features of the development
    of new targeted therapeutics is how routinely drug resistance emerges
    and the disease begins to progress. Resistance to treatment with
    anticancer drugs results from a number of factors--every cancer
    expresses a different array of drug-resistance genes, and various
    mechanisms have evolved as protection from toxic agents. As therapy has
    become more effective, acquired resistance has become common. NCI is
    aggressively pursuing research to gain an understanding of the
    mechanisms that lead to drug resistance and is looking for agents that
    overcome these mechanisms. NCI is supporting studies of combination
    therapies for patients whose disease has become resistant to therapy,
    as well as exploring alternative approaches through the Provocative
    Questions Initiative to determine if controlling rather than killing
    cancer cells can avoid the development of drug resistance.
        One example of the development of resistance following dramatic
    response is the clinical experience with the targeted drug vemurafenib
    (Zelboraf), a BRAF inhibitor that has been shown to nearly double the
    survival of patients with advanced melanoma. Because nearly one-half of
    all cases of metastatic melanoma--about 4,000 patients per year--have
    the BRAF mutation, vemurafenib represents a significant breakthrough in
    treatment. Unfortunately, after an average of 8 months of treatment,
    many patients become resistant to the drug and their disease begins to
    progress. However, with NCI support, researchers are making headway in
    understanding vemurafenib resistance. Recent data from Memorial Sloan
    Kettering, for example, demonstrated that some resistant BRAF-mutated
    melanoma cells produce a shortened version of the mutated BRAF protein
    that remains active even in the presence of vemurafenib. Strategies to
    overcome the resistance include finding ways to increase potency of the
    therapy, disrupting the activity of the altered form, or combining
    therapies. Other leads have come from researchers at the Moffitt Cancer
    Center, who identified a new approach utilizing a small molecule
    inhibitor called XL-888 to target a family of proteins known as Heat
    Shock Proteins 90 (Hsp90). The Moffitt researchers reported preclinical
    data that XL-888 overcame six different models of vemurafenib
    resistance, demonstrating its therapeutic potential. This work was made
    possible by early NCI research on Hsp90 as an anticancer agent.
        Melanoma is just one example of a disease in which drug resistance
    is driving creative approaches in cancer research. The drug imatinib
    (Gleevec), for example, is widely recognized for its success in
    treating chronic myeloid leukemia by targeting a protein known as BCR-
    ABL. However, some CML patients relapse when new mutations make the
    BCR-ABL protein resistant to Gleevec, preventing it from binding to its
    target and allowing the abnormal enzyme to drive white blood cell
    growth, again despite treatment. It is encouraging to report that NCI-
    supported research has identified a number of drugs that can target
    BCR-ABL proteins even after they acquire mutations that confer
    resistance to Gleevec. Although two of these, approved a few years ago,
    could not overcome a relatively common resistance mutation, a third
    generation of drugs has a new way to attack the mutation, freezing the
    target protein and rendering it inactive. This example illustrates
    another important point: many different research fields--from genetics
    to structural biology to pharmacology--were required for these advances
    in treatment. The need for multidisciplinary teams to address key
    questions like drug resistance in cancers increasingly defines modern
    biomedical research.
                           national children's study
        Question. NIH wants to cut 15 percent from National Children's
    Study's (NCS) current $193 million budget in fiscal year 2013 by
    shifting away from the sampling plan put forth by the Institute of
    Medicine in 2008 to an health maintenance organization (HMO)-based
    sample.
        New Orleans was selected as one of the sites for national sampling
    and this is particularly important because, as Louisiana is near the
    bottom of every health outcome ranking and near the top in indicators
    of poverty, this new knowledge could prove invaluable to improving
    both. The gulf region has a number of health disparity issues and a
    large number of uninsured mothers who do not participate in an HMO.
        How do you plan on maintaining the scientific integrity of the NCS
    study so that it reflects a national sample, including unique
    populations such as those in the gulf region?
        Answer. The change in the NCS Study design is being considered
    primarily for scientific reasons but also with awareness of our need to
    be fiscally responsible. It is based on data generated during the
    ongoing Vanguard, or pilot phase, of the NCS. As currently envisioned,
    the NCS Main Study would use a provider-based participant selection and
    recruitment strategy that the NIH and the Agency for Healthcare
    Research and Quality have both employed effectively in other studies.
    This approach uses research-ready healthcare provider networks as the
    primary source for recruitment. The NCS would gain additional
    participants through the award of contracts for supplemental
    recruitment from secondary sources (such as title V clinics, Indian
    Health Service clinics, or contract research organizations) to assure
    inclusion of appropriate population groups, specifically those with
    health disparities. The use of these two coordinated selection and
    recruitment strategies would improve the quality of the Main Study and
    allow analyses not feasible with either approach alone.
        If adopted, this revised approach would offer several advantages,
    including:
      --greater recruitment efficiency;
      --leveraging access to consenting participants' electronic health
            records, thus improving the amount and consistency of data
            collected while lowering costs;
      --the potential to leverage the existing infrastructure of networks
            of healthcare providers, again improving the quality of data
            and lowering costs;
      --allowing built-in continuity for participants who move but remain
            within the provider network (many provider networks have
            statewide or regional coverage) or join another provider
            network affiliated with the Main Study.
        Current Vanguard Study contracts are due to expire over the next 17
    months. New contracts are required to continue into the next phase of
    the Vanguard Study, and the NCS has issued a pre-solicitation to
    request preliminary information on the services available to meet the
    study's evolving needs. (Please see https://www.fbo.gov/
    index?s=opportunity&mode=form&id=674a4f3a690d6584870fc84c9cb2b
    511&tab=core&-cview=0.) All new Requests for Proposals for both the NCS
    Vanguard and Main Studies will have full and open competitions. Whoever
    is awarded the new contracts, the NCS plans to remain in the Vanguard
    locations and to following current Vanguard participants until the last
    enrolled child turns 21 years old.
        Question. On a related topic, Tulane University, in New Orleans,
    was one of the sites selected for national sampling. The New Orleans
    Study Location represents a strong collaboration among major healthcare
    providers and universities, including Tulane, LSU, and Ochsner, and
    employs many full-time and part-time professionals.
        Termination of the contract would be a very significant loss both
    to the universities, the local community and damage the capacity that
    has been built.
        How will this new system account for the loss of expertise and jobs
    at study sites throughout the Nation?
        Answer. To date, the NCS Vanguard Study has accomplished what it
    set out to do, provide data on recruitment and early retention into the
    Study. We will continue to follow all children born into the Vanguard
    Study, until age 21. We have no intention to lose NCS participants from
    the Vanguard Study; instead, we are developing and field testing a
    proactive plan that includes personal contacts, special events for
    participants, linkages to local health resources through other Health
    and Human Services programs, returning results of Study assessments,
    and soliciting feedback about the Study experience. In addition,
    participants that might have been lost under the original Study design
    because they moved out of a particular geographic area might still be
    included in a health provider network involved in the Study.
        Current NCS Vanguard Study contracts expire over the next 17
    months, but none are expected to be prematurely terminated. The NCS is
    working to standardize the transition process so that if a new
    contractor replaces a current contractor at an NCS location, the data,
    the knowledge, the relationships and the continuity can be maintained.
    We are targeting a minimum 90-day overlap in contracts, to allow for an
    orderly and systematic transfer.
        All new Requests for Proposals for both the Vanguard and Main
    Studies will have full and open competitions. Academic institutions can
    offer proposals for new Study contracts for primary data collection,
    and have other options as well, including partnering with a primary
    data collector, conducting ancillary studies using NCS infrastructure,
    or doing their own research analyses using NCS data as they become
    available. Finally, contractors that complied with NCS specifications
    for field operations will have established a platform that is flexible
    and adaptable to multiple uses, so they can leverage that investment
    for additional projects.
         national institutes of health investigator-initiated research
        Question. Will the investigator-initiated research be able to grow
    in the area of translational science, and will basic science be a part
    of it?
        Answer. Within the administration's fiscal year 2013 budget request
    for NIH of $30.86 billion, the same overall program level as in fiscal
    year 2012, we plan to continue to maintain funding emphasis and
    increase the overall number of Research Project Grants (RPGs). RPGs are
    NIH's fundamental funding mechanism for investigator-initiated
    research. The NIH budget request will support an estimated 9,415 new
    and competing RPGs in fiscal year 2013, an increase of 672 more than
    fiscal year 2012. The total number of RPGs funded for fiscal year 2013
    is expected to be around 35,888, or approximately the same as the
    35,944 estimated for fiscal year 2012.
        In pursuit of its mission to alleviate the burden of illness, NIH
    supports a continuum of research, from understanding basic causes and
    mechanisms of health and disease to translating that understanding into
    new ways of identifying and intervening upon disease processes, and in
    turn translating those new interventions into clinical practice. As the
    leading supporter of basic biomedical research in the world, NIH
    commits slightly more than one-half its annual budget to better
    understand the basics of how life works.
        Yet, the path from basic research to clinical practice is not
    always linear; each step in the process may inform any other step. For
    example, clinical research can inform basic research. This is
    exemplified by a recent clinical finding made by NIH scientists in the
    intramural program's Undiagnosed Diseases Program that has led to a
    dramatic new understanding of basic functioning. These scientists
    studied a pair of sisters from Kentucky who suffered from joint pain
    and a mysterious calcification of the arteries in their extremities.
    Their research uncovered a novel genetic condition that affected a
    previously unknown enzyme pathway, resulting in blocked arteries. The
    discovery provides a dramatically new understanding of how large
    arteries maintain normal functioning, and it has opened the door to
    many other lines of inquiry across both basic and clinical arenas.
        The proposed increase in RPGs provides the framework for NIH to
    prospectively expand investigator-initiated research across the
    continuum of biomedical and behavioral science. Each new finding in one
    arena will inform and lead to new investigations in other areas of
    basic, translational, and clinical research.
                                     ______

                Questions Submitted by Senator Richard J. Durbin
                            congenital heart disease
        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 National
    Institutes of Health (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 Centers for Disease Control and Prevention (CDC) to
    expand surveillance and track the epidemiology of CHD across the life-
    course, with an emphasis on adults. The Consolidated Appropriations Act
    of 2012 provided the CDC with $2 million in new funding for enhanced
    CHD surveillance. Please describe how NIH is working with CDC to
    enhance CHD surveillance across the life-course. CDC is using a portion
    of the newly appropriated funds to convene a congenital heart defects
    experts meeting. Please summarize NIH's role at the expert meeting and
    in shaping the meeting's research agenda.
        Answer. NHLBI continues to make an extensive investment in research
    related to congenital heart defects across the life-span. The Institute
    is working in conjunction with the CDC on a number of activities to
    expand surveillance of CHD and improve our understanding of its
    epidemiology, including the following:
          Newborn Screening for Critical Congenital Heart Diseases.--In
            September 2011, Secretary Sebelius recommended that screening
            for Critical Congenital Heart Diseases (CCHD) be added to
            routine newborn screening and called for research to address
            evidence gaps that are presently constraining implementation of
            screening programs. In response, the NHLBI, the National
            Institute of Child Health and Human Development (NICHD), the
            CDC, and other Federal partners involved in newborn screening
            have set up regular calls and meetings to determine how best to
            proceed. As an example, the CDC and NHLBI have been discussing
            details of a common nomenclature to be used in screening for
            cardiovascular malformations and the potential for combining
            the efforts of the CDC's robust birth defects case-
            ascertainment and research programs with the NHLBI-funded
            Pediatric Heart Network and the Pediatric Cardiac Genomics
            Program to answer research questions about approaches to and
            effectiveness of screening for CCHD.
          Data Set on Sudden Cardiac Death in the Young.--Development of
            effective screening and prevention strategies for Sudden
            Cardiac Death in the Young (SCDY) is limited by a lack of
            prospectively defined epidemiological data, including incidence
            rates and etiology. NHLBI is planning an innovative program to
            address this knowledge gap. Its initial phase, in coordination
            with the CDC and others, would be to develop a surveillance
            system and registry that broadens and enhances the activities
            of the National Center for Child Death Review and the Sudden
            Unexpected Infant Death Registry. This phase would result in
            the first prospective, population-based U.S. data set on SCDY;
            it would include data from death certificates, medical records,
            death-scene investigations, and pathology reports and also
            include serum samples for DNA extraction. It would be followed
            by a second phase that would support scientific research using
            the data set.
          Congenital Heart Public Health Consortium.--NHLBI and the CDC
            were founding Federal advisors to the Congenital Heart Public
            Health Consortium (CHPHC), a group formed in 2008 to address
            the public health burden of CHD. The CHPHC has united a variety
            of organizations, including Federal agencies, patient advocacy
            groups, and physician associations that have a strong interest
            in CHD. Its approach includes strong emphasis on enhanced
            surveillance via monitoring CHD throughout the lifespan, as
            well as assessment of the needs of patients and families for
            chronic disease management and age-appropriate preventive care.
            Representatives from NHLBI and the CDC currently serve as
            advisors to the Consortium Steering Committee.
        NHLBI is working closely with the CDC to organize the upcoming
    congenital heart defects experts meeting which will occur September 10-
    11, 2012. Its goal is to determine priorities for public health
    research on congenital heart disease across the life course in the
    United States. The planning committee consists of representatives from
    the CDC and the NHLBI and pediatric cardiologists from academia. The
    meeting agenda will focus on three main areas of public health concern
    for congenital heart disease--epidemiology, long-term health outcomes
    (both medical and nonmedical), and health services research (including
    access to care, employability, and economics). Invitations have been
    sent to a variety of experts, including pediatric cardiologists, adult
    congenital heart specialists, adult cardiologists with expertise in
    epidemiology, epidemiologists, cardiac surgeons, health services/
    outcomes researchers, patient advocates, health economists, and other
    Federal partners.
                            antimicrobial resistance
        Question. NIH is part of an Interagency Task Force on Antimicrobial
    Resistance (ITFAR) that was created in 1999. What is the status of the
    subcommittee's recommendations to address the complex issue of
    antimicrobial resistance?
        Answer. In 2001, the ITFAR published a Public Health Action Plan to
    Combat Antimicrobial Resistance (the Public Health Action Plan). This
    plan was updated, with stakeholder input, in 2011 and lays out specific
    action items in the areas of Surveillance, Prevention and Control,
    Research, and Product Development to address the complex issue of
    antimicrobial resistance. The updated plan is posted here: http://
    www.cdc.gov/drugresistance/pdf/public-health-action-plan-combat-
    antimicrobial-resistance.pdf.
        Progress toward the implementation of Action Items under each of
    the goals in the Public Health Action Plan is reported annually by all
    participating agencies and documented at this link: http://www.cdc.gov/
    drugresistance/annualReports.html.
        At NIH the National Institute of Allergy and Infectious Diseases
    (NIAID) is the lead institute responsible for research on antimicrobial
    resistance. NIAID supports basic, translational, and clinical research
    to understand and combat the problem of antimicrobial resistance. NIH,
    with support from NIAID, co-chairs the ITFAR and conducts research
    addressing several of the goals of the Public Health Action Plan,
    including goals supporting basic, applied, and clinical research on
    antimicrobial resistance. For example, NIAID is supporting a robust
    response to Action Items under Goal 7.2: Design and implement studies
    focused on optimizing the dose and duration of antibacterial agents
    prescribed for treatment of community-acquired pneumonia, urinary tract
    infections, skin and soft-tissue infections, and other infectious
    illnesses. To address this goal, NIAID is supporting clinical trials to
    inform the rational use of existing antimicrobial drugs to help limit
    the development of antimicrobial resistance, and is also supporting a
    clinical study to optimize the use of colistin, an antibiotic approved
    in the late 1950s that is increasingly being used today to treat multi-
    drug resistant Gram-negative infections. NIAID-supported clinical
    trials evaluating the effectiveness of different drug combinations in
    treating influenza, HIV, and malaria are also ongoing.
        In addition, NIAID supports basic research to identify new
    antimicrobial targets and translational research on strategies to
    combat antimicrobial-resistant infections. NIAID supports the
    development of effective diagnostics, drugs, and vaccines to identify,
    treat, and prevent infectious diseases. As part of this effort, NIAID
    provides a broad array of preclinical and clinical research resources
    to researchers in academia and industry designed to facilitate the
    movement of a product from bench to bedside. By providing these
    critical services to the research community, NIAID can help to bridge
    gaps in the product development pipeline and lower the financial risks
    incurred by industry to develop novel antimicrobials. For example,
    NIAID supports the preclinical development of new antibacterial agents
    through directed contracts to companies involved in novel drug design
    and synthesis. These contracts were solicited through a Broad Agency
    Announcement entitled ``Development of Therapeutics for BioDefense.''
    To foster clinical research on antimicrobial resistance, in January
    2012, NIAID released a request for applications to support a new
    leadership group for an antibacterial resistance clinical trial network
    similar to the existing HIV/AIDS clinical research networks (http://
    grants.nih.gov/grants/guide/rfa-files/RFA-AI-12-019.html). The
    antibacterial resistance leadership group would develop and implement a
    comprehensive clinical research agenda to address the pressing problem
    of antibacterial resistance.
        The research described above represents only a small portion of
    NIAID's significant investment in research addressing the problem of
    antimicrobial resistance. For more information, please visit the ITFAR
    annual report linked above as well as the NIAID Web page at: http://
    www.niaid.nih.gov/topics/antimicrobialresistance/Pages/default.aspx.
                          diabetes prevention program
        Question. Diabetes Prevention Program (DPP) was a clinical research
    study investigating the impact of lifestyle and drug interventions on
    diabetes prevention. Two new NIH initiatives have taken advantage of
    DDP's findings and are building on the discoveries. Please summarize
    the two new programs and explain how they are different from DPP.
        Answer. NIH's landmark DPP clinical trial proved that an intensive
    lifestyle intervention reduced rates of diabetes incidence by 58
    percent among an at-risk population. The lifestyle intervention was
    effective in all ethnic groups, and was particularly effective in those
    older than age 60 at the beginning of the trial, among whom it reduced
    diabetes incidence by 71 percent. The trial also found that the safe,
    well-tolerated, inexpensive, generic diabetes drug metformin reduced
    diabetes incidence by 31 percent, and was most effective in younger
    participants, and women with a history of gestational diabetes, who
    otherwise develop type 2 diabetes at particularly high rates.
        NIH has built on these major findings in several ways. First, most
    of the DPP participants elected to enroll in a follow-on study, the DPP
    Outcomes Study (DPPOS). Phase 1 of this study showed that both
    interventions are durable, and continue to provide significant diabetes
    prevention benefit for at least a decade. Moreover, participants in the
    lifestyle arm of the study had dramatically better quality of life and
    a reduced need for medications to control blood pressure and
    cholesterol. Both lifestyle and metformin were also found to be highly
    cost effective, and metformin was actually found to be cost saving.
    Phase 2 of DPPOS will assess the long-term impact of the interventions
    on diabetes complications. The National Institute of Diabetes and
    Digestive and Kidney Diseases (NIDDK) is also currently working with
    National Cancer Institute (NCI) to determine the feasibility of
    detecting potential effects of the interventions on later development
    of cancer.
        To develop ways to make diabetes prevention more practical and
    affordable, the NIH-funded research to translate the DPP lifestyle
    intervention into widespread practice. Some particularly promising
    projects have focused on research to reduce costs, while maintaining
    efficacy, by delivering the intervention in a group-based form. Strong
    preliminary results from one such ongoing study led to creation of the
    ``National'' DPP (NDPP) by the Centers for Disease Control and
    Prevention, which is working to train and credential a cadre of group
    lifestyle intervention providers for diabetes prevention. Many of the
    providers trained so far work at YMCAs, which now provide access to
    these services to people with prediabetes at more than 50 locations
    (http://www.ymca.net/diabetes-prevention/participating-ys.html).
    Additional work to help realize the potential of the DPP and other
    diabetes studies is being conducted through the Diabetes Translational
    Research Centers program.
        Detailed DPP genetic analyses have shown that the lifestyle
    intervention helps prevent diabetes even among those at greatest
    genetic risk. Interestingly, a gene was identified that substantially
    reduces the efficacy of metformin in about 1 in 3 people. NIH is
    supporting a June 7 conference on metformin pharmacogenetics to explore
    this and related issues.
        Question. Although the long-term outlook for children with type 1
    diabetes has improved, the rates of diagnoses continue to rise. Please
    provide an update on research efforts within NIH related to type I
    diabetes and how additional innovations in research could prevent
    children from developing this disease.
        Answer. NIH-supported research has shown that people with type 1
    diabetes are living longer and healthier lives than ever before.
    However, research has also shown that rates of type 1 diabetes are
    rising, especially in children under 4 years of age. One approach to
    curb the rising rates of type 1 diabetes is to identify a disease
    prevention strategy. Toward this goal, the NIDDK has undertaken a bold,
    long-term initiative--called The Environmental Determinants of Diabetes
    in the Young (TEDDY) study--to identify the environmental triggers that
    intersect with genetic risk and lead to the development of type 1
    diabetes. More than 8,600 newborns are enrolled in the study--after
    screening more than 420,000 newborns--and researchers are collecting
    biological samples, as well as information about the children's diet,
    illnesses, vaccinations, and allergies, until the children are 15 years
    of age. Knowledge gained from the TEDDY study can revolutionize our
    ability to prevent type 1 diabetes. For example, the discovery of a
    viral cause could lead to development of a vaccine to prevent the
    disease. Identification of a dietary factor as a cause could lead to
    changes in feeding practices.
        NIH-supported researchers are also conducting clinical trials
    testing promising prevention therapies in people at high genetic risk
    of developing type 1 diabetes. For example, the NIDDK's Type 1 Diabetes
    TrialNet is conducting two clinical trials testing agents to prevent
    the disease in relatives of people with type 1 diabetes. The NICHD's
    Trial to Reduce IDDM (insulin-dependent diabetes mellitus) in the
    Genetically At-Risk, or TRIGR, is testing whether hydrolyzed infant
    formula compared to cow's milk-based formula decreases the risk of
    developing type 1 diabetes in at-risk children.
                           national children's study
        Question. The National Children's Study (NCS) will examine
    environmental influences on the health and development of a cohort of
    U.S. children from birth until age 21. Field work for the study ended
    in March 2012, which provided data about recruitment processes and
    costs associated with the study. How are these data being used to
    inform the cost-effectiveness of the main study?
        Answer. Data generated during the ongoing Vanguard, or pilot, phase
    of the NCS showed that a study design based on recruiting through
    healthcare providers was more efficient than recruitment through door-
    to-door contact or direct outreach to the public. Other large Federal
    studies have also effectively employed provider-based approaches.
        More specifically, the NCS uses several methods to analyze costs
    and cost effectiveness. We maintain our own internal data base of
    contract invoices and analyze the invoice data for costs and level of
    effort based on activity. In addition, operational data elements that
    record the activities, logistics and costs of all aspects of the
    Vanguard Study have been embedded into the protocol data collection.
    These operational data elements are the primary outcome measures for
    the Vanguard Study goals of testing feasibility, acceptability, and
    cost-of-study operations. These data are captured in a central data
    repository and analyzed every 2 weeks to guide operations and assess
    overall data quality. In a third approach, two contractors, one a
    consulting firm and the other an academic institution, have been
    engaged to project operational resources and potential costs based on
    data from the field.
        Question. A recent restructuring of the field operations will
    centralize some data collection to a single subcontractor. Please
    explain the rationale and cost-effectiveness of this restructuring.
        Answer. The change in Vanguard Study operations, to have primary
    data collection performed by another contractor, affects 7 of the 40
    Vanguard locations for a period of 6 months, from July to December
    2012. That contractor, Research Triangle Institute, was selected
    through a full and open competition in 2010 for the purpose of
    providing additional data collection capacity for the Vanguard Study.
    During this 6-month period, the seven locations will participate in a
    pilot project to optimize the transition process and maintain the
    scientific quality and integrity of the Study.
        Prior to July 2012, new funding opportunities to provide data
    collection for all of the Vanguard locations will be announced. These
    new contracts will also be awarded through a full and open competition.
    All current contractors are eligible to compete for these new
    contracts. Following award of those contracts, all Vanguard Study
    centers, including the seven locations in the transition pilot, will
    transition to the new contractors.
        Question. The NIH/NICHD has suggested an alternative sampling
    strategy that uses health plans or health providers to identify and
    recruit pregnant women. How can the proposed strategy ensure the sample
    represents all U.S. children, particularly uninsured, minority,
    immigrants, and low-income children?
        Answer. As currently envisioned, the NCS Main Study would use a
    provider-based participant selection and recruitment strategy that the
    NIH and the Agency for Healthcare Research and Quality have both
    employed effectively in other studies. This approach uses research
    ready healthcare provider networks as the primary source for
    recruitment. The NCS would gain additional participants through the
    award of contracts for supplemental recruitment from secondary sources
    (such as title V clinics, Indian Health Service clinics, or contract
    research organizations) to assure inclusion of appropriate population
    groups, specifically those with health disparities. The use of these
    two coordinated selection and recruitment strategies would improve the
    quality of the Main Study and allow analyses not feasible with either
    approach alone.
                                     ______

                    Questions Submitted by Senator Jack Reed
                           national children's study
        Question. You mentioned during the hearing that the proposed re-
    design of the National Children's Study (NCS) will be as effective and
    more efficient in enrolling study participants. However, you didn't
    mention the scientific basis for this re-design. Did you consult the
    national panel of experts--the Institute of Medicine (IOM), and the
    National Children's Study Federal Advisory Committee that informed the
    original design of the study with this new re-design? If these
    individuals and entities have already been consulted, do you plan to
    make those comments available to the public? If they have not already
    been consulted, do you intend to consult these groups and make those
    comments public?
        Answer. The change in NCS design is being considered primarily for
    scientific reasons but also with awareness of our need to be fiscally
    responsible. It is based on data generated during the ongoing Vanguard,
    or pilot phase, of the NCS. The Vanguard data showed that the proposed
    study design would not enroll sufficient numbers of families within a
    scientifically acceptable timeframe or within a fiscally sound budget.
    Pilot testing conducted through the Vanguard sites showed that a study
    design based primarily on recruiting participants through healthcare
    providers was most efficient and could offer scientific advantages that
    would more than offset its scientific compromises. This provider-based
    approach also has been employed effectively in other large Federal
    studies. The President's fiscal year 2013 budget request, which shows a
    reduction of approximately 15 percent, to $165 million annually, for
    the NCS, appropriately reflects these proposed design changes.
        As currently envisioned, the NCS Main Study would use a provider-
    based participant selection and recruitment strategy that the NIH and
    the Agency for Healthcare Research and Quality have both employed
    effectively in other studies. This approach uses research ready
    healthcare provider networks as the primary source for recruitment. The
    NCS would gain additional participants through the award of contracts
    for supplemental recruitment from secondary sources (such as title V
    clinics, Indian Health Service clinics, or contract research
    organizations) to assure inclusion of appropriate population groups,
    specifically those with health disparities. The use of these two
    coordinated selection and recruitment strategies would improve the
    quality of the Main Study and allow analyses not feasible with either
    approach alone.
        If adopted, this revised approach would offer several advantages,
    including:
      --greater recruitment efficiency;
      --leveraging access to consenting participants' electronic health
            records, thus improving the amount and consistency of data
            collected while lowering costs;
      --the potential to leverage the existing infrastructure of networks
            of healthcare providers, again improving the quality of data
            and lowering costs; and
      --allowing built-in continuity for participants who move but remain
            within the provider network (many provider networks have
            statewide or regional coverage) or join another provider
            network affiliated with the Main Study.
        NCS continues to refer to the IOM report that was written by a
    panel of experts convened to review the original study design. Many of
    the changes recommended in the report have already been addressed,
    including the need for an ongoing Vanguard Study to test the study
    protocol and scientific methodology. The report also noted that the
    large number of field contractors was a weakness of the Study design,
    and the NCS is moving to correct this weakness.
        The NCS Study Advisory Committee meets at least four times a year;
    the April 24, 2012 meeting was the 32d meeting of the subcommittee.
    These meetings are open to the public, and a public comment period is
    provided. Presentations to the Advisory Committee also are posted on
    the NCS Web site. As they have become available, data from the Vanguard
    Study have been presented at each of the subcommittee's meetings. The
    topic of a provider-based approach to Study recruitment was discussed
    twice in the last year with the Advisory Committee, first in April 2011
    and then again in July 2011, before being the focus of the entire April
    24, 2012 meeting. The NCS Study Director holds weekly national
    conference calls for Vanguard Study contractors to update them on
    recent developments and to receive their input. The investigators also
    provide expertise and comments through a monthly Executive Steering
    Committee meeting, through 2-day, face-to-face meetings every 6 months,
    through circulation of all study instruments and protocol changes to
    all investigators for comment, and through a mailbox account dedicated
    to contractors.
        Question. I am also concerned that the re-design will jeopardize 70
    high-quality jobs in Rhode Island, including 20 full-time positions
    that would have otherwise been created for the Main Study. How will
    this proposal impact the work of researchers and practitioners already
    participating in the study and the potential for job growth in my
    State? Does NIH plan to abandon its commitment to the 105 counties that
    have been selected to participate in the study?
        Answer. To date, the NCS Vanguard Study has accomplished what it
    set out to do, provide data on recruitment and early retention into the
    Study. We will continue to follow all children born into the Vanguard
    Study, until age 21. We have no intention to lose NCS participants from
    the Vanguard Study; instead, we are developing and field testing a
    proactive plan that includes personal contacts, special events for
    participants, linkages to local health resources through other Health
    and Human Service programs, returning results of Study assessments, and
    soliciting feedback about the Study experience. In addition,
    participants that might have been lost under the original Study design
    because they moved out of a particular geographic area might still be
    included in a health provider network involved in the Study.
        Current NCS Vanguard Study contracts expire over the next 17
    months. All Requests for Proposals for both the Vanguard and Main
    Studies will have full and open competitions. Academic institutions can
    offer proposals for new Study contracts for primary data collection,
    and have other options as well, including partnering with a primary
    data collector, conducting ancillary studies using NCS infrastructure,
    or doing their own research analyses using NCS data as they become
    available. Finally, contractors that complied with NCS specifications
    for field operations will have established a platform that is flexible
    and adaptable to multiple uses, so they can leverage that investment
    for additional projects.
        As indicated above, the change in study design is based on data
    generated during the ongoing Vanguard pilot phase of the NCS, which
    showed that the previously proposed study design would not enroll
    sufficient numbers of families within a scientifically acceptable
    timeframe or within a fiscally sound budget. Pilot testing conducted
    through the Vanguard sites showed that a study design based primarily
    on recruiting participants through healthcare providers was most
    efficient and could offer scientific advantages that would more than
    offset its scientific compromises.
                           pediatric cancer research
        Question. Dr. Varmus, last year you and Dr. Collins provided me
    with a detailed explanation of NIH efforts to address pediatric
    cancers, including late-term effects. However, I am still concerned
    that a mere 4 percent--just $200 million--of NCI funding is allocated
    to cancer research specifically for this population. I am concerned
    that this funding level remains stagnant because the peer-review
    process doesn't recognize the importance of pediatric cancer research
    in terms of years of life lost and poor quality of life for many
    survivors. How could a Pediatric Cancer Study Section improve the
    funding devoted to pediatric cancer research?
        Answer. Over the past year, the National Cancer Institute (NCI) has
    worked with members of the Congressional Childhood Cancer Caucus to
    discuss this very question, and to explore how pediatric cancer
    research proposals fare in comparison to other proposals under the
    current peer-review process, with a goal of determining whether or not
    pediatric cancer grant applications are competitive in the peer-review
    process. NCI performed this analysis, which showed that pediatric
    cancer grant applications actually have success rates (number of grants
    awarded/number of grants received) that are equal to--and in some cases
    higher than--grant applications focusing on adult cancers. NCI further
    focused on R01 (individual investigator initiated) grant applications
    to exclude large program grants (such as cancer center support grants,
    for example) that have little competition. And again the data showed
    that pediatric cancer-focused R01 grant applications are quite
    competitive in the peer-review process.
        The NIH Center for Scientific Review (CSR), which oversees the NIH
    peer-review process, considers a number of criteria when it establishes
    study sections. These criteria were developed by an external blue
    ribbon panel set up to systematically assess and reorganize CSR's
    review groups. For example, these guiding principles indicate that
    applications pertaining to a given disease/organ system are best
    reviewed in the context of the biological question being addressed.
    They provide that study section boundaries should not be too broad or
    too narrow, and that sufficient overlap should exist between other
    study sections inside and outside their integrated review groups
    (IRGs--clusters of study sections based on scientific discipline).
        Therefore, the NIH has no standing study sections that review
    applications relevant to specific diseases, groups of diseases, or
    organ sites; rather, study sections are formed around scientific
    disciplines, e.g., epidemiology, genomics, therapeutics development,
    populations, behavior, etc., and are populated by productive
    investigators with expertise in those areas.
        Within the category of pediatric cancer research, applications
    under consideration for funding pose an extremely diverse set of
    biological questions, as evidenced by the array of standing study
    sections that are called upon to review grant applications relevant to
    pediatric cancer. Because pediatric cancers are so heterogeneous, it
    makes sense scientifically to distribute review of these applications
    among multiple study sections.
        Data analyzed from fiscal year 2008 through fiscal year 2010
    indicate that the NCI supports pediatric cancer research applications
    via numerous mechanisms, and that support of pediatric cancer research
    grants has increased during that time period. As previously noted,
    success rates were in line with--and in many cases exceeded--those for
    other cancer types. This evidence suggests that pediatric cancer
    applications are very competitive within NIH's scientific review
    process.
        Additionally, although disease-specific funding estimates can be
    useful indicators of some focused work, they do not reflect the full
    level of NCI's investment (approximately $1.9 billion) into research
    exploring cancer biology and cancer causation--broad areas of inquiry
    applicable to all types of cancers, including pediatric cancers. It is
    important to consider NCI's full cancer research portfolio, and to also
    recognize that investments in one area of cancer research can, and
    often do, contribute to advances in others. For example, identifying
    the clinical value of crizotinib in the treatment of adults affected by
    lung cancer with abnormalities of the Alk gene has led to the current
    clinical testing children with neuroblastoma whose tumors have Alk
    abnormalities.
                                     ______

                   Questions Submitted by Senator Mark Pryor
                           pancreatic cancer research
        Question. Dr. Varmus, during the hearing you testified that
    research for pancreatic cancer is being prioritized by National Cancer
    Institute (NCI) and that the Institute currently has flexibility to
    fund grant applications that fall below what used to be called the
    ``pay line'' in cases where therapeutic progress in relation to a
    disease has been low. Are there examples you can describe of grants in
    relations to pancreatic cancer where the Institute exercised this
    flexibility?
        Answer. Pancreatic cancer is a high priority for the NCI, and we
    are supporting a wide range of research projects to rapidly develop the
    tools needed to diagnose pancreatic tumors as early as possible, to
    characterize tumors genetically, and to find new ways to treat this
    disease. NCI has been paying special attention to grants that might not
    be funded because they fell below what used to be considered a
    ``payline,'' a percentile score derived from the results of peer
    review. Beginning in fiscal year 2011, NCI scientific program leaders
    have been performing additional evaluations of grant applications to
    ensure a balanced grant portfolio and to recognize the value of
    research proposals that are highly original or address important
    scientific priorities, such as research on pancreatic cancer, even
    though they might not have received percentile scores that fall within
    a pre-determined payline. Of the applications that were focused
    exclusively on pancreatic cancer and were funded in fiscal year 2011,
    more than one-third were selected as a result of this programmatic
    review, rather than on the basis of receiving exceptionally high
    scores.
        Examples of pancreatic cancer projects approved by this process
    include:
      --a case-control study aimed at characterizing a select group of
            biomarker candidates in pancreatic juice that may enable
            earlier detection;
      --a study to develop a multifunctional nanoparticle platform with
            both imaging and drug delivery capabilities;
      --a study of corcetin (a carotenoid molecule isolated from saffron)
            that has been shown to have anticancer effects as a potential
            therapy for pancreatic cancer; and
      --a study focused on identifying vulnerable areas of pancreatic
            tumors and overcoming the tough ``stromal barrier'' of
            pancreatic tumors that limits the delivery and diffusion of
            drugs.
                                long-term goals
        Question. In the past, this subcommittee has urged NCI to develop a
    long-range plan for research in the area of pancreatic cancer research.
    Research advocates have been disappointed with the plan and view it
    more as a summary of research that's already underway. Would it be
    possible for NCI to lay out more of a long-term research strategy--
    something that sets out concrete goals and objectives for the future
    that moves beyond current practice?
        Answer. Pancreatic cancer is distinct from other cancers due to its
    complex biology, late manifestation of symptoms, and the lack of early
    screening tools. In addition, there are a large number of genetic
    mutations involved, which complicates the development of effective
    targeted therapies to disable the growth of cancer cells and arrest
    progression of the disease. These factors explain the poor outcomes for
    most pancreatic cancer patients. However, there is great opportunity to
    change these outcomes. Recent NCI-supported research has demonstrated
    that there is a long time period--more than 11 years--between the first
    cancer-related mutation in a pancreatic cell and the development of a
    mature pancreatic tumor. This means that with the right tools for
    detection and targeted treatments, pancreatic cancer could be diagnosed
    while it is surgically curable.
        Both NCI's research portfolio and the fiscal year 2011 strategic
    plan for pancreatic cancer reflect several specific goals, including:
      --in-depth gene sequencing of pancreatic tumors to develop tools for
            detection and treatment;
      --identification of genetic factors, environmental exposures, and
            gene-environment interactions that contribute to the
            development of this cancer;
      --identification and development of biomarkers to allow early
            detection;
      --improvement in our ability to detect tumors when they are much
            smaller than those currently able to be detected with our
            imagining capabilities; and
      --development of effective targeted therapies.
        To accomplish these goals, NCI is supporting a breadth of research
    across its portfolio that applies to the scientific underpinnings of
    all of these goals, including in-depth sequencing of pancreatic tumors
    through The Cancer Genome Atlas. But it is also important to note that
    advances in oncology that have great benefit for a particular type of
    cancer do not necessarily flow from research specifically on that
    cancer type. For example, investment in a rare disease, retinoblastoma,
    was critical for the discovery of tumor suppressor genes, a class of
    genes that is altered in essentially every cancer. Similarly, work on
    an animal model of neuroblastoma led to the discovery of an oncogene,
    HER2, which is targeted by antibodies now widely used in the treatment
    of breast cancer. Thus, while it is crucial for the NCI to give full
    attention to the clinical consequences of every cancer type, we must
    also be responsive to opportunities and ideas that seem likely to offer
    the best chances of making discoveries that bring us closer to
    understanding all cancers, as well as individual cancer types.
                                     ______

               Questions Submitted by Senator Barbara A. Mikulski
                              cancer genome atlas
        Question. Dr. Varmus, please provide an update on how The Cancer
    Genome Atlas (TCGA) is proceeding and how it is contributing to
    reaching the goal of precision medicine that was described in the 2011
    Institute of Medicine report, ``Toward Precision Medicine: Building a
    Knowledge Network for Biomedical Research and a New Taxonomy of
    Disease.''
        Answer. TCGA, a joint effort of the National Cancer Institute (NCI)
    and the National Human Genome Research Institute (NHGRI), is the
    largest and most comprehensive analysis of the molecular basis of
    cancer ever undertaken. Through the application of genome analysis
    technologies, including large-scale genome sequencing, TCGA is
    beginning to provide a comprehensive foundation of the abnormalities
    associated with the tumor types under study, the degree to which tumors
    within each type are similar and distinct, and the degree of overlap
    between tumor types. This foundation has the potential of improving our
    ability to diagnose, treat, and prevent cancer, providing an important
    element in reaching the goal of precision medicine.
        TCGA began as a pilot project in 2006, studying cancers of the
    lung, brain (glioblastoma) and ovary, and it has been expanded over
    time to include additional tumor types. Currently in the third year of
    its post-pilot phase, TCGA has begun the comprehensive analysis of 16
    additional cancers including breast, colorectal, kidney, lung,
    endometrial, and pancreatic cancers, among others. Of these projects,
    one-quarter are published or in manuscript form; one-quarter are in
    late-stage analysis; and the remaining one-half are still being
    collected and studied, with TCGA on track to conclude this phase in
    2014. TCGA has also initiated a small project on rare tumors, with
    plans to complete initial discovery by the end of this year.
        TCGA's efforts to advance the understanding of the molecular basis
    of cancer are already providing the biological insights considered
    critical by the 2011 report, ``Toward Precision Medicine: Building a
    Knowledge Network for Biomedical Research and a New Taxonomy of
    Disease,'' to reaching the goal of precision medicine. The report,
    produced by the National Research Council of the National Academy of
    Sciences, and sponsored by the National Institutes of Health,
    identifies a ``knowledge network of disease'' as necessary to enable a
    new taxonomy of disease that integrates molecular and clinical data, as
    well as health outcomes. TCGA's findings, as well as other work
    supported by the NCI's Center for Cancer Genomics, are poised to
    contribute directly to this network. The NCI is taking a leadership
    role in advancing precision medicine in cancer, and in April 2012
    hosted a workshop that brought together NCI scientists and colleagues
    from across the cancer community to consider ways in which NCI can
    support the acceleration of precision medicine to cancer research and
    treatment.
                               angiogenic levels
        Question. Dr. Collins, what work is NIH conducting to help
    establish baseline angiogenic levels in healthy individuals and those
    with disease? How will this work impact NIH's ability to measure the
    effects of diet on blood vessel development?
        Answer. NCI funds angiogenesis-related research that includes
    examination of cancer-related angiogenesis and exploration of therapies
    targeting this process, as well as research on diet, angiogenesis, and
    cancer prevention. Research is also underway to investigate the effect
    of moderate intensity exercise on blood vessels. Angiogenesis, and
    specifically research measuring the effects of diet on blood vessel
    development, is an area of research the NCI continues to support. Two
    examples of ongoing NCI research related to angiogenesis include:
      --An examination of the underlying mechanisms for the association
            between increased physical exercise and decreased risk of
            several types of cancer and the effects of exercise on
            angiogenesis-related biomarkers in serum.
      --A diagnostic imaging study examining baseline tissue angiogenic
            markers and the outcomes of chemotherapy delivered directly to
            liver tumors via a catheter (transarterial chemo embolization
            therapy).
                           strategic scientific plan
        Question. Dr. Collins, NIH has published a Request for Information
    seeking comments on the Strategic Scientific Plan for the proposed new
    Substance Use and Addiction Disorders Institute. Does NIH intend to
    provide access to these comments to the scientific community and the
    general public? Will NIH make all of the responses available to the
    public as they are received?
        Answer. The Request for Information seeking input into the
    Scientific Strategic Plan is open through May 11, 2012. NIH will
    provide access to all of the responses after the comment period closes.
    NIH will also provide a summary of the comments after completing an
    analysis of the responses.
                                     ______

                Questions Submitted by Senator Richard C. Shelby
                           national children's study
        Question. Dr. Collins, I am hearing serious concerns from the
    research community regarding proposed changes to the National
    Children's Study (NCS). The study was originally designed around a
    representative door-to-door sampling of the U.S. population and now the
    sampling strategy has been significantly changed to be based on
    provider locations instead.
        How much input did you receive from the scientific community and in
    particular the principal investigators participating in the study and
    your advisory committee, on the changes being made to the sampling
    strategy?
        Answer. The change in the NCS Study design is being considered
    primarily for scientific reasons but also with awareness of our need to
    be fiscally responsible. It is based on data generated during the
    ongoing Vanguard, or pilot phase, of the NCS. The Vanguard data showed
    that the proposed study design would not enroll sufficient numbers of
    families within a scientifically acceptable timeframe or within a
    fiscally sound budget. Pilot testing conducted through the Vanguard
    sites showed that a study design based primarily on recruiting
    participants through healthcare providers was most efficient and could
    offer scientific advantages that would more than offset its scientific
    compromises. This provider-based approach also has been employed
    effectively in other large Federal studies. The President's fiscal year
    2013 budget request, which shows a reduction of approximately 15
    percent, to $165 million annually, for the NCS, appropriately reflects
    these proposed design changes.
        As currently envisioned, the NCS Main Study would use a provider-
    based participant selection and recruitment strategy that the National
    Institutes of Health (NIH) and the Agency for Healthcare Research and
    Quality have both employed effectively in other studies. This approach
    uses research ready healthcare provider networks as the primary source
    for recruitment. The NCS would gain additional participants through the
    award of contracts for supplemental recruitment from secondary sources
    (such as title V clinics, Indian Health Service clinics, or contract
    research organizations) to assure inclusion of appropriate population
    groups, specifically those with health disparities. The use of these
    two coordinated selection and recruitment strategies would improve the
    quality of the Main Study and allow analyses not feasible with either
    approach alone.
        If adopted, this revised approach would offer several advantages,
    including:
      --greater recruitment efficiency;
      --leveraging access to consenting participants' electronic health
            records, thus improving the amount and consistency of data
            collected while lowering costs;
      --the potential to leverage the existing infrastructure of networks
            of healthcare providers, again improving the quality of data
            and lowering costs; and
      --allowing built-in continuity for participants who move but remain
            within the provider network (many provider networks have
            statewide or regional coverage) or join another provider
            network affiliated with the Main Study.
        NCS continues to refer to the Institute of Medicine (IOM) report
    that was written by a panel of experts convened to review the original
    study design. Many of the changes recommended in the report have
    already been addressed, including the need for an ongoing Vanguard
    Study to test the study protocol and scientific methodology. The report
    also noted that the large number of field contractors was a weakness of
    the Study design, and the NCS is moving to correct this weakness.
        The National Children's Study Advisory Committee meets at least
    four times a year; the April 24, 2012 meeting was the 32d meeting of
    the committee. These meetings are open to the public, and a public
    comment period is provided. Presentations to the Advisory Committee
    also are posted on the NCS Web site. As they have become available,
    data from the Vanguard Study have been presented at each of the
    committee's meetings. The topic of a provider based approach to Study
    recruitment was discussed twice in the last year with the Advisory
    Committee, first in April 2011 and then again in July 2011, before
    being the focus of the entire April 24, 2012 meeting. The NCS Study
    Director holds weekly national conference calls for Vanguard Study
    contractors to update them on recent developments and to receive their
    input. The investigators also provide expertise and comments through a
    monthly Executive Steering Committee meeting, through 2-day face-to-
    face meetings every 6 months, through circulation of all study
    instruments and protocol changes to all investigators for comment, and
    through a mailbox account dedicated to contractors.
        Question. How will the academic community be involved going
    forward?
        Answer. Current NCS Vanguard Study contracts expire over the next
    17 months. All Requests for Proposals for both the Vanguard and Main
    Studies will have full and open competitions. Academic institutions can
    offer proposals for new Study contracts for primary data collection,
    and have other options as well, including partnering with a primary
    data collector, conducting ancillary studies using NCS infrastructure,
    or doing their own research analyses using NCS data as they become
    available.
        In addition, the NCS holds workshops and conferences several times
    a year and holds open Advisory Committee meetings on a quarterly basis
    to which the academic community is welcome. NCS also meets with
    professional societies and other organizations on an ongoing basis and
    NCS personnel plan and attend academic meetings throughout the year.
        Question. In 2010, the committee was informed by NIH that the
    approximate cost of the entire NCS program would double--from $3.1 to
    $6 billion. Now, you are cutting the request by 15 percent. The budget
    justification provides no details on how you arrived at the request
    amount for fiscal year 2013. Can you lay out, specifically, how the
    $165 million request was reached?
        Answer. NCS is able to reduce overhead costs through greater
    operational efficiencies and redistribution of tasks and
    responsibilities. Examples include the use of nonproprietary software
    to eliminate license fees and proprietary support; use of a federated
    model for human subject protection to reduce redundancy and speed
    approvals through elimination of duplicate administrative resources;
    use of the NCS program office as a coordinating center to develop study
    instruments and protocol documents, to perform data analysis, and to
    manage field operations and general consolidation of overlapping field
    operations.
        With the reduction in overhead, we anticipate that for fiscal year
    2013 we need about $35 million for support services and about $130
    million for ongoing Vanguard operations and Main Study initiation.
        Question. Why are there no longer any study hypotheses which
    address the congressional concerns for the NCS put forth in the
    Children's Health Act of 2000?
        Answer. As directed by the Children's Health Act of 2000, the NCS
    is a longitudinal birth cohort study with the overall goal of examining
    the role that environmental influences (including physical, chemical,
    biological, and psychosocial) have on children's health and
    development. Hypotheses about what factors affect children's health and
    development will inform the questions asked and the data collected for
    the Study, but the NCS will not be hypothesis-driven. Children's
    environments are likely to change substantially over the next two
    decades, and our goal is to create the richest possible data,
    biospecimen, and environmental specimen resource to answer important
    questions about health and development as they arise.
        Question. It is my understanding that the new proposal will move
    the sampling scope from a door-to-door model to a health maintenance
    organization-based model. By design, this would exclude involvement of
    the uninsured and likely the involvement of rural and minority
    populations. These populations are a critical component to achieving
    scientifically valid findings. How will you address this issue?
        Answer. As currently envisioned, the NCS Main Study would use a
    provider-based participant selection and recruitment strategy that the
    NIH and the Agency for Healthcare Research and Quality (AHRQ) have both
    employed effectively in other studies. This approach uses research
    ready healthcare provider networks as the primary source for
    recruitment. The NCS would gain additional participants through the
    award of contracts for supplemental recruitment from secondary sources
    (such as title V clinics, Indian Health Service clinics, or contract
    research organizations) to assure inclusion of appropriate population
    groups, specifically those with health disparities. The use of these
    two coordinated selection and recruitment strategies would improve the
    quality of the Main Study and allow analyses not feasible with either
    approach alone.
        Question. The Vanguard Centers have created nearly a decade's worth
    of research infrastructure including costly ``build outs'' of field
    office space composed of laboratories for processing biological and
    environmental specimens, and call centers. These facilities were built
    to detailed specifications provided by the NCS program office. Other
    NCS research infrastructure include the hiring, certifying and training
    of staff, development of a Federated Institutional Review Board, and
    establishment of a Federal Information Security Management Act
    compliant environment. In addition, the Vanguard Centers have spent
    years developing cooperative agreements and memoranda of understanding
    with countless delivery hospitals to ensure that NCS participant
    biological and medical data can be obtained at the time of birth. Given
    the newly proposed design of the NCS, it appears as though this
    infrastructure could go to waste without utilizing the resources of the
    existing Vanguard Centers. What assurances can you provide that these
    Vanguard Centers will be eligible to compete for continued
    participation in the NCS and be afforded a reasonable, full, and fair
    opportunity to do so?
        Answer. The Vanguard Study will continue to pilot study methods in
    its current 40 locations, several years in advance of the Main Study,
    following the children already recruited by the Vanguard Study until
    they turn 21. In this follow-up phase, it will use a smaller number of
    contractors than in its earlier recruitment phase, thus following
    recommendations in the IOM report from 2008 and realizing cost savings,
    while improving scientific quality by achieving greater consistency in
    data and specimen collection among study sites.
        Current NCS Vanguard Study contracts expire over the next 17
    months; new contracts will be awarded following full and open
    competitions. The NCS is working with current contractors to ensure the
    orderly transition of data collection services and of relationships
    with participants, communities, and other local institutions. As is
    usual with longitudinal studies that extend across many years,
    individual contractors may continue to change during the course of the
    study, and it is important for the NCS to have procedures in place to
    ensure smooth transitions that may occur in the future.
        All Requests for Proposals for both the Vanguard and Main Studies
    will have full and open competitions. Academic institutions can offer
    proposals for new Study contracts for primary data collection, and have
    other options as well, including partnering with a primary data
    collector, conducting ancillary studies using NCS infrastructure, or
    doing their own research analyses using NCS data as they become
    available. Finally, contractors that complied with NCS specifications
    for field operations will have established a platform that is flexible
    and adaptable to multiple uses, so they can leverage that investment
    for additional projects.
                          drug rescue and repurposing
        Question. Dr. Collins, at the NIH hearing last year, we discussed
    drug rescue and repurposing--that is, leveraging existing compounds to
    develop new, novel treatments for patients. In January, NIH released a
    concept for a program called the Drug Rescue Program to fund research
    to identify new therapeutic uses of proprietary investigational drugs
    and biologics. I am pleased to see NIH moving forward on this issue
    since it is an ideal opportunity for academia to team with industry to
    bring treatments to patients faster. However, repurposing compounds
    brings up a number of challenges, including concerns regarding
    intellectual property rights and liability. In particular, will
    pharmaceutical companies be interested in repurposing drugs they
    currently make money on if a new patient population could open them up
    to new lawsuits? How will you address these concerns?
        Answer. In early May, National Center for Advancing Translational
    Sciences (NCATS) expects to establish a pilot collaborative drug rescue
    program, Discovering New Therapeutic Uses for Existing Molecules, to
    match researchers with a selection of industry-developed molecular
    compounds in an attempt to identify a therapeutic use. These compounds
    are currently not approved for any use and are not being pursued by the
    pharmaceutical company. The program will incorporate innovative
    template agreements designed to streamline the legal and administrative
    process for participation by multiple organizations. These templates
    will reduce time, cost, and effort, as well as enable greater
    participation than traditional partnerships. The templates also provide
    a roadmap for handling intellectual property used in or developed
    through the program. Participating industry partners will retain the
    ownership of their compounds, while academic research partners will own
    any intellectual property they discover through the research project
    with the right to publish the results of their work.
        This pilot program will focus on drug rescuing only. It does not
    include drug repurposing, which is an attempt to find a new use for a
    drug that is already approved for another therapeutic use. NCATS is
    considering how best to structure initiatives which enable drug
    repurposing, with the understanding that repurposed drugs would undergo
    the same Federal Drug Administration (FDA) requirements and clinical
    development investments as newly developed compounds and will need to
    meet FDA patient safety and efficacy requirements.
                                health economics
        Question. Dr. Collins, the President's budget requests $13 million
    from the Common Fund for health economics research. Diverting
    biomedical research funds to pay for health economics research is not
    only a significant departure from traditional NIH research funding but
    also duplicative of AHRQ health economics research and the Center for
    Disease Control and Prevention research on the economics of prevention.
    For example, one of the programs four major initiatives in the budget
    request is for a program entitled: ``The Science of Structure,
    Organization, and Practice Design in the Efficient Delivery of
    Healthcare.'' This initiative appears directly duplicative of AHRQ's
    existing program, the Patient-Centered Health Research/Effective Health
    Care, that seeks to conduct research around the same areas on
    healthcare delivery and efficiency. Since AHRQ's mission seems more
    appropriately suited toward researching the economics and efficiency of
    healthcare delivery, why should we be taking money away from valuable
    investments in biomedical research, when much of this work appears to
    be in progress within other Health and Human Services Operating
    Divisions?
        Answer. We are working with AHRQ and other agencies to collaborate
    on this critical issue to ensure that NIH research does not conflict
    with their efforts and missions. NIH's mission is ``to seek fundamental
    knowledge about the nature and behavior of living systems and the
    application of that knowledge to enhance health, lengthen life, and
    reduce the burdens of illness and disability.'' We initiated this
    Common Fund program in Health Economics as a way to measure the success
    of the translation of the benefits of our research into enhanced health
    of the U.S. population.
        Much of the NIH research enterprise generates optimism that a new
    era of personalized medicine (meaning both prevention and treatment)
    will lead to improved outcomes while keeping cost growth under control.
    For this promise to be realized, we will need to understand the reasons
    organizations and individuals adopt new approaches.
                                     ______

                 Questions Submitted by Senator Lamar Alexander
                   clinical and translational science awards
        Question. The largest single Federal grant at Vanderbilt University
    is a clinical and translational science award (CTSA) for approximately
    $50 million. Vanderbilt is also the national coordinating center for
    all of the CTSA's. How do you see the interactions between the CTSAs
    and the rest of the National Center for Advancing Translational Science
    (NCATS) developing, and what is being done to support a high level of
    interaction?
        Because of the shortage of products in the drug pipeline, do you
    see NCATS as more focused on drug development, or will the CTSAs also
    continue to be able to build on the programs of training, career
    development for young investigators, research informatics, community
    engagement, and clinical research infrastructure? All of these are
    still important for biomedical research.
        Answer. With the creation of NCATS on December 23, 2011, the
    administration of the CTSA program moved into a new home. Within NCATS,
    the program will continue to support the highest quality translational
    research. Now as part of a new division, the Division of Clinical
    Innovation (DCI), the CTSA program is benefiting from adjacency to the
    new Division of Preclinical Innovation (DPI). DPI includes programs
    that focus on re-engineering the early phases of translation (including
    assay development, high-throughput screening, lead optimization, and
    predictive toxicology) as well as the Therapeutics for Rare and
    Neglected Diseases program. A fully integrated program will be put in
    place so that the DPI and the DCI are truly a single effort guided by a
    shared mission.
        One of the great successes of the CTSA program has been its
    development of training programs for clinical researchers and allied
    professionals in the many aspects of translational science. As the CTSA
    program incorporates the mission of NCATS, this emphasis on training
    will be sustained and expanded to build in specific areas of need, such
    as informatics and pharmacology. We anticipate that the CTSAs will have
    an important role in facilitating first-in-human trials for new
    therapies, promoting innovation in research methods, and re-engineering
    the processes for clinical research. We expect that they will continue
    to provide a home for community outreach and education at institutions
    across the country. The CTSA program will continue to support the
    entire spectrum of translational research, evolving to meet the most
    pressing scientific needs and opportunities. NCATS is not a drug
    development center; its broader mission is to enhance the development,
    testing, and implementation of diagnostics and therapeutics across a
    wide range of diseases and conditions.
                             personalized medicine
        Question. The physicians and researchers at Vanderbilt 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 National Institutes of Health (NIH)?
        Answer. Personalized medicine, or more precisely ``genomic
    medicine,'' is the medical application of genomics for the purposes of
    disease prevention, diagnosis, and treatment. It is sometimes referred
    to as ``precision medicine'' or ``individualized medicine.'' Through
    genomic medicine, we will anticipate and often pre-empt the onset of
    disease, diagnose disease more quickly and accurately, and tailor the
    choice of medications according to an individual's genomic information.
        This vision for improved healthcare tools and options was a key
    driving force behind the Human Genome Project (HGP; http://
    www.genome.gov/10001772)--a major international project led by the NIH.
    Scientists recognized that, in order to realize genomic medicine, we
    would first need much more detailed knowledge of the human genome.
    Through the HGP, scientists were able to determine the full molecular
    sequence of the human genome and its genes.
        NIH, led by the National Human Genome Research Institute (NHGRI),
    is now building on the success of the HGP. In 2011, NHGRI published a
    new strategic vision describing the research path necessary for genomic
    medicine to become reality (http://www.genome.gov/sp2011/). The plan
    emphasizes that a deeper understanding of the basic biology of the
    genome, such as identifying all its functional elements and how genomes
    vary from person to person is needed. It also highlights the need to
    investigate how genome variation influences health and disease and the
    work to be accomplished to explore the clinical applications of
    genomics. NIH is now leading this research through cutting-edge
    programs and research initiatives.
        For instance, NHGRI and the National Cancer Institute
    collaboratively lead ``The Cancer Genome Atlas'' to better understand
    the molecular basis of cancer. NHGRI also is funding research to detect
    the genetic underpinnings of thousands of rare diseases for which there
    is no known cause, as well as undertaking a major project to
    investigate the genetic causes of Alzheimer's disease. While it will be
    many years before genomics is fully incorporated into patient care,
    NHGRI-funded researchers are investigating the clinical use of genomics
    in patients at risk for many diseases, including those with mysterious
    conditions that have long eluded diagnosis. Institutes and Centers
    (ICs) across NIH are conducting genomic research to elucidate the
    genomic causes of disease and how the genome influences the
    effectiveness of treatment.
        Though sometimes envisioned as a phenomenon of the future, genomic
    medicine is already having an impact on how patients are treated. This
    is especially true in the field of pharmacogenomics, where drug
    selection and administration increasingly is assisted by prior genetic
    testing. The Food and Drug Administration now lists approximately 100
    approved drugs with pharmacogenomic information on their labels. These
    include abacavir, now the standard of care for HIV-infected patients,
    as well as drugs for the treatment of cancers, clopidogrel for treating
    cardiovascular disease, and warfarin for preventing blood clotting.
        Genomics is also being used to help patients who do not respond to
    conventional treatment. An example of this was described by NIH
    Director Francis Collins, M.D., Ph.D. during his testimony before the
    subcommittee during the NIH hearing on March 28. Dr Collins told the
    story of twins Alexis and Noah Beery, who suffered from a rare and
    devastating movement disorder called dystonia. The causative mutation
    was identified through sequencing of their genomes, after which their
    treatment was changed and their health improved remarkably.
        Genomics promises to advance healthcare over the next several
    decades. NIH will continue to lead the way toward genomic medicine
    through funding and conducting the pioneering science that will be
    necessary to realize the full potential of genomic medicine.
                                    diabetes
        Question. Diabetes continues to be a costly and growing epidemic
    for Tennessee and the United States. Dr. Collins and Dr. Rodgers, can
    you tell us how NIH, and National Institute of Diabetes and Digestive
    and Kidney Diseases (NIDDK) in particular, are addressing this
    epidemic?
        Answer. NIH and NIDDK are working to develop and test prevention
    and treatment strategies for type 1 and type 2 diabetes through a
    robust research program that supports basic, clinical, and
    translational research, as well as research training. Future research
    will be guided by a strategic plan for diabetes research that was
    recently released by the NIDDK (http://www2.niddk.nih.gov/AboutNIDDK/
    ReportsAndStrategicPlanning/DiabetesPlan/PlanPosting.htm). Landmark
    clinical research supported by the NIH has included the Diabetes
    Control and Complications Trial and the United Kingdom Prospective
    Diabetes Study, which established the value of tight blood glucose
    control in reducing complications in type 1 and type 2 diabetes
    respectively; and the Diabetes Prevention Program, which proved that
    type 2 diabetes can be prevented or delayed through delivery of an
    intensive lifestyle intervention, or, to a lesser degree, with the
    generic drug metformin. Knowledge from NIH diabetes research is
    communicated to patients, health professionals, and the public through
    the National Diabetes Information Clearinghouse and the National
    Diabetes Education Program.
        In 2011, NIDDK completed the first major trial of type 2 diabetes
    management in children and adolescents, a newly emerging problem, and
    demonstrated that intensive glucose control in people with type 1
    diabetes can reduce rates of chronic kidney disease and end-stage renal
    disease by 50 percent 22 years later. NIDDK supported planning grants
    for a comparative effectiveness clinical trial testing different
    medications, in combination with metformin, for type 2 diabetes
    treatment, and for a clinical trial testing vitamin D in prevention of
    type 2 diabetes based on a promising pilot study. Other clinical trials
    include Action for Health in Diabetes (Look AHEAD), to determine the
    value of a lifestyle intervention for improving diabetes outcomes, and
    investigation of bariatric surgery as treatment for diabetes,
    complemented by studies in animal models.
        New initiatives are fostering research toward preserving function
    of insulin-producing beta cells early in the course of type 2 diabetes,
    and a new consortium was launched to study approaches to prevent
    gestational diabetes. The Beta Cell Biology Consortium identified a
    potential new strategy to induce beta cell regeneration to replace lost
    beta cells and reverse aging-associated decline in beta cell growth.
    NIDDK is also working to understand and ameliorate disparities in
    diabetes with research to identify gene regions conferring type 2
    diabetes risk in multiple ethnic groups, translational research to
    bring scientific discoveries to all who can benefit, and a clinical
    trial of type 2 diabetes management including minority youth and
    adolescents.
                     minority health and health disparities
        Question. Dr. Collins, the healthcare reform law clarified the role
    of the National Institute on Minority Health and Health Disparities
    (NIMDH) at NIH as it pertains to coordinating health disparities
    research. How are you and the IC Directors going to work together to
    make the newly elevated NIMHD the coordinating body at NIH on health
    disparities?
        Answer. The law clearly identifies the NIMHD as the coordinating
    body for minority health and health disparities at NIH. The NIH
    Institutes and Centers will continue to administer their programs on
    minority health and health disparities and work with the NIMHD as
    required in its coordinating role.
        Question. Where does the NIH stand in terms of funding that is
    allotted to minority health and health disparities? In the last
    strategic plan, there was $2.5 billion being spent on minority health
    and health disparities at various ICs. What is that amount now, and how
    are you going to work with the new health reform law so that the NIMHD
    is the coordinating entity at NIH for these issues?
        Answer. The overall NIH fiscal year 2011 funding for health
    disparities was $2.7 billion. NIMHD recently hired a Deputy Director
    for strategic scientific planning and program coordination, who will
    lead the NIMHD coordination of minority health and health disparities
    working with the Institutes and Centers.
        Question. Considering last year's NIH study, which showed possible
    bias against African Americans with the awarding of NIH R01 grants,
    will you work with Meharry Medical College and the Association of
    Minority Health Professions Schools to ensure their annual health
    profession pipeline symposium, exposing hundreds of students to the
    health professions, receives adequate funding?
        Answer. A working group of the National Advisory Council (ACD) has
    been working on this vexing problem and is scheduled to report its
    recommendations at the June 14 meeting of ACD. The president of Meharry
    Medical College, Dr. Wayne Riley, is a member of this working group. As
    part of this deliberative process, outreach efforts have included many
    of the institutions represented by the Association of Minority Health
    Professions Schools (AMHPS). Meharry Medical College and the AMHPS have
    successfully competed in the past for NIH funding to support the annual
    health professions symposium, and are encouraged to continue applying
    for NIH funding. Several of the NIH Institutes and Centers have
    contributed funds to support the symposium.
        Question. The NIH has issued two strategic plans and budgets to
    reduce and eliminate health disparities since the Congress enacted the
    legislation requiring it. What is the status of the next strategic
    plan?
        Answer. The NIH Health Disparities Strategic Plan and Budget fiscal
    year 2009-2013 has been approved and is available on the NIMHD Web site
    at http://www.nimhd.nih.gov/about_ncmhd/index2.asp.
        Question. Can you provide detailed funding information for minority
    health and health disparities activities at the NIH broken out
    programmatically by Institute and Center?
        Answer. The NIH Health Disparities Strategic Plan and Budget fiscal
    year 2009-2013 provides information on programs/activities by
    Institutes and Centers with associated budgets for each goal by IC and
    is available on the NIMHD Web site at http://www.nimhd.nih.gov/
    about_ncmhd/index2.asp.
                                     ______

                   Questions Submitted by Senator Jerry Moran
       intersection of national cancer institute and national center for
                        advancing translational science
        Question. We have heard Dr. Collins and others discuss the value to
    National Institutes of Health (NIH) of the newly created National
    Center for Advancing Translational Science, or (NCATS). NCATS is being
    positioned to become a resource that will support the translational
    research work across all of NIH's Institutes and Centers.
        Could you clarify how the National Cancer Institute (NCI) will work
    with NCATS to optimize the investments that will be made in NCATS and
    the knowledge that will be developed in this new center?
        Answer. Translational research supported by NCI transforms
    scientific discoveries arising from laboratory, clinical, or population
    studies into clinical applications to reduce cancer incidence,
    morbidity, and mortality--it is a critical piece of the NCI's research
    portfolio and encompasses numerous programs and funding mechanisms.
        For example, researchers working in NCI's Specialized Programs of
    Research Excellence (SPOREs) and investigator initiated Program Project
    (P01) grants at NCI-supported research institutions across the country,
    conduct promising translational research. The NCI Drug Discovery and
    Development Program, run through the Frederick National Laboratory for
    Cancer Research, has successfully guided drug candidates through the
    final steps of development to first-in-human studies. The Cancer Genome
    Atlas (TCGA) and Therapeutically Applicable Research to Generate
    Effective Treatment (TARGET) programs are generating data on the
    genomic foundations of cancer, and the Cancer Target Discovery and
    Development (CTDD) Network is accelerating the transition of molecular
    data from initiatives like TARGET and TCGA to new treatments through
    gene validation studies as well as high-throughput screening of small
    molecules.
        NCATS will complement these efforts, particularly by providing
    resources and infrastructure to assist the basic research community in
    moving their discoveries to the next phase. NCATS will work to improve
    the methodology of translational research, and will also collaborate
    with and utilize NCI programs in the process. There will be points
    where NCI and NCATS intersect to share knowledge and technology. For
    example, Clinical and Translational Science Awards (CTSA) are an
    initiative funded principally by NCATS. Most academic institutions that
    have an NCI-designated Cancer Center also have a CTSA and many
    collaborative projects have emerged from these synergies.
                            value of cancer centers
        Question. I have had the opportunity to visit a cancer center in my
    home State--The University of Kansas Cancer Center. I have seen basic
    research at work in impressive labs. In particular, at the University
    of Kansas (KU) I have seen how this research is being translated into
    the development of early phase drugs--in one case through a ground-
    breaking collaboration between the University of Kansas Cancer Center,
    NIH, and the Leukemia Lymphoma Society. I believe that collaborations
    such as this that bring public and private resources and expertise
    together are important if we are to maximize the return on the
    investments of our Federal dollars. And last but definitely not least,
    I have seen patients coming to KU with the ability to participate in
    clinical trials, with the hope and real potential that the delivery of
    cutting-edge research into their care may change the course of their
    disease for the better.
        What are the programs at NCI that make this cycle of innovation and
    translation possible?
        Specifically, do you see a specific role for the Cancer Centers
    program in making sure that this cycle of translation of basic research
    findings into clinic application continues to take place?
        Answer. NCI engages in multiple collaborations along the research
    continuum, including funding a variety of innovative biotechnology
    companies via its Small Business Innovation Research program.
        The NCI's 66 Designated Cancer Centers, which are distributed in
    all regions of the United States, play a crucial role in the Nation's
    cancer research effort and are the primary source of new discoveries
    about cancer prevention, diagnosis, and treatment. The Cancer Centers
    deliver state-of-the-art care to patients and their families, inform
    healthcare professionals and the general public, and often work through
    partnerships with other healthcare organizations to reach underserved
    populations. Clinical application--providing prevention, diagnosis, and
    therapies for patients--is the ultimate goal for all cancer research,
    and NCI-designated Cancer Centers have a proud history of leadership in
    clinical trials, many of which have led to changes in the standard of
    care for cancer patients. Along with the many other NCI-funded research
    and academic institutions, and NCI's intramural program, they are a
    major source of new discoveries into cancer's causes, prevention,
    diagnosis, and treatment.
        The NCI-Designated Cancer Centers are required to facilitate the
    rapid transfer of clinical observations to laboratory experiments, and
    promising lab-based discoveries to innovative applications in the
    prevention, detection, diagnosis, treatment, and survivorship of
    cancer. The Cancer Centers are required to work together and with the
    NCI to facilitate the translation of fundamental discoveries into
    tangible patient benefit. For example, researchers at the University of
    California San Francisco Cancer Center have shown that a molecular test
    measuring the activity of 14 genes in cancerous lung tissue can improve
    the accuracy of prognosis and guide treatment options for patients with
    the most common form of lung cancer. Other recent developments include
    identification of the first major genetic mutation associated with
    inherited prostate cancer by researchers from the Johns Hopkins Cancer
    Center, with implications for the development of genetic tests to
    identify the mutation and screening practices for men with a family
    history of prostate cancer. And at the Koch Institute for Integrative
    Cancer Research at MIT, cancer researchers and engineers are working
    together to develop more effective drug delivery systems such as
    nanoparticle ``smart bombs'' that deliver high concentrations of drugs
    directly to the cancer cells, a technology currently being studied in a
    phase I clinical trial.
                update on national cancer institute initiatives
        Question. When I read stories about the development of cutting-edge
    treatments, particularly those that use the body's own immune system to
    fight cancer and other diseases, I know that we are doing something
    right to save lives and lower healthcare costs. Can you explain some of
    the most promising cancer research opportunities and discoveries that
    the NCI is currently pursuing?
        Answer. NCI supports a diverse research portfolio aimed at
    increasing our understanding of the genomic foundations of cancer,
    improving screening technologies, advancing effective treatments
    including immunotherapies, and developing new approaches for overcoming
    drug resistance.
          Genomic Foundations of Cancer.--Using genomics to match drugs to
            the patients most likely to benefit from them, and conversely
            sparing patients courses of treatment from which they will not
            benefit, promises to be among the new modalities for
            successfully managing cancer. Understanding the genomic
            underpinnings of cancer allows for the development of
            molecularly targeted agents that may be effective against
            several cancer types, and can often be used in combination with
            other therapies. NCI's Center for Cancer Genomics, with a
            mission of developing and applying genome science to better
            treat cancer patients, coordinates this research area across
            the NCI.
          Screening Technologies.--Tools that can accurately detect and
            diagnose tumors have potential to markedly improve outcomes for
            cancer patients since these tools often detect cancer early,
            before it has spread throughout the body and when treatment is
            more likely to be curative. Last year, NCI released results
            from the National Lung Screening Trial indicating that
            screening with low-dose-computed tomography results in 20
            percent fewer lung-cancer deaths among current and former heavy
            smokers compared with screening with chest xray. This
            development marks the first time that a screening test has been
            found to reduce mortality from lung cancer, the most common
            cause of cancer deaths in the United States and the world.
            Other initiatives and projects, including a large portfolio of
            grants, are pursuing biomarkers and imaging techniques with
            potential to aid in early detection and diagnosis of several
            types of cancers.
          Immunotherapies.--The pace of research advances to stimulate the
            body's immune system to fight cancer has quickened in recent
            years, with clinical trials of different therapies showing
            positive results for several different cancer types. In 2010,
            data from a large clinical trial established a monoclonal
            antibody called ipilimumab as the first immunotherapeutic agent
            to show an increase in survival for patients with advanced
            melanoma. The drug stimulates the immune system to attack
            melanoma cells by binding to and inhibiting a molecule called
            CTLA-4 that is found on the surface of immune cells.
          In March 2011, the Food and Drug Administration (FDA) approved
            the antibody (marketed as Yervoy) to treat late-stage melanoma.
            NCI-supported research has validated CTLA-4 as a target and has
            paved the way for studies of the drug for prostate, lung, and
            renal cancers. Other potentially promising immunotherapy
            approaches include ``adoptive cell transfer,'' in which T-cells
            are taken from a patient's tumor, stimulated and reproduced,
            then put back into the body; and the targeting of ``tumor
            initiating cells'' (thought to be the chief cause of cancer
            recurrences) as well as normal cells that cooperate with cancer
            cells to help them survive and spread.
          Drug Resistance.--One of the most disappointing features of the
            development of new targeted therapeutics is how routinely drug
            resistance emerges and the disease begins to progress.
            Resistance to treatment with anticancer drugs results from a
            number of factors--every cancer expresses a different array of
            drug-resistance genes, and various mechanisms have evolved as
            protection from toxic agents. As therapy has become more
            effective, acquired resistance has become common. NCI is
            aggressively pursuing research to gain an understanding of the
            mechanisms that lead to drug resistance and is looking for
            agents that overcome these mechanisms. NCI is supporting
            studies of combination therapies for patients whose disease has
            become resistant to therapy, as well as exploring alternative
            approaches through the Provocative Questions Initiative to
            determine if controlling rather than killing cancer cells can
            avoid the development of drug resistance.
        Question. Also, since NIH's work has been managed over the past few
    years with flat and decreased funding when you account for inflation,
    what innovative strategies have you found, or do you plan, that will
    allow NIH to continue making research progress in this challenging
    budgetary environment?
        Answer. NCI is employing a number of innovative strategies to
    ensure efficient stewardship of the Nation's investment in cancer
    research, particularly in the face of stagnant budgets. As mentioned at
    the recent subcommittee hearing, the Provocative Questions (PQ) project
    is one creative approach that contributes to this goal. The project is
    assembling a list of important but nonobvious questions that will
    stimulate the NCI's research communities to use laboratory, clinical,
    and population sciences in especially effective and imaginative ways.
    While this initiative does not replace the NCI's longtime and essential
    emphasis on funding investigator-initiated research, it represents a
    useful new approach to making the greatest impact with our research
    dollars. Reductions in funding tend to prompt all parts of the research
    community to become more conservative, often converging on similar
    subjects, narrowing research portfolios. By pooling the imaginations of
    the research community to address understudied areas, an initiative
    such as PQ provides a venue for innovative approaches even in times of
    fiscal constraint.
        Another area where NCI is making strategic changes is its Clinical
    Trials Cooperative Groups program. Clinical trials are a critical step
    in moving potential therapies into clinical practice, and the
    Cooperative Groups are an essential part of this process. The groups
    are now being reorganized, consolidating nine adult groups into four,
    with the Children's Oncology Group remaining a separate group. The
    consolidation is an effort to streamline the development and execution
    of trials, while continuing to select and prioritize trials through
    stringent peer review, and to fund the most promising and innovative
    studies. This process will reduce redundancy and improve the
    effectiveness and efficiency of trials; and will also result in
    simplified and better harmonized operations centers, data management
    centers, and tumor banks. The streamlined framework will also foster a
    more collaborative approach to selecting the most important trials to
    perform.
        NCI is also changing the way it conducts early phase clinical
    research. Over the last several years, NCI has developed the ability to
    do ``proof of mechanism'' studies, which allow the research community
    to understand early on whether a drug hits its target. This work
    defines patient populations that are most likely to benefit from
    targeted therapies as early in the process as possible. Continued
    progress in this area will lead to clinical research models that are
    not only more efficient, but more effective in identifying the
    appropriate treatment approach for specific patient populations. These
    are just a few examples that demonstrate NCI's strategic approaches to
    continue to make progress in a challenging budgetary environment.
        Question. The Cancer Genome Atlas (TCGA) is one of NIH's most
    prominent examples of research growing out of the HGP and is the basis
    for much of the work taking place today that explores the genomic
    foundations of cancer. Researchers are working to increase our
    understanding of the genetic basis of various forms of cancer and how
    to best capitalize on these genomic breakthroughs. Can you provide an
    update on how TCGA is proceeding and how this project is contributing
    to advancements in precision medicine?
        Answer. TCGA, a joint effort of the NCI and the National Human
    Genome Research Institute (NHGRI), is the largest and most
    comprehensive analysis of the molecular basis of cancer ever
    undertaken. Through the application of genome analysis technologies,
    including large-scale genome sequencing, TCGA is beginning to provide a
    comprehensive foundation of the abnormalities associated with the tumor
    types under study, the degree to which tumors within each type are
    similar and distinct, and the degree of overlap between tumor types.
    This foundation has the potential of improving our ability to diagnose,
    treat, and prevent cancer, providing an important element in reaching
    the goal of precision medicine.
        TCGA began as a pilot project in 2006, studying cancers of the
    lung, brain (glioblastoma) and ovary, and it has been expanded over
    time to include additional tumor types. Currently in the third year of
    its post pilot phase, TCGA has begun the comprehensive analysis of 16
    additional cancers including breast, colorectal, kidney, lung,
    endometrial and pancreatic cancers, among others. Of these projects,
    one quarter are published or in manuscript form; one quarter are in
    late-stage analysis; and the remaining one-half are still being
    collected and studied, with TCGA on track to conclude this phase in
    2014. TCGA has also initiated a small project on rare tumors, with
    plans to complete initial discovery by the end of this year.
        TCGA's efforts to advance the understanding of the molecular basis
    of cancer are already providing biological insights considered critical
    to reaching the goal of precision medicine. The work supported by NCI's
    Center for Cancer Genomics, including not only TCGA but also CTDD and
    Therapeutically Applicable Research to Generate Effective Treatments
    (TARGET), will contribute to the advancement of precision medicine.
        Question. Last year, the Journal of Oncology published an article
    entitled ``Tumor Angiogenesis as a Target for Dietary Cancer
    Prevention'' examining the suppression of tumor growth by controlling
    blood vessel growth through diet. I understand that promoting healthy
    blood vessel growth may have applications in not only fighting cancer
    but also Alzheimer's disease, arthritis, and cardiovascular disease. I
    also understand that evaluating baseline angiogeneic levels in healthy
    individuals and those with disease are critical to measuring the
    effects of diet on blood vessel development. What work is NIH
    conducting to help establish baseline angiogenic levels?
        Answer. NCI funds angiogenesis-related research that includes
    examination of cancer-related angiogenesis and exploration of therapies
    targeting this process, as well as research on diet, angiogenesis, and
    cancer prevention. Research is also underway to investigate the effect
    of moderate intensity exercise on blood vessels. Angiogenesis, and
    specifically research measuring the effects of diet on blood vessel
    development, is an area of research the NCI continues to support. NCI's
    Division of Cancer Prevention is considering hosting a workshop to
    bring together experts in angiogenesis and nutrition to explore current
    science regarding angiogenesis modification, diet, and cancer. Two
    examples of ongoing NCI research related to angiogenesis include:
      --an examination of the underlying mechanisms for the association
            between increased physical exercise and decreased risk of
            several types of cancer and the effects of exercise on
            angiogenesis-related biomarkers in serum; and
      --a diagnostic imaging study examining baseline tissue angiogenic
            markers and the outcomes of chemotherapy delivered directly to
            liver tumors via a catheter (transarterial chemo embolization
            therapy).

                              SUBCOMMITTEE RECESS

        Senator Harkin. Thank you all very much.
        [Whereupon, at 11:54 a.m., Wednesday, March 28, 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 2013

                                  ----------

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

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

                             DEPARTMENTAL WITNESSES

                           RAILROAD RETIREMENT BOARD

        Prepared Statement of Michael S. Schwartz, Chairman of the Board
        Mr. Chairman and members of the subcommittee: We are pleased to
    present the following information to support the Railroad Retirement
    Board's (RRB) fiscal year 2013 budget request of $112,415,000 to
    operate the agency.
        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. In recent years,
    the RRB has also administered extended unemployment benefits under the
    American Recovery and Reinvestment Act of 2009 (Public Law 111-5) and
    the Worker, Homeownership, and Business Assistance Act of 2009 (Public
    Law 111-92), as amended. The recently enacted Middle Class Tax Relief
    and Job Creation Act of 2012, (Public Law 112-96) provides extended
    unemployment benefits for periods of eligibility beginning through
    calendar year 2012.
        During fiscal year 2011, the RRB paid $11 billion, net of
    recoveries and offsetting collections, in retirement and survivor
    benefits to about 578,000 beneficiaries. We also paid $90.9 million in
    net unemployment and sickness insurance benefits under the Railroad
    Unemployment Insurance Act and $7.8 million under Public Law 111-92, as
    amended, for special extended unemployment benefits to a total of about
    28,000 claimants. In addition, the RRB paid benefits on behalf of the
    Social Security Administration amounting to $1.4 billion to about
    115,000 beneficiaries.
                   proposed funding for agency administration
        The President's proposed budget would provide $112,415,000 for
    agency operations, which would enable us to maintain a staffing level
    of 885 full-time equivalent staff years (FTEs) in 2013. The proposed
    budget would also provide $3,562,000 for conversion of our obsolete
    integrated financial management system to a shared service provider.
    Furthermore, $1,176,000 would be invested into more information
    technology (IT) to continue stretching the value of our baseline
    funding that has remained substantially below required amounts for the
    past 3 years. The IT investments include $621,000 for IT tools and
    infrastructure replacement, $275,000 for network operations and
    emergency services, and $280,000 for E-Government initiatives and
    conversion of employee official personnel files to an electronic
    format.
                               agency operations
        Although funding for agency operations has been held at nearly the
    same level for the past 3 years, the RRB is achieving its mission.
    During fiscal year 2011, the agency provided benefit services within
    the timeframes promised in the RRB Customer Service Plan 99.2 percent
    of the time, and maintained benefit payment accuracy rates exceeding 99
    percent. Customer satisfaction with RRB services has also been high. In
    January 2012, the RRB achieved a score of 81 in a survey of claimants
    receiving unemployment and sickness insurance benefits. This was 14
    points higher than the Federal Government average.
        These results have been possible due to the efforts of the RRB's
    experienced and dedicated workforce, supported by advanced information
    technology. To ensure that the RRB can continue to provide this level
    of service in future years, the agency will need sufficient funding to
    recruit and train qualified staff to replace 40 percent of our
    retirement eligible workforce, sustain our technological
    infrastructure, continue with modernization of systems, and uphold
    optimal results of processing operations against a constrained
    baseline. As rising costs of doing business erode the agency's buying
    power each year, it becomes more of a challenge today to fiscally plan
    for the outyears to protect current services without undermining the
    impact of modernization activities, which are essential to maintaining
    service levels in the future.
                     financial management integrated system
        The RRB's fiscal year 2013 budget request includes $3,562,000 for a
    major project to migrate from our obsolete legacy financial management
    system to the cloud or a shared service provider. While the system
    continues to meet our financial processing and reporting requirements,
    conversion to a shared service provider hosted solution follows
    applicable laws and current Office of Management and Budget guidance
    while removing the risk associated with dependence on a system that has
    reached the end of its lifecycle in 2003.
        Advantages of a conversion include compliance with the Financial
    Management Lines of Business processes established by the Financial
    Systems Integration Office, improved end-user reporting capabilities
    that replace manual processes, a user-friendly interface supporting
    faster transaction processing, and the transfer of daily system
    operations to an outside service provider. The transfer of system
    operations relieves the RRB of activities such as supporting the
    financial management system application upgrades, configurations,
    maintenance, and modifications.
                            other requested funding
        The President's proposed budget includes $45 million to fund the
    continuing phase-out of vested dual benefits, plus a 2-percent
    contingency reserve of $900,000 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
    financial activities with the National Railroad Retirement Investment
    Trust (Trust), which was established by the Railroad Retirement and
    Survivors' Improvement Act of 2001 (RRSIA) to manage and invest
    railroad retirement assets. Pursuant to the RRSIA, the RRB has
    transferred a total of $21.276 billion to the Trust. All of these
    transfers were made in fiscal years 2002 through 2004. The Trust has
    invested the transferred funds, and the results of these investments
    are reported to the RRB and posted periodically on the RRB's Web site.
    The net asset value of Trust-managed assets on September 30, 2011, was
    approximately $22.1 billion, a decrease of $1.6 billion from the
    previous year. As of March 2012, the Trust had transferred
    approximately $12.5 billion to the Railroad Retirement Board for
    payment of railroad retirement benefits.
        In June 2011, 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 2011-2035, and included
    projections of the status of the retirement trust funds under three
    employment assumptions. These assumptions 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 2034. 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 2011. The report indicated that even as
    maximum daily benefit rates rise 38 percent (from $66 to $91) from 2010
    to 2021, experience-based contribution rates are expected to keep the
    unemployment insurance system solvent. Due to short-term cash-flow
    problems, $46.5 million was borrowed from the Railroad Retirement
    Account during fiscal year 2010. The loans were fully repaid by the end
    of fiscal year 2011.
        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.
        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.
                                     ______

                          OFFICE OF INSPECTOR GENERAL

           Prepared Statement of Martin J. Dickman, Inspector General
        Mr. Chairman and members of the subcommittee: My name is Martin J.
    Dickman, and I am the Inspector General for the Railroad Retirement
    Board. I would like to thank you, Mr. Chairman, and the members of the
    subcommittee for your continued support of the Office of Inspector
    General.
                                 budget request
        The President's proposed budget for fiscal year 2013 would provide
    $8,820,000 to the Office of Inspector General (OIG) to ensure the
    continuation of the OIG's independent oversight of the Railroad
    Retirement Board (RRB). During fiscal year 2013, 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 Virginia, Texas, California,
    Florida, and 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 2013, 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. OA must also 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 2013, OA will complete the audit of the RRB's
    fiscal year 2012 financial statements and begin its audit of the
    agency's fiscal year 2013 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 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 2011
    ------------------------------------------------------------------------

    ------------------------------------------------------------------------
    Civil judgments.........................................              21
    Indictments/Informations................................              60
    Convictions.............................................              62
    Recoveries/Receivables..................................  \1\ $106,717,4
                                                                          26
    ------------------------------------------------------------------------
    \1\ This total includes the results of joint investigations with other
      agencies.

        OI anticipates an ongoing caseload of about 480 investigations in
    fiscal year 2013. During fiscal year 2011, OI opened 369 new cases and
    closed 234. At present, OI has cases open in 48 States, the District of
    Columbia, and Canada with estimated fraud losses of nearly $42 million.
    Disability fraud cases represent the largest portion of OI'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. Of particular significance is an ongoing
    investigation related to alleged disability fraud in New York. Eleven
    individuals have been indicted, and OI agents will likely have to spend
    a substantial amount of time traveling for trial preparation in fiscal
    year 2013.
        During fiscal year 2013, 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 2013, 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.
                                     ______

                      CORPORATION FOR PUBLIC BROADCASTING

           Prepared Statement of Patricia Harrison, President and CEO
        Mr. Chairman and members of the subcommittee, thank you for
    allowing me to submit this testimony on behalf of our country's public
    media service--public television and public radio, on-air, online, and
    in your community.
        American public media serves our citizens with quality and trusted
    content that educates, informs and inspires. This trusted noncommercial
    service is available for free to all Americans of all backgrounds, race
    and ethnicities, and to underserved and unserved audiences in rural and
    urban communities throughout the country.
        We are a system comprising approximately 1,300 locally owned and
    operated public radio and television stations connected to communities
    across the country. Together, these stations ensure that 99 percent of
    the American people have access to quality educational and
    informational services that may not otherwise be available to them.
    Public media stations work for, and are accountable to, the people in
    the communities they serve. That connection is important as stations
    acquire national programming and produce local content and services
    based on the needs of their respective communities.
        By design of the Public Broadcasting Act, the Federal investment in
    this service, administered by the Corporation for Public Broadcasting
    (CPB), is the foundation on which the public broadcasting system
    operates. More than 95 percent of the Federal investment goes to
    support public media's service to the American people. Approximately 70
    percent of CPB funding goes directly to local stations, and
    approximately 19 percent of CPB funding is directed to the production
    or acquisition of programming, making CPB the largest single funder of
    content--for children's programming like ``Sesame Street'' and ``The
    Electric Company''; for public affairs programming like ``PBS
    NewsHour'', ``Morning Edition'' and ``Frontline''; and for programming
    like ``Nature'', ``Nova'', ``American Experience'', ``Native American
    News'', ``StoryCorps'', and the films of Ken Burns.
        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, the five Minority Consortia in television (which
    represent African-American, Latino, Asian American, Native American,
    and Pacific Islander producers) and numerous minority stations in
    radio.
        Stations use CPB funding for local operations and to produce and
    acquire programming, which allows them to raise additional operational
    funds from corporations, foundations, State and local governments and
    from individual contributions, which are the largest source of non-CPB
    funding for public media. On average, every Federal $1 invested in CPB
    is leveraged by stations to raise $6 locally. This successful public-
    private partnership is uniquely entrepreneurial and uniquely American.
    Though models vary, funding for other countries' public broadcasting
    systems comes almost exclusively from their governments, from licensing
    fees or from dedicated taxes. At $1.39 per American, the cost of our
    country's service is proportionally small compared to other developed
    nations.
        And for this investment Americans have a safe place to educate
    their children with unmatched noncommercial educational programming
    that is proven to prepare children to learn. For this investment,
    Americans have access to quality news and public affairs programming
    and information that is trusted and treats the audience as citizens,
    not consumers. For this investment, Americans can access lifelong
    educational programming about science, nature, and history that is
    otherwise not supported in the commercial marketplace. And for this
    investment, Americans have a valuable public service that reflects our
    country, contributes to our civil society, and is accountable to the
    citizens we serve.
                      corporation for public broadcasting
        CPB's mission is to strengthen and advance public media's service
    to the American people. We are a nonprofit private corporation, and we
    serve as the steward of the taxpayer's investment in this service.
    Although our funding is distributed through a statutory formula, under
    which we can only use 5 percent for administrative expenses, we work
    every day to ensure that the taxpayers' money is wisely invested in
    stations and programs that contribute to our country and serve our
    citizens. Over the past few years, we have instituted policies and
    procedures to make us even more accountable and transparent to the
    taxpayers who fund us. In this respect, CPB acts as a guardian of the
    mission and purposes for which public broadcasting was established.
        For the past 3 years, CPB has strategically focused our investments
    on the ``Three D's''--Digital, Diversity, and Dialogue. This refers to
    our support for innovation on digital platforms, extending public
    media's reach and service over multiple platforms; content that is for,
    by and about diverse people; and services that foster dialogue and a
    deeper engagement between the American people and the public service
    media organizations that serve them.
        One example of a CPB investment that embodies each of the Three D's
    is our education investment. 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.'' For more than 40
    years, public broadcasting stations have made a robust and vital
    contribution to education, with proven results in improving reading and
    math skills for the Nation's youngest children, particularly those
    furthest behind. We have built on our success in early education and
    launched a new national initiative to help communities tackle the high
    school dropout crisis called, ``American Graduate: Let's Make It
    Happen.''
        Every year, approximately 1 million kids drop out of high school, a
    tragedy for these kids and a travesty for our country. The dropout
    epidemic is costing our Nation more than $100 billion annually in lost
    wages and taxes, plus increased social costs due to crime and
    healthcare. American Graduate is a significant public media effort to
    help improve our Nation's high school graduation rates and, through
    this initiative, public media, both nationally and locally, is bringing
    our collective resources to bear to address the dropout epidemic.
        Sixty-eight public media stations in key dropout epicenters across
    30 States, Puerto Rico, and the District of Columbia are working
    directly with students, parents, teachers, mentors, volunteers and
    business leaders to lower the dropout rate in their communities by
    communicating the need and highlighting solutions. Stations are using
    broadcast, web and mobile platforms to create content that helps to
    tell this story in a compelling way. Some of the activities include:
    producing public service announcements to improve understanding about
    dropout statistics and their implications, hosting teacher town hall
    meetings and community forums on strategies to decrease dropout rates
    in their communities, and local news and public affairs reporting to
    deepen the understanding of the scope of the problem and the unique
    community challenges and solutions.
        This is a united effort across the country and across public media.
    In addition to local action by stations in their communities, there has
    been significant work done by national producers to increase
    understanding of the crisis, including work by ``PBS NewsHour'',
    ``Tavis Smiley'', ``StoryCorps'', NPR, ``Roadtrip Nation'', ``Ideas in
    Action'' with Jim Glassman, and others.
        Through strategic investments, CPB has also fueled innovation in
    the system. In New York and Florida, stations are coming together to
    consolidate engineering and master control operations, which allows
    them to save money, operate more efficiently, and spend more time and
    resources on content and services for their communities. Stations
    throughout the country are looking to replicate this model, which could
    save stations millions over several years.
        CPB has invested in seven regional local journalism centers, which
    are clusters of public television and radio stations who have come
    together to increase the quality and capacity of their local reporting
    on critically important topics to their communities and regions.
    Whether it is border issues in the Southwest, agribusiness issues in
    the Heartland, economic revitalization in upstate New York or education
    issues in the South, these station collaborations are creating and
    sharing original content that is vital to the communities they serve.
        The focus on diversity is deeply embedded in CPB's culture and
    increased service to diverse audiences is a consideration in virtually
    every investment CPB makes. In 2009, we created the Diversity and
    Innovation fund, which is dedicated to supporting the creation of
    content of interest and service to diverse communities. The D&I fund
    supports documentaries such as the award-winning ``Freedom Riders'' and
    ``Slavery By Another Name'', expanded news and public affairs
    programming for diverse communities, translation services for news and
    election programming, a new radio service in Los Angeles and the full-
    time multicast World Channel, designed to attract a diverse audience.
        corporation for public broadcasting's request for appropriations
        Public media stations continue to evolve, both operationally and in
    the ways they serve their communities. Stations are committed to
    reaching viewers and listeners on whatever platform they use--from
    smart phones to tablets to radios to television sets. While stations
    can and will continue to adapt and operate in the digital age, they
    cannot provide service on evolving platforms without sufficient
    support. 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.''
        Corporation for Public Broadcasting Base Appropriation (Fiscal Year
    2015).--CPB requests a $445 million advance appropriation for fiscal
    year 2015, to be spent in accordance with the Public Broadcasting Act's
    funding formula. The 2-year advance appropriation for public
    broadcasting, in place since 1976, is the most important part of the
    ``firewall'' that the 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 2015 request, which is the same level as the
    administration's request for CPB, balances the fiscal reality facing
    our Nation with the stark fact that stations are struggling to provide
    service to their communities in the face of shrinking non-Federal
    revenues--a $380 million, or 16 percent, drop between fiscal year 2008
    and 2010 alone. Even with these challenges, public broadcasting
    contributes to American society in many ways that are worthy of greater
    Federal investment. In fiscal year 2015, CPB will continue to support a
    range of programming and initiatives through which stations provide a
    valuable and trusted service to millions of Americans.
        Ready To Learn (Fiscal Year 2013).--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 2012. Mr. Chairman,
    education is at the heart of public media. RTL is a partnership between
    the Department, CPB, PBS and local public television stations that
    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 2013 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.
        Mr. Chairman, all told, the Federal contribution to public media
    through CPB amounts to $1.39 per American per year and the returns for
    taxpayers are exponential. Whether 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; or inspiring arts and cultural
    content; we in America's public media system are working every day to
    serve our citizens.
        In last year's final appropriations legislation, CPB was instructed
    to report to the Congress about alternative sources of funding for
    public media. We are actively looking at that question and will report
    back to the subcommittee prior to our deadline on June 20.
        Mr. Chairman and members of the subcommittee, thank you again for
    allowing CPB to submit this testimony. On behalf of the public
    broadcasting community, including the stations in your States and those
    they serve, we sincerely appreciate your support.
                           NONDEPARTMENTAL WITNESSES

               Prepared Statement of the Alzheimer's Association
        The Alzheimer's Association appreciates the opportunity to comment
    on the fiscal year 2013 appropriations for Alzheimer's disease
    research, education, outreach, and support at the Department of Health
    and Human Services.
        Founded in 1980, the Alzheimer's Association is the world's leading
    voluntary health organization in Alzheimer's care, support and
    research. Our mission is to eliminate Alzheimer's disease and other
    dementias through the advancement of research; to provide and enhance
    care and support for all affected; and to reduce the risk of dementia
    through the promotion of brain health. As the largest, private
    nonprofit funder of Alzheimer's research, the Association is committed
    to accelerating progress of new treatments, preventions and ultimately,
    a cure. Through our partnerships and funded projects, we have been part
    of every major research advancement over the past 30 years. Today, the
    Association works on a global level to enhance care and support for all
    those affected by Alzheimer's and reaches millions of people affected
    by Alzheimer's, and their caregivers, through our national office and
    more than 70 local chapters and service areas.
    Alzheimer's Impact on the American People and Economy
        In addition to the human suffering caused by the disease,
    Alzheimer's is creating an enormous strain on the healthcare system,
    families and the Federal budget. Alzheimer's is a progressive brain
    disorder that damages and eventually destroys brain cells, leading to
    loss of memory, thinking and other brain functions. Ultimately,
    Alzheimer's is fatal. Currently, Alzheimer's is the sixth leading cause
    of death in the United States and the only 1 of the top 10 without a
    means to prevent, cure, or slow its progression. Today, there are 5.4
    million Americans living with Alzheimer's--5.2 million aged 65 and
    over, and 200,000 under the age of 65.\1\ Of Americans aged 65 and
    over, 1 in 8 has Alzheimer's, and nearly one-half of people aged 85 and
    older have the disease. While deaths from other major diseases,
    including heart disease, stroke and HIV continue to experience
    significant declines, those from Alzheimer's have increased 66 percent
    between 2000 and 2008.
    ---------------------------------------------------------------------------
        \1\ Alzheimer's Association, 2012 Alzheimer's Disease Facts and
    Figures, Alzheimer's & Dementia, Volume 8, Issue 2.
    ---------------------------------------------------------------------------
        Although Alzheimer's is not normal aging, age is the biggest risk
    factor, which means the graying of America equates to the bankrupting
    of America. With the first of the baby boomer generation now turning
    65, the U.S. population aged 65 and over is expected to double, meaning
    there will be more and more Americans living with Alzheimer's--as many
    as 16 million by 2050, when there will be nearly 1 million new cases
    each year. Caring for people with Alzheimer's will cost all payers--
    Medicare, Medicaid, individuals, private insurance, and HMOs--$20
    trillion over the next 40 years. In 2012, America will spend an
    estimated $200 billion in direct costs caring for those with
    Alzheimer's, including $140 billion in costs to Medicare and Medicaid.
    Average per person Medicare costs for those with Alzheimer's and other
    dementias are 3 times higher than those without these conditions.
    Medicaid spending is 19 times higher. Moreover, Alzheimer's makes
    treating other diseases more expensive, as most individuals with
    Alzheimer's have one or more co-morbidity that complicate the
    management of the condition(s) and increase costs. For example, a
    senior with diabetes and Alzheimer's costs Medicare 81 percent more
    than a senior who only has diabetes. Nearly 30 percent of people with
    Alzheimer's or another dementia who have Medicare also have Medicaid
    coverage, compared with 11 percent of individuals without dementia or
    Alzheimer's. Alzheimer's disease is also extremely prevalent among
    dual-eligibles in nursing homes, where 64 percent of residents live
    with the disease. Unless something is done, the costs of Alzheimer's in
    2050 are estimated to total $1.1 trillion (in today's dollars).\2\
    Costs to Medicare and Medicaid will increase nearly 500 percent and
    there will be a 400 percent increase in out-of-pocket costs.
    ---------------------------------------------------------------------------
        \2\ Alzheimer's Association, Changing the Trajectory of Alzheimer's
    Disease: A National Imperative, 2010.
    ---------------------------------------------------------------------------
        With Alzheimer's, it is not just those with the disease who
    suffer--it is also their caregivers and families. In 2011, 15.2 million
    family members and friends provided unpaid care valued at more than
    $210 billion. Caring for a person with Alzheimer's takes longer, lasts
    longer, is more personal and intrusive, and takes a heavy toll on the
    health of the caregivers themselves. More than 60 percent of
    Alzheimer's and dementia caregivers rate the emotional stress of
    caregiving as high or very high; with one-third reporting symptoms of
    depression. Caregiving may also have a negative impact on health,
    employment, income, and family finances. Due to the physical and
    emotional toll of caregiving on their own health, Alzheimer's and
    dementia caregivers had $8.7 billion in additional healthcare costs in
    2011.
    Changing the Trajectory of Alzheimer's
        Until recently, there was no strategy on how to address this
    looming crisis. In 2010, thanks to bipartisan support in the Congress,
    the National Alzheimer's Project Act (NAPA) (Public Law 111-375) passed
    unanimously, requiring the creation of an annually updated strategic
    National Alzheimer's Plan (Plan) to help those with the disease and
    their families today and to change the trajectory of the disease for
    the future. The Plan is required to include an evaluation of all
    federally funded efforts in Alzheimer's research, care, and services--
    along with their outcomes. In addition, the Plan must outline priority
    actions to reduce the financial impact of Alzheimer's on Federal
    programs and on families; improve health outcomes for all Americans
    living with Alzheimer's; and improve the prevention, diagnosis,
    treatment, care, institutional-, home-, and community-based Alzheimer's
    programs for individuals with Alzheimer's and their caregivers. NAPA
    will allow the Congress to assess whether the Nation is meeting the
    challenges of this disease for families, communities and the economy.
    Through its annual review process, NAPA will, for the first time,
    enable the Congress and the American people to answer this simple
    question: Did we make satisfactory progress this past year in the fight
    against Alzheimer's?
        As mandated by NAPA, the Secretary of Health and Human Services, in
    collaboration with the Advisory Council on Alzheimer's Research, Care,
    and Services, is developing the first-ever Plan to be transmitted to
    the Congress later this Spring. The Advisory Council, made of both
    Federal members and expert non-Federal members, is an integral part of
    the planning process as it advises the Secretary in developing and
    evaluating the annual Plan, makes recommendations to the Secretary and
    the Congress, and assists in coordinating the work of Federal agencies
    involved in Alzheimer's research, care, and services. In advance of the
    first Plan, the President's fiscal year 2013 budget request included
    $80 million for Alzheimer's research and $20 million for education,
    outreach, and support. These funds are a critically needed downpayment
    for needed research and services for Alzheimer's patients and their
    families.
        A disease-modifying or preventative therapy would not only save
    millions of lives but would save billions of dollars in healthcare
    costs. Specifically, if a treatment became available in 2015 that
    delayed onset of Alzheimer's for 5 years (a treatment similar to anti-
    cholesterol drugs), savings would be seen almost immediately, with
    Medicare and Medicaid spending reduced by $42 billion in 2020. Today,
    despite the remarkable advances in Alzheimer's research, there are
    growing concerns that we still lack effective treatments that will
    slow, stop, or cure the disease and that the pace of progress in
    understanding the disease and developing breakthrough discoveries is
    much too slow to make any impact on the growing crisis before us.
    Currently, for every $28,000 Medicare and Medicaid spends caring for
    individuals with Alzheimer's, the National Institutes of Health (NIH)
    spends only $100 on Alzheimer's research. Scientists fundamentally
    believe that we have the ideas, the technology and the will to develop
    new Alzheimer's interventions, but that progress depends on a
    prioritized scientific agenda and on the resources necessary to carry
    out the scientific strategy for both discovery and translation for
    therapeutic development. The Alzheimer's Association urges the Congress
    to support the President's budget request of $80 million for
    Alzheimer's research at the National Institutes of Health in fiscal
    year 2013, and the priority research recommendations included in the
    National Alzheimer's Plan required under Public Law 111-375.
        For too many individuals with Alzheimer's and their families, the
    system has failed them, and today we are unnecessarily losing the
    battle against this devastating disease. Despite the fact that an early
    and documented formal diagnosis allows individuals to participate in
    their own care planning, manage other chronic conditions, participate
    in clinical trials, and ultimately alleviate the burden on themselves
    and their loved ones, as many as one-half of the 5.4 million Americans
    with Alzheimer's have never received a formal diagnosis. Unless we
    invest in an effective dementia-capable system that finds new solutions
    to providing high-quality care, provides community support services and
    programs, and addresses Alzheimer's health disparities, Alzheimer's
    will break the healthcare system. For example, people with Alzheimer's
    and other dementias have more than 3 times as many hospital stays as
    other older people. Furthermore, 1 out of 7 individuals with
    Alzheimer's or another dementia lives alone and up to one-half do not
    have an identifiable caregiver. These individuals are more likely to
    need emergency medical services because of self-neglect or injury, and
    are found to be placed into nursing homes earlier, on average, than
    others with dementia. It has been estimated that delaying long-term
    care by 1 month for each person in the United States age 65 or older
    could save $60 billion a year. Ultimately, supporting individuals with
    Alzheimer's disease and their families and caregivers requires giving
    them the tools they need to plan for the future and ensuring the best
    quality of life for individuals and families impacted by the disease.
    The Alzheimer's Association urges the Congress to support the
    President's budget request of $20 million for Alzheimer's education,
    outreach, and support at the Administration on Aging (AoA) in fiscal
    year 2013, and the priorities included in the National Alzheimer's Plan
    required under Public Law 111-375.
    Additional Alzheimer's Programs:
        National Alzheimer's Call Center.--The National Alzheimer's Call
    Center, funded by the AoA, provides 24/7, year-round telephone support,
    crisis counseling, care consultation, and information and referral
    services in 140 languages for persons with Alzheimer's, their family
    members and informal caregivers. Trained professional staff and
    master's-level mental health professionals are available at all times.
    In the 12 month period ending July 31, 2011, the Call Center handled
    more than 300,000 calls through its national and local partners, and
    its online message board received more than 13 million page views and
    more than 100,000 individual postings. The Alzheimer's Association
    urges the Congress to support $1.3 million for the National Alzheimer's
    Call Center.
        Healthy Brain Initiative.--The Centers for Disease Control and
    Prevention's (CDC) Healthy Brain Initiative (HBI) program works to
    educate the public, the public health community and health
    professionals about Alzheimer's as a public health issue. Although
    there are currently no treatments to delay or stop the deterioration of
    brain cells caused by Alzheimer's, evidence suggests that preventing or
    controlling cardiovascular risk factors may benefit brain health. In
    light of the dramatic aging of the population, scientific advancements
    in risk behaviors, and the growing awareness of the significant health,
    social and economic burdens associated with cognitive decline, the
    Federal commitment to a public health response to this challenge is
    imperative. The Alzheimer's Association urges the Congress to support
    $2.2 million for the Healthy Brain Initiative.
        Alzheimer's Disease Supportive Services Program.--The Alzheimer's
    Disease Supportive Services Program (ADSSP) at the AoA supports family
    caregivers who provide countless hours of unpaid care, thereby enabling
    their family members with Alzheimer's and dementia to continue living
    in the community. The program develops coordinated, responsive, and
    innovative community-based support service systems for individuals and
    families affected by Alzheimer's. The Alzheimer's Association urges the
    Congress to support $11.441 million for the Alzheimer's Disease
    Supportive Services Program.
    Conclusion
        The Association appreciates the steadfast support of the
    subcommittee and its priority setting activities. We look forward to
    continuing to work with the Congress in order to address the
    Alzheimer's crisis. We ask the Congress to address Alzheimer's with the
    same bipartisan collaboration demonstrated in the passage of the
    National Alzheimer's Project Act (Public Law 111-375) and with a
    commitment equal to the scale of the crisis.
                                     ______

      Prepared Statement of the Association of American Cancer Institutes
        The Association of American Cancer Institutes (AACI), representing
    95 of the Nation's premier academic and free-standing cancer centers,
    appreciates the opportunity to submit this statement for consideration
    by the United States Senate Subcommittee on Labor, Health and Human
    Services, Education and Related Agencies, Committee on Appropriations.
        AACI appreciates the long-standing commitment of the President, the
    Congress, and the subcommittee to ensuring quality care for cancer
    patients, as well as for providing researchers with the resources that
    they need to develop better cancer treatments and, ultimately, to cure
    this disease.
        President Obama's fiscal year 2013 budget calls for maintaining the
    fiscal year 2012 funding levels for the National Institutes of Health
    (NIH) and the National Cancer Institute (NCI) ($30.9 billion and $5
    billion, respectively). AACI joins with our colleagues in the
    biomedical research community in recommending that the subcommittee
    recognize NIH as a critical national priority by providing at least $32
    billion in funding in the fiscal year 2013 Labor-HHS-Education
    appropriations bill, including an equivalent percentage increase in
    funding for NCI. This funding level represents the minimum investment
    necessary to avoid further loss of promising research.
        AACI cancer centers are at the front line in the national effort to
    eradicate cancer. The cancer centers that AACI represents house more
    than 20,000 scientific, clinical, and public health investigators who
    work collaboratively to translate promising research findings into new
    approaches to prevent and treat cancer. But making progress against
    cancer is complex. It is more a marathon than a sprint, and it takes
    time for the scientific discovery process to yield fruit. However, the
    pace of discovery and translation of novel basic research to new
    therapies could be faster if researchers could count on a significant
    and predictable investment in Federal cancer funding.
        AACI and its members are keenly aware of the country's fiscal
    obstacles. The vast majority of our cancer centers exist within
    universities that already face drastic budget reductions. Furthermore,
    because of the reduced funding pool for meritorious grant applications,
    many of our senior and most promising young investigators are now
    without NCI funding and require 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.
        The Obama administration has estimated that if the NIH budget stays
    flat in fiscal year 2013, as it has proposed, the agency would be able
    to fund 9,415 new grants. However, even with flat funding relatively
    few people who apply for grants from NIH can expect to receive them.
    Over the past 9 years NIH has lost about 20 percent of its purchasing
    power for medical research due to inflation, and only about 1 in 7
    grant applications are approved for funding, the lowest rate in NIH
    history. NIH's ability to sustain current research capacity and
    encourage promising new areas of science has been significantly
    compromised by stagnant funding.
        This situation will be even more acute if an 8-percent budget cut
    being considered as part of the Budget Control Act of 2011, takes
    effect in January. The cut is even deeper than it appears because the
    agency's fiscal year starts October 1, 3 months into the fiscal year.
    As a result, NIH would be able to fund 2,300 fewer grants in fiscal
    year 2013, according to NIH Director Francis Collins.
    Impact Beyond the Lab
        The negative effects of diminished biomedical research funding
    reach beyond the lab and into local communities, as chronicled this
    past winter by a number of AACI cancer center directors who were
    featured in newspaper editorials that highlighted the impact of NIH and
    NCI funding on people and local economies in their individual States.
        For example, the leaders of the UC San Diego Moores Cancer Center
    and the San Diego-based Sanford Burnham Medical Research Institute
    noted that NIH funding brought $1.3 billion to their local economy in
    2010. In San Antonio, the director of the Cancer Therapy & Research
    Center at the University of Texas Health Science Center noted that his
    institution received more than $30 million in cancer-related grants and
    clinical trials.
        AACI Past President Michael A. Caligiuri, MD, director of the Ohio
    State University Comprehensive Cancer Center and chief executive
    officer of the Arthur G. James Cancer Hospital and Richard J. Solove
    Research Institute, put it succinctly in an editorial in his hometown
    paper, The Columbus Dispatch: ``The work we do at Ohio State affects
    the entire continuum of cancer acre. And cancer research done at Ohio
    State and other organizations supports high-quality jobs in Ohio
    communities and allows our residents to benefit from the advances
    happening right here.''
        An AACI-commissioned economic analysis of proposals for NIH's
    fiscal year 2011 budget estimated that a ``conservative'' 0.8-percent
    cut in the NIH's annual budget would result in about 4,000 jobs lost
    nationally. Looking specifically at NCI's budget, the Nation's research
    institutions, which house AACI's member cancer centers, received an
    estimated $3.71 billion from NCI to conduct cancer research in fiscal
    year 2010; more than two-thirds of NCI's total budget. At the time that
    AACI's analysis was published, an ``aggressive'' budget reduction of
    5.3 percent was under consideration and would have led to more than
    4,200 jobs lost nationwide and an economic loss of more than $564
    million.
        Other recent studies have also concluded that Federal support for
    medical research is a major determinant in the economic health of
    communities across the country. In one such report, United for Medical
    Research, a coalition of leading research institutions, patient and
    health advocates and private industry, estimated that NIH funding
    generated the greatest number of jobs in California (63,196),
    Massachusetts (34,598), New York (33,193), Texas (25,878), and Maryland
    (24,557) and also supported more than 10,000 jobs each in Pennsylvania,
    North Carolina, Washington, Illinois, Ohio, Florida, Michigan, and
    Georgia. Fifty-three AACI cancer centers are located in those 13
    States.
        Cancer centers are already challenged to provide infrastructure
    resources necessary to support funded researchers, and cuts in Federal
    cancer center grants will limit our members' ability to provide well-
    functioning shared resources to investigators who depend on them to
    complete their research. For most academic cancer centers, the majority
    of NCI grant funds are used to sustain shared resources that are
    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.
        Independent investigator research is a particularly valuable
    resource, especially in genomics and molecular epidemiology. Such
    research depends 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 acquire
    alternative funding if NCI grants for these efforts were reduced.
    Cancer Research: Improving America's Health
        The broad portfolio of research supported by NIH and NCI is
    essential for improving our basic understanding of diseases, and it has
    paid off handsomely in terms of improving Americans' health.
        Death rates from all cancers combined for men, women, and children
    in the United States continued to decline between 2004 and 2008, the
    latest year for which we have complete analysis. Age-adjusted mortality
    rates for 11 of the 18 most common cancers among men and for 14 of the
    16 most common cancers in women have declined. The overall rate of new
    cancer diagnoses among both men and women also declined over similar
    periods, although for women the decline leveled off from 2006-2008
    (National Cancer Institute, 2012 Annual Report to the Nation on the
    Status of Cancer). A broader data set shows that cancer death rates
    have dropped 11.4 percent among women and 19.2 percent among men over
    the past 15 years, due in large part to better detection and more
    effective treatments.
        Despite that success, cancer remains the second leading cause of
    death in the United States, exceeded only by heart disease. In 2007,
    more than 562,000 people died of cancer, and more than 1.45 million
    people had a diagnosis of cancer (Centers for Disease Control and
    Prevention, United States Cancer Statistics: 1999-2007 Cancer Incidence
    and Mortality Data).
        The network of cancer centers represented by AACI continues the
    fight against cancer by conducting the highest-quality cancer research
    in the world and provides exceptional patient care. In 2010, $3.9
    billion from NCI was awarded extramurally to research institutions,
    including the AACI's member cancer centers. This represents 77 percent
    of NCI's total budget (U.S. Department of Health and Human Services,
    National Institutes of Health, National Cancer Institute 2010 Fact
    Book). Because these centers are networked nationally, opportunities
    for collaborations are many--assuring wise and nonduplicative
    investment of scarce Federal dollars.
    Conclusion
        The National Institutes of Health estimates overall costs of cancer
    in 2010 at $263.8 billion: $102.8 billion for direct medical costs
    (total of all health expenditures); $20.9 billion for indirect
    morbidity costs (cost of lost productivity due to illness); and $140.1
    billion for indirect mortality costs (cost of lost productivity due to
    premature death) (American Cancer Society, 2010 Facts & Figures).
        In the face of that economic burden, the Nation's financial support
    of NIH and NCI has paid dividends by wiping out diseases that killed
    our grandparents. Those investments have led us to the brink of new
    discoveries in deadly and debilitating illnesses, cancer perhaps
    foremost among them. The AACI cancer center network is unsurpassed in
    its pursuit of excellence, and places the highest priority on
    delivering superior cancer care to all Americans, including novel
    treatments and clinical trials. It is through the power of
    collaborative innovation that we will continue to move toward a future
    without cancer, and Federal research funding is essential to achieving
    our goals.
                                     ______

     Prepared Statement of the American Association of Colleges of Nursing
        As the national voice for baccalaureate and graduate nursing
    education, the American Association of Colleges of Nursing (AACN)
    represents 700 schools of nursing that educate more than 360,000
    students and employ more than 16,000 full-time faculty members.
    Collectively, these institutions produce approximately one-half of our
    Nation's Registered Nurses (RNs) and all nurse faculty and researchers.
    AACN requests that nursing education, research, and practice are
    strongly supported in fiscal year 2013 through a continued investment
    in 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 the Nurse-Managed
    Health Clinics (NMHCs) (Title III of the Public Health Service Act), so
    that our Nation's nurses will be prepared to care for the growing
    number of patients requiring a complex range of healthcare services.
                      job growth in the nursing workforce
        The demand for nurses is greater than previously anticipated. In
    February of this year, the Bureau of Labor Statistics (BLS) released
    their publication Employment Projections for 2010-2020, which projects
    significant growth in the nursing workforce from 2.74 million in 2010
    to 3.45 million in 2020. This upsurge in demand translates to 712,000
    nurses, or an increase of 26 percent. The BLS further projects the need
    for 495,500 additional nurses to replace those soon to retire, bringing
    the total number of job openings for nurses due to growth and
    replacements to 1.2 million by 2020.
        The aging of the nursing workforce and America's patients
    underscores this alarming projection. According to the 2008 National
    Sample Survey of Registered Nurses, of the 2.6 million RNs currently
    practicing in America, more than 1 million are age 50 or older, and of
    these more than 275,000 nurses are over the age of 60. As this large
    segment of the workforce begins to retire, the Nation will soon face a
    significant deficit in the number of experienced nurses available to
    provide services. Concurrent with the aging of the nursing workforce is
    the aging of America's baby boomer population. It is estimated that
    more than 80 million baby boomers reached age 65 in 2011. As this
    population transitions into the Nation's oldest generation, these
    citizens will continue to require more primary care services related to
    chronic illness treatment, medication management, and patient
    education. A significant investment must be made in the education of
    new nurses to provide the Nation with the nursing services it requires.
               title viii nursing workforce development programs
        For nearly five decades, the Nursing Workforce Development
    programs, authorized under title VIII of the Public Health Service Act,
    have helped build the supply and distribution of qualified nurses to
    meet our Nation's healthcare needs. Between fiscal year 2005 and 2010
    alone, the title VIII programs supported more than 400,000 nurses and
    nursing students as well as numerous academic nursing institutions and
    healthcare facilities. 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 by supporting future practicing nurses and the faculty who
    educate them.
        Given the projected demand for RNs, nursing schools are looking to
    admit more students into their programs. However, faculty vacancies
    have repeatedly been cited as a fundamental obstacle to maximizing
    nursing school enrollment. Data from AACN's 2011-2012 enrollment and
    graduations survey show that nursing schools were forced to turn away
    75,587 qualified applications from entry-level baccalaureate and
    graduate nursing programs in 2011 due primarily to faculty vacancies.
    To counter this disparity, the title VIII Nurse Faculty Loan Program
    aids in increasing nursing school enrollment capacity by supporting
    students pursuing graduate education, provided they serve as faculty
    for 4 years after graduation. In fiscal year 2010, the title VIII Nurse
    Faculty Loan Program supported 271 faculty members who graduated and
    went on to teach in our Nation's nursing schools. Yet this only fills a
    small portion of the nearly 1,800 vacant faculty positions reported by
    AACN member schools in academic year 2011-2012.
        The title VIII programs also increase the number of practicing
    nurses entering the pipeline and the placement of these nurses into
    medically underserved areas. AACN's title VIII Student Recipient
    Survey, which gathers information annually about title VIII funding and
    outcomes related to nursing education and career trajectories, provides
    evidence to the effectiveness of these programs in recruiting more
    students to the nursing profession and more importantly, practice in
    rural and underserved areas. The 2011-2012 survey, which included
    responses from more than 1,600 students, revealed that 52 percent of
    respondents reported that title VIII funding affected their decision to
    enter nursing school, and that practicing in a rural or underserved
    community was in the top five career plans after graduation. In fiscal
    year 2011, the title VIII Nursing Education Loan Repayment Program
    committed to supporting 1,304 nurses working in these facilities. In
    addition, the Advanced Education Nursing Traineeship Program graduated
    7,744 nursing students during the 2010-2011 academic cycle, of which
    7,548 (97 percent) went on to practice in medically underserved areas.
    Moreover, personal testimony of several survey respondents revealed
    that many title VIII recipients intend to practice in the community in
    which they were educated, a direct State investment.
        Additionally, 68 percent of respondents stated that title VIII
    funding allowed them to attend school full-time, as these loan and
    scholarship programs alleviated the financial burden that obligates
    many students to complete their education on a part-time basis. The
    title VIII programs decrease the length of time needed to obtain their
    education, thus helping to ensure that students enter the workforce
    without delay. These efforts directly align with recommendations in the
    Institute of Medicine's landmark report ``Future of Nursing: Leading
    Change, Advancing Health'' which state, ``Nurses should achieve higher
    levels of education and training through an improved education system
    that promotes seamless academic progression.'' Financial support from
    title VIII programs ensure that more nurses are efficiently integrated
    into the workforce.
        AACN respectfully requests $251 million for the Nursing Workforce
    Development programs authorized under title VIII of the Public Health
    Service Act in fiscal year 2013.
       national institute of nursing research: advancing nursing science
        The healthcare community is increasingly concerned with
    investigating methods to improve the delivery of high-quality care in a
    financially sustainable manner. As one of the 27 Institutes and Centers
    at the National Institutes of Health (NIH), the NINR is dedicated to
    promoting this endeavor through research initiatives aimed at reducing
    disease prevalence and improving health outcomes. While other health-
    related research is aimed at curing disease, nurse-researchers at NINR
    focus on the prevention of illnesses that threaten to exacerbate an
    already overburdened healthcare system. More specifically, NINR funded
    research investigates methodologies that improve chronic illness
    management, communicable disease prevention, pain management, and
    caregiver support.
        Studies conducted at NINR address health and wellness across the
    entire lifespan. Reducing rates of infant prematurity, controlling
    rates of high-blood pressure among adults, and evaluating transitional
    care models to improve outcomes of the elderly represent the vast array
    of population-specific NINR research initiatives. Additionally, NINR
    seeks to improve understanding of the processes underlying palliative
    care efforts to develop patient-centered care delivery models.
        NINR allocates a generous 6 percent of its overall budget to the
    education and training of nurse researchers, many of whom dually serve
    as nurse faculty within our Nation's nursing schools. As researchers,
    these nurses work to strengthen the foundation of evidence-based
    nursing practice. As educators, they help to fulfill the need for nurse
    faculty and teach current, evidence-based practice that is consistent
    with changing healthcare needs.
        For NINR to adequately continue and further its mission, the
    institute must continue to receive adequate 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.
        AACN respectfully requests $150 million for the NINR in fiscal year
    2013. This level of funding is on par with the Ad Hoc Group for Medical
    Research's $32 billion request for the total NIH budget in fiscal year
    2013.
             nurse-managed health clinics: expanding access to care
        Managed by Advanced Practice Registered Nurses and staffed by an
    interdisciplinary team, NMHCs provide necessary primary care services
    to medically underserved communities. Often times, nurse-managed health
    clinics and nurse practitioners are the sole providers for primary care
    for these areas. NMHCs serve as critical access points to keep patients
    out of the emergency room, thus saving the healthcare system millions
    of dollars annually.
        NMHCs provide care to vulnerable populations in a host of regions
    of the country, including rural communities, Native American
    reservations, senior citizen centers, elementary schools, and urban
    housing developments. These communities are the most susceptible to
    developing chronic illnesses that create heavy financial burden on
    patients and the healthcare system. NMHCs aim to reduce disease and
    create healthier communities through improved patient education and
    health practices. NMHCs provide primary care, health promotion, and
    disease prevention to individuals with limited access to care,
    regardless of their ability to pay. These vulnerable individuals who
    are often plagued with highest rates of detrimental chronic disease
    rely on the services provided at these clinics, which help to target
    early screening and risk reduction. These services include physical
    exams, cardiovascular checks, diabetes and osteoporosis screenings,
    smoking cessation programs, immunizations, and other additional
    services.
        Often associated with a school, college, university, department of
    nursing, federally qualified health center, or independent nonprofit
    healthcare agency, NMHCs also serve as clinical education training
    sites for students of nursing, medicine, physical therapy, social work,
    and ancillary healthcare services. According to AACN, the lack of
    clinical training sites is often cited as a top reason for turning away
    qualified applications in nursing programs.
        AACN respectfully requests $20 million for the Nurse-Managed Health
    Clinics in fiscal year 2013.
                                   conclusion
        AACN recognizes that the subcommittee and the Congress face
    difficult decisions regarding appropriations for fiscal year 2013. AACN
    respectfully requests the Congress to continue a robust investment in
    the health of our Nation by providing $251 million for the title VIII
    Nursing Workforce Development programs, $150 million for the National
    Institute of Nursing Research, and $20 million for Nurse-Managed Health
    Clinics in fiscal year 2013. These programs directly advance the
    nursing profession in the areas of education, research, and practice,
    to meet our Nation's calling for a more highly skilled nursing
    workforce. A strong investment in our Nation's nurses is a strong
    investment in the future of America's health.
                                     ______

         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 2013 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 25
    States. Today, more than 20,000 students are enrolled in osteopathic
    medical schools. Nearly 1 in 5 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 $247.5 million for
    Title VII. We strongly support investment in the following programs in
    order to address the primary care workforce shortage: Primary Care
    Training and Enhancement (PCTE) Program at $58 million, the Health
    Careers Opportunity Program (HCOP) at $14.9 million, the Centers of
    Excellence (COE) at $22.9 million, the Geriatric Education Centers
    (GECs) at $30.6 million and the Area Health Education Centers (AHECs)
    at $33.142 million. 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 facing this country.
    Teaching Health Centers Graduate Medical Education Program
        The Teaching Health Center Graduate Medical Education (THCGME)
    Program is the first of its kind to shift 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 THCGME
    Development Grants. This funding would allow potential THCGME 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 Professions 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 strongly
    supports fully funding all aspects of the NHSC from both discretionary
    and mandatory funding sources and recommends that the full $300 million
    in mandatory funding be allocated and should be supplemented by
    discretionary dollars in fiscal year 2013.
    Workforce Commission
        As the United States struggles to address with healthcare provider
    shortages in certain specialties and in rural and underserved areas,
    the country lacks a defined policy to address these critical issues.
    The National Health Care Workforce Commission was designed to develop
    and evaluate training activities to meet demand for healthcare workers.
    Without funding, the Commission cannot identify barriers that may
    create and exacerbate workforce shortages and improve coordination on
    the Federal, State and local levels. Having this type of coordinating
    body in place is becoming more critical as more Americans have
    insurance coverage and the population ages, requiring access to care.
    For these reasons, AACOM recommends that $3 million be appropriated to
    fund the Commission.
    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 2013 for the NIH.
        In today's increasingly demanding and evolving medical curriculum,
    there is a critical need for more research geared toward evidence-based
    osteopathic medicine. AACOM believes that it is vitally important to
    maintain and increase funding for biomedical and clinical research in a
    variety of areas related to osteopathic principles and practice,
    including osteopathic manipulative medicine and comparative
    effectiveness. In this regard, AACOM encourages support for the NIH's
    National Center for Complementary and Alternative Medicine to continue
    fulfilling this essential research role.
    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 $400 million
    in fiscal year 2013 for AHRQ's base, discretionary budget. 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
        The American Association of Colleges of Pharmacy (AACP) is pleased
    to submit this statement for the record regarding fiscal year 2013
    funding. The 126 accredited pharmacy schools are engaged in a wide
    range of programs supported by funding administered through the
    agencies of the Department of Health and Human Services (HHS) and the
    Department of Education. Recognizing the difficult task of balancing
    needs and expectations with fiscal responsibility, AACP respectfully
    offers the following recommendations for consideration as you undertake
    your deliberations.
                  u.s. department of health and human services
    Health Resources and Services Administration
        AACP supports the Friends of HRSA recommendation of $7 billion for
    Health Resources and Services Administration (HRSA) in fiscal year
    2013. Faculty at schools of pharmacy are integral to the success of
    many HRSA programs conducting research rural health delivery to reduce
    healthcare costs through the integration of pharmacist-provided patient
    care services. Schools of pharmacy are supported by HRSA to operate 9
    of the 42 Poison Control Centers and, this year, Dr. Scott Schaeffer of
    the University of Oklahoma received a $100,000 poison center incentive
    grant for a deaf and hard of hearing poison prevention outreach
    project.
        AACP supports the Bureau of Health Professions and the National
    Center for Health Workforce Analysis. Through the Pharmacy Workforce
    Center, AACP joins HRSA-funded efforts to compile national health
    workforce statistics to better inform future health professions
    workforce needs in the United States.
        AACP supports the Health Professions and Nursing Education
    Coalition (HPNEC) recommendation of $280 million for title VII and VIII
    programs in fiscal year 2013. AACP member institutions are active
    participants in BHPr programs. Schools of pharmacy engage in title VII
    programs, including Geriatric Education Centers and Area Health
    Education Centers (AHEC). These community-based, interprofessional
    programs are essential for providing the educational models to improve
    quality through team-based, patient-centered care and serve as valuable
    experiential education sites for student pharmacists and other health
    professions students. Nine North Carolina AHECs are supported by 500
    preceptor pharmacists and 22 academic pharmacists from the State's
    schools of pharmacy. The Northeast Pennsylvania (NEPA) AHEC partners
    with the NEPA Interprofessional Education Coalition to train student
    pharmacists from Wilkes University to develop interprofessional
    communication skills and recognize the importance of patient-centered
    care.
        For the AHEC program AACP recommends a funding level of at least
    $75 million in fiscal year 2013. Pharmacy schools are eligible to
    participate in the Centers of Excellence program and the Scholarships
    for Disadvantaged Students program, to increase the number of
    underserved individuals attending health professions schools and
    minority workforce representation.
    Agency for Healthcare Research and Quality
        AACP supports the Friends of AHRQ recommendation of $400 million
    for AHRQ programs in fiscal year 2013. Pharmacy faculty are strong
    partners with the Agency for Healthcare Research and Quality (AHRQ).
    Academic pharmacists Drs. Glen T. Schumock, University of Illinois at
    Chicago, and Sean Hennessy, University of Pennsylvania, are 2 of 11
    principal investigators involved in the Developing Evidence to Inform
    Decisions about Effectiveness center to support research on patient-
    centered outcomes of healthcare with a focus on comparing clinical
    effectiveness, safety and usefulness of medical treatments. Drs. Gary
    R. Matzke, Virginia Commonwealth University, and Leigh Ann Ross,
    University of Mississippi School of Pharmacy, were appointed to the
    AHRQ Effective Health Care Program Pharmacy Workgroup. The Minnesota
    Pharmacy Practice-Based Research Network has been accepted for the AHRQ
    Primary Care Registry, existing as a living laboratory with a focus on
    the collection of information using a network of pharmacies to address
    the medication use process related to health and wellness.
    Centers for Disease Control and Prevention
        AACP supports the CDC Coalition recommendation of $7.7 billion for
    Centers for Disease Control and Prevention (CDC) core programs in
    fiscal year 2013 and the Friends of NCHS recommendation of $162 million
    for the National Center for Health Statistics. Information from the
    NCHS is essential for faculty engaged in health services research and
    for the professional education of the pharmacist. The educational
    outcomes established through the Center for the Advancement of
    Pharmaceutical Education include those related to public health. The
    opportunity for pharmacists to identify potential public health threats
    through regular interaction with patients provides public health
    agencies with on-the-ground epidemiologists providing risk
    identification measures when patients seek medications associated with
    preventing and treating travel-related illnesses. Pharmacy faculty are
    engaged in CDC-supported research and activities including delivery of
    immunizations, integration of pharmacogenetics in the pharmacy
    curriculum, inclusion of pharmacists in emergency preparedness, and the
    Million Hearts campaign. Faculty pharmacists at the University of
    Mississippi received a $300,000 grant from CDC for a project evaluating
    pharmacy cardiovascular risk reduction and $49,000 to study active
    surveillance attitudes and perceptions in prostate cancer. Pharmacy
    schools actively participate in disaster relief response efforts in
    their community. Student pharmacists and faculty from University of
    Missouri Kansas City School of Pharmacy organized efforts to assist
    Joplin and southern Missouri just hours after the disaster and were
    among the first to respond to the area.
    National Institutes of Health
        AACP supports the Adhoc Group for Medical Research recommendation
    of $32 billion for National Institutes of Health (NIH) funding in
    fiscal year 2013. Pharmacy faculty are supported in their research by
    nearly every institute at the NIH. The NIH-supported research at AACP
    member institutions spans the full spectrum from the creation of new
    knowledge through the translation of that new knowledge to providers
    and patients. In 2011, pharmacy faculty researchers received more than
    $263 million in grant support from the NIH and retain a strong
    commitment to increasing the number of biomedical researchers. At
    Purdue University, Karen S. Hudmon received $264,927 in funding from
    NIH National Cancer Institute for a pharmacy-based tobacco cessation
    program. University of Tennessee Health Sciences Center School of
    Pharmacy's Junling Wang received $886,742 from the NIH National
    Institute on Aging to study medication therapy management and its
    effect on racial and ethnic disparities. Christopher J. Destache,
    Creighton University, received $410,913 to study on once-monthly
    antiretroviral nanoparticles for HIV-1 treatment. James C. Cloyd,
    University of Michigan, received up to $7,500,000 for
    neurophysiologically based response pharmacotherapy for epilepsy. And,
    Jennifer Marie Cochoba, University of California San Francisco,
    received $165,952 from the NIH for a study on the effect of Pharmacist
    counseling on antiretroviral adherence, 5K23MH087218-02.
    Centers for Medicare and Medicaid Services
        AACP recommends a funding level of $526.2 billion for Centers for
    Medicare and Medicaid Services (CMS) programs in fiscal year 2013. The
    impact of the ongoing efforts from CMS and the Innovation Center
    continue depends on the integration of pharmacist into healthcare
    teams. Marie A. Smith of the University of Connecticut received
    $133,453 from CMS to study transitions of care from hospital to home
    care and the role of medication reconciliation and medication therapy
    management and Almut G. Winterstein, University of Florida, received
    $255,000 from CMS for the development of new medication measures that
    address the detection and prevention of adverse medication-related
    patient safety events for future quality improvement and reporting
    programs. Miriam Mobley-Smith, Dean of the Chicago State University
    School of Pharmacy, was appointed to the CMS Advisory Panel on Outreach
    and Education (APOE) in 2011. Pharmacy faculty work to integrate
    pharmacists as members of the health team through studies in health
    information technology, electronic health records, transitions of care,
    and medication management.
                          u.s. department of education
        The Department of Education supports the education of healthcare
    professionals by assuring access to education through student financial
    aid programs, educational research allows faculty to determine
    improvements in educational approaches; and the oversight of higher
    education through the approval of accrediting agencies. AACP supports
    the Student Aid Alliance's recommendations to maintain the $5,550
    maximum Pell grant. Admission to the pharmacy professional degree
    program requires at least 2 years of undergraduate preparation. Student
    financial assistance programs are essential to assuring student have
    access to undergraduate, professional and graduate degree programs.
    AACP recommends a funding level of at least $80 million for the Fund
    for the Improvement of Post Secondary Education (FIPSE) as this is the
    only Federal program that supports the development and evaluation of
    higher education programs that can lead to improvements in higher
    education quality.
                                     ______

       Prepared Statement of the American Association for Cancer Research
        The AACR, representing 34,000 laboratory, translational, and
    clinical researchers; other healthcare professionals; and cancer
    survivors and patient advocates, is pleased to offer the following
    testimony. As the world's oldest and largest scientific organization
    focused on every aspect of high-quality, innovative cancer research,
    our mission is to prevent and cure cancer through research, education,
    communication, and collaboration.
        To improve the health of all Americans, sustain the momentum
    generated through past investments in biomedical research and restore
    lost purchasing power due to stagnant budgets, the AACR recommends a
    funding level increase to $33 billion for the NIH in fiscal year 2013
    and a commensurate increase for the National Cancer Institute (NCI).
    This level of support will enable the future scientific advances needed
    to seize today's scientific momentum, save countless lives, and spur
    innovation and economic prosperity for our country and all of our
    citizens.
        The vigorous pursuit of new breakthroughs in cancer research and
    biomedical science supported through the NIH, as well as the NCI, saves
    lives and promises to improve the entire spectrum of patient care, from
    prevention, early detection, and diagnosis, to treatment and long-term
    survivorship. As detailed in the AACR Cancer Progress Report 2011,
    there has been an amazing acceleration in the rate of advances against
    the 200 diseases we call cancer, reaching back 40 years to the signing
    of the National Cancer Act. We are in a time of unprecedented
    scientific opportunity, driven in large part by the vast new knowledge
    generated through the mapping of the human genome and growing knowledge
    of the biology of cancer. This wealth of information is being
    translated into new treatments and preventive strategies for a number
    of cancers.
        Some of the extraordinary advances made against cancer include:
      --From 1990 to 2007, death rates from all cancers combined dropped by
            22 percent for men and 14 percent for women, resulting in
            nearly 900,000 fewer deaths during that time.
      --Today, more than 68 percent of adults live 5 years or more after
            diagnosis, up from 50 percent in 1975.
      --Today, 80 percent of children live 5 years or more after diagnosis,
            up from 52 percent in 1975.
      --There are about 12 million cancer survivors living in the United
            States; 15 percent of them were diagnosed 20 or more years ago.
      --Breast cancer death rates fell by about 28 percent from 1990 to
            2006.
      --Death rates from cervical cancer have dropped by nearly 31 percent
            from 1990 to 2006.
      --Prostate cancer death rates have fallen by 39 percent from 1990 to
            2006.
      --Colorectal cancer death rates have fallen by 28 percent in women,
            and 33 percent in men.
      --Death rates from stomach cancer have fallen by 34 percent in women,
            and 43 percent in men.
        The research community's ability to sustain this scientific
    momentum, however, is increasingly jeopardized--particularly given the
    Nation's current fiscal constraints. Funding for NIH has remained
    essentially flat for the past decade, and due to the rate of biomedical
    inflation, the agency has lost approximately $5.5 billion in purchasing
    power since 2003. Even without adjusting for inflation, enacted
    spending bills in recent years have imposed outright cuts, and looming
    sequestration mandated by the Budget Control Act threatens further
    reductions in 2013.
    Cancer Remains a Significant Public Health Challenge
        Despite the significant progress we have achieved, cancer remains
    the leading cause of death for Americans under age 85, and the second-
    leading cause of death overall. In 2012, more than 1.6 million new
    cancer cases will be diagnosed and more than one-half million American
    lives will be lost to this devastating disease. And due to its enormous
    complexity, progress against certain cancers--such as pancreatic, brain
    and lung cancers--has been extremely difficult.
        Furthermore, funding challenges come at a time when we are facing a
    ``cancer tsunami'' as the baby boomer generation reaches age 65 and
    beyond. More than three-quarters of all cancers are diagnosed in
    individuals aged 55 and older, and the number of new cancer cases is
    estimated to approach 2 million per year by 2025. This will
    dramatically exacerbate the current problems with our healthcare
    system, and will undoubtedly hit hardest those who can least afford
    it--the elderly, medically underserved, and minority populations. We
    have reached a critical inflection point in our ability to conquer
    cancer, and we can only continue to make significant advances if we
    renew our commitment to allocate the required resources to do so.
        The investments that our Nation makes in cancer research and
    biomedical science, particularly those supported by public funds
    through the NCI and NIH will play a vital role in addressing the rising
    cancer incidence, while at the same time curbing the overall annual
    costs of cancer--which exceeded $263 billion in 2010.
    Targeted Therapies as the Future of Cancer Treatment
        One of the most promising new approaches in modern cancer treatment
    is our ability to treat patients based on the specific characteristics
    of a patient and his or her disease--often referred to as personalized
    or precision medicine. Cancer research is leading the way toward the
    realization of personalized medicine, in no small part thanks to
    Federal investment in deciphering the underlying biology, 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.
        Building on the tremendous progress in our understanding of the
    molecular mechanisms of cancer, numerous novel agents have been
    developed in recent years and many more are in development. New and
    innovative clinical trials are now being conducted that use molecular
    tests to identify which patients should be treated with which drugs.
    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.
        In fact, in 2011, two newly approved drugs--one for melanoma and
    one for lung cancer--were breakthroughs in personalized medicine. Each
    drug was approved with a diagnostic test that identifies patients for
    whom the drug is most likely benefit.
    Fighting Cancer in Challenging Fiscal Times
        It is imperative that efforts to improve our Nation's fiscal
    stability be grounded in the goal of securing the prosperity and well-
    being of the American people. And it is not by chance that the United
    States remains a leader in cancer research innovation and the
    development of lifesaving treatments. Our preeminence is a direct
    result of the steadfast determination of the American public and the
    Congress to reduce the burden of this devastating disease by supporting
    and investing in research through the NIH and NCI.
        Further, maintaining American global competitiveness is predicated
    on its commitment to Federal support for biomedical research and
    development (R&D). The United States led the world's economies in the
    20th century because it led the world in innovation. Today, we
    recognize that the competition is more intense; the challenge is
    tougher; and therefore, continuing to innovate is more important than
    ever before. A sustained investment in research and development is
    essential to creating new jobs for the 21st century. According to
    Science and Engineering Indicators 2012, between 1999 and 2009, the
    United States share of global R&D dropped from 38 percent to 31
    percent, whereas it grew from 24 percent to 35 percent in the ``Asia-
    10'' (China, India, Indonesia, Japan, Malaysia, Philippines, Singapore,
    South Korea, Taiwan and Thailand). While the United States remains a
    leader in supporting science and technology, that position could soon
    be overtaken as Asian countries, particularly China, continue to
    increase their national investments in R&D. Biomedical research not
    only keeps America competitive globally, it also has a strong positive
    impact on State and local economies. NIH dollars are creating and
    saving high-wage, high-tech jobs at a critical time for the U.S.
    economy. A recent report published by a consortium of science and
    research medical organizations estimated that NIH directly and
    indirectly supported nearly 488,000 public and private sector jobs, and
    generated $68 billion in new economic activity in 2010 alone.
    The National Institutes of Health Needs Stable, Predictable Increases
            in Funding
        One out of every three women and one out of every two men in
    America will develop cancer over their lifetime. More than a half
    million people will succumb to this disease in 2012--accounting for
    nearly 1 of every 4 deaths in America. This is the challenge we face
    today. Only a sustained investment in research will allow us to
    continue to build on the advances made during the past few decades to
    curb the number of lives lost to cancer.
        The AACR recognizes that the Congress is being called upon to make
    difficult decisions among many competing priorities. However, one of
    the most important investments our country can make is in the NIH. Our
    ability to exploit new and exciting findings for the benefit of cancer
    patients is contingent on a strong, bipartisan commitment from the
    Congress to provide the necessary funding for the NIH and NCI. Millions
    of current and future cancer patients and their loved ones are relying
    on your support to change the face of cancer.
                                     ______

       Prepared Statement of the American Association for Dental Research
    Introduction
        Mr. Chairman and members of the subcommittee, I am Rena D'Souza,
    Chair of the Department of Biomedical Sciences at the Texas A&M Health
    Science Center at Baylor College of Dentistry. My testimony is on
    behalf of the American Association for Dental Research (AADR).
        I thank the subcommittee for this opportunity to testify about the
    exciting advances in oral health science and for your past support of
    research at the National Institutes of Health (NIH). This support has
    made it possible for research funded by the National Institute of
    Dental and Craniofacial Research (NIDCR) to improve oral health. The
    investments we make today will create an exciting tomorrow for the
    treatment and prevention of oral health diseases and disorders. In this
    testimony, I will highlight how the advances described above have
    benefited taxpayers and some of the challenges that lie ahead that need
    to be addressed to prevent lapsing further behind other nations
    throughout the world both scientifically and economically.
    What is the American Association for Dental Research?
        The American Association for Dental Research is a nonprofit
    organization with more than 4,000 members in the United States. Its
    mission is to: (1) advance research and gain a better understanding of
    the importance of oral health; (2) support and represent the oral
    health research community; and (3) educate the public about 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 throughout life.
    Poor oral health and untreated oral diseases and conditions can affect
    the most significant human needs including the ability to eat and
    drink, swallow, maintain proper nutrition, smile and communicate. For
    over half a century, there has been a dramatic improvement in oral
    health. However, it is still a major concern. Tooth decay and gum
    disease represent most of the problem but complete tooth loss, oral
    cancer, and facial anomalies are also factors. Tooth decay is the most
    common oral health problem in the United States. More than 40 percent
    of poor adults 20 years and older have at least one untreated decayed
    tooth. Tooth decay affects more than 90 percent of adults over age 40.
    Moreover, as the nation ages, oral health issues related to gum disease
    and the impact of medical treatments and medicines will increase.
    Oral Health Research and Development
        Oral and Pharyngeal Cancer.--Most oral diseases and disorders arise
    from the interplay of complex biological, behavioral, environmental and
    genetic factors. Scientists now have the tools to understand health and
    disease from a powerful systems perspective. Such deep insights will
    enhance our ability to predict and more effectively manage many oral,
    dental diseases and craniofacial abnormalities such as orofacial
    clefting and ectodermal dysplasias. However, understanding and
    addressing complex oral diseases will require melding these advances
    with state-of-the-science clinical, epidemiological and bioinformatics
    approaches to more precisely identify diseases at their earliest
    inception, direct individualized therapies, and predict disease
    outcomes. One area that offers considerable opportunity is oral and
    pharyngeal cancer, which kills about 7,600 Americans each year. These
    deaths are particularly tragic because detection and treatment of early
    stage oral cancer usually results in much higher survival rates than if
    the disease is diagnosed and treated at late stages. Despite annual
    U.S. spending of approximately $3.2 billion on head and neck cancer
    treatment, relative survival rates have not improved during the past 16
    years and remain among the lowest of all major cancers. Oral cancer
    survival among African-American men has actually decreased. Approaches
    under development include devices to aid in earlier detection such as
    rapid gene-expression measurement tools that assess suspicious lesions
    removed for biopsy and integration of screening, diagnosis, and
    treatment. For example, toward achieving this goal, NIDCR-supported
    researchers recently devised a customized optical device that allows
    clinicians to visualize in a completely new way areas in the oral
    cavity that may be developing oral cancer.
        Genome-Wide Association Studies.--The emerging science of genome-
    wide association studies (GWAS) and other rapidly evolving genome-wide
    technologies is producing exciting findings in oral, dental and
    craniofacial health. A recent family based genome-wide linkage study
    indicated possible developmental links between cleft lip and/or palate,
    caries and a range of dental malformations and identified several
    candidate genes for caries risk, pointing unexpectedly to genetic loci
    for salivary flow and diet preference. The NIDCR's continued support of
    genomic approaches may yield important new insights into the causes and
    progression of other complex conditions such as temporomandibular
    muscle and joint disorders associated with chronic orofacial pain, oral
    cancer, periodontal diseases and Sjogren's syndrome.
        Saliva-based Diagnostic Tests.--Saliva-based diagnostic tests offer
    significant potential for improving both oral and general health. Thus
    further development and validation of these approaches will enable
    improved preemptive care by detecting molecular markers predictive of
    disease before symptoms arise, or by providing diagnosis of the
    earliest signs of disease. Recently, a consortium of NIDCR-supported
    research groups compiled the first comprehensive list of proteins
    secreted by the major salivary glands, leading to a compendium of
    salivary proteins that will form the basis for future efforts in
    salivary diagnostics and therapeutics.
        Biomedical Research Workforce.--The investment decisions that the
    Congress makes this year will have a profound impact on the future of
    America's physical, dental, and economic health. Federal investments in
    basic research play a major role in scientific discovery, leading to
    economic growth and fostering global competitiveness. NIDCR is
    committed to ensuring that the biomedical research workforce is
    prepared to address unique dental and craniofacial research questions.
    The task of getting students interested in biomedical research needs to
    be combined with mentoring opportunities to bolster retention.
        National Center for Advancing Translational Sciences.--NIH has
    established a new center, called the National Center for Advancing
    Translational Sciences (NCATS). Currently, many costly, time-consuming
    bottlenecks exist in the translational pipeline. Working in partnership
    with the public and private sectors, the Center will develop innovative
    ways to reduce, remove or bypass these bottlenecks. This will speed the
    delivery of new drugs, diagnostics and medical devices to patients,
    including the results of oral health research.
        National Institutes of Health Public Access Policy.--The NIH Public
    Access Policy ensures that the public has access to the published
    results of NIH funded research. It requires scientists to submit final
    peer-reviewed journal manuscripts that arise from NIH funds to the
    digital archive PubMed Central upon acceptance for publication. The
    scientific community relies on publishers to manage the post-grant peer
    review process to evaluate the merit and authenticity of the
    conclusions of the research. However, post-grant peer review is not
    funded by the agencies at all. No Federal funding goes into the
    publication process. In essence, privately funded articles, which are
    not subject to an open or public access policy, will have to subsidize
    the decreased readership resulting from the public access policy. In
    order for a journal to maintain readership, a ratio of privately funded
    research versus federally funded research will have to be maintained.
    With an expanded open access policy, it is feared that a number of
    small nonprofit scholarly journals will experience decreased
    subscriptions that will create an operating loss for the journal.
    Challenges to Research
        For many years, the United States has been a world leader in
    research and development. In order for the United States to thrive in
    today's innovation-oriented economy, we need to maintain a world class
    commitment to science and research. Future advances in healthcare
    depend on today's investments in basic research on the fundamental
    causes and mechanisms of disease, new technologies to accelerate
    discoveries, innovations in clinical research, and a robust pipeline of
    creative and skillful biomedical researchers. To continue reaping the
    benefits of a bold research funding platform, the Congress must make
    science a national priority. With continued support, NIH investigators
    will help to revolutionize patient care, reduce the growth of
    healthcare costs, and generate significant national economic growth.
    Fiscal Year 2013 Budget Request
        As you can see, Mr. Chairman, there are many research opportunities
    with an immediate impact on patient care that need to be pursued. A
    steady and substantial funding stream for NIH overall, and NIDCR in
    particular, is absolutely necessary in order to continue improving the
    oral health of Americans. We support the recommendation of the Ad Hoc
    Group for Medical Research that the Subcommittee recognize NIH as a
    critical national priority by providing at least $32 billion in funding
    in the fiscal year 2013 Labor, Health and Human Services, Education
    appropriations bill. Of this amount, NIDCR should receive a fiscal year
    2013 appropriation of $450 million. This funding recommendation
    represents the minimum investment necessary to avoid further loss of
    promising research and at the same time allows the NIH's budget to keep
    pace with biomedical inflation.
        Thank you for this opportunity to testify. We at AADR look forward
    to having the opportunity to work with the Congress and NIH to help
    build a strong and successful research enterprise.
                                     ______

        Prepared Statement of the American Academy of Family Physicians
        The American Academy of Family Physicians, representing 100,300
    family physicians and medical students nationwide, urges the Senate
    Appropriations Subcommittee on Labor, Health and Human Services, and
    Education to invest in our Nation's primary care physician workforce in
    the fiscal year 2013 appropriations bill to promote the efficient,
    effective delivery of healthcare.
        We recommend that the Committee provide the Health Resources and
    Services Administration and the Agency for Healthcare Research and
    Quality:
      --At least $71 million for Health Professions Primary Care Training
            and Enhancement, authorized under title VII, section 747 of the
            Public Health Service Act (PHSA);
      --$10 million for Teaching Health Centers development grants (PHSA
            Title VII, Sec. 749A);
      --$4 million for Rural Physician Training Grants (PHSA Title VII,
            Sec. 749B);
      --$122.2 million for the Office of Rural Health Policy (PHSA
            Sec. Sec. 301, 330A, and 338J, and Sec. Sec. 711 and 1820(j),
            title XVIII of the Social Security Act);
      --At least $300 million for the National Health Service Corps (PHSA
            Sec. 338A, B, and I);
      --$120 million for the Primary Care Extension program (PHSA
            Sec. 399V-1) in fiscal year 2013; and
      --$3 million for the National Health Care Workforce Commission (ACA
            Sec. 5101).
                  health resources and services administration
        The AAFP urges the subcommittee to provide at least $7 billion for
    Health Resources and Services Administration (HRSA) in the fiscal year
    2013 appropriations bill. Fundamental to HRSA's mission of improving
    access is supporting efforts to train and place the necessary primary
    care physician workforce. There is ample evidence that primary care
    physicians serve as a strong foundation for a more efficient and
    effective healthcare system. Federal investment not only would help to
    guide health system change to achieve optimal, cost-efficient health
    for everyone, but also would support primary care medicine training in
    what the January 2012 Bureau of Labor Statistics Projections recognized
    as ``the most rapidly growing sector in terms of employment through
    2020.''
        Title VII Health Professions Training Programs.--As the only
    medical specialty society devoted entirely to primary care, the AAFP is
    gravely concerned that a failure to provide adequate funding for the
    title VII, section 747, Primary Care Training and Enhancement (PCTE)
    program, will destabilize education and training support for family
    physicians. Between 1998 and 2008, in spite of persistent primary care
    physician shortages, family medicine lost 46 training programs and 390
    residency positions, and general internal medicine lost nearly 900
    positions.\1\ A study published in the Annals of Family Medicine on the
    impact of title VII training programs found that physicians who work
    with the underserved at Community Health Centers and National Health
    Service Corps sites are more likely to have trained in title VII-funded
    programs.\2\ Title VII primary care training grants are vital to
    departments of family medicine, general internal medicine, and general
    pediatrics; they strengthen curricula; and they offer incentives for
    training in underserved areas. 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 people. These
    demographic trends will worsen family physician shortages. The AAFP
    urges the subcommittee to increase the level of Federal funding for
    primary care training to at least $71 million in fiscal year 2013 to
    support the continuing work of grantees and allow for a new grant
    cycle.
    ---------------------------------------------------------------------------
        \1\ Phillips RL and Turner, BJ. The Next Phase of Title VII Funding
    for Training Primary Care Physicians for America's Health Care Needs.
    Ann Fam Med. 2012;10(2):163-168.
        \2\ 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.
    ---------------------------------------------------------------------------
        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 nonhospital settings, where most primary
    care is delivered. An excellent first step is the innovative Teaching
    Health Centers program, authorized under Title VII, Sec. 749A, to
    increase primary care physician training capacity now administered by
    HRSA.
        Federal financing of graduate medical education has led to training
    that occurs mainly in hospital inpatient settings, even though most
    patient care is delivered outside of hospitals in ambulatory settings.
    The Teaching Health Centers program provides resources to qualified
    community-based ambulatory care settings that operate a primary care
    residency. We believe that this program requires an investment of $10
    million in fiscal year 2013 for planning grants.
        Rural Health Needs.--HRSA's Office of Rural Health Policy focuses
    on key rural health policy issues and administers targeted rural grant
    programs. As members of the medical specialty most likely to enter
    rural practice, family physicians recognize the need to dedicate
    resources to rural health needs.
        A recent study found that medical school rural programs have had a
    significant impact on rural family physician supply and called for
    wider adoption of that model to substantially increase access to care
    in rural areas, compared with greater reliance on international medical
    graduates or unfocused expansion of traditional medical schools.\3\
    HRSA's Rural Physician Training Grant Program will help medical schools
    recruit students most likely to practice medicine in rural communities.
    This program will help provide rural-focused experience and increase
    the number of medical school graduates who practice in underserved
    rural communities. The AAFP recommends that the Committee provide $4
    million for the Rural Physician Training Grant Program in fiscal year
    2013.
    ---------------------------------------------------------------------------
        \3\ Rabinowitz, HK, et al. Medical School Rural Programs: A
    Comparison With International Medical Graduates in Addressing State-
    Level Rural Family Physician and Primary Care Supply. Academic
    Medicine, Vol. 87, No. 4/April 2012.
    ---------------------------------------------------------------------------
        Primary Care in Underserved Areas.--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 physicians 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 AAFP
    recommends that the Committee provide at least $300 million for the
    National Health Service Corps for fiscal year 2013.
        The AAFP has worked closely with HRSA to promote data-driven
    community health center expansion. The mapping tool developed and
    managed by the Robert Graham Center for Policy Studies in Family
    Practice and Primary Care identifies areas in greatest need of
    federally Qualified Health Centers. Since the launch of the tool on
    July 1, 2010, the UDS Mapper has registered more than 4,500 users; it
    can be found at http://www.udsmapper.org/about.cfm.
                   agency for healthcare research and quality
        The AAFP supports the work of AHRQ's Center for Primary Care,
    Prevention, and Clinical Partnerships (CP\3\), which serves as the home
    for the AHRQ's Practice-Based Research Network of primary care
    ambulatory practices. This network studies community-based practice.
        Furthermore, we recognize AHRQ as an important resource for primary
    care workforce data. The AAFP asks that the Committee provide at least
    $400 million for AHRQ in fiscal year 2013.
        Primary Care Extension Program.--The AAFP supports AHRQ's Primary
    Care Extension Program to provide information to primary care
    physicians about evidence-based therapies and techniques so that they
    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 the
    information learned 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 agricultural information and
    guidance. The AAFP recommends that the subcommittee provide $120
    million for the AHRQ Primary Care Extension program in fiscal year
    2013.
                   national health care workforce commission
        Appointed on September 30, 2010, the 15-member National Health Care
    Workforce Commission was intended to serve as a national resource with
    a broad array of expertise. The Commission was directed to analyze
    current workforce distribution and needs; evaluate healthcare education
    and training; identify barriers to improved coordination at the
    Federal, State, and local levels and recommend ways to address them;
    and encourage innovations to address population needs, changing
    technology, and other factors.
        There is broad consensus about the waning availability of primary
    care physicians in the United States, but estimates of the severity of
    the regional and local shortages vary. The AAFP supports the work of
    the Commission to analyze primary care shortages and propose
    innovations to help produce the physicians that our Nation needs and
    will need in the future. We request that the Committee provide $3
    million in fiscal year 2013 so that this important Commission can begin
    this important work.
                                     ______

        Prepared Statement of the American Association of Immunologists
        The American Association of Immunologists (AAI), a not-for-profit
    professional society comprised of more than 7,400 of the world's
    leading experts on the immune system, appreciates this opportunity to
    submit this testimony regarding appropriations for the National
    Institutes of Health (NIH) for fiscal year 2013. AAI members work in
    academia, Government, and industry. Most of our members either receive
    funding from NIH to support their research \1\ or depend on the basic
    research conducted by NIH-funded scientists in developing therapeutics
    to prevent or treat disease.\2\ Whether public or private sector;
    basic, translational or clinical; American or international; most
    biomedical researchers rely on the leadership of, and funding from, the
    NIH--the world's premier medical research organization.
    ---------------------------------------------------------------------------
        \1\ Many AAI members receive grants from the National Institute of
    Allergy and Infectious Diseases, the National Cancer Institute, and the
    National Institute on Aging, as well as other NIH Institutes and
    Centers.
        \2\ NIH funding has a definite impact on the private sector. ``. .
    . [T]he National Bureau of Economic Research concluded that, in
    contrast to the pattern of public spending . . . displacing private
    activity in the economy, a dollar of NIH support for research leads to
    an increase of private medical research of roughly 32 cents.'' Everett
    Ehrlich, An Economic Engine: NIH Research, Employment and the Future of
    the Medical Innovation Sector, http://www.unitedformedicalresearch.com/
    wp-content/uploads/2011/05/UMR_Economic-Engine.pdf.
    ---------------------------------------------------------------------------
        NIH's preeminence--and America's dominance--in advancing medical
    research, discovering treatments and cures, and ``growing'' brilliant
    young scientists has been unchallenged for more than 50 years. However,
    continued erosion of NIH funding has already led to the loss of highly
    qualified scientists and the closures of labs.\3\ For those scientists
    who are able to continue, competing and securing research support
    increasingly occupies the time that could--and should--be dedicated to
    new advances and discoveries.
    ---------------------------------------------------------------------------
        \3\ FASEB, ``Federal Funding for Biomedical and Related Life
    Sciences Research FY 2013,'' http://www.faseb.org/
    LinkClick.aspx?fileticket=10Qs6teI4kY%3D&tabid=64. Everett Ehrlich,
    NIH's Role in Sustaining the U.S. Economy, http://
    www.unitedformedicalresearch.com/wp-content/uploads/2012/03/NIHs-Role-
    in-Sustaining-the-US-Economy-2011.pdf.
    ---------------------------------------------------------------------------
        NIH funding is an important driver of our economy. Unlike many
    Federal agencies, NIH distributes most (>80 percent) of its $30.7
    billion budget to scientists in all 50 States, making NIH funding a
    formidable engine for local and national economic growth.\4\ NIH
    funding supports highly skilled jobs focused on improving human and
    animal health; less skilled jobs which support laboratories, academic
    institutions, and a community of employees; \5\ and the training of our
    Nation's future researchers, inventors, and innovators. NIH-funded
    discoveries also fuel the success of our Nation's biotechnology and
    pharmaceutical industries.
    ---------------------------------------------------------------------------
        \4\ NIH funding supports ``almost 50,000 competitive grants to more
    than 300,000 researchers at more than 2,500 universities, medical
    schools, and other research institutions in every State and around the
    world.'' http://nih.gov/about/budget.htm. (March 1, 2012).
        \5\ ``One study estimates that every dollar of NIH support returns
    $2.21 in goods and services in just 1 year, and that on average, every
    NIH grant creates seven high-quality jobs.'' Testimony of Francis S.
    Collins, M.D., Ph.D., March 28, 2012, page 7, http://
    www.appropriations.senate.gov/ht-
    labor.cfm?method=hearings.view&id=8a1dcace-6f68-4e35-ad94-4409966e2ffb.
    See also Ehrlich, NIH's Role in Sustaining the U.S. Economy (see
    footnote 1, above).
    ---------------------------------------------------------------------------
    The Broad Reach of the Immune System
        All humans and other animals require a properly working immune
    system to survive. Optimally, this system defends against infectious
    agents which require a host to persist and propagate. Many infectious
    diseases, including influenza, HIV/AIDS, tuberculosis, malaria, and the
    common cold, challenge--and sometimes overcome--the defenses mounted by
    the immune system. Other malfunctions result in the immune system
    attacking our normal body tissues, causing ``autoimmune'' diseases or
    disorders, including Type 1 diabetes, multiple sclerosis, rheumatoid
    arthritis, asthma, allergies, inflammatory bowel diseases, and
    lupus.\6\ The immune system also impacts many other diseases and
    conditions, including cancer, Alzheimer's,\7\ obesity, Type II
    diabetes, psoriasis, alopecia areata, and pregnancy loss.
    ---------------------------------------------------------------------------
        \6\ The immune system works by recognizing and attacking bacteria,
    viruses, and tumor cells inside the body. It is also responsible for
    the rejection response following transplantation of organs or bone
    marrow.
        \7\ Allison Bond, ``Immune Response May Worsen Alzheimer's,''
    Scientific American, January 18, 2010, http://
    www.scientificamerican.com/article.cfm?id=inflamed-neurons.
    ---------------------------------------------------------------------------
        In addition, urgent public health challenges require understanding
    the immune response to pathogens that might cause the next pandemic;
    man-made and natural infectious organisms (including plague, smallpox
    and anthrax) that could be used for bioterrorism; and environmental
    threats that could cause or exacerbate disease.\8\ Although immunology
    is a relatively young field,\9\ research advances have already yielded
    remarkable progress.\10\ But solving key scientific questions that lead
    to prevention and cures cannot occur without a strong, sustained
    biomedical research enterprise, adequately funded through
    appropriations to NIH.
    ---------------------------------------------------------------------------
        \8\ To best protect against emergent threats, AAI believes that
    scientists should focus on basic research, including understanding the
    immune response, identifying new pathogens, and developing tools
    (including vaccines) to protect against these pathogens. For example,
    to best protect against an influenza 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.
        \9\ Most of our basic understanding of the immune system has
    developed in the last 50 years, although the first vaccine (against
    smallpox) was developed in 1798.
        \10\ In 2011, three NIH-supported immunologists (the late Ralph
    Steinman, M.D., Bruce Beutler, M.D., and Jules Hoffman, Ph.D.) received
    the Nobel Prize in Medicine for their important contributions to the
    field.
    ---------------------------------------------------------------------------
    Recent Immunological Discoveries and Translation to Treatment
        AIDS Vaccine.--Study of the immune system has helped lengthen the
    lives of those diagnosed with
        HIV from months in the 1980s to as much as 50 years today.\11\
    Recently, several key advances have helped us understand how HIV evades
    immune recognition and how to generate more efficacious HIV vaccines.
    In one discovery, scientists were able to visualize neutralizing
    antibodies bound to HIV on a molecular level, determine the nature of
    the interaction, and find a broadly neutralizing antibody that combats
    several strains of HIV.\12\ Such advances may lead to effective
    therapies and vaccines against many viruses, including HIV.
    ---------------------------------------------------------------------------
        \11\ Anthony S. Fauci, ``After 30 years of HIV/AIDS, real progress
    and much left to do,'' Washington Post, May 27, 2011, http://
    www.washingtonpost.com/opinions/after-30-years-of-hivaids-real-
    progress-and-much-left-to-do/2011/05/27/AGbimyCH_story.html.
        \12\ Robert Pejchal et al., ``A Potent and Broad Neutralizing
    Antibody Recognizes and Penetrates the HIV Glycan Shield,'' Science
    334, (2011):1097.
    ---------------------------------------------------------------------------
        Universal Flu Vaccine.--Remarkable advances are also being made on
    improved seasonal influenza vaccines and ``universal'' flu vaccines
    that would provide protection against multiple strains of influenza.
        Anti-Cancer Vaccines.--In testimony submitted to this subcommittee
    in 2009, AAI described a promising new cancer treatment that would
    redirect the immune system to attack cancer cells by manipulating the
    inhibitory molecule CTLA-4. In 2011, the Food and Drug Administration
    (FDA) approved CTLA-4 blockade (ipilimumab) for the treatment of
    metastatic melanoma after Phase III clinical trials showed that
    ipilimumab improved survival for these patients.\13\ In 2010, the first
    therapeutic cancer vaccine (Provenge), for the treatment of prostate
    cancer, was approved by the FDA. This vaccine takes advantage of the
    immune system's ability to sense and then attack cancer cells.\14\ Both
    therapies were based on fundamental immunological discoveries of the
    past several decades and are now guiding the development of numerous
    other therapeutics which direct the immune system to specifically
    attack cancer cells.
    ---------------------------------------------------------------------------
        \13\ Stephen Hodi et al., ``Improved Survival with Ipilimumab in
    Patients with Metastatic Melanoma,'' N Engl J Med 363, (2010): 711-723.
        \14\ See http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/
    ucm210174.htm.
    ---------------------------------------------------------------------------
        Malaria Vaccine.--A recent phase III study for the malaria vaccine
    RTS,S showed that the progression of severe disease could be reduced by
    the vaccine by about half, promising data toward the development of a
    vaccine for a disease that is of urgent concern to people worldwide and
    to U.S. troops stationed abroad.
    The Importance of Sustained National Institutes of Health Funding
        AAI greatly appreciates this subcommittee's long history of strong
    bipartisan support for biomedical research. NIH funding has supported
    many excellent projects to advance human health and strengthen the
    Nation's research infrastructure. However, fiscal pressures in recent
    years have resulted in flat or reduced NIH funding. Together with
    increases in biomedical research inflation, these budgets have
    significantly eroded NIH's purchasing power; the President's fiscal
    year 2013 budget would reduce NIH's purchasing power to 2001
    levels.\15\ AAI is deeply concerned that inadequate NIH funding will
    harm ongoing research, weaken the U.S. biomedical research enterprise,
    and enable global competitors to recruit our best scientists.
    ---------------------------------------------------------------------------
        \15\ FASEB, Predictable and Sustainable Funding for NIH Will Drive
    Innovation and Progress, 2012, http://www.faseb.org/
    LinkClick.aspx?fileticket=aDQlNW4adp0%3d&tabid=431.
    ---------------------------------------------------------------------------
    American Association of Immunologists Recommendation for National
            Institutes of Health Funding for Fiscal Year 2013
        Although AAI believes that NIH needs a substantial infusion of
    funds, we realize that such an increase is unlikely this year.
    Therefore, AAI recommends a budget for NIH of at least $32 billion to
    enable NIH to support existing research projects, fund a limited number
    of excellent new ones, and stabilize the research enterprise. More is
    needed, however, to grow the system or inspire confidence in it,
    particularly among the brightest young students who are increasingly
    hesitant to pursue careers in biomedical research.
    American Association of Immunologists Priorities for Fiscal Year 2013
        Biomedical innovation and discovery are best achieved through
    individual investigator-initiated research, i.e., researchers working
    all around the country, whose grant applications are peer-reviewed and
    funded by NIH. ``Top-down'' science, in which the Government specifies
    the type of research it wishes to fund, is less likely to achieve the
    desired goals than funding the best grant applications. AAI is
    concerned, therefore, that the President's budget reduces funding for
    research project grants (RPGs) by $26 million. While NIH's new
    management plan anticipates funding a larger number (672) of new and
    competing RPGs, this reduced funding would require awards to be smaller
    and/or shorter in duration. Although this may be the best way for NIH
    to manage less RPG funding, it will not solve the fundamental problem
    caused by the erosion of the NIH budget: fewer scientists receiving the
    support they need to do their work.
        The President's budget provides an increase of $64 million to the
    National Center for Advancing Translational Sciences (NCATS), including
    an increase of $40 million for the Cures Acceleration Network (CAN).
    Although AAI supports NIH's desire to facilitate the translation of
    basic research from ``bench to bedside,'' AAI questions whether such
    large increases are wise when overall RPG funding is experiencing a
    significant and worrisome decline.
        AAI is concerned about a new administration policy that limits the
    ability of Government scientists to attend privately sponsored
    scientific meetings and conferences.\16\ Government scientists are
    valued members of our organization and contribute significantly to
    scientific advancement in the field. It is as important to AAI to have
    them attend our meetings as it is for them to attend. Dialogue and
    information exchange among scientists from Government, academia,
    industry and private institutes are absolutely essential, and any
    barriers to the participation of Government scientists undermines the
    best interests of science.
    ---------------------------------------------------------------------------
        \16\ See http://www.hhs.gov/travel/policies/
    2012%20policy%20manual.pdf.
    ---------------------------------------------------------------------------
    The National Institutes of Health Public Access Policy
        As the owner and publisher of The Journal of Immunology (The JI),
    AAI believes that the NIH Public Access Policy (Policy) duplicates
    publishing services which are already provided cost-effectively and
    well by the private sector, including not-for-profit scientific
    societies. AAI and other scholarly publishers already publish, and make
    publicly available, thousands of scientific journals with millions of
    articles that report cutting-edge research. Many publishers make
    abstracts available online immediately and at no cost to the public.
    Most publishers who impose an embargo period (necessary to prevent the
    loss of subscriptions which defray publication costs) make available
    not only the articles supported by NIH funding, but all articles
    regardless of funding source. As a result, many publisher Web sites
    contain a more complete repository of relevant literature than does
    NIH, and often include the entire archives of the journal.
        NIH should work with, rather than compete with, private publishers
    to enhance public access; address publishers' key concerns, including
    respecting copyright and ensuring journals' continued ability to
    provide quality, independent peer review of NIH-funded research; and
    publicly report on the cost of the Policy.
                                   conclusion
        AAI thanks this subcommittee for its strong support for medical
    research, NIH and the thousands of researchers who devote their lives
    to scientific discovery and the prevention, treatment, and cure of
    disease.
                                     ______

           Prepared Statement of the American Association of Museums
        Chairman Harkin, Ranking Member Shelby, and members of the
    subcommittee, thank you for inviting me to submit this testimony. My
    name is Ford Bell and I serve as President of the American Association
    of Museums (AAM). I also submit this testimony on behalf of the larger
    museum community--including the American Association for State and
    Local History, the Association of Art Museum Directors, the Association
    of Children's Museums, the American Public Gardens Association, and
    Heritage Preservation--to request that the subcommittee make a renewed
    investment in museums in fiscal year 2013. We urge your support for $50
    million for the Office of Museum Services (OMS) at the Institute of
    Museum and Library Services (IMLS).
        AAM is proud to represent the full range of our Nation's museums--
    including aquariums, art museums, botanic gardens, children's museums,
    culturally specific museums, historic sites, history museums, maritime
    museums, military museums, natural history museums, planetariums,
    presidential libraries, science and technology centers, and zoos, among
    others--along with the professional staff and volunteers who work for
    and with museums. AAM is proud to work on behalf of the 17,500 museums
    that employ 400,000 people, spend more than $2 billion annually on K-12
    educational programming, receive more than 90 million visits each year
    from primary and secondary school students, and contribute more than
    $20 billion to local economies.
        IMLS is the primary Federal agency that supports the Nation's
    museums, and OMS awards grants to help museums digitize, enhance, and
    preserve their collections; provide teacher training; and create
    innovative, cross-cultural and multi-disciplinary programs and exhibits
    for schools and the public. The 2012-2016 IMLS Strategic Plan lists
    clear priorities: placing the learner at the center of the museum
    experience, promoting museums as strong community anchors, supporting
    museum stewardship of their collections, advising the President and the
    Congress on how to sustain and increase public access to information
    and ideas, and serving as a model independent Federal agency maximizing
    value for the American public. IMLS is indeed a model Federal agency.
        In late 2010, a bill to reauthorize IMLS for 5 years was enacted
    (by voice vote in the House and unanimous consent in the Senate). The
    bipartisan reauthorization included several provisions proposed by the
    museum field, including enhanced support for conservation and
    preservation, emergency preparedness and response, and statewide
    capacity building. The reauthorization also specifically supports
    efforts at the State level to leverage museum resources, including
    statewide needs assessments and the development of State plans to
    improve and maximize museum services throughout the State. The bill
    (now Public Law 111-340) authorized $38.6 million for the IMLS Office
    of Museum Services to meet the growing demand for museum programs and
    services. The fiscal year 2012 appropriation of $30,859,000--equal to
    President Obama's fiscal year 2013 budget request--represents a nearly
    15-percent decrease from the fiscal year 2010 appropriation of
    $35,212,000. We urge the subcommittee to provide $50 million for the
    IMLS Office of Museum Services.
        To be clear, museums are essential in our communities for many
    reasons:
          Museums are Key Education Providers.--Museums already offer
            educational programs in math, science, art, literacy, language
            arts, history, civics and government, economics and financial
            literacy, geography, and social studies, in coordination with
            State and local curriculum standards. Museums also provide
            experiential learning opportunities, STEM education, youth
            training, and job preparedness. They reach beyond the scope of
            instructional programming for schoolchildren by also providing
            critical teacher training. There is a growing consensus that
            whatever the new educational era looks like, it will focus on
            the development of a core set of skills: critical thinking, the
            ability to synthesize information, the ability to innovate,
            creativity, and collaboration. Museums are uniquely situated to
            help learners develop these core skills.
          Museums Create Jobs and Support Local Economies.--Museums serve
            as economic engines, bolster local infrastructure, and spur
            tourism. Both the U.S. Conference of Mayors and the National
            Governors Association agree that cultural assets such as
            museums are essential to attracting businesses, a skilled
            workforce, and local and international tourism. Museums pump
            more than $20 billion into the American economy, creating many
            jobs.
          Museums Address Community Challenges.--Many museums offer
            programs tailored to seniors, veterans, children with special
            needs, persons with disabilities, and more, greatly expanding
            their reach and impact. For example, some have programs
            designed specifically for children on the autism spectrum, some
            are teaching English as a second language, and some are serving
            as locations for supervised family visits through the family
            court system. In 2011, more than 1,500 museums participated in
            the Blue Star Museums initiative, offering free admission to
            all active duty and reserve personnel and their families from
            Memorial Day through Labor Day.
          Digitization and Traveling Exhibitions Bring Museum Collections
            to Underserved Populations.--Teachers, students, and
            researchers benefit when cultural institutions are able to
            increase access to trustworthy information through online
            collections and traveling exhibits. Most museums, however, need
            more help in digitizing collections.
        Grants to museums are highly competitive and decided through a
    rigorous, peer-reviewed process. Even the most ardent deficit hawks
    view the IMLS grantmaking process--the ``regular process''--as a model
    for the Nation. It would take approximately $124.6 million to fund all
    the grant applications that IMLS received from museums in 2011. But
    given the significant budget cuts, many highly rated grant applications
    go unfunded each year:
      --Only 32 percent Museums for America/Conservation Project projects
            were funded;
      --Only 15 percent National Leadership/21st Century Museum
            Professionals projects were funded;
      --Only 64 percent Native American/Hawaiian Museum Services projects
            were funded; and
      --Only 37 percent African American History and Culture projects were
            funded.
        It should be noted that each time a museum grant is awarded,
    additional local and private funds are also leveraged. In addition to
    the required dollar-for-dollar match required of museums, grants often
    spur additional giving by private foundations and individual donors. A
    recent IMLS study found that 67 percent of museums that received
    Museums for America grants reported that their IMLS grant had
    positioned the museum to receive additional private funding.
        Here are just a few examples of how Office of Museum Services
    funding is used:
      --The Iowa Children's Museum in Coralville will use its $117,769
            Museums for America grant awarded in 2011 to establish
            ``MoneyWorks!''--a financial literacy project targeting
            children aged 4 to 10. The proposed project will empower
            children by adding active financial literacy experiences to the
            museum's current CityWorks exhibit. ``MoneyWorks!'' enables
            children and their families to take on the roles of bank
            tellers, pizza chefs, doctors, and more in a pretend city
            environment where they can explore the concepts of earning,
            spending, saving, and giving. Through basic math skills,
            creative problem solving, and increased awareness of financial
            choices and consequences, kids will acquire a lifetime of
            essential financial literacy skills.
      --The National Czech and Slovak Museum and Library in Cedar Rapids,
            Iowa, will use its $148,351 Museums for America grant awarded
            in 2011 to capture the personal stories and family sagas of
            Czech and Slovak Cold War emigres and recent (post-Velvet
            Revolution) Czech and Slovak immigrants to America. Beginning
            in Cedar Rapids and then extending to New York, Chicago, the
            District of Columbia, Florida, and the San Francisco Bay Area,
            this project will involve a new permanent exhibition, a
            traveling exhibit, and an oral history recording booth to be
            designed, constructed, and implemented in the museum.
      --The University of Northern Iowa Museums in Cedar Falls will use its
            $149,684 Museums for America grant awarded in 2011 to protect
            and preserve the archive's resources (9,000 original documents
            relating to early Iowa education), ensuring public access to
            this valuable historical information. The historically
            important Marshall Center School, owned by UNI Museums,
            maintains a collection of more than 3,000 photographs, school
            board records, oral histories, teacher certificates and
            contracts, teaching materials, maps, diaries, letters,
            furnishings, and textbooks from the 1850s to the 1960s. With
            the addition of the statewide collection of official rural
            school documents, the UNI Museums' Center for the History of
            Rural Iowa Education and Culture is poised to become a
            significant national center for the study of educational,
            rural, and women's history.
      --The McWane Science Center in Birmingham, Alabama, will use its
            $140,020 Museums for America grant awarded in 2011 to partner
            with the W.J. Christian public school in Birmingham to provide
            teacher training workshops, classroom outreach programs,
            science laboratories and programs, and a school-based science
            resource center. The partnership is designed to pair a formal,
            public school with an informal education institution to provide
            low-income and disadvantaged students with the opportunity to
            access quality learning environments, equipment, and
            laboratories. The project will result in a revised science
            curriculum and professional development resources for science
            teachers. The project aims to engage students in science and
            inspire them to pursue opportunities for advanced science
            education. The Science Education Partnership will help further
            the museum's mission of ``changing lives through science and
            wonder'' by serving as an extension of the school-based science
            classroom.
      --The Alabama Space Science Exhibit Commission in Huntsville,
            Alabama, will use its $150,000 Museums for America grant
            awarded in 2011 to develop, ``Carrying Out the Mission,'' an
            exhibit on astronaut training at its museum, the U.S. Space &
            Rocket Center. The center houses one of the world's largest
            collections of space artifacts and ``Carrying Out the Mission''
            is one part of a 12-module exhibit plan that will use
            historical artifacts, hands-on interactive stations, two
            problem-solving computer simulators, and oral histories to
            explore human space exploration, and in the process inspire
            current and future generations to engage in science.
      --The Birmingham Civil Rights Institute in Birmingham, Alabama, is
            using its $129,830 Museum Grants for African American History
            and Culture awarded in 2010 to better engage its diverse
            audiences by enhancing the staff capacity to effectively
            utilize technology. With the recent installation of new
            interactive exhibits and a fiber optic network, the museum will
            now develop the skills of its staff to more fully utilize the
            museum's education programs and services. The museum will hire
            a computer and information systems assistant to provide
            technical support for exhibitions and staff functions, and a
            series of technology training programs will be offered to all
            staff. The project will promote greater efficiency between the
            various museum departments through improved communication and
            coordination, information sharing, data collection and
            analysis, and external communication with visitors and other
            stakeholders.
        In closing, I would like to share with you for the record a letter
    to the subcommittee requesting $50 million for the IMLS Office of
    Museum Services signed by 18 of your Senate colleagues. Thank you once
    again for the opportunity to submit this testimony.
                                     ______

                                          United States Senate,
                                        Washington, DC, March 29, 2012.
    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.
        Dear Chairman Harkin and Ranking Member Shelby: We are writing to
    thank you for your support for the Institute of Museum and Library
    Services (IMLS) Office of Museum Services (OMS) and to urge the
    subcommittee to support $50 million for OMS in the fiscal year 2013
    Labor, Health and Human Services and Education Appropriations bill.
        Museums are economic engines--spending more than $20 billion in
    their communities, employing 400,000 Americans, and spurring local
    tourism. Museums are also fostering the kind of critical thinking
    skills and innovation that are necessary to keep our Nation competitive
    in the global economy.
        The demand for museum services is greater than ever. At a time when
    school resources arc strained and many families cannot afford to travel
    or make ends meet, museums are working overtime to fill the gaps--
    providing more than 18 million instructional hours to schoolchildren,
    bringing art and cultural heritage, dynamic exhibitions and living
    specimens into local communities, encouraging national service and
    volunteerism, collecting food and other resources for needy families
    and individuals, and offering free or reduced admission to military
    families. Unfortunately, museums are struggling significantly in these
    difficult economic times. They are being forced to cut back on hours,
    educational programming, community services, and jobs. And according to
    the 2005 Heritage Health Index, at least 190 million artifacts are at
    risk, suffering from light damage and harmful and insecure storage
    conditions.
        The Institute of Museum and Library Services--the primary Federal
    agency that supports our Nation's 17,500 museums--was unanimously
    reauthorized in 2010 by both the House and Senate. The agency is highly
    accountable, and its competitive, peer-reviewed grants serve every
    State. Although the agency has been successful in creating and
    supporting advancements in areas such as technology, lifelong community
    learning and conservation and preservation efforts, only a small
    fraction of the Nation's museums are currently being reached, and many
    highly rated grant applications go unfunded each year. The re-
    authorization contained several provisions to further support museums,
    particularly at the State level, but much of the recently authorized
    activities cannot be accomplished without meaningful funding.
        We therefore recommend a critical investment in our Nation's
    museums. Specifically, we are requesting $50 million for IMLS Office of
    Museum Services for fiscal year 2013. Again, we appreciate the
    subcommittee's prior support for OMS and request this investment to
    strengthen and sustain the work of our Nation's museums.
                Sincerely,
                        Kirsten E. Gillibrand; Daniel K. Akaka; Max Baucus;
                                Jeff Bingaman; Richard Blumenthal; Benjamin
                                L. Cardin; Richard J. Durbin; Tim Johnson;
                                Frank R. Lautenberg; Patrick J. Leahy;
                                Barbara A. Mikulski; Jack Reed; Bernie
                                Sanders; Charles E. Schumer; Jeanne
                                Shaheen; Debbie Stabenow; Tom Udall;
                                Sheldon Whitehouse.
                                                         U.S. Senators.
                                     ______

       Prepared Statement of the Association of American Medical Colleges
        The Association of American Medical Colleges (AAMC) is a not-for-
    profit association representing all 137 accredited United States 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 Federal
    priorities that play essential 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 student aid
    through the Department of Education and HRSA's 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 Federal
    Government's greatest achievements. Congress' long-standing 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 foundation of scientific knowledge built through NIH-funded
    research drives medical innovation that improves health through new and
    better diagnostics, improved prevention strategies, and more effective
    treatments.
        The AAMC supports the recommendation of the Ad Hoc Group for
    Medical Research that the Subcommittee recognize NIH as a critical
    national priority by providing at least $32 billion in funding in its
    fiscal year 2013 Labor-HHS-Education appropriations bill. This funding
    recommendation represents the minimum investment necessary to avoid
    further loss of promising research and at the same time allows the
    NIH's budget to keep pace with biomedical inflation.
        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 AAMC opposes the administration's proposal to retain at
    Executive Level II of the Federal Executive Pay Scale the limit on
    salaries that can be drawn from NIH extramural awards. The reduction in
    the limit in the fiscal year 2012 appropriation comes at a time when
    medical schools' and teaching hospitals' discretionary funds from
    clinical revenues and other sources are increasingly constrained and
    less available to invest in research. As institutions and departments
    divert funds to compensate for the reduction in the salary limit, they
    will have less funding for critical activities such as bridge funding
    to investigators who may be between grants and seed grants and start-up
    packages for young investigators. The lower salary cap will
    disproportionately affect physician investigators, who will be forced
    to make up salaries from clinical revenues, thus leaving less time for
    research. This may serve as a deterrent to their recruitment into
    research careers. The AAMC urges the Subcommittee to restore the limit
    to Executive Level I, as it was for every year since fiscal year 2001.
        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 $400 million in base
    discretionary funding for the agency in fiscal year 2013.
        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 the full spectrum
    of research portfolios at the agency, from patient safety to patient-
    centered health research and other valuable research initiatives. 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.--HRSA's Title VII health professions
    and Title VIII nursing education programs are the only Federal programs
    designed to improve the supply, distribution, and diversity of the
    Nation's 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. The AAMC joins the Health Professions and
    Nursing Education Coalition (HPNEC) in recommending $520 million for
    these important workforce programs in fiscal year 2013.
        This funding recommendation is necessary to ensure continuation of
    all Title VII and Title VIII programs at least at fiscal year 2012 base
    discretionary levels, while also supporting promising initiatives such
    as the Pediatric Subspecialty Loan Repayment program and other efforts
    to bolster the workforce. The AAMC strongly objects to the
    administration's proposal to eliminate the Area Health Education
    Centers (AHEC), which in 2010 alone, trained more than 50,000 health
    professions students in community-based settings, and the Health
    Careers Opportunity Program (HCOP), which research shows has helped
    students from disadvantaged backgrounds achieve higher grade point
    averages and matriculate into health professions programs. Continued
    support for these and the full spectrum of Title VII programs is
    essential to prepare our next generation of medical professionals to
    adapt to the evolving healthcare needs of the changing population.
        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 AAMC has serious concerns about the
    President's plan to drastically reduce support for this essential
    program in fiscal year 2013. At a time when the Nation faces a critical
    doctor shortage, any cuts to funding that supports physician training
    will have serious repercussions for Americans' health. We strongly urge
    restoration to the program's fiscal year 2010 level of $317.5 million
    in fiscal year 2013.
        Student Aid and the National Health Service Corps (NHSC).--The AAMC
    urges the committee to sustain student loan and repayment programs for
    graduate and professional students at the Department of Education. The
    average graduating debt of medical students currently exceeds $160,000,
    and typical repayment can range from $300,000 to $450,000. The Budget
    Control Act (BCA, Public Law 112-25) adds another $10,000 to $20,000 to
    total repayment as a result of eliminating graduate and professional
    in-school subsidies, effective July 1, 2012.
        The AAMC opposes any rescissions from the National Health Service
    Corps (NHSC) Fund created under the Affordable Care Act (ACA, Public
    Law 111-142 and Public Law 111-152). The steady, sustained, and certain
    growth established by this mandatory funding for the NHSC has resulted
    in program expansion and innovative pilots such as the Student to
    Service (S2S) Loan Repayment Program that incentivizes fourth year
    medical students to practice primary care in underserved areas after
    residency training. The AAMC further requests that any expansion of
    NHSC eligible disciplines or specialties be accompanied by a
    commensurate increase in NHSC appropriations so as to prevent a
    reduction of awards to current eligible health professions.
    Furthermore, the AAMC believes that such changes are best tested
    through the NHSC State Loan Repayment Program (SLRP), and that funds
    provided for this program should allow the States to define specialty
    and geographic shortages.
        Once again, the AAMC appreciates the opportunity to submit this
    statement for the record and looks forward to working with the
    Subcommittee as it prepares its fiscal year 2013 spending bill.
                                     ______

      Prepared Statement of the American Association of Nurse Anesthetists

                                     FISCAL YEAR 2013 APPROPRIATIONS REQUEST SUMMARY
    ----------------------------------------------------------------------------------------------------------------
                                                            Fiscal year--
                                    -------------------------------------------------------------  AANA fiscal year
                                         2011 actual          2012 actual         2013 budget        2013 request
    ----------------------------------------------------------------------------------------------------------------
    HHS/HRSA/BHPr Title VIII         Awards amounted to   Grant allocations   Grant allocations   $4 million for
     Advanced Education Nursing,      approx. $3.5         not specified.      not specified.      nurse anesthesia
     Nurse Anesthetist Education      million.                                                     education
     Reserve.
    Total for Advanced Education     $64.046 million for  $63.925 million     $83.925 million     $83.925 million
     Nursing, from Title VIII.        Advanced Education   for Advanced        for Advanced        for Advanced
                                      Nursing.             Education Nursing.  Education Nursing.  Education Nursing
    Title VIII HRSA BHPr Nursing     $242,387,000.......  $231,948,000......  $251,099,000......  $251,099,000
     Education Programs.
    CDC/Division of Healthcare       ...................  ..................  Maintain level      Maintain level
     Quality and Promotion.                                                    funding.            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.
    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 ensure that rural medical facilities have access to
    obstetrical, surgical, and trauma stabilization, and pain management
    capabilities. In addition, CRNAs provide the lion's share of anesthesia
    care required by our U.S. Armed Forces through active duty and the
    reserves. 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 2010 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).
    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
    $83.925 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 $63.93
    million in fiscal year 2012 to $83.925 million is necessary to meet the
    continuing demand for nursing faculty and other advanced education
    nursing services throughout the United States. The program provides for
    competitive grants that help enhance advanced nursing education and
    practice and traineeships for individuals in advanced nursing education
    programs.
        There continues to be high demand for CRNA workforce in clinical
    and educational settings. Between 2000-2010, 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. The demand for nurse anesthetists
    continues to rise. The problem is not that our 112 accredited programs
    of nurse anesthesia are failing to attract qualified applicants. It is
    that they have to turn them away by the hundreds. The AANA has been
    working with the 112 accredited nurse anesthesia educational programs
    to increase the number of qualified graduates. 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 Economics
    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.
        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 $251.099 million in fiscal year 2013 for nursing
    shortage relief through Title VIII. AANA asks that of the $251.099
    million, $83.925 million go to Advanced Education Nursing and $4
    million go to nurse anesthesia. The AANA appreciates the support for
    nurse education funding in fiscal year 2012 from this Subcommittee and
    from the Congress. In the interest of patients, we ask the Congress to
    invest in CRNA and nursing educational funding programs. 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.
                                     ______

          Prepared Statement of the American Academy of Ophthalmology
                               executive summary
        The American Academy of Ophthalmology requests fiscal year 2013 NIH
    funding of at least $32 billion, which reflects a $1.38 billion, or 4.5
    percent increase over fiscal year 2012, which consists of biomedical
    inflation of 2.8 percent plus modest growth, and is necessary since:
      --After nearly a decade of budgets below biomedical inflation, NIH's
            inflation-adjusted funding is close to 20 percent lower than
            fiscal year 2003.
      --Even before adjusting for inflation, enacted spending bills in
            recent years have cut the NIH budget. The looming sequestration
            mandated by the Budget Control Act threatens further cuts,
            estimated by the Congressional Budget Office (CBO) at 8 percent
            in fiscal year 2013 alone.
        NIH, our Nation's biomedical research enterprise, is unique in
    that:
      --Its basic and clinical research has helped to understand the basis
            of disease, thereby resulting in innovations in healthcare to
            save and improve lives.
      --Its research serves an irreplaceable role that the private sector
            could not duplicate.
      --It has been shown through several studies to be a major force in
            the economic health of communities across the Nation. The
            latest United for Medical Research report estimates that NIH
            funding supported more than 432,000 jobs in 2011, directly or
            indirectly, and generated more than $62.1 billion in economic
            activity.
        The American Academy of Ophthalmology requests National Eye
    Institute (NEI) funding at $730 million, commensurate with the overall
    NIH funding increase, especially since:
      --Fiscal year 2012 NEI funding of $702 million reflects little more
            than 1 percent of the $68 billion annual cost of eye disease
            and vision impairment in the United States.
      --NEI has funded breakthrough research ranging from determining the
            genetic basis of eye disease to developing treatments that save
            and restore sight.
      --In 2009, the 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. A
            cut, level funding, or even an inflationary increase is not
            sufficient for NEI to meet the vision challenges presented by
            the ``Silver Tsunami.''
     congress must improve upon the president's fiscal year 2013 request,
    since it cuts nei funding by $8.86 million, or 1.2 percent below fiscal
    year 2012, which results in funding close to the base fiscal year 2009
                                     level
        Although the President's budget request level-funds NIH, it
    proposes to cut NEI by $8.8 million. Although most of this cut reflects
    the NIH Office of AIDS Research pulling its funding from the NEI's
    Studies of Ocular Implications of AIDS (SOCA) clinical trials, which
    established the efficacy of combination antiviral drug therapy in
    treating cytomegalorvirus (CMV) retinitis, the resulting total NEI
    funding of $693 million reflects a funding level just slightly higher
    than that in fiscal year 2009, prior to the addition of American
    Recovery and Reinvestment Act (ARRA) funding. Although the NEI's
    Congressional Justification (CJ) notes that this funding level will
    still enable NEI to increase Research Project Grant (RPG) funding by $3
    million, it will still cut training programs and Research and
    Development contracts.
        NEI is already facing enormous challenges in this Decade of Vision
    2010-2020. Each day, from 2011 to 2029, 10,000 citizens will turn 65
    and be at greatest risk for eye disease, the fast growing African-
    American and Hispanic populations will experience a disproportionately
    higher incidence of eye disease, and the epidemic of obesity will
    significantly increase the incidence of diabetic retinopathy.
        The Academy requests NEI funding at $730 million, reflecting
    biomedical inflation plus modest growth commensurate with that of NIH
    overall, since our Nation's investment in vision health is an
    investment in overall health. NEI's breakthrough research is a cost-
    effective investment, since it is leading to treatments and therapies
    that can ultimately delay, save, and prevent health expenditures,
    especially those associated with the Medicare and Medicaid programs. It
    can also increase productivity, help individuals to maintain their
    independence, and generally improve the quality of life, especially
    since vision loss is associated with increased depression and
    accelerated mortality.
        The very health of the vision research community is also at stake
    with a decrease in NEI funding. Not only will funding for new
    investigators be at risk, but also that of seasoned investigators,
    which threatens the continuity of research and the retention of trained
    staff, while making institutions more reliant on bridge and
    philanthropic funding. If an institution needs to let staff go, 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 2013 nih funding of at least $32 billion, nei at $730
    million lets nei build upon its past record of basic and translational
                                    research
        In late June 2010, NIH Director Francis Collins, M.D., Ph.D.
    recognized NEI's leadership in translational research at an NEI-
    sponsored Translational Research and Vision Conference. Just 2 weeks
    earlier, Dr. Collins testified before the House Energy and Commerce
    Committee, stating 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 fiscal year 2013 funding at $730 million, NEI can build upon
    its past research in several different areas, including:
        Genetic Basis of Eye Disease.--As NEI Director Paul Sieving, M.D.,
    Ph.D. has stated, of the more than 2,000 genes identified to date, more
    than 500, or one-quarter, are associated with both common and rare eye
    diseases. By further understanding the genetic basis of eye disease,
    NEI can study underlying disease mechanisms and develop appropriate
    diagnostic and therapeutic applications for such blinding eye diseases
    as AMD, glaucoma, and retinitis pigmentosa (RP).
      --NEI's AMD Gene Consortium, which consolidates 15 international
            Genome Wide Association Studies (GWAS) representing more than
            8,000 patients, has validated 8 previously known gene variants
            and identified 19 new variants.
      --NEI's Glaucoma Human Genetics Collaboration (NEIGHBOR) has
            identified the first risk variant in a gene thought to play a
            role in the development of the optic nerve head, the
            degeneration of which leads to glaucoma and loss of peripheral
            vision, and then ultimately blindness.
      --The NEI-led human gene therapy clinical trial for neurodegenerative
            eye disease Leber Congenital Amaurosis (LCA) has resulted to
            date in 15 patients being treated and experiencing visual
            improvement. NEI's pioneering work, as well as subsequent
            refinement of gene therapy techniques, is enabling further
            research into ocular gene therapy through the launch of NEI-
            funded clinical trials for AMD, choroideremia, Stargardt
            disease, and Usher Syndrome. The latter three neurodegenerative
            diseases occur in early childhood and progressively destroy the
            retina, leading to vision loss and blindness and resulting in a
            lifetime of direct medical and indirect support costs. NEI is
            also funding pre-clinical safety trials for human gene therapy
            for RP, juvenile retinoschisis (``splitting'' of the retina,
            resulting in vision loss), and achromatopsia (affecting color
            perception and visual acuity).
        Diabetic Eye Disease.--NEI's Diabetic Retinopathy Clinical Research
    (DRCR) Network found that laser treatment for diabetic macular edema,
    when combined with anti-angiogenic drug treatment, is more effective
    than laser treatment alone and will revolutionize the standard of care
    in place the past 25 years. With the National Institute for Diabetes
    and Digestive and Kidney Diseases (NIDDK) leading a new NIH strategic
    plan to combat diabetes, NEI's research through its various diabetic
    eye disease networks over the past 40 years--in partnership with
    NIDDK--will be more important than ever. For example, about 1-in-5
    individuals in the NEI-funded Los Angeles Latino Eye Study (LALES) was
    newly diagnosed with diabetes during the study, and of those newly
    diagnosed, 23 percent were found to already have diabetic retinopathy.
       blindness and vision loss is a growing public health problem that
            individuals fear and would trade years of life to avoid
        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.
    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 2012
    funding of $702 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.
        Vision loss also presents a real fear to most citizens:
      --In public opinion polls over the past 40 years, Americans have
            consistently identified fear of vision loss as second only to
            fear of cancer.
      --NEI's Survey of Public Knowledge, Attitudes, and Practices Related
            to Eye Health and Disease reported that 71 percent of
            respondents indicated that a loss of their eyesight would rate
            as a ``10'' on a scale of 1 to 10, meaning that it would have
            the greatest impact on their day-to-day life.
      --In patients with diabetes, going blind or experiencing other vision
            loss rank among the top four concerns about the disease. These
            patients are so concerned about vision loss diminishing their
            quality of life that those with nearly perfect vision (20/20 to
            20/25) would be willing to trade 15 percent of their remaining
            life for ``perfect vision,'' while those with moderate
            impairment (20/30 to 20/100) would be willing to trade 22
            percent of their remaining life for perfect vision. Patients
            who are legally blind from diabetes (20/200 to 20/400) would be
            willing to trade 36 percent of their remaining life to regain
            perfect vision.
        The Academy urges the Congress to fund the NIH and NEI at funding
    levels of at least $32 billion and $730 million, respectively, which
    will ensure the momentum of breakthrough vision research and the
    retention of trained vision researchers.
                  about the american academy of ophthalmology
        The American Academy of Ophthalmology is the largest national
    membership association of Eye M.D.s. Eye M.D.s are ophthalmologists,
    medical and osteopathic doctors who provide comprehensive eye care,
    including medical, surgical and optical care. More than 90 percent of
    practicing U.S. Eye M.D.s are Academy members, and the Academy has more
    than 7,000 international members.
                                     ______

            Prepared Statement of the American Academy of Pediatrics
        The American Academy of Pediatrics (AAP), a nonprofit professional
    organization of 60,000 primary care pediatricians, pediatric medical
    subspecialists, and pediatric surgical specialists dedicated to the
    health, safety, and well-being of infants, children, adolescents, and
    young adults, appreciates the opportunity to submit this statement for
    the record in support of strong Federal investments in children's
    health in fiscal year 2013 and beyond. AAP urges all Members of
    Congress to put children first when considering short and long-term
    Federal spending decisions.
        Every adult was once a child. Many adult diseases have their
    origins in childhood. Early and continued investments in our children's
    health are needed to prevent obesity, heart disease, substance use, and
    other chronic conditions that threaten America's health and fiscal
    solvency. As clinicians we not only diagnose and treat our patients, we
    also promote preventive interventions to improve overall health.
    Likewise, as policymakers, you have an integral role in ensuring the
    health of future generations through adequate and sustained funding of
    vital Federal programs.
        The economic strength and prosperity of our Nation rests largely on
    the health and well-being of our children. Therefore, the Nation's
    pediatricians insist that the Congress prioritize funding for programs
    that support the healthy development of children and adolescents.
    America's Children Deserve Better
        Babies born in the United States are less likely to survive until
    their first birthday than those in 30 other industrialized nations.
    Twenty-two percent of children in the United States now live in
    poverty. Many children suffer from food insecurity, unstable housing,
    family dysfunction, abuse and neglect. Such adverse childhood
    experiences are linked with ``toxic stress,'' a biologic phenomenon
    associated with profound and irreversible changes in brain anatomy and
    chemistry that have been implicated in the development of health-
    threatening behaviors and medical complications later in life including
    drug use, obesity, and altered immune function. Adults affected by such
    adverse childhood experiences are more likely to have experienced
    school failure, gang membership, unemployment, violent crime, and
    incarceration.
        Of the world's richest 21 nations, the United States comes in dead
    last in terms of overall health and safety of its children due to poor
    indicators on child health at birth, infant mortality rates, prevalence
    of low birth weight, child immunization rates for children aged 12 to
    23 months, and deaths from accidents or injuries among people aged 0 to
    19 years. America's current generation of children is at risk of having
    shorter life expectancies than their parents. This is unacceptable.
    America's children deserve better. As a Nation we must rise above
    partisan politics and reclaim the health and well-being of our children
    through strong Federal investments in programs that promote and protect
    the health of all children.
    Children's Healthcare Is Not the Cost Driver of Overall Healthcare
            Spending
        The United States continues to spend less on our children's health,
    education, and general welfare than most other developed nations in the
    world. Children under age 18 represent 30 percent of the total United
    States population, yet healthcare services for infants, children, and
    young adults are only 12 percent of total annual healthcare spending.
    Children, including those with special healthcare needs, make up more
    than 50 percent of all Medicaid recipients, but account for less than
    25 percent of Medicaid costs.
        By contrast, currently over two-thirds of Medicare expenditures are
    for beneficiaries with five or more chronic conditions, conditions like
    diabetes, arthritis, and hypertension that are largely preventable over
    the course of a lifetime. Strong and continued investments during
    childhood are critical to curbing the onset of chronic conditions that
    are growing healthcare costs. Proposed cuts to prevention and public
    health initiatives, community health programs, and child safety net
    services are counterproductive to efforts to reduce Government spending
    and control the deficit in the long-term.
    Children's Programs Are Cost-Effective and Improve Our Nation's Health
            and Economy
        Every $1 spent on childhood vaccines in the Section 317
    immunization program saves the healthcare system $16.50 in future
    medical costs. Every $1 spent on preventative services for a pregnant
    woman in the Special Supplemental Nutrition Program for Women, Infants,
    and Children saves Medicaid up to $4.20 by reducing the risk of pre-
    term birth and its associated costs. Every $1 spent on high-quality
    home visiting programs saves up to $5.70 as a result of improved
    prenatal health, decreased mental health and criminal justice costs,
    and fewer children suffering from abuse and neglect. Our Nation's
    sickest and most vulnerable children rely on Federal programs like
    these to support their physical and mental health needs. Reducing
    funding for vital child health programs during a time when many
    families are still struggling financially will disproportionately hurt
    children.
        The Administration for Children and Families, Centers for Disease
    Control and Prevention, Health Resources and Services Administration,
    and other agencies within the Department of Health and Human Services
    and the Department of Education provide essential services, research,
    and surveillance that help our Nation's children grow into healthy and
    productive citizens. Federal and State partnerships like the Title V
    Maternal and Child Health block grants and Section 317 immunization
    program support families by providing newborn screenings,
    immunizations, preventive health services and medical care that
    children need to be healthy.
        Devoting adequate resources to Federal health programs helps ensure
    children have safe and healthy food at home and school, homes and
    communities free of environmental toxins, and disaster preparedness and
    response systems that address their unique health needs. Federal funds
    support critical programs that address pressing public health
    challenges including: efforts to prevent infant mortality and birth
    defects; healthy child development; antimicrobial resistance and
    infectious diseases; emergency medical services for children; mental
    health and substance abuse prevention; tobacco prevention and
    cessation; unintentional injury and violence prevention; child
    maltreatment prevention; childhood obesity; environmental and chemical
    exposures; poison control; teen pregnancy prevention and family
    planning; health promotion in schools; and medical research and
    innovation.
        Meeting our children's health needs also requires a robust
    pediatric workforce. Children are not just little adults.
    Pediatricians, including medical and surgical specialists, are trained
    to diagnose and treat the unique healthcare needs of children and
    adolescents. Unlike the adult population, our Nation currently faces a
    shortage of pediatric subspecialists, resulting in many children with
    serious acute and chronic illnesses being forced to travel long
    distances--or wait several months--to see a needed pediatric
    subspecialist. Federal support for pediatric workforce programs--Public
    Health Service Act Title VII health professions programs, Children's
    Hospital Graduate Medical Education Program and the Pediatric
    Subspecialty Loan Repayment Program--is crucial to building the
    necessary supply of pediatricians to ensure all children, regardless of
    where they live or their insurance status, have access to timely and
    appropriate healthcare.
    Healthier Children, Healthier Future
        On behalf of the 75 million American children and their families
    that we serve and treat, the Nation's pediatricians expect the Congress
    to respond to mounting evidence that child health has life-long impacts
    and put children first during appropriations negotiations. Investing in
    children is not only the right thing to do for the long-term physical,
    mental, and emotional health of the population, but is imperative for
    the Nation's long-term fiscal health as well. At a time when States are
    facing unprecedented challenges with dwindling budgets yet rising
    demand for health services, Federal investments in the public health
    infrastructure could not be more important. Federal support for
    children's health programs, such as early brain and child development,
    parenting and health education, and preventive health services, will
    yield high returns for the American economy.
        We fully recognize the Nation's fiscal challenges and respect that
    difficult budgetary decisions must be made; however, we do not support
    funding decisions made at the expense of the health and welfare of
    children and families. Rather, focus on the long-term needs of children
    and adolescents will ensure that the United States can compete in the
    modern, highly educated global marketplace. Strong and sustained
    financial investments in children's healthcare, research, and
    prevention programs will help keep our children healthy and pay
    extraordinary dividends for years to come.
        The American Academy of Pediatrics looks forward to working with
    Members of Congress to prioritize the health of our Nation's children
    in fiscal year 2013 and beyond. If we may be of further assistance
    please contact the AAP Department of Federal Affairs at 202-347-8600 or
    aperencevich@aap.org. Thank you for your consideration.
                                     ______

                      Prepared Statement of AcademyHealth
        AcademyHealth is pleased to offer this testimony regarding the role
    of health services research in improving our Nation's health and the
    performance of the healthcare and public health systems.
    AcademyHealth's mission is to support research that leads to
    accessible, high value, high-quality healthcare, reduces disparities,
    and improves health. We represent the interests of more than 4,000
    scientists and policy experts and 160 organizations that produce and
    use research to improve health and healthcare. We advocate for the
    funding to support health services research; a robust environment to
    produce this research; and its more widespread dissemination and use.
        Health services research studies how to make the healthcare and
    public health systems work better and deliver improved outcomes for
    more people, at greater value. These scientific findings improve health
    systems by informing patient and healthcare provider choices; enhancing
    the quality, efficiency, and value of the care patients receive;
    improving patients' access to care, and supporting efficient community
    wide systems. Health services research both uncovers critical
    challenges confronting our Nation's healthcare system, and seeks ways
    to address them.
        Finding new ways to get the most out of every healthcare dollar is
    critical to our Nation's long-term fiscal health. Like any corporation
    making sure it is developing and providing high-quality products, the
    Federal Government has a responsibility to get the most value out of
    every taxpayer dollar it spends on Federal health programs, including
    Medicare, Medicaid, Children's Health Insurance Program, and veterans'
    and service members' 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
    choice.
        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 one 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.
        AcademyHealth greatly appreciates the subcommittee's historic
    efforts to increase the Federal investment in health services research.
    We respectfully ask that the subcommittee further strengthen the
    capacity of health services research to address the pressing challenges
    America faces in providing access to high-quality, efficient care. The
    following list summarizes AcademyHealth's fiscal year 2013 funding
    recommendations for agencies that support health services research and
    health data under the subcommittee's jurisdiction.
                   agency for healthcare research and quality
        AHRQ funds health services research and healthcare improvement
    programs that are 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.
        AcademyHealth 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
    $400 million in base discretionary funding for AHRQ in fiscal year
    2013.
        In light of the need for increased funding of health services
    research, AcademyHealth is concerned about the President's use of the
    Patient-Centered Outcomes Research (PCOR) Trust Fund transfer to
    supplant AHRQ's discretionary budget. The PCOR Trust Fund transfer was
    intended to supplement AHRQ's base discretionary budget. In the
    President's fiscal year 2013 budget request, however, $62 million from
    the PCOR Fund transfer is used to supplant AHRQ's existing programs.
    This de facto 10 percent funding cut further compromises AHRQ's ability
    to achieve its statutory mission: generating the broad evidence base on
    healthcare quality, costs, and access necessary to build a high-
    quality, high-value healthcare system.
                   centers for disease control and prevention
        The National Center for Health Statistics (NCHS) is the Nation's
    principal health statistics agency. Housed within the Centers for
    Disease Control and Prevention (CDC), it 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.
    AcademyHealth 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
    enhanced 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 2013
    request of $162 million in base discretionary funding, to build on your
    previous investments and put the agency on track to become a fully
    functioning, 21st century, national statistical agency.
        The Affordable Care Act recognizes the need for linking the medical
    care and public health delivery systems by authorizing a new CDC
    research program to identify effective strategies for organizing,
    financing, and delivering public health services in real-world
    community settings. AcademyHealth joins the CDC Coalition in seeking
    $7.8 billion for CDC in fiscal year 2013, and seeks new funding for
    public health services and systems research.
                         national institutes of health
        NIH spends approximately $1 billion on health services research
    annually--roughly 3 percent of its entire budget--making it the largest
    Federal sponsor of health services research. We join the Ad Hoc Group
    for Medical Research in seeking at least $32 billion for NIH in fiscal
    year 2013. This funding recommendation represents the minimum
    investment necessary to avoid further loss of promising research and at
    the same time allows the NIH's budget to keep pace with biomedical
    inflation. AcademyHealth 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, and to sustain investment in its Clinical and
    Translational Science Awards (CTSA) as the agency transitions to its
    new National Center for Advancing Translational Sciences (NCATS). The
    CTSA program enables innovative research teams to speed discovery and
    advance science aimed at improving our Nation's health. The program
    encourages collaboration in solving complex health and research
    challenges and finding ways to turn their discoveries into practical
    solutions for patients.
                   centers for medicare and medicaid services
        Steady funding decreases 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, which together cover nearly 100 million Americans and
    comprise 45 percent of America's total health expenditures. As these
    Federal entitlement programs continue to pose significant budget
    challenges for both Federal and State governments, it is critical that
    we adequately fund research to evaluate the programs' efficiency and
    effectiveness and seek ways to manage their projected spending growth.
    AcademyHealth supports CMS's discretionary research and development
    budget to improve the effectiveness and efficiency of these programs.
        In conclusion, the accomplishments of health services research
    would not be possible without the leadership and support of this
    subcommittee. We urge the subcommittee to accept our fiscal year 2013
    funding recommendations for the Federal agencies funding health
    services research and health data.
                                     ______

          Prepared Statement of the Adult Congenital Heart Association
    Introduction
        The Adult Congenital Heart Association (ACHA)--a national not-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 2013 funding for congenital heart research and
    surveillance. We respectfully request $2 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 nearly 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. Children born with heart defects have a significantly decreased
    life expectancy. One in 10 won't survive to adulthood. Among those with
    the most complex heart defects, only half will make it to age 18.
        The success of childhood cardiac intervention has created a new
    chronic disease--congenital heart disease (CHD). Thanks to the increase
    in survival, of the over 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. Fifty percent of all congenital heart survivors have complex
    problems for which lifelong 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.
        The public health burden of CHD has yet to be fully assessed.
    However, the limited available research suggests that medical costs
    associated with congenital heart defects are substantial. $1.2 billion
    is the estimated lifetime cost for U.S. children born in a single year
    with one of four major heart defects. It is estimated that in 2009, the
    hospital cost for roughly 27,000 hospital stays for children treated
    primarily for CHD in the United States was nearly $1.5 billion. In the
    same year, hospital costs for roughly 12,000 hospital stays of adults
    treated primarily for CHD was at least $280 million. Investing in CHD
    surveillance and research will improve outcomes for CHD survivors,
    decreasing disability and improving productivity.
    Adult Congenital Heart Association
        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 policymakers 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
    bipartisan 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 Centers
            for Disease Control and Prevention
        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 lifespan 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.
        The fiscal year 2012 appropriations bill provided $2 million to the
    CDC for surveillance of congenital heart defects. In February 2013, the
    CDC announced a funding opportunity using these authorized funds. The
    CDC states that the ``purpose of this program is to provide support
    through CDC cooperative agreements for non-research activities to
    develop robust, population-based estimates of the prevalence of CHDs
    focusing on adolescents and adults, and better understand the survival,
    healthcare utilization, and longer term outcomes of adolescents and
    adults affected by CHDs. The program is a pilot and designed as a
    learning collaborative effort between CDC and grantees with potentially
    unique and innovative approaches to monitoring CHDs among adolescents
    and adults.''
        ACHA requests that the Congress provide the CDC $2 million in
    fiscal year 2013 to continue 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 National
            Institutes of Health
        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 CHD.
    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 lifespan for
    people with CHD. The overall goal is to provide the structure to turn
    knowledge into clinical practice, and use clinical practice to inform
    basic research.
        ACHA urges the Congress to support the NHLBI in efforts to continue
    its work with patient advocacy organizations, other NIH Institutes and
    Centers, and the CDC to expand collaborative research initiatives and
    other related activities targeted to the diverse lifelong needs of
    individuals living with congenital heart disease.
    Summary
        Thank you for the opportunity to highlight this important disease
    and the important work done by the CDC and NIH. We know that you face
    many difficult funding decisions for fiscal year 2013 and hope that you
    consider addressing the lifelong 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 3 million.
                                     ______

       Prepared Statement of the American Congress of Obstetricians and
                                 Gynecologists
        The American Congress of Obstetricians and Gynecologists,
    representing 57,000 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 some of the most 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 and infant outcomes through investment in all aspects
    of the cycle of research, including comprehensive data collection and
    surveillance, biomedical research, and translation of research into
    evidence-based practice and programs delivered to women and babies, and
    we urge you to make this a top priority in fiscal year 2013.
    data collection and surveillance at the centers for disease control and
                                prevention (cdc)
        In order to conduct robust research, uniform, accurate and
    comprehensive data and surveillance are critical. The National Center
    for Health Statistics is the Nation's principal health statistics
    agency and collects State data from records like birth certificates
    that give us raw, vital statistics. The birth certificate is the key to
    gathering vital information about both mother and baby during pregnancy
    and labor and delivery. The 2003 United States standard birth
    certificate collects a wealth of knowledge in this area, yet 25 percent
    of States are still not using it. States without these resources are
    likely underreporting maternal and infant deaths and complications from
    childbirth and causes of these deaths remains unknown. Use must be
    expanded to all 50 States, ensuring that uniform, accurate data is
    collected nationwide. ACOG supports the President's fiscal year 2013
    budget request of $16.45 million to modernize the National Vitals
    Statistics System, which would help States update their birth and death
    records systems.
        The Pregnancy Risk Assessment Monitoring System (PRAMS) at CDC
    extends beyond vital statistics and surveys new mothers on their
    experiences and attitudes during pregnancy, with questions on a range
    of topics, including what their insurance covered to whether they had
    stressful experiences during pregnancy, when they initiated prenatal
    care, and what kinds of questions their doctor covered during prenatal
    care visits. By identifying trends and patterns in maternal health,
    researchers better understand indicators of preterm birth. This data
    allows CDC and State health departments to identify behaviors and
    environmental and health conditions that may lead to preterm births.
    Only 40 States use the PRAMS surveillance system today.
        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 Health and Human
    Services (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 the Congress to provide $10 million to Health and Human
    Services to assist States in setting up maternal mortality reviews.
    ACOG also urges the 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.
         biomedical research at the national institutes of health (nih)
        Biomedical research is critically important to understanding the
    causes of prematurity and developing effective prevention and treatment
    methods. Prematurity rates have increased almost 35 percent since 1981,
    and 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. A breakthrough study conducted by the Eunice Kennedy
    Shriver National Institute for Child Health and Human Development
    (NICHD) last year showed a significant reduction in preterm delivery
    among women with short cervixes who are administered vaginal
    progesterone. The results were especially positive in reducing births
    pre-28 weeks. The results of this study are expected to save the
    healthcare system $500 million a year. Additional research can help
    drive down our prematurity rates further, saving dollars and lives.
    Sustaining the investments at NIH is vital to achieving this goal, and
    therefore ACOG supports a minimum of $32 billion for NIH in fiscal year
    2013.
        Adequate levels of research require a robust research workforce.
    The average investigator is in his/her forties before receiving their
    first NIH grant, a huge disincentive 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.
          public health programs at the health resources and services
         administration (hrsa) and the centers for disease control and
                                prevention (cdc)
        Projects at HRSA and CDC are integral to translating research
    findings into evidence-based practice changes in communities. Where NIH
    conducts research to identify causes of preterm birth, CDC and HRSA
    fund programs that provide resources to mothers to help prevent preterm
    birth, and help identify factors contributing to preterm birth and poor
    maternal outcomes. The Maternal Child Health Block Grant at HRSA 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. Every $1 spent on
    preconception care for women with diabetes can reduce health costs by
    up to $5.19 by preventing costly complications in both mothers and
    babies. Every $1 spent on smoking cessation counseling for pregnant
    women saves $3 in neonatal intensive care costs. The MCH block grant
    has seen an almost $30 million decrease in funding in the past 5 years
    alone. ACOG urges you not to cut the MCH block grant any further and
    for fiscal year 2013 we request $645 million for the block grant to
    maintain its current level of services.
        Family planning is essential to helping ensure healthy pregnancies
    and reducing the risk of preterm birth. The Title X Family Planning
    Program provides services to more than 5 million low-income men and
    women at more than 4,500 service delivery sites. 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 $327 million for Title X in fiscal year 2013
    to sustain its level of services.
        The Healthy Start Program through HRSA promotes community-based
    programs that help reduce 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 specifically address local issues
    contributing to infant mortality. Today, more than 220 local programs
    in 42 States find FIMR a powerful tool to help reduce infant mortality,
    including understanding issues related to preterm delivery. For over 20
    years, ACOG have partnered with the Maternal and Child Health Bureau to
    sponsor the designated resource center for FIMR Programs, the National
    FIMR Program. ACOG supports $.5 million for HRSA to increase the number
    of Healthy Start programs that use FIMR.
        The Safe Motherhood Initiative at CDC works with State health
    departments to collect information on pregnancy-related deaths, track
    preterm births, and improve maternal outcomes. The Initiative also
    promotes preconception care, a key to reducing the risk of preterm
    birth. For fiscal year 2013, we recommend a sustained funding level of
    at least $44 million for the Safe Motherhood Program, and the inclusion
    of a $2 million preterm birth sub-line to ensure continued support for
    preterm birth research, as authorized by the PREEMIE Act.
        Regional quality improvement initiatives encourage use of evidence-
    based quality improvement projects in hospitals and medical practices
    to reduce the rate of preterm birth. Under the Ohio Perinatal Quality
    Collaborative, started in 2007 with funding from CDC, 21 OB teams in 25
    hospitals have decreased scheduled deliveries between 36 and 39 weeks
    gestation, in accordance with ACOG guidelines, significantly reducing
    pre-term births.
        Finally, ACOG is proud to partner with the Department of Health and
    Human Services and the March of Dimes on Strong Start, a multi-faceted
    perinatal health campaign to reduce preterm births. Strong Start
    contains two strategies. The first is a public-private partnership to
    reduce elective deliveries prior to 39 weeks through a public awareness
    campaign and quality improvement efforts. The second is a funding
    opportunity to test innovative prenatal care approaches to reduce
    preterm births for women covered by Medicaid and at risk for preterm
    birth. Strong Start has the potential to make a huge difference in
    reducing the rate of pre-term birth. We urge the subcommittee to
    continue investing in programs like Strong Start.
        Again, we would like to thank the subcommittee for its
    consideration of funding for programs to improve women's health, and we
    urge you to consider our MOMS Initiative in fiscal year 2013.
                                     ______

            Prepared Statement of the American College of Physicians
        The American College of Physicians (ACP) is pleased to submit the
    following statement for the record on its priorities, as funded under
    the U.S. Department of Health and Human Services, for fiscal year 2013.
    ACP is the largest medical specialty organization and the second-
    largest physician group in the United States. ACP members include
    132,000 internal medicine specialists (internists), related
    subspecialists, and medical students.
        As the Subcommittee begins deliberations on appropriations for
    fiscal year 2013, ACP is urging funding for the following proven
    programs to receive appropriations from the Subcommittee:
      --Title VII, Section 747, Primary Care Training and Enhancement, at
            no less than $71 million;
      --National Health Service Corps, $535,087,442 in discretionary
            funding, in addition to the $300 million in enhanced funding
            through the Community Health Centers Fund;
      --National Health Care Workforce Commission, $3 million;
      --Agency for Healthcare Research and Quality, $400 million in base
            discretionary funding; and
      --Centers for Medicare and Medicaid Services, Operations and
            Management of Exchanges, $574.5 million.
        The United States is facing a growing shortage of physicians in key
    specialties, most notably in general internal medicine and family
    medicine--the specialties that provide primary care to most adult and
    adolescent patients. With enactment of the Affordable Care Act (ACA),
    we expect the demand for primary care services to increase with the
    addition of 32 million Americans receiving access to health insurance,
    once the law is fully implemented. A recent study projects that there
    will be a shortage of up to 44,000 primary care physicians for adults,
    even before the increased demand for healthcare services that will
    result from near universal coverage is taken into account (Colwill JM,
    Cultice JM, Kruse RL. Will generalist physician supply meet demands of
    an increasing and aging population? Health Aff (Millwood). 2008 May-
    June; 27(3):w232-41. Epub 2008 April 29. Accessed at http://
    content.healthaffairs.org/content/27/3/w232.full on January 14, 2011.).
    Without critical funding for vital workforce programs, this physician
    shortage will only grow worse. A strong primary care infrastructure is
    an essential part of any high-functioning healthcare system, with over
    100 studies showing primary care is associated with better outcomes and
    lower costs of care (http://www.acponline.org/advocacy/where_we_stand/
    policy/primary_shortage.pdf).
        The health professions education programs, authorized under Title
    VII of the Public Health Service Act and administered through the
    Health Resources and Services Administration (HRSA), support the
    training and education of healthcare providers to enhance the supply,
    diversity, and distribution of the healthcare workforce, filling the
    gaps in the supply of health professionals not met by traditional
    market forces, and are critical to help institutions and programs
    respond to the current and emerging challenges of ensuring all
    Americans have access to appropriate and timely health services. Within
    the Title VII program, while we applaud the President's request for $51
    million for the Section 747, Primary Care Training and Enhancement, we
    urge the Subcommittee to fund the program at $71 million, in order to
    maintain and expand the pipeline of primary care production and
    training. The Section 747 program is the only source of Federal
    training dollars available for general internal medicine, general
    pediatrics, and family medicine. For example, general internists, who
    have long been at the frontline of patient care, have benefitted from
    Title VII training models that promoted interdisciplinary training that
    helped prepare them to work with other health professionals, such as
    physician assistants, patient educators and psychologists. Without a
    substantial increase of funding, HRSA will not be able to carry out a
    competitive grant cycle for the second year in a row for physician
    training; the Nation needs new initiatives relating to increased
    training in inter-professional care, the patient-centered medical home,
    and other new competencies required in our developing health system.
        The College urges $535,087,442 in appropriations for the National
    Health Service Corps (NHSC), the amount authorized for fiscal year 2013
    under the ACA; this is in addition to the $300 million in enhanced
    funding the Health and Human Services Secretary has been given the
    authority to provide to the NHSC through the Community Health Care
    Fund. Since enactment of the ACA, the NHSC has awarded nearly $900
    million in scholarships and loan repayment to healthcare professionals
    to help expand the country's primary care workforce and meet the
    healthcare needs of communities across the country and there are nearly
    three times the number of NHSC clinicians working in communities across
    America than there were 3 years ago, increasing Americans' access to
    healthcare. With field strength of more than 10,000 clinicians, NHSC
    provides healthcare services to about 10.5 million patients across the
    country; the increase in funds must be sustained to help address the
    health professionals' workforce shortage and growing maldistribution.
    The programs under NHSC have proven to make an impact in meeting the
    healthcare needs of the underserved, and with more appropriations, they
    can do more.
        We urge the Subcommittee to fully fund the National Health Care
    Workforce Commission, as authorized by the ACA, at $3 million. The
    Commission is authorized to review current and projected healthcare
    workforce supply and demand and make recommendations to the Congress
    and the administration regarding national healthcare workforce
    priories, goals, and polices. Members of the Commission have been
    appointed but have not been able to do any work, due to a lack of
    funding. The College believes the Nation needs sound research
    methodologies embedded in its workforce policy to determine the
    Nation's current and future needs for the appropriate number of
    physicians by specialty and geographic areas; the work of the
    Commission is imperative to ensure the Congress is creating the best
    policies for our Nation's needs.
        The Agency for Healthcare Research and Quality (AHRQ) is the
    leading public health service agency focused on healthcare quality.
    AHRQ's research provides the evidence-based information needed by
    consumers, providers, health plans, purchasers, and policymakers to
    make informed healthcare decisions. The College is dedicated to
    ensuring AHRQ's vital role in improving the quality of our Nation's
    health and recommends a base discretionary budget of $400 million. This
    amount will allow AHRQ to continue its critical healthcare safety,
    quality, and efficiency initiatives; strengthen the infrastructure of
    the research field; reignite innovation and discovery; develop the next
    generation of scientific pioneers; and ultimately, help transform
    health and healthcare.
        Finally, ACP is supportive of the Centers for Medicare and Medicaid
    Services, Operations and Management of Exchanges request for $574.5
    million. Such funding will allow the Federal Government to administer
    an insurance exchange, as authorized by the ACA, if a State declines to
    establish one by early 2013 that meets Federal requirements. If the
    Subcommittees decides to deny the requested funds, it may make it much
    more difficult for the Federal Government to organize a federally
    facilitated exchange in those States, raising questions about where and
    how their residents would get coverage. It is ACP's belief that all
    legal Americans--regardless of income level, health status, or
    geographic location--must have access to affordable health insurance.
        In conclusion, the College is keenly aware of the fiscal pressures
    facing the Subcommittee today, but strongly believes the United States
    must invest in these programs in order to achieve a high performance
    healthcare system and build capacity in our primary care workforce and
    public health system. The College greatly appreciates the support of
    the Subcommittee on these issues and looks forward to working with the
    Congress as you begin to work on the fiscal year 2013 appropriations
    process.
                                     ______

     Prepared Statement of the Association for Clinical Research Training,
     the Association for Patient-Oriented Research, the Clinical Research
         Forum, and the Society for Clinical and Translational Science
        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 its continued support of clinical and
    translational research and clinical research training. The translation
    of basic science to clinical treatment is an integral component of
    modern research and a necessity to developing the treatments and cures
    of tomorrow. We applaud the recent establishment of the National Center
    for Advancing Translational Sciences (NCATS) and its focus on the
    entire spectrum of translational research from the bench to
    implementation in the community. Housing translational research
    activities with a focus on translational science methods at a single
    Center at NIH will allow these programs to achieve new levels of
    success.
        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 comparative effectiveness research 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 an invaluable resource in this
    area, and full funding is critical if we are truly to take advantage of
    the CTSA infrastructure.
    Full Funding and Support for the Clinical and Translational Science
            Awards Program at National Institutes of Health
        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. In 2011, the CTSA Consortium reached its expected size of
    60 medical research institutions located throughout the Nation, linking
    them together to energize the discipline of clinical and translational
    science. 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 stated
    strategic goals of the CTSA program are to: (1) build national clinical
    and translational research capability, (2) provide training and career
    development of clinical and translational scientists, (3) enhance
    consortium-wide collaborations, (4) improve the health of our
    communities and the Nation through community engagement and comparative
    effectiveness research, and (5) advance T1 (bench-to-bedside)
    translational research, which transfers knowledge from basic research
    to clinical research.
        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, in the past, the National Center for
    Research Resources (NCRR). In 2006, 16 initial CTSAs were funded,
    followed by an additional 12 in 2007, 14 in 2008, 4 in 2009, 9 in 2010,
    and 5 in 2011. 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. Without enough funding, 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 appreciate the difficult economic situation our country is
    currently experiencing, and greatly appreciate the commitment to
    healthcare the Congress has demonstrated in recent years. The CTSAs are
    currently funding 60 academic research institutions nationwide at a
    level of $488 million. The translation of laboratory research to
    clinical treatment directly benefits patients suffering from complex
    diseases across all fields of medicine, and impacts all of NIH's
    Institutes and Centers (ICs). The CTSA program has created improved
    translational research capacity and processes from which all NIH's ICs
    stand to benefit.
        In order to fully 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 2013. Without full funding, CTSAs will be expected to
    operate with fewer resources, curtailing their transformative promise.
    It is also critical that the emphasis on the full spectrum of
    translational research be maintained during the program's transition to
    NCATS.
        It is our recommendation that the Subcommittee support full funding
    of the CTSA program by providing $700 million in fiscal year 2013, and
    that support for the full spectrum of translational research be
    protected during the transition of the CTSA program to NCATS.
    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 reversed if we are to continue
    our pursuits of better treatments and cures for patients.
        The T and K series 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 to 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 is 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 urge the Subcommittee to continue its 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 Comparative Effectiveness Research
        Comparative effectiveness research (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. Both AHRQ and NIH have long histories of
    supporting CER, and the standards for research instituted by these
    agencies 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. Moreover, their approach
    is supplemental to, not duplicative of, that of the new Patient-
    Centered Outcomes Research Institute, and its continued support is
    critical.
        We are pleased that the 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 drive 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.
                                     ______

            Prepared Statement of the American Diabetes Association
        Thank you for the opportunity to submit testimony on behalf of the
    American Diabetes Association (Association). As the Chair of the Board
    of the Association, I am proud to be a representative of the nearly 105
    million American adults and children living with diabetes or
    prediabetes, including my 17-year-old daughter, Leah. My daughter was
    diagnosed with type 1 diabetes on March 16, 2001, at the age of 6, and
    is living a very full life today due in part to the Federal investment
    in diabetes research programs.
        My family and many others have been affected by diabetes. Nearly 26
    million Americans have diabetes, and 79 million have prediabetes, a
    condition that puts them at high risk for developing diabetes. Every 17
    seconds, someone in this country is diagnosed with diabetes. Every day,
    230 people with diabetes undergo an amputation, 120 people enter end-
    stage kidney disease programs and 55 people go blind from diabetes. If
    we do not take action, 1 of every 3 children today faces a life with
    diabetes. The diabetes epidemic should not be ignored by anyone,
    including the Congress and the administration.
        As the Nation's leading nonprofit health organization providing
    diabetes research, information and advocacy, the Association knows how
    critical it is for our country to increase Federal funding for diabetes
    research and prevention. The Association acknowledges the challenging
    fiscal climate and supports fiscal responsibility, but our country
    cannot afford the consequences of failing to adequately fund diabetes
    research and prevention programs, a cost paid in painful and expensive
    complications. We cannot afford to turn our backs on the promising
    research that provides tools to prevent diabetes, better manage the
    disease, prevent complications, and bring us closer to a cure.
        The rising epidemic of diabetes in America is daunting, but not
    insurmountable. The Association is pressing forward by supporting
    research and expanding education and awareness efforts. But we cannot
    do it alone. The millions of people living with, or at risk for,
    diabetes are looking to the Congress now more than ever to step up its
    response to the diabetes epidemic.
        Accordingly, the Association urges the Subcommittee on Labor,
    Health and Human Services, Education and Related Agencies to invest in
    research and prevention efforts reflective of the magnitude of the
    burden diabetes has on our country to change the future of diabetes in
    America. The 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 2013.
                                   background
        The CDC has warned diabetes is a disabling, deadly, and growing
    epidemic. Last year, the CDC identified the diabetes belt, which
    stretches across 644 counties in 15 States, including my State of South
    Carolina. According to the CDC, 1 in 3 adults in our country will have
    diabetes in 2050 if present trends continue. Among minority
    populations, this ratio will be nearly 1 in 2.
        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.
    Blood glucose levels that are too high or too low (as a result of
    medication to treat diabetes) can be life threatening in the short
    term. In the long term, diabetes is the leading cause of kidney
    failure, new cases of adult-onset blindness and non-traumatic lower
    limb amputations as well as a leading cause of heart disease and
    stroke. Additionally, an estimated 18 percent of pregnancies are
    affected by gestational diabetes, a form of glucose intolerance
    diagnosed during pregnancy that places both mother and baby at risk. In
    those with prediabetes, blood glucose levels are higher than normal and
    taking action to reduce their risk of developing diabetes is essential.
        In addition to the physical toll, diabetes also tugs at our purse
    strings. A study by the Lewin Group found when factoring in the 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. That same year, medical expenditures due to
    diabetes totaled $116 billion, including $27 billion for diabetes care,
    $58 billion for chronic diabetes-related complications, and $31 billion
    for excess general medical costs. Indirect costs resulting from
    increased absenteeism, reduced productivity, disease-related
    unemployment disability and loss of productive capacity due to early
    mortality totaled $58 billion. Approximately $1 out of every $5 for
    healthcare is spent caring for someone with diagnosed diabetes, while
    $1 in $10 for healthcare is directly attributed to diabetes. Further,
    one-third of Medicare expenses are associated with treating diabetes
    and its complications.
        A greater Federal investment in diabetes research at the NIDDK at
    the NIH, and prevention, surveillance, control, and research work
    currently being done by the 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
    working to dramatically decrease the number of new diabetes cases in
    high-risk individuals.
        Accordingly, for fiscal year 2013, the Association requests funding
    for the following programs:
      --$2.216 billion for the NIDDK. This level of funding will act to
            offset years of decreased or flat funding combined with bio-
            medical inflation that has lead to cutbacks in promising
            research. It will also demonstrate the Congress' commitment to
            science and research in the face of this deadly epidemic.
      --$86.3 million for the DDT's critical prevention, surveillance and
            control programs. Even as proposals to consolidate the CDC's
            chronic disease programs, including the 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.
     the national institute of diabetes and digestive and kidney diseases
                               (niddk) at the nih
        NIDDK is leading the way in supporting research across the country
    that moves us closer to a cure and better treatments for diabetes.
    Researchers are working on a variety of projects in each of your States
    representing hope for the millions of individuals with diabetes. The
    Association is extremely worried that without increased funding, the
    NIDDK will slow or halt promising research that would enable
    individuals with the disease to live healthier, more productive lives.
    It is our understanding the percentage of research grants NIDDK was
    able to fund decreased last year and is expected to decrease again this
    year without additional funding.
        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. For example, the continuous
    glucose monitor and insulin pump my daughter uses allow her to better
    manage her blood glucose levels--and better pave the way to a healthier
    future.
        Examples of NIDDK-funded breakthroughs include: new drug therapies
    for type 2 diabetes; the advent of modern treatment regimens that have
    reduced the risk of costly complications like heart disease, stroke,
    amputation, blindness and kidney disease; ongoing development of the
    artificial pancreas, a closed looped system combining continuous
    glucose monitoring with insulin delivery; and research showing modest
    weight loss through dietary changes and increased physical activity can
    reduce the risk of type 2 diabetes by 58 percent, the foundation for
    the National Diabetes Prevention Program at the DDT.
        Increased fiscal year 2013 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.
    Additionally, increased funding will continue to support researchers
    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. Funding will also support a
    clinical trial testing vitamin D in the prevention of type 2 diabetes,
    and support ongoing studies on the environmental triggers of disease,
    which could identify an infectious cause of type 1 diabetes and lead to
    a vaccine.
             the division of diabetes translation (ddt) at the cdc
        The President's fiscal year 2013 budget proposal includes a
    proposal to consolidate certain programs at CDC, including the DDT.
    While we think coordination across chronic disease programs at CDC is
    an important endeavor, the Congress must ensure the needs of people
    with, and at risk for, diabetes are adequately addressed. For such a
    coordinated effort to be successful, significant resources must be
    provided. In addition, there must be a clear design focusing precisely
    on chronic diseases with similar risk factors and populations, allowing
    for the delivery of primary, secondary and tertiary prevention, and
    ensuring performance measures result in improved prevention of chronic
    disease and complications.
        Given that the DDT's funding has not kept pace with the magnitude
    of the growing diabetes epidemic, the Federal investment in DDT
    programs should be substantially increased to a minimum of $86.3
    million in fiscal year 2013 regardless of the organization of chronic
    disease programs at CDC and even as the evaluation of the
    administration's proposal continues. As the dialogue moves forward
    about how best to address chronic disease prevention, the 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 DDT 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. Funding for the DDT must focus on maintaining State-
    based Diabetes Prevention and Control Programs, supporting the National
    Diabetes Education Program, defining the diabetes burden through the
    use of public health surveillance, and translating research findings
    into clinical and public health practice.
        The DDT's work in this regard is organized into several key
    components, which are also part of the part of the President's fiscal
    year 2013 budget proposal. As outlined in the Obama administration's
    budget these include: (1) the implementation of strategies that support
    and reinforce healthful behaviors and expand access to healthy choices;
    (2) health systems interventions to improve the delivery and use of
    clinical and other preventive services; and (3) community-clinical
    linkage enhancement to better support chronic disease self-management.
        For example, the DDT's Diabetes Prevention and Control Programs
    (DPCPs), located in all 50 States, the District of Columbia, and all
    U.S. territories work to prevent diabetes, lower blood glucose and
    cholesterol levels, and reduce diabetes-related emergency room visits
    and hospitalizations. These activities are designed to improve
    education and awareness of diabetes by engaging health providers,
    health systems and community-based organizations to ensure that these
    outcomes are achieved. Additionally, DDT funding also supports vital
    and groundbreaking translational research like the Search for Diabetes
    in Youth study, a collaboration between the DDT and the NIDDK designed
    to determine the impact of type 2 diabetes in youth in order to improve
    prevention efforts aimed at young people. This work is illustrative of
    efforts at DDT to transform clinical research into cutting-edge tools
    to track the diabetes epidemic and prevent new cases and help
    individuals with diabetes to avoid complications.
        With additional funding, the DDT will be able to expand the efforts
    of DPCPs to improve primary, secondary and tertiary prevention efforts
    at the State and local levels. 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. Additionally, increased funding for the DDT is needed to
    allow it to build upon its work in reducing health disparities through
    vital programs such as the Native Diabetes Wellness Program, which
    furthers the development of effective health promotion activities and
    messages tailored to American Indian/Native Alaskan communities. These
    resources will also enable the DDT to expand its translational research
    studies, leading to improved public health interventions.
                    the national diabetes prevention program
        The CDC's National Diabetes Prevention Program (NDPP) supports the
    national network of community-based sites where trained staff will
    provide those at high risk for diabetes with cost-effective, group-
    based lifestyle intervention programs.
        The NDPP is a proven and inexpensive means of combating a growing
    epidemic. Research has shown the NDPP can reduce the risk of type 2
    diabetes by 58 percent for individuals with prediabetes. Furthermore,
    the NDPP costs approximately $300 per participant, as compared to an
    average of $6,649 in annual healthcare costs for the treatment of a
    person with diabetes. 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. The Association urges the Congress to
    provide $80 million for the NDPP in fiscal year 2013, funding needed to
    bring this program to scale nationwide using rigorous standards
    established by DDT.
                                   conclusion
        Not a day passes that I don't imagine a world free of diabetes and
    all its burdens on my daughter. This future is possible and the
    Association is counting on the Congress to significantly expand its
    investment of programs to prevent, treat, and cure diabetes. As you
    consider the fiscal year 2013 funding levels for the NIDDK, the DDT,
    and the NDPP, we urge you to remember diabetes is an epidemic growing
    at an astonishing rate and will overwhelm the healthcare system with
    tragic consequences unless our elected officials take action. Thank you
    for the opportunity to submit this testimony. The Association looks
    forward to working with you to stop diabetes.
                                     ______

        Prepared Statement of the American Dental Education Association
        The American Dental Education Association (ADEA), on behalf of all
    61 dental schools in the United States, 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, submits this statement for the
    record and for your consideration as you begin to prioritize fiscal
    year 2013 appropriation requests.
        ADEA urges you to preserve the funding and fundamental structure of
    Federal programs that provide access to oral healthcare for underserved
    populations, funding for cutting-edge oral research, access to careers
    in dentistry and oral health services and funding for programs that
    help promote diversity in the healthcare professions. Oral health
    services are provided through our campuses 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.
        We are asking the committee to protect and maintain adequate
    funding for the dental programs in Title VII of the Public Health
    Service Act; the National Institutes of Health (NIH) and the National
    Institute of Dental and Craniofacial Research (NIDCR); 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. We elaborate below the merits of each
    program.
    $32 Million for Primary Oral Healthcare Workforce Improvements
        ADEA, recognizing the constrained fiscal situation the Congress and
    the Nation face, does not request an increase in the President's
    request in these funds, but rather respectfully suggests a reallocation
    of the funds requested. Specifically, we ask for $8 million for General
    Dental Residencies; $8 million for Pediatric Dental Residencies; $5.7
    million for dental accounts under title VII; and, $10.7 million for
    DHIA.
        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 pre-
    doctoral 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 populations.
        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 more
    than 300 open faculty positions in dental schools. These two programs
    provide schools with assistance in recruiting and retaining faculty.
    ADEA is increasingly concerned that the oral health research community
    is not growing and that the pipeline of new researchers is inadequate
    to address future needs.
        The President's fiscal year 2013 request proposes $228 million for
    Title VII health professions, a $40 million (15 percent) cut below the
    current fiscal year. The budget request proposes no new funds for the
    Title VII Health Careers Opportunity Program (HCOP) and Area Health
    Education Centers (AHEC) program. HCOP helps schools provide
    opportunities to students from disadvantaged backgrounds to develop the
    skills needed to enter the health professions. While the AHEC program
    is focused on exposing medical students and health professions students
    to primary care and practice in rural and underserved communities. It
    is anticipated that the AHEC program grantees will continue their
    efforts to provide interprofessional/interdisciplinary training to
    health professions students with an emphasis on primary care
        ADEA is pleased that last year's committee report included language
    supporting opportunities for advanced training for dentists and dental
    educational institutional faculty loan repayment programs because of
    its recognition of the shortage of pediatric and public health
    dentists. Those who complete a general dentistry residency are eligible
    to receive additional training which allows them to take on complex
    cases of patients with autoimmune or systemic diseases. The Committee
    expressed its concern, shared by the academic dentistry community,
    about the growing aging population and agrees with the Committee's
    suggestion that HRSA create a grant program to provide access to
    unpaid, volunteer dental services for medically necessary but otherwise
    uncovered and unaffordable dental treatment that would cover the
    salaries and other employment costs of professionals who verify the
    medical and financial needs, including the absence of other insurance
    coverage, of individual patients potentially eligible for such
    services.
        During the current fiscal year HRSA anticipates providing nearly
    $10.5 million in continuation funding for advanced training of dentists
    through the Postdoctoral and Dental Faculty Loan Repayment Programs. It
    will also provide $10 million in new grants under the Dental Health
    Improvement Act, State Oral Health Workforce grant program, and the
    Faculty Development in General, Pediatric and Public Health Dentistry
    and Dental Hygiene Program.
        These are important achievements. But momentum and focus cannot be
    lost by not funding, in fiscal year 2013, programs that assist in
    identifying and encouraging the future generations of dental
    professionals who will serve the most in need of access to adequate
    dental care. There is no higher priority in the allocation of Federal
    resources to training programs than to directly increase the number of
    primary care dental providers for these patients.
    $32 Billion for the National Institutes of Health, Including $450
            Million for the National Institute of Dental and Craniofacial
            Research
        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 at San Francisco; the University of
    Colorado at Denver; the University of Florida; and the University of
    Washington.
    $19 Million for Part F of the Ryan White HIV/AIDS Treatment and
            Modernization Act: Dental Reimbursement Program 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.
    $107 Million for Title VII Diversity and Student Aid Programs
        $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. ADEA is most concerned that the administration did not
    request any funds for HCOP. HCOP helps schools provide opportunities to
    students from disadvantaged backgrounds to develop the skills needed to
    enter the health professions. These programs are significant because
    students from disadvantaged backgrounds are more likely to return to
    those areas to serve the communities.
    $25 Million for the Division of Oral Health at the Centers for Disease
            Control and Prevention
        The CDC Division of Oral Health 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.
        We are disappointed that the President's request represents only a
    marginal increase over fiscal year 2012 appropriated levels, well below
    an amount needed to keep up with inflation. The appropriated level for
    fiscal year 2012 and the request for fiscal year 2013 are below the
    inadequate level of fiscal year 2011 appropriations. We look forward to
    sharing information with the committee in the coming weeks about the
    impact that the current path of funding will have on the overall health
    and preparedness of the Nation's States and communities.
        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 as a
    resource. We can be reached by contacting Yvonne Knight, J.D., Senior
    Vice President for Advocacy and Governmental Relations, ADEA Policy
    Center, at knighty@adea.org.
                                     ______

       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 2013. 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 150,000 licensed dental hygienists
    across the country. 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. 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 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 130,000
    million Americans struggle to obtain the oral healthcare required to
    remain healthy, the 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 $32 million in fiscal year 2013.--A
    number of existing grant programs offered under Title VII support
    health professions education programs, students, and faculty. ADHA is
    pleased dental hygienists are 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 $32 million for fiscal year
    2013.
        Alternative Dental Health Care Provider Demonstration Project
    Grants--Fund at a level of $10 million in fiscal year 2013.--Congress
    recognized the need to improve the oral healthcare delivery system when
    it authorized the Alternative Dental Health Care Provider Demonstration
    Grants, Section 340G-1 of the Public Health Service Act. The
    Alternative Dental Health Care Providers Demonstration Grants program
    is a Federal grant program that recognizes the need for innovations to
    be made in oral healthcare delivery to bring quality care to the
    underserved by pilot testing new models. This is an opportunity for
    dental education programs, health centers, public-private partnerships
    and other eligible entities to apply for funding that will allow for
    innovation, within the confines of State laws, to further develop the
    dental workforce and extend the reach of the oral healthcare system.
    This grant program, administered by the Health Resources and Services
    Administration (HRSA), would fund workforce innovations, including
    building on the existing dental hygiene workforce, utilizing medical
    providers, and pilot testing new providers, like dental therapists and
    advanced practice dental hygienists, who practice in accordance with
    State practice acts.
        A number of dental hygiene-based models are listed as eligible for
    the grants, including advanced practice dental hygienists, public
    health hygienists and independent practice dental hygienists.
    Currently, 35 States have policies that allow dental hygienists to work
    in community-based settings (like public health clinics, schools, and
    nursing homes) to provide preventive oral health services without the
    presence or direct supervision of a dentist. Among the 35 direct access
    States are the Senators' home States of Iowa, Wisconsin, Washington
    State, Rhode Island, Arkansas, Ohio, Texas, South Carolina and Kansas.
    Direct access to dental hygiene services is especially critical for
    vulnerable populations like children, the elderly, and the
    geographically isolated who often struggle to overcome transportation,
    lack of insurance coverage, and other barriers to oral healthcare.
        Dental workforce expansion is one of many areas that need to be
    addressed as we move forward with efforts to increase access to oral
    healthcare services to those who are currently not able to obtain the
    care needed to maintain a healthy mouth and body. The authorizing
    statute makes clear that pilots must ``increase access to dental care
    services in rural and underserved communities'' and comply with State
    licensing requirements. Such new providers are already authorized in
    Minnesota and are under consideration in Connecticut, Vermont, Kansas,
    Maine, New Hampshire, Washington State and several other States.
        The fiscal year 2012 Labor, Health and Human Services funding bill
    included language designed to block funding for this important
    demonstration program. We seek your leadership in removing this
    unjustified prohibition on funding for the Alternative Dental Health
    Care Providers Demonstration Grants. This is a grant program to explore
    new ways of delivering oral healthcare in rural and underserved areas
    in compliance with State law. There is unanimity in the call for new
    types of dental providers and there simply is no health policy
    justification for the prohibition.
        Please keep the following points in mind as you consider funding
    this dental workforce grant program for the underserved:
      --The existing dental delivery model has increased in efficiency and
            is highly effective for those who have access to a dental
            office and are covered through insurance. However, the system
            fails the more than 80 million Americans who lack dental
            insurance, those who are geographically isolated, and those who
            are unable to travel to a private dental office for treatment.
      --Reports that these workforce pilots will allow non-dentists to do
            dental surgery/irreversible procedures are unfounded. All
            grants must, by statute, be conducted in accordance with State
            law. The grant program cannot authorize or allow non-dentists
            to perform irreversible/surgical dental procedures unless State
            law allows for the provision of such services.
      --All pilots must be specifically designed to increase access in
            rural and other underserved areas. This is a dental workforce
            grant program for the underserved.
      --Nearly 48 million Americans live in dental health professional
            shortage areas according to the Health Resources and Services
            Administration (HRSA), and HRSA included funding for this
            program in its fiscal year 2012 and fiscal year 2013 budget
            justifications.
      --An estimated 9,500 new dental practitioners are needed to end the
            Nation's dental care shortages. New types of models must be
            explored and, by statute, HRSA must contract with IOM to
            evaluate the demonstrations, which will yield valuable
            information to inform decisions about the dental workforce of
            the future.
      --All evidence available demonstrates the safety and quality of care
            delivered by non-dentist providers, including for Dental Health
            Aide Therapists in Alaska. Dental therapists have successfully
            been in practice overseas for nearly a century. Funding to
            support pilot testing of new dental workforce models will yield
            additional data on the economic viability of new oral health
            providers.
      --The Alternative Dental Health Care Providers Demonstration Program
            is a grant program to pilot dental workforce innovations that,
            by statute, must ``increase access to dental healthcare
            services in rural and other underserved communities'' and must
            be compliant with ``all applicable State licensing
            requirements.'' New types of dental providers are essential to
            solving the Nation's oral health access crisis and this grant
            program will help determine what types of providers are viable.
        ADHA, along with more than 60 other oral healthcare organizations,
    advocated for funding of 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 $10 million for fiscal year
    2013 to support these vital demonstration projects.
        Oral Health Prevention and Education Campaign--Fund at a level of
    $5 million in fiscal year 2013.--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 2013 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 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 2013.
        Oral Health Programming Within the Centers for Disease Control--
    Fund at a level of $25 million in fiscal year 2013.--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 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 2013.--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 2013.
        National Institute of Dental and Craniofacial Research--Fund at a
    level of $450 million in fiscal year 2013.--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 $450 million in fiscal year 2013.
                                   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 ($14 million for fiscal year 2013)
    as well as block grants offered by HRSA's Maternal Child Health Bureau
    ($8 million for fiscal year 2013). ADHA also supports full funding for
    community health centers, and urges HRSA be directed to further bolster
    the delivery of oral health services at community health centers,
    including through the use of new types of dental providers.
        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 Arthritis Foundation
        On behalf of the more than 50 million Americans--or one and five
    adults who live with the heavy burden of arthritis--the pain,
    disability, cost and more; The Arthritis Foundation would like to
    provide recommendations for the Labor Health and Human Services (Labor
    HHS) budget for fiscal year 2013.
        The Arthritis Foundation is committed to raising awareness and
    reducing the unacceptable impact of arthritis, which strikes one in
    every five adults and 300,000 children, and is the Nation's leading
    cause of disability. To conquer this painful, debilitating disease, we
    support education, research, advocacy and other vital programs and
    services.
        The Arthritis Foundation would like to comment on three specific
    agencies of jurisdiction of the Labor-HHS Appropriations Subcommittee,
    the National Institutes of Health (NIH) and in particular the National
    Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS),
    the Health Services Resources Administration (HRSA) and the Centers for
    Disease Control (CDC).
                   summary request--arthritis related funding
        The Arthritis Foundation strongly recommends that funding research
    funding at the National Institutes of Health and specifically at the
    National Institute of Arthritis and Musculoskeletal and Skin Diseases
    (NIAMS) should both be increased at least 4.5 percent which would be
    the minimum level to maintain current research and account for
    inflation. NIH funding should be allocated $32 billion for fiscal year
    2013 and NIAMS should be funded at $559 million to fund critical
    research on arthritis and other related diseases at the Institute. For
    the more than 300,000 children with Juvenile Arthritis (JA), access to
    a pediatric rheumatologist in most States is a challenge. A HRSA report
    to the Congress in 2007 highlighted the lack of a pediatric
    rheumatologist for most children with juvenile arthritis; in fact, many
    States have less than two pediatric rheumatologists who treat these
    patients. The Arthritis Foundation strongly urges the Congress to
    support the President's budget allocation of $5 million significantly
    less than the $30 million authorized to support loan repayment for
    pediatric specialists. Finally, the President' once again proposes to
    consolidate the Center for Disease Control's (CDC) disease programs
    including the CDC Arthritis Program into one chronic disease program.
    Last year the Congress rejected a similar proposal, and the Arthritis
    Foundation continues to have concerns about consolidation. We instead
    request that the Congress provide an increase ($10 million) to expand
    the CDC Arthritis Program to $23 million for fiscal year 2013. These
    additional funds would allow the Program to expand to 10 additional
    States.
     arthritis related research investments at the national institutes of
       health (nih): fudning for the national insttute of arthritis and
                   musculoskeletal and skin diseases (niams)
        Research holds the key to preventing, controlling, and curing
    arthritis, the Nation's leading cause of disability. The prevalence,
    impact and disabling pain continues to increase. 50 million Americans--
    one in five adults--have arthritis now. Within 20 years, the Centers
    for Disease Control and Prevention (CDC) estimate 67 million adults or
    25 percent of the population will have arthritis. Arthritis limits the
    daily activities of 21 million Americans and accounts for $128 billion
    annually in economic costs. The National Institute of Arthritis and
    Musculoskeletal and Skin Diseases (NIAMS) supports research into the
    causes, treatment, and prevention of arthritis and musculoskeletal and
    skin diseases. The critical research done at NIAMS improves the quality
    of life for people with arthritis and decreases the overall burden of
    the disease. Two examples include:
      --Cartilage regeneration studies for patients with osteoarthritis
            (OA), which afflicts 27 million Americans. This innovation
            could lead to the first disease-reversing drug to be available
            for patients with OA.
      --A randomized, controlled trial on effectiveness of daily calcium
            supplementation for increasing bone mineral density in children
            with JA. The trial found that supplementation resulted in a
            small, but statically significant, increase in total body
            mineral density compared with a placebo in children with JA.
        The Arthritis Foundation recommends at least $32 billion for fiscal
    year 2013 ($559 million for NIAMS) representing a 4.5 percent increase
    in funding, the minimum level to maintain current research and account
    for inflation.
              hrsa pediatric subspeciality loan repayment program
        Juvenile arthritis is one of the most common childhood diseases,
    affecting more children than cystic fibrosis and muscular dystrophy.
    Currently, there are less than 250 pediatric rheumatologists in the
    United States and about 90 percent of those are clustered in and around
    large cities. Pediatric rheumatology has one of the smallest numbers of
    doctors of any pediatric subspecialty. Of those children with juvenile
    arthritis, only one-fourth see a pediatric rheumatologist due to their
    scarcity. The other 75 percent of juvenile arthritis patients see
    either pediatricians (who tend not to be trained in how to care for
    juvenile arthritis) or adult rheumatologists, who aren't trained to
    deal with pediatric issues. Issues such as whether it's the stunted
    bone growth that can result from arthritis and its treatment, or the
    unwillingness of an adolescent to take his medicine. There are
    currently six States that do not have a single practicing pediatric
    rheumatologist and eight States with only one pediatric rheumatologist.
        The pediatric subspecialty loan repayment program was authorized by
    Section 5203 of the Affordable Care Act (ACA) in March 2010. The
    program would incentivize training and practice in pediatric medical
    subspecialties, like pediatric rheumatology, in underserved areas
    across the United States. The program would offer up to $35,000 in loan
    forgiveness for each year of service for a maximum of 3 years. The
    program was authorized for $30 million for fiscal year 2010 through
    fiscal year 2014, but has yet to be appropriated any funding. The
    Arthritis Foundation supports the President's request of $5 million to
    fund the Pediatric Subspecialty Loan Repayment Program.
                center for disease control: cdc arthrits program
        Arthritis is a complex family of more than 100 different diseases
    or conditions that destroys joints, bones, muscles, cartilage and other
    connective tissues, hampering or halting physical movement. It is the
    most common cause of disability in the United States, striking people
    of all ages, races and ethnicities and currently affects 1 in 5
    Americans. Its impact on the economy is about $128 billion including
    more than $81 billion in direct costs for expense like physicians
    visits and surgical interventions.
        The goal of the CDC Arthritis Program is to improve the quality of
    life for people affected by arthritis and other rheumatic conditions by
    working with States and other partners to (1) increase awareness about
    appropriate arthritis self-management activities, (2) expanding the
    reach of programs proven to improve the quality of life for people with
    arthritis and (3) decrease the overall burden of arthritis as well as
    its associated disability, work and activity limitations.
        Overall, the Foundation supports the public health community
    recommendation to fund the CDC at $7.8 billion for fiscal year 2013.
    Unfortunately, the Foundation has concerns about the CDC Arthritis
    Program. The President's budget for fiscal year 2013 again, proposes to
    combine existing chronic disease programs (including those for
    diabetes, heart disease, arthritis, stroke and cancer) into a single
    consolidated program. Last year the Congress rejected a similar
    proposal, and the Arthritis Foundation continues to have concerns about
    consolidation. With the rising burden of arthritis and other chronic
    diseases, along with the mounting fiscal pressures your panel faces,
    now is not the time to undermine the extensive arthritis public health
    infrastructure which has been erected across the country.
        We instead request that the Congress provide a slight increase ($10
    million) to expand the CDC Arthritis Program to $23 million for fiscal
    year 2013. These additional funds would allow the Program to expand to
    10 additional States. Additional funding would allow the CDC Arthritis
    Programs to expand into 10 new States. These State-based programs would
    (1) increase evidence based interventions, such as the Arthritis
    Foundation's Walk with Ease Program, into more communities; (2) reach
    diverse populations by funding partnership activities; and (3) support
    the OA Action Alliance, a coalition committed to elevating OA as a
    national priority. www.oaactionalliance.org.
        The Arthritis Foundation appreciates the opportunity to provide
    recommendations to the Senate Labor, Health and Human Services
    Committee on recommendations for fiscal year 2013.
        If you have questions about these comments please don't hesitate to
    contact the Arthritis Foundation. Questions about HRSA requests--Kim
    Beer, Director, Government Relations, kbeer@arthritis.org or Maria
    Spencer, Director, Federal Affairs for NIH/CDC mspencer@arthritis.org.
                                     ______

          Prepared Statement of the Alzheimer's Foundation of America
        On behalf of the Alzheimer's Foundation of America (AFA), a New
    York-based national nonprofit organization that unites more than 1,600
    member organizations nationwide with the goal of providing optimal care
    and services to individuals confronting dementia, and to their
    caregivers and families, we are making the following appropriations
    requests for programs impacting Alzheimer's disease research and
    caregiving services in the fiscal year 2013 budget. These Federal
    programs and support services are vital to advancing promising clinical
    research, providing necessary respite care and promoting best practice
    tools to family caregivers.
        Specifically, AFA makes the following appropriations requests for
    these specific agencies and programs:
        National Institutes of Health (NIH).--Adequate investment in
    scientific research that could lead to new treatments and cures is
    critical in order to reduce long-term healthcare costs. The President's
    fiscal year 2013 budget calls for an additional $80 million for
    clinical research into Alzheimer's disease. AFA urges the Subcommittee
    to honor the President's budget request to help fund effective
    pharmaceutical therapies to prevent, cure or slow the progression of
    Alzheimer's disease and provide the necessary seed money to implement
    and facilitate the ambitious and laudable goals of the National Plan to
    Address Alzheimer's Disease.
        AFA also urges the Subcommittee to include $32 billion in total
    funding for NIH, as recommended by the Ad Hoc Group for Medical
    Research, in the fiscal year 2013 appropriations bill. Even if funding
    remains flat, NIH's actual budget will still be effectively cut as
    spending will not be able to keep pace with the predicted 3.5 percent
    in biomedical inflation.
        National Institute on Aging (NIA).--Since NIA is the primary agency
    responsible for Alzheimer's disease research, AFA urges that the
    Subcommittee include a minimum budget appropriation of $1.4 billion, an
    increase of $300 million for NIA.
        NIA leads the national scientific effort to understand the nature
    of aging in order to promote the health and well-being of older adults,
    whose numbers are projected to rise dramatically in the coming years
    due to increased life expectancy and the aging of the baby boom
    generation.
        This funding is essential to increase the NIA's baseline to a level
    consistent with comparable research initiatives conducted under the
    auspices of NIH, and to support additional research into Alzheimer's
    disease and related dementias.
        Cures Acceleration Network (CAN).--AFA recommends $100 million to
    fund this important program. CAN was established within the Office of
    the Director of the NIH to aid in speeding the translation of basic
    scientific discoveries into treatments for diseases like Alzheimer's
    and getting them faster to market.
        U.S. Department of Health and Human Service's Prevention and Public
    Health Fund (PPHF).--The President's fiscal year 2013 budget request
    proposes $1.25 billion from the PPHF to supplement the budgets of the
    Centers for Disease Control and Prevention ($903 million), Substance
    Abuse and Mental Health Services Administration ($105 million), and the
    Agency for Healthcare Research and Quality ($12 million), among other
    agencies. The request also proposes $80 million from the fund to
    support Alzheimer's disease research and related initiatives. However,
    the ``extenders bill'' (Public Law 112-96), amends the fund to allow $1
    billion in fiscal year 2013, rather than the original $1.25 billion.
        AFA urges the Subcommittee to maintain the President's proposed
    budget request of $1.25 billion for PPHF and preserve the $80 million
    earmarked for Alzheimer's disease grants. Utilizing public health funds
    to pay physicians is truly a case of ``robbing Peter to pay Paul'' and
    could increase overall healthcare costs if funding for preventive
    services and caregiver training are slashed.
        Administration on Aging Programs (AoA).--AFA would like to single
    out the following programs within the AoA that are critical to
    individuals with Alzheimer's disease and their caregivers:
      --National Family Caregiver Support Program (NFCSP).--NFCSP provides
            grants to States and territories, based on their share of the
            population aged 70 and over, to fund a range of supportive
            services that assist family and informal caregivers in caring
            for their loved ones at home for as long as possible, thus
            providing a more patient-friendly and cost-effective approach
            than institutional care. Last year's appropriation of $153
            million cannot possibly keep up with the need for respite care
            as our population ages. AFA urges that $192 million be
            appropriated to support this important program.
      --Lifespan Respite Care Program (LRCP).--AFA urges the Subcommittee
            to commit $50 million of LRCP in fiscal year 2013. LRCP
            provides competitive grants to State agencies working with
            Aging and Disability Resource Centers and nonprofit State
            respite coalitions or organizations to make quality respite
            care available and accessible to family caregivers regardless
            of age or disability by establishing State Lifespan Respite
            Systems. The Lifespan Respite Care Act was signed into law in
            2006, but received no funding until 2009. Last year, only $2
            million was appropriated to this successful, yet deeply
            underfunded program.
      --Alzheimer's Disease Supportive Services Program (ADSSP).--The
            President's budget requests an additional $5.5 million to
            restore funding for the ADSSP, which was reduced in the fiscal
            year 2012 appropriation. In addition, the request complements
            the Alzheimer's Initiative recently announced by HHS, which
            calls for an additional $26 million for caregiver support,
            provider education, public awareness and improvements in data
            infrastructure. AFA supports funding of $12 million for this
            program; in addition, we ask the Subcommittee to build upon the
            administration's request for funding.
        Food and Drug Administration (FDA).--AFA supports funding of the
    FDA at $2.656 billion, an increase of $150 million or 6 percent more
    than appropriated in fiscal year 2012. FDA activities are necessary to
    ensure proper evaluation and testing of pharmaceutical treatments for
    Alzheimer's disease before they enter the market. In addition, the
    science is becoming more complex, and FDA plays an increasingly
    important and often resource-intensive role in pharmaceutical
    innovation. AFA's request is in line with the appropriations request
    being recommended by the Alliance for a Stronger FDA and the coalition
    to Accelerate Cure/Treatments for Alzheimer's Disease (ACT-AD).
        Taken together, these programs represent a lifeline to families who
    care for a loved one with Alzheimer's disease and provide hope to
    Americans living with the disease and those who face it in the future
    that there will be funding for a cure. AFA thanks the Subcommittee for
    the opportunity to present its recommendations and looks forward to
    working with you through the appropriations process. Please contact
    Eric Sokol, AFA's vice president of public policy, at esokol@alzfdn.org
    if you have any questions or require further information.
                                     ______

      Prepared Statement of the American Foundation for Suicide Prevention
        Chairman Harkin, Ranking Member Shelby and members of the
    subcommittee. 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.
        Data from the Centers for Disease Control for 2009 (latest
    available) 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 $36 billion in lost wages and work
    productivity.
        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 2013:
    Garrett Lee Smith Memorial Act Programs
        We respectfully request that Garrett Lee Smith Memorial Act (GLSMA)
    youth suicide prevention grant programs receive $48.2 million for
    fiscal year 2013.
        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 $35 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 $8.2 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 2011 (latest data) only $41 million
    was devoted directly to suicide research. AFSP urges the 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.''

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    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
    $1.022 billion for SAMHSA's Center for Mental Health Services in fiscal
    year 2013. By this action the 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 2013
        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 $5
    million for the NVDRS in fiscal year 2013.

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    Provide Funding for Depression Centers of Excellence
        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 the
    Congress to appropriate funds to the DCOE at the highest levels
    possible in fiscal year 2013.
        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
    subcommittee. 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 nearly 37,000 people of
    all ages and costs an estimated $36 billion annually in lost wages and
    work productivity. 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 Heart Association
        Despite considerable progress in the fight against heart disease,
    stroke and other forms of cardiovascular disease, CVD remains our
    Nation's No. 1 and most costly killer, with one person dying from it
    every 39 seconds. CVD is also a major cause of disability, costing our
    country an estimated $298 billion in medical expenses and lost
    productivity in 2008. Today, an estimated 83 million adults suffer from
    CVD. In addition, risk factors for CVD, such as obesity, diabetes, and
    high blood pressure, are on the rise. At age 40, the lifetime risk for
    CVD is 2 in 3 for men and more than 1 in 2 for women. Many are
    surprised to learn that CVD is the leading cause of death in women,
    outweighing cancer and other diseases.
        Unfortunately, these startling statistics will likely worsen. A
    recent study projects that by the year 2030, more than 40 percent of
    adults in the United States will live with the effects of CVD at a cost
    exceeding $1 trillion annually that would impoverish both the healthy
    and the ill. The graying of America's baby boomers along with the
    volatile growth in medical spending are the key drivers of these rising
    costs. Compounding this dire situation, heart disease and stroke
    prevention, research, and treatment programs remain not only woefully
    underfunded, but there is no steady and dependable stream of resources
    for the National Institutes of Health (NIH) to mount a long-term
    strategy to fight this terrible disease, enhance prevention and foster
    best care.
        CVD is the No. 1 killer in each State, except Alaska. Yet, research
    has shown that it is mostly preventable when treatable risk factors,
    such as high blood pressure and smoking, are addressed.
        Where one lives can affect survival from a deadly type of heart
    disease--sudden cardiac arrest. Only 21 States received fiscal year
    2010 funds for Health Resources and Services Administration's Rural and
    Community Access to Emergency Devices Program (HRSA) to save lives from
    SCA.
        To avoid a looming CVD crisis, American Heart Association
    challenges the Congress to prioritize prevention. Evidence-based
    prevention programs must reach people where they live, work and play.
    Prevention must be a keystone to encourage early age heart healthy and
    stroke-free habits.
        Thanks to the insight of Department of Health and Human Services,
    heart attack and stroke prevention will likely improve. AHA proudly
    partners with HHS to effect and achieve Million Hearts. Co-led by
    Centers for Disease Control and Prevention (CDC) and Centers of
    Medicare and Medicaid Services, this public-private partnership seeks
    to prevent 1 million heart attacks and strokes in 5 years.
        In this time of budgetary belt-tightening, AHA lauds the Congress
    for providing a glimmer of hope to the 1-in-3 adult CVD sufferers in
    the United States by wisely investing in the NIH, HRSA, CDC, and in the
    Prevention and Public Health Fund for fiscal year 2012. While we
    advocated for higher increases, these funds will help improve our
    Nation's physical and fiscal health. Stable and sustained fiscal year
    2013 funding is critical to advance heart disease and stroke research,
    prevention and treatment. However, the failure of the Joint Select
    Committee on Deficit Reduction to agree on a plan to reduce deficits
    will result in automatic across-the-board cuts in January 2013. Based
    on current projections, nearly every CVD research and prevention
    program will be cut by 9 percent.
         funding recommendations: investing in the health of our nation
        Sadly, promising research remains unfunded that could stem the
    increase of heart disease and stroke risk factors. Also, 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 our Nation's leading and most
    costly killer. If the Congress fails to capitalize on the progress of
    the past 50 years, Americans will pay more in lives lost and healthcare
    costs. Our recommendations below address the issues in a thorough and
    fiscally responsible way.
    Capitalize on Investment for the National Institutes of Health
        NIH-funded research prevents and cures disease, generates economic
    growth, fosters innovation, and preserves the U.S. role as the world
    leader in pharmaceuticals and biotechnology. NIH sponsored studies have
    revolutionized patient care. Further, NIH remains the single largest
    funder of basic research--the starting point for all medical advances
    and an essential function of the Federal Government. The private sector
    cannot fill this gap because there is no guarantee that this type of
    research will lead to an instant or profitable product or cure.
        NIH research produces major returns on investment by developing new
    technologies that create high-paying jobs. Also, the typical NIH grant
    supported about seven mainly high-tech full-time or part-time jobs in
    fiscal year 2007. In fiscal year 2010, NIH created nearly a half
    million U.S. jobs and produced about $70 billion in economic activity.
    Each dollar NIH distributes in a grant returns $2.21 in goods and
    services to the local community in 1 year.
        However, with sequestration looming, NIH faces an estimated 9
    percent or $2.8 billion cut, reducing its budget to the 2004 level.
    Since NIH invests in each State and in 90 percent of congressional
    districts, thousands of jobs will be lost, with a ripple effect on our
    fragile economic recovery. Such draconian budget cuts will both
    endanger NIH's role as the world leader in medical research--when our
    competitors are escalating their investment--and will severely delay
    research and development of disease treatments and cures.
        American Heart Association Advocates.--We ask for a fiscal year
    2013 appropriation of $32 billion for NIH to build on successes to save
    lives, improve health, spur our economy and spark innovation. Also, we
    urge the Congress to protect NIH from across-the-board cuts for the
    aforesaid reasons.
    Enhance Funding for National Institutes of Health Heart and Stroke
            Research: A Proven and Wise Investment
        From 1998 to 2008, death rates for coronary heart disease and
    stroke fell nearly 29 percent and 35 percent respectively. Yet, more
    must be done to improve lives and to prevent these illnesses. Declines
    in these deaths are directly linked to NIH research, with scientists
    now on the verge of exciting discoveries that could lead to game-
    changing treatments and even cures. For example, the largest U.S.
    stroke rehabilitation study showed that intensive, home-based physical
    therapy as well as a more complex program using a body weight-supported
    treadmill can improve walking. Both programs resulted in superior
    walking ability as compared to usual care.
        One of the largest-ever NIH-sponsored analyses of CVD lifetime
    risks demonstrated that middle-age adults with one or more classic CVD
    risk factors have a much greater chance of suffering a major CVD event.
    Further, it showed traditional risk factors predicted one's long-term
    development of CVD more than just age. Also, NIH studies identified 29
    genetic variants that influence blood pressure, providing new clues for
    control, and demonstrated that those at highest risk of a second stroke
    should undergo aggressive medical treatment rather than with a stent.
        In addition to saving lives, NIH research can cut healthcare costs.
    For example, the first NIH tPA drug trial resulted in a 10-year net
    $6.47 billion drop in stroke healthcare costs. Also, the Stroke
    Prevention in Atrial Fibrillation Trial 1 produced a 10-year net
    savings of $1.27 billion.
    Cardiovascular Disease Research: National Heart, Lung, and Blood
            Institute
        In spite of lower mortality rates and many promising avenues, there
    is still no cure for CVD. With an aging population, demand will only
    increase to find better ways for Americans to live healthy and
    productive lives, despite CVD. Stable and sustained NHLBI funding is
    needed to build on investments that provided grants to use genetics to
    identify and treat those at greatest risk of heart disease; hasten drug
    development to reduce high cholesterol and blood pressure; and create
    tailored strategies to treat, slow or prevent heart failure. Other key
    studies include an analysis of whether lower blood pressure than now
    recommended further reduces risk of heart disease, stroke, and
    cognitive decline. Sustained critical funding will allow for aggressive
    implementation of other priority initiatives in the cardiovascular
    strategic plan.
    Stroke Research: National Institute of Neurological Disorders and
            Stroke
        An estimated 795,000 Americans will suffer a stroke this year, and
    more than 134,000 will die from one. Many of the 7 million survivors
    face severe physical and mental disabilities and emotional distress. In
    addition to the physical and emotional toll, stroke cost a projected
    $34 billion in medical expenses and lost productivity for 2008. The
    future does not bode well. A recent study projects stroke prevalence
    will increase 25 percent over the next 20 years, striking more than 10
    million individuals with direct medical costs rising 238 percent over
    the same time period.
        Stable and sustained NINDS funding is required 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 to develop priorities to
    advance the most promising prevention, treatment and recovery research.
        American Heart Association Advocates.--While AHA supports increased
    funding for all the 18 NIH Institutes and centers that conduct heart
    and stroke research, we specifically recommend that NHLBI be funded at
    $3.214 billion and NINDS at $1.698 billion for fiscal year 2013.
    Increase Funding for the Centers for Disease Control and Prevention
        Prevention is the best way to protect the health of Americans and
    reduce CVD's costs. Yet, effective prevention strategies are not being
    implemented due to inadequate funds. In addition to conducting research
    and evaluation and developing a surveillance system, the Division for
    Heart Disease and Stroke Prevention (DHDSP) manages Sodium Reduction
    Communities, Paul Coverdell National Acute Stroke Registry, and State
    Heart Disease and Stroke Prevention Program. The State program also
    promotes the ``A-B-C-S'' of prevention: appropriate aspirin therapy,
    blood pressure control, cholesterol management and smoking cessation.
        The DHDSP manages WISEWOMAN that serves uninsured and under-insured
    low-income women ages 40 to 64. It 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 risk factors to promote lasting behavior
    change. From July 2008 to June 2010, it served more than 70,000 women.
    In this timeframe, 89 percent of them were found to have at least one
    risk factor and 28 percent had three or more. Yet, more than 43,000 of
    them participated in at least one session to address them.
        American Heart Association Advocates.--AHA concurs with the CDC
    Coalition in asking for $7.8 billion for CDC's ``core programs.'' We
    recommend $75 million to bolster the DHDSP and $37 million for
    WISEWOMAN to add States and serve more women. We also join with 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
            Program
        About 90 percent of sudden cardiac arrest victims die outside of a
    hospital. However, prompt CPR and defibrillation, with an automated
    external defibrillator, 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
    competitive grants to States to buy AEDs, train lay rescuers and first
    responders in their use and place AEDs where SCA is likely to occur--
    and with tangible results. From September 2007 to August 2008, 3,051
    AEDs were bought and 10,287 people were trained. Due to this effort,
    almost 800 patients were saved between August 1, 2009 and July 31,
    2010. Requests for these AED grant dollars have exceeded available
    limited funds. In fiscal year 2009, less than 8 percent of the
    applicants were funded and only 21 States received funds in fiscal year
    2010. We applaud the Congress for restoring this program to its fiscal
    year 2010 level for fiscal year 2012. However, HRSA transferred $1.4
    million to the AIDS Drug Assistance program, thereby diminishing the
    positive impact of the funding increase.
        American Heart Association Advocates.--We ask for a fiscal year
    2013 appropriation of $8.927 million to restore the Rural and Community
    AED Program to its fiscal year 2005 level as 47 States were funded.
    Increase Funding for the Agency for Healthcare Research and Quality
        AHRQ develops scientific evidence to improve healthcare and
    provides patients and caregivers with vital evidence to make the right
    decisions about their care. AHRQ's research also enhances quality and
    efficiency of healthcare.
        American Heart Association Advocates.--AHA joins Friends of AHRQ in
    advocating for $400 million for AHRQ to preserve its vital initiatives.
                                   conclusion
        Cardiovascular disease continues to wreak a deadly, disabling and
    costly toll on Americans. Our funding recommendations for NIH, CDC and
    HRSA outlined above will save lives and cut rising healthcare costs. We
    urge the Congress to seriously consider our proposals that represent a
    wise investment for our Nation and for the health and well-being of
    this and future generations.
                                     ______

          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. We
    appreciate the opportunity to submit this statement in support of
    enhancing the Federal investment in biomedical, behavioral, and
    population-based research conducted and supported by the National
    Institutes of Health (NIH).
        We are deeply grateful to the Subcommittee for its long-standing
    and bipartisan leadership in support of NIH. These are difficult times
    for our Nation and for people all around the globe, but science and
    innovation are the key to a better future. To ensure continued
    improvement of our Nation's health and to sustain our global leadership
    in medical research, the Ad Hoc Group for Medical Research recommends
    at least $32 billion for NIH in fiscal year 2013.
    National Institutes of Health: A Public-Private Partnership to Save
            Lives and Provide Hope
        The partnership between NIH and America's scientists, medical
    schools, teaching hospitals, universities, and research institutions is
    a unique and highly productive relationship, leveraging the full
    strength of our Nation's research enterprise to foster discovery,
    improve our understanding of the underlying cause of disease, and
    develop the next generation of medical advancements. 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.
        Research funded by NIH has contributed to nearly every medical
    treatment, diagnostic tool, and medical device developed in modern
    history, and we are all enjoying longer, healthier lives thanks to the
    Federal Government's wise investment in this lifesaving agency. From
    the major advances--including a nearly 70 percent reduction in the
    death rate for coronary heart disease and stroke--to moving stories of
    personalized medicine--such as children with rare diseases like dopa-
    responsive dystopia, whose prognosis has been transformed from severely
    disabled to happy and healthy through genomic medicine--NIH's role in
    improving human health has been extraordinary. For example:
      --Between 1990 and 2007, death rates in the United States for all
            cancers combined decreased by 22 percent for men and 14 percent
            for women, resulting in 898,000 fewer deaths from the disease
            during this time period;
      --Genomic advances have led us to the brink of approval for a new
            drug for cystic fibrosis, which tragically affects 30,000
            Americans, whose current average life expectancy is only 37
            years;
      --Remarkable breakthroughs in HIV/AIDS announced within the past year
            have put the possibility of an AIDS-free world within sight;
            and
      --We are within reach of a universal influenza vaccine, eliminating
            the need for annual flu shots.
        NIH research impacts the full spectrum of the human experience,
    resulting in a 40 percent decline in infant mortality over the past 20
    years, as well as a 30 percent decrease in chronic disability among
    seniors. For patients and their families, the scientific opportunities
    addressed by NIH provide hope.
        NIH is the world's premiere supporter of peer-reviewed,
    investigator-initiated basic research. This fundamental understanding
    of how disease works and insight into the cellular, molecular, and
    genetic processes underlying life itself, including the impact of
    social environment on these processes, underpin our ability to conquer
    devastating illnesses. The application of the results of basic research
    to the detection, diagnosis, treatment, and prevention of disease is
    the ultimate goal of medical research. Ensuring a steady pipeline of
    basic research discoveries while also supporting the translational
    efforts absolutely necessary to bring the promise of this knowledge to
    fruition requires a sustained investment in NIH.
    National Institutes of Health Supports Jobs, the Economy, and
            Innovation
        The research supported by NIH drives not only medical progress but
    also local and national economic activity, creating skilled, high-
    paying jobs and fostering new products and industries. A report
    released in March by United for Medical Research showed NIH directly
    and indirectly supported more than 432,000 jobs nationwide, while
    generating $62.1 billion in new economic activity. Another report,
    produced by Tripp Umbach, calculated a $2.60 return on investment for
    every dollar spent on research at American medical schools and teaching
    hospitals.
        At the same time, the private sector depends on the basic research
    funded by NIH to fuel the next generation of drugs, diagnostics, and
    devices. Chris Viehbacher, CEO of Sanofi, recently warned of the
    negative impact on the drug industry that withdrawal of support for NIH
    would have, saying, ``I don't think there's enough appreciation in the
    United States about what a jewel the NIH is. It's fundamentally
    important to health everywhere in the world that the NIH be properly
    funded.''
        NIH also plays a significant role in supporting the next generation
    of innovators, the young and talented scientists and physicians who
    will be responsible for the breakthroughs of tomorrow. As competition
    for NIH grant funding reaches historically high levels, there is a real
    and present danger of losing our best and brightest minds at a time
    when scientific opportunity has never been better. Only with an
    increase in funding can NIH continue to attract the highest quality
    research talent from all over the world. The challenges of maintaining
    a cadre of physician-scientists to facilitate translation of basic
    research to human medicine, ensuring a biomedical workforce that
    reflects the racial and gender diversity of our citizenry, and
    maximizing our Nation's human capital to solve our most pressing health
    problems will only be addressed through continued support of NIH.
    National Institutes of Health Is Critical to U.S. Competitiveness
        While the United States maintains our preeminence in biomedical
    research, we must not take for granted the agency that established us
    as the world life sciences leader. Even as we have seen NIH's budget
    eroded by inflation--with a purchasing power 20 percent lower than it
    was in fiscal year 2003--other nations have emulated our example and
    begun to invest in what can only be described as a life science
    revolution. A 2011 report by the Milken Institute warned that the
    United States was beginning to lose its competitive edge in the
    biomedical sciences, stating, ``Europe and Japan are working to close
    the gap, while China, India, and Singapore have made impressive strides
    . . . These efforts are part of larger economic development plans that
    increasingly focus on cultivating biomedical innovation for its
    economic contributions and high-wage jobs.'' To illustrate this, a
    single Chinese company, BGI (formerly the Beijing Genomics Institute)
    has recently acquired more genomic sequencing capacity in terms of
    machines and people than the entire United States sequencing capacity
    combined.
        In the past 6 months alone, we have heard ambitious pledges from
    India, the European Union, Russia, and China to commit substantial
    funding to research, even as the world struggles to recover from
    unprecedented fiscal challenges. Talented medical researchers from all
    over the world, who once flocked to the United States for training and
    stayed to contribute to our innovation-driven economy, are now
    returning to better opportunities in their home countries.
        According to a new national public opinion poll commissioned by
    Research!America, more than half of likely voters doubt that the United
    States will be the world leader in science, technology, and healthcare
    by the year 2020. The findings reveal deep concerns among Americans
    about the country's ability to maintain its world-class status in
    innovation, research and development before the next decade.
        We cannot afford to lose that intellectual capacity, much less the
    jobs and industries fueled by medical research. The United States has
    been the leader in medical research because of bipartisan recognition
    of the critical role played by NIH. To maintain our dominance, we must
    reaffirm this commitment to provide NIH the funds needed to maintain
    our competitive edge.
    National Institutes of Health: A Priority in Challenging Times
        The Ad Hoc Group's funding recommendation represents the minimum
    investment necessary to avoid further loss of promising research and at
    the same time allows the NIH's budget to keep pace with biomedical
    inflation. Even before adjusting for inflation, enacted spending bills
    in recent years have imposed cuts on the NIH budget and the agency can
    now fund only one in six highly meritorious grant applications it
    receives--the lowest in history. Accordingly, NIH's ability to sustain
    current research capacity and encourage promising new areas of science
    is significantly limited. More distressing, the looming sequestration
    mandated by the Budget Control Act threatens to continue this trend
    with further cuts estimated between 7 and 10 percent in fiscal year
    2013 alone.
        We recognize the tremendous challenges facing our Nation's economy
    and acknowledge the difficult decisions that must be made to restore
    our country's fiscal health. Nevertheless, we believe strongly that NIH
    is part of the solution to the Nation's economic restoration, and we
    are thankful that the Subcommittee has recognized that role in its past
    support. Strengthening our commitment to medical research, through
    funding NIH, is a critical element in ensuring the health and well-
    being of the American people and our economy.
        Therefore, 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 2013 appropriations bill.
                                     ______

     Prepared Statement of the American Indian Higher Education Consortium
        This statement includes the fiscal year 2013 recommendations of the
    Nation's Tribal Colleges and Universities (TCUs), covering three areas
    within the Department of Education.
                         higher education act programs
        Strengthening Developing Institutions.--Titles III and V of the
    Higher Education Act support institutions that enroll large proportions
    of financially disadvantaged students and that have low per-student
    expenditures. TCUs, funded under Title III-A Sec. 316, which are truly
    developing institutions, are providing quality higher education
    opportunities to some of the most rural, impoverished, and historically
    underserved areas of the country. The goal of HEA--Titles III/V
    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 more than 11 percent and by another 4 percent in
    fiscal year 2012. The TCUs urge the Subcommittee to appropriate $30
    million in fiscal year 2013 for HEA Title III-A section 316, which is
    slightly less than the fiscal year 2010 appropriated funding level.
        TRIO.--Retention and support services are vital to achieving the
    national goal of having the highest percentage of college graduates
    globally by 2020. TRIO programs, such as Student Support Services and
    Upward Bound were created out of recognition that college access is not
    enough to ensure advancement and that multiple factors work 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 the 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
    remain enrolled in and ultimately complete their postsecondary courses
    of study.
        Pell Grants.--The importance of Pell Grants to TCU students cannot
    be overstated. A majority of TCU students receive Pell Grants,
    primarily because student income levels are so low and they 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. However, beginning July 1,
    2012, new Department of Education regulations will be imposed, limiting
    Pell eligibility to 12 full-time semesters. This change in policy will
    impede many TCU students from attaining a postsecondary degree, which
    is widely recognized as being critical for access to, and advancement
    in, today's highly technical workforce. Recent placement tests
    administered at TCUs indicated that 62 percent of first-time entering
    students required remedial math, 55 percent needed remedial writing,
    and 46 percent required remedial reading. Students requiring
    remediation can use as much as a full year of eligibility enhancing
    their math, and or reading/writing skills, thereby hampering their
    future postsecondary degree plans. A prior national goal was to provide
    access to quality higher education opportunities for all students
    regardless of economic means, at which TCUs have been extremely
    successful. While the new national goal is to produce the graduates
    with postsecondary degrees by 2020, this policy does not advance that
    goal. On the contrary, the new regulations will cause many low-income
    students to once again abandon their dream of a postsecondary degree,
    as they will simply not have the means to pursue it. The goal of a
    well-trained technical workforce will be greatly compromised. This new
    policy recalls the adage ``penny wise-pound foolish.'' The TCUs urge
    the Subcommittee to continue to fund this essential program at the
    highest possible level, and to direct the Secretary of Education to
    implement a process to waive the very restrictive 12 semester Pell
    Grant eligibility for TCU students.
                perkins career and technical education programs
        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 Sec. 117 of the Perkins
    Act, a modest increase of $54,000 over the President's fiscal year 2013
    budget request.
        Native American Career and Technical Education Program (NACTEP).--
    NACTEP (Sec. 116) 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 career and technical education programs
    offered at TCUs that provide job training and certifications to remote
    reservation communities.
      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 adult basic 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 adult
    basic educational programs, and TCUs must have adequate and stable
    funding to provide these essential activities. TCUs request that the
    Subcommittee direct that $8 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.
      justifications for fiscal year 2013 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 programs, operated by the National Science
    Foundation and NASA were cut, and for the first time since the NSF
    program was established in fiscal year 2001, no new TCU-STEM awards
    were made in fiscal year 2011. Additionally, TCUs and their students
    suffer the impact of cuts to programs such as GEAR-UP, TRIO, SEOG, and
    are greatly impacted by the new highly restrictive Pell eligibility
    criteria more profoundly than mainstream institutions of higher
    education, which can realize economies of scale due to large
    endowments, alternative funding sources, including the ability to
    charge higher tuition rates and enroll more financially stable
    students, and access to affluent alumni. 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.
        We respectfully ask the members of the subcommittee for their
    continued support of the nation's TCUs and full consideration of our
    fiscal year 2013 appropriations needs and recommendations.
                                     ______

     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 2013 Labor-HHS, Education appropriations bill. AIRS is the
    national voice of Information and Referral/Assistance (I&R/A) and
    includes a membership of more than 1,200 I&R/A providers in both public
    and private organizations, which includes 2-1-1 providers. Our primary
    purpose for submitting this testimony is to urge you to support Title
    IIIB--Supportive Services funding of the Older Americans Act (OAA) as
    this provides Federal funding to the States for I&R/A.
        As you know, in the President's fiscal year 2011 and fiscal year
    2012 budget, an increase of $48 million was proposed for Title IIIB of
    the OAA. AIRS was disappointed that an increase to IIIB was not
    recommended in the President's fiscal year 2013 budget. Given the
    economic climate, Information and Referral/Assistance (I&R/A) is a
    lifeline, bringing people and services together. Last year, AIRS
    members answered about 25 million calls for help. A top focus of the
    calls included housing, food, caregiver support, mental health,
    healthcare, transportation, employment, education and disaster
    services.
        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.
        While our preference is for an increase of $48 million to be
    reflected in this year's appropriations, at a minimum, we encourage you
    to maintain the funding level of $367 million for Title III B of the
    Older Americans Act. Thank you for your consideration as well as the
    opportunity to submit this testimony.
                                     ______

              Prepared Statement of the American Lung Association
        The American Lung Association is pleased to present our
    recommendations for fiscal year 2013 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.
    Founded in 1904 to fight tuberculosis, the American Lung Association is
    the oldest voluntary health organization in the United States. 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 investment is necessary
        Mr. Chairman, investments in prevention and wellness pay near- and
    long-term dividends for the health of the American people. A recent
    study published in the American Journal of Public Health showed
    Washington State saved $5 in tobacco-related hospitalization costs for
    every $1 the State invested in its tobacco control and prevention
    program from 2000-2009. In order to save healthcare costs in the long-
    term, investments must be made in proven public health interventions
    including tobacco control, asthma programs and TB infrastructure.
    Lung Disease
        Each year, more than 400,000 Americans die of lung disease. It is
    America's number three killer, responsible for 1 in every 6 deaths.
    More than 33 million Americans suffer from a chronic lung disease and
    it costs the economy an estimated $173 billion each year. 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 and Maintaining Our Investment in Medical
            Research
        The American Lung Association strongly supports increasing overall
    CDC funding to $7.8 billion in order for CDC to carry out its
    prevention mission and to assure an adequate translation of new
    research into effective State and local programs.
        The United States must also maintain its commitment to medical
    research. While our focus is on lung disease research, we support
    increasing the investment in research across the entire 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 and Health Disparities and the Fogarty
    International Center.
    The Prevention and Public Health Fund
        The American Lung Association strongly supports the Prevention and
    Public Health Fund established in the Affordable Care Act and asks the
    Committee to oppose any attempts to divert or use the Fund for any
    purposes other than what it was originally intended. The Prevention
    Fund provides funding 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. Money from the Prevention Fund has also been used to pay for
    the new CDC media campaign ``Tips from Former Smokers'' which resulted
    in more than 33,000 people calling 1-800-QUIT-NOW during the campaign's
    first week of air. This represents a 128 percent increase in calls from
    the previous week.
    Tobacco Use
        Tobacco use is the leading preventable cause of death in the United
    States, killing more than 443,000 people every year. More than 46
    million adults and 3.6 million youth in the United States smoke. Annual
    healthcare and lost productivity costs total $193 billion in the United
    States 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, the Congress has
    failed to invest in tobacco control--even though public health
    interventions have been scientifically proven to reduce tobacco use,
    the leading cause of preventable death in the United States. This
    neglect cannot continue if the Nation wants to prevent disease, promote
    wellness and reduce healthcare costs. The American Lung Association
    supports the President's budget request and urges that $197.1 million
    be appropriated to OSH for fiscal year 2013.
    Asthma
        Asthma is highly prevalent and expensive. More than 25 million
    Americans currently have asthma, of whom 7 million are children. Asthma
    prevalence rates are more than 37 percent higher among African-
    Americans than whites. Asthma is also the third leading cause of
    hospitalization among children under the age of 15 and is a leading
    cause of school absences from chronic disease. Asthma costs our
    healthcare system more than $50.1 billion annually and indirect costs
    from lost productivity add another $5.9 billion, for a total of $56
    billion annually.
        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
    further reduce funding for both. The Lung Association asks this
    Committee to retain the National Asthma Control Program as a stand-
    alone program and appropriate $25.3 million to it in fiscal year 2013.
    In addition, we recommend that the National Heart, Lung, and Blood
    Institute receive $3.214 billion and the National Institute of Allergy
    and Infectious Diseases receive $4.689 billion, and that both agencies
    continue their investments in asthma research in pursuit of treatments
    and cures.
    Lung Cancer
        More than 370,000 Americans are living with lung cancer. During
    2011, approximately 221,000 new cases of lung cancer were diagnosed,
    and in 2008, more than 158,000 Americans died from lung cancer.
    Survival rates for lung cancer tend to be much lower than those of most
    other cancers. African-Americans are more 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.
    The National Lung Screening Trial showed promising results for a small
    segment of the population at high risk for developing lung cancer but
    more research must be done in order to see if others would similarly
    benefit. We support a funding level of $5.296 billion for the National
    Cancer Institute and urge more attention and focus on lung cancer.
    Chronic Obstructive Pulmonary Disease
        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 2008, 137,693 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. We strongly support funding the National Heart, Lung,
    and Blood Institute and its lifesaving lung disease research program at
    $3.214 billion. The American Lung Association also asks the Committee
    to continue its support of the National Heart, Lung, and Blood
    Institute working 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
        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
    $159.6 million.
    Tuberculosis
        There are an estimated 10 million to 15 million Americans who carry
    latent TB infection, and it is estimated that 10 percent of these
    individuals will develop active TB disease. In 2010, there were 11,182
    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 and totally drug resistant TB also poses a significant
    public health threat. We request that the Congress increase funding for
    tuberculosis programs at CDC to $243 million for fiscal year 2013.
    Additional Priorities
        We strongly encourage improved disease surveillance and health
    tracking to better understand diseases like asthma. We support an
    appropriations level of $35 million for the Environment and Health
    Outcome Tracking Network. We strongly recommend at least $52.8 million
    in funding for the Healthy Communities program and that it remain a
    separate, stand-alone program. This program supports investments in
    communities to identify and improve policies and environmental factors
    influencing health and reduce the burden of chronic diseases.
                                   conclusion
        Mr. Chairman, lung disease is a continuing, growing problem in the
    United States. It is America's number three killer, responsible for 1
    in 6 deaths. Progress against lung disease is not keeping pace with
    progress against 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 the impact of lung disease.
                           fiscal year 2013 requests
    Centers for Disease Control and Prevention
        Increase overall CDC funding--$7.8 billion
        Funding Healthy Communities--$52.8 million
        Office on Smoking and Health--$197.1 million
        Asthma programs--$25.3 million
        Environment and Health Tracking Network--$35 million
        Tuberculosis programs--$243 million
        CDC influenza preparedness--$159.6 million
        NIOSH--$522.3 million
        Prevention and Public Health Fund--Please Protect the Fund
    National Institutes of Health
        Increase overall NIH funding--$32 billion
        National Heart, Lung, and Blood Institute--$3.214 billion
        National Cancer Institute--$5.296 billion
        National Institute of Allergy and Infectious Diseases--$4.689
    billion
        National Institute of Environmental Health Sciences--$717.9 million
        National Institute of Nursing Research--$151.178 million
        National Institute on Minority Health and Health Disparities--
    $288.678 million
        Fogarty International Center--$72.7 million
                                     ______

      Prepared Statement of the Association of Maternal and Child Health
                                    Programs
        The Association of Maternal and Child Health Programs (AMCHP), is
    pleased to submit testimony describing our request for $645 million in
    funding for fiscal year 2013 for the Title V Maternal and Child Health
    (MCH) Services Block Grant. This funding request is level with fiscal
    year 2012 and represents an $85 million decrease from its highest level
    of $730 million in fiscal year 2003. While this request does not
    address all of the needs of pregnant women, children and children with
    special healthcare needs, we recognize that in the current budget
    climate a request for increased funding would come at the detriment of
    other public health programs designed to promote optimal health for the
    very populations our programs serve.
        Additionally, we are gravely concerned about the proposed cuts to
    the Centers for Disease Control and Prevention (CDC). We urge you to
    recognize the value of health in improving the lives of American
    families. Further cuts to any programs that promote and protect the
    health of all Americans may seem penny wise but are definitely pound
    foolish.
        In 2010 the Title V MCH Services Block Grant provided support and
    services to 41 million American women, infants and children, including
    children with special healthcare needs. It has been proven a cost
    effective, accountable, and flexible funding source used to address the
    most critical, pressing and unique MCH needs of each State. States and
    jurisdictions use the Title V 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 States and jurisdictions, all of them work with local, State, and
    national partners 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.
      --Facilitate the development of comprehensive, family centered,
            community-based, culturally competent, coordinated systems of
            care for children with special healthcare needs.
        In addition to providing services to more than 40 million
    Americans, Title V MCH Services Block Grant programs save Federal and
    State governments' money by ensuring that people receive preventive
    services to avoid more costly chronic conditions later in life. Below
    are some examples of the cost effectiveness of maternal and child
    health interventions and the role of the Title V MCH Block Grant.
      --Comprehensive prenatal care is associated with reduced incidence of
            low birth weight and infant mortality. State MCH programs link
            uninsured women to available prenatal services, and coordinate
            closely with State Medicaid programs to improve outreach and
            enrollment services to eligible women. Preconception health is
            a focus of many State MCH programs that work to improve women's
            health prior to pregnancy in order to improve pregnancy related
            outcomes.
      --Total medical costs are lower for exclusively breastfed infants
            than never-breastfed infants since breastfed infants typically
            need fewer sick care visits, prescriptions and
            hospitalizations. State MCH programs promote breastfeeding by
            developing educational materials for new mothers on
            breastfeeding practices and providing information on
            breastfeeding to all residents of their States through
            websites, toll free telephone lines and coordinating with other
            local and State programs.
      --Studies demonstrate that every $1 spent on smoking cessation
            counseling for pregnant women saves $3 in neonatal intensive
            care costs. State MCH programs fund state-wide smoking
            cessation or ``quit lines'' for pregnant women and provide
            education within their State about the dangers of smoking
            during pregnancy, helping moms and moms-to-be quit smoking and
            reducing their risk of premature birth.
      --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. Investing $10
            per person per year in community based disease prevention could
            save more than $16 billion annually within 5 years. State MCH
            and Chronic Disease programs work together at the State and
            community levels to educate women, children and families about
            the importance of physical activity, nutrition and obesity
            prevention throughout the lifespan.
      --Early detection of genetic and metabolic conditions can lead to
            reductions in death and disability as well as saved costs. For
            example, phenylketonuria (PKU) a rare metabolic disorder
            affects approximately 1 of every 15,000 infants born in the
            United States. Studies have found that PKU screening and
            treatment represent a net direct costs savings. State MCH
            programs are responsible for assuring that newborn screening
            systems are in place statewide and that clinicians are alerted
            when follow up is required.
      --Early detection of physical and intellectual disabilities results
            in more efficient and effective treatment and support for
            children with special healthcare needs. High-quality programs
            for children at risk produce strong economic returns ranging
            from about $4 per $1 invested to more than $10 per $1 invested.
            State MCH programs administer the State and territorial Early
            Childhood Comprehensive Systems Initiative to support State and
            community efforts to strengthen, improve and integrate early
            childhood service systems.
      --The injuries incurred by children and adolescents in 1 year create
            total lifetime economic costs estimated at more than $50
            billion in medical expenses and lost productivity. State MCH
            programs examine data and translate it into information and
            policy to positively impact the incidence of infant mortality
            and other factors that may contribute to child deaths. State
            MCH programs invest in injury prevention programs, including
            State and local initiatives to promote the proper use of child
            safety seats and helmets. Additionally State MCH programs
            promote safe sleeping practices to prevent Sudden Infant Death
            Syndrome (SIDS).
      --The total cost of adolescent health risk behaviors is estimated to
            be $435.4 billion per year. Risky behaviors have impact on the
            health and well-being of adolescents included smoking, binge
            drinking, substance abuse, suicide attempts and high risk
            sexual behavior. State MCH programs and their partners address
            access to healthcare, violence, mental health and substance
            use, reproductive health and prevention of chronic disease
            during adulthood. State MCH programs often support State
            adolescent health coordinators who work to improve the health
            of adolescents within their States and territories.
        Members of Congress contend that savings in such as these will not
    be realized in the near future and therefore won't result in immediate
    savings in these tight fiscal times. But today we can highlight a real-
    time example of how the Title V MCH Services Block Grant has played a
    role in helping save millions in annual healthcare costs. In Ohio,
    Title V played a lead role in providing funding for the Ohio Perinatal
    Quality Collaborative (OPQC). The OPQC is charged with reducing preterm
    births and improving outcomes of preterm newborns. Using the Institute
    for Healthcare Improvement Breakthrough Series, OPQC worked with 20
    maternity hospitals (47 percent of all births in the State) through a
    collaborative focused on several obstetric improvement projects. OPQC
    reports that as a result of their efforts more than 9,000 births are
    full term and that approximately 250 NICU admissions have been avoided.
    OPQC estimates approximately $10 million in annual healthcare cost
    savings. Other States have similar initiatives and we are tracking
    their successes.
        The Title V MCH Services block grant is the foundation upon which
    State and territorial maternal and child health programs are built.
    Without a Federal investment the aforementioned savings will not be
    realized and our Nation's ability to address the most pressing needs of
    these vulnerable populations will not be possible. The Title V MCH
    Service Block Grant supports a system which treats a whole person, not
    by their specific disease and AMCHP therefore strongly urge you to
    sustain this investment at $645 million in fiscal year 2013.
        In addition to the Title V MCH block grant AMCHP is extremely
    concerned about current proposals to cut funding from other core
    programs designed to assure the health of our Nation's families. We
    strongly urge you to sustain funding for the Centers for Control and
    Prevention (CDC). It is short sighted and counterproductive to further
    cut discretionary funding for prevention in the interest of deficit
    reduction. CDC programs should be protected from further cuts that will
    have profound consequences on our capacity to address the needs of the
    most vulnerable.
                                     ______

     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 medicine schools. The members are two
    dental schools at Howard University and Meharry Medical College; four
    colleges 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
    college 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 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)--during the Bush administration--entitled ``The
    Rationale for Diversity in the Health Professions: A Review of the
    Evidence'' found that minority health professionals serve minority and
    other medically underserved populations at higher rates than 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 2013, funding for the Title VII Health Professions
    Training programs must be robust, 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 2013, 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 2013, 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), newly moved to the National
    Institute on Minority Health and Health Disparities 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 2013.
        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 its Centers of Excellence
    program. For fiscal year 2013, I recommend funded increases
    proportional with the funding of the overall NIH, with increased FTEs.
    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 health careers, and
    supporting cooperative agreements with minority institutions for the
    purpose of strengthening their capacity to train more minorities in the
    health professions.
        The OMH has the potential to play a critical role in addressing
    health disparities. For fiscal year 2013, 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 2013, 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 American Nurses Association
        The American Nurses Association (ANA) appreciates the opportunity
    to comment on fiscal year 2013 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 3.2 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. As the Nation works 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.
        ANA is grateful to the Subcommittee for your past commitment to
    Title VIII funding, and we understand the immense fiscal pressures the
    Subcommittee is facing. However, we respectfully request you support
    $251 million for the Nursing Workforce Development programs authorized
    under Title VIII of the Public Health Service Act in fiscal year 2013.
    Additionally, we respectfully request $20 million for the Nurse-Managed
    Health Clinics authorized under Title III of the Public Health Service
    Act in fiscal year 2013.
                      demand for nurses continues to grow
        A sufficient supply of nurses is critical in providing our Nation's
    population with quality healthcare now and into the future. Registered
    Nurses (RNs) and Advanced Practice Registered Nurses (APRNs) 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 Bureau of Labor Statistics' (BLS) Employment
    Projections for 2010-2020 state the expected number of practicing
    nurses will grow from 2.74 million in 2010 to 3.45 million in 2020, an
    increase of 712,000 or 26 percent.
        Contrary to the good news that there are a growing number of
    nurses, the current nurse workforce is aging. According to the 2008
    National Sample Survey of Registered Nurses, more than 1 million of the
    Nation's 2.6 million practicing RNs are over the age of 50. Within this
    population, more than 275,000 nurses are over the age of 60. As the
    economy continues to rebound, many of these nurses will seek
    retirement, leaving behind a significant deficit in the number of
    experienced nurses in the workforce. According to Douglas Staiger,
    author of a New England Journal of Medicine study, the nursing shortage
    will ``re-emerge'' from 2010 and 2015 as 118,000 nurses will stop
    working full time as the economy grows.
        Furthermore, as of January 1, 2011 baby boomers began turning 65 at
    the rate of 10,000 a day. With this aging population, the healthcare
    workforce will need to grow as there is an increase in demand for
    nursing care in traditional acute care settings as well as the
    expansion of non-hospital settings such as home care and long-term
    care.
        The BLS projections explain a need for 495,500 replacements in the
    nursing workforce, bringing the total number of job openings for nurses
    due to growth and replacements to 1.2 million by 2020. 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.
               title viii: 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.), include
    programs such as Nursing Loan Repayment Program and Scholarships
    Program, (Sec. 846, Title VIII, PHSA); Advanced Nursing Education (ANE)
    Grants; (Sec. 811), Advanced Education Nursing Traineeships, (AENT);
    Nurse Anesthetist Traineeships (NAT): Comprehensive Geriatric Education
    Grants, (Sec. 855, Title VIII, PHSA); Nurse Faculty Loan Program, (Sec.
    846A, Title VIII, PHSA); and Nursing Workforce Diversity Grants, (Sec.
    821). These programs support the supply and distribution of qualified
    nurses to meet our nation's healthcare needs.
        Without support for Title VIII funding and nursing education; there
    will be a shortage of nurse educators. With a shortage of nurse
    educators, schools will have to turn away nursing students. With less
    financial assistance to deserving nursing students; there will be fewer
    nursing students. With fewer nursing students, there will be fewer
    nurses. As noted above, the nursing shortage will have 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 rates. 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.
        Over the last 48 years, Title VIII programs have provided the
    largest source of Federal funding for nursing education; offering
    financial support for nursing education programs, individual students,
    and nurse educators. These programs bolster nursing education at all
    levels, from entry-level preparation through graduate study and in many
    areas including rural and medically underserved communities.
        The American Association of Colleges of Nursing's (AACN) Title VIII
    Student Recipient Survey gathers information about Title VIII dollars
    and its impact on nursing students. The 2011-2012 survey, which
    included responses from more than 1,600 students, stated that Title
    VIII programs played a critical role in funding their nursing
    education. The survey showed that 68 percent of the students receiving
    Title VIII funding are attending school full-time. Between fiscal year
    2005 and 2010 alone, the Title VIII programs supported more than
    400,000 nurses and nursing students as well as numerous academic
    nursing institutions, and healthcare facilities.
        However, current funding levels are falling short of the growing
    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 community health centers, departments
    of public health, and disproportionate share hospitals. Additionally
    according to the AACN Title VIII Student Recipient Survey, a record
    58,327 qualified applicants were turned away due to insufficient
    clinical teaching sites, a lack of faculty, limited classroom space,
    insufficient preceptors and budget cuts.
        Monies you appropriate for these programs help move nurses into the
    workforce without delay. Your investment in programs, and the nurses
    that participate, is returned by more students entering into the
    profession and serving in rural and underserved areas; by nurses
    continuing with their education and studying to be nurse practitioners,
    thereby addressing our Nation's growing need for primary care
    providers; or by going on to become a nurse faculty member and teaching
    the next generation of nurses. While the 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. 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. For these reasons and many
    more, we again respectfully request you appropriate $251 million for
    the Nursing Workforce Development programs authorized under Title VIII
    of the Public Health Service Act in fiscal year 2013.
                          nurse-managed health clinics
        A healthcare system must value primary care and prevention to
    achieve an improved health status of individuals, families and the
    community. 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 financial expenditures 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 more than 2
    million patients annually. ANA believes that Nurse Managed Health
    Centers (NMHCs) are an efficient, cost-effective way to deliver primary
    healthcare services. NMHCs are effective in disease prevention and
    early detection, management of chronic conditions, treatment of acute
    illnesses, health promotion, and more. These clinics are also used as
    clinical sites for nursing education.
        The ANA again respectfully requests the committee provide $20
    million for the Nurse-Managed Health Clinics authorized under Title
    VIII of the Public Health Service Act in fiscal year 2013.
        Thank you for your time and your attention to this matter.
                                     ______

       Prepared Statement of the American National Red Cross and United
                               Nations Foundation
        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 the Congress has shown in
    funding CDC for these essential activities. We sincerely hope that the
    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 providing technical and financial
    support to governments and communities worldwide.
        The Measles Initiative has achieved ``spectacular'' results by
    supporting the vaccination of more than 1 billion children. Largely due
    to the Measles Initiative, global measles mortality dropped 74 percent,
    from an estimated 535,300 deaths in 2000 to 139,300 in 2010 (the latest
    year for which data is available). During this same period, measles
    deaths in Africa fell by 85 percent.

         FIGURE 1.--ESTIMATED NUMBER OF GLOBAL MEASLES DEATHS, 2000-2010
    ------------------------------------------------------------------------
                                                                    Number
    ------------------------------------------------------------------------
    2000.......................................................        535.3
    2001.......................................................        528.8
    2002.......................................................        373.8
    2003.......................................................        484.3
    2004.......................................................        331.4
    2005.......................................................        384.8
    2006.......................................................        227.7
    2007.......................................................        130.1
    2008.......................................................        137.5
    2009.......................................................        177.9
    2010.......................................................        139.3
    ------------------------------------------------------------------------

        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 $870 million
    and provided technical support in more than 60 developing countries on
    vaccination campaigns, surveillance and improving routine immunization
    services. From 2000 to 2010, an estimated 9.6 million measles deaths
    were averted as a result of these accelerated measles control
    activities at a donor cost of less than $200/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 42 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 and in 2011, Europe
    experienced more than 30,000 cases with half of these cases in one
    country--France. 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.
      --Acceleration of MCV2 introduction in eligible countries with
            support from the GAVI Alliance.
      --Securing sufficient funding for measles-control activities both
            globally and nationally. The Measles Initiative faces a funding
            shortfall of an estimated United States $112 million for 2012-
            2015. 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 global goal of
            reducing measles mortality by 95 percent and supporting
            regional measles elimination goals.
        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. Studies show that a single case of measles in
    the United States can cost between $100,000 and $200,000 to control.
    The United States had 222 measles cases in 2011, the highest in 15
    years and Canada experienced a large outbreak of more than 800 cases.
    The Role of the Centers for Disease Control and Prevention in Global
            Measles Mortality Reduction
        Since fiscal year 2001, the Congress has provided between $43.6 and
    $49.3 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 80 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 the Congress--was essential in helping achieve
    the sharp reduction in measles deaths in just 10 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 and fiscal year 2012, the Congress appropriated
    approximately $49 million each year to fund CDC for global measles
    control activities. This amount represents a $2.7 million decrease from
    2010. The American Red Cross and the United Nations Foundation
    respectfully request a return to fiscal year 2010 funding levels ($52
    million) for fiscal year 2013 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 Americans for Nursing Shortage Relief
        The undersigned organizations of the ANSR Alliance greatly
    appreciate the opportunity to submit written testimony regarding fiscal
    year 2013 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 the 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 the Congress to:
      --Appropriate $251 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 2013.
      --Appropriate $20 million in fiscal year 2013 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 3.854 million licensed RNs in 2010. 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, schools, and hospitals. The March 2008
    study, The Future of the Nursing Workforce in the United States: Data,
    Trends, and Implications, calculates an adjusted 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 26 percent from 2010 to 2020 resulting in 711,900
    new jobs. Based on these scenarios, the shortage presents an extremely
    serious challenge in the delivery of high quality, cost-effective
    services.
    Build Capacity of Nursing Education Programs and Enhance Nursing
            Research
        New models of overall healthcare delivery are being developed to
    address a range of challenges in healthcare and impact the structure of
    the workforce and care delivery. Government estimates indicate the
    nursing shortage 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 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.
    Strengthen the Capacity of the National Nursing Public Health
            Infrastructure
        Nurses make a difference in the lives of patients from disease
    prevention and management to education to responding to emergencies.
    Nearly half of Americans suffer from one or more chronic conditions and
    chronic disease accounts for 70 percent of all deaths. An October 2008
    report issued by Trust for America's Health entitled ``Blueprint for a
    Healthier America'' found that the health and safety of Americans
    depends on the next generation of professionals in public health.
    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.
        Public health nursing is the critical resources for healthy
    communities. Nurses are key healthcare workers that can help our Nation
    achieve its public health goals and protect our Nation from the full
    impact of disasters, both natural and man-made. Data from the 2000
    National Sample Survey of Registered Nurses (conducted by the Health
    Resources Services Administration, Division of Nursing) indicate that
    the number of registered nurses (RNs) employed in public/community
    health settings with the title ``public health nurse'' has decreased
    from 39 percent in 1980 to just 17.6 percent in 2000. Even in the
    overall public/community nursing group, there was a decrease of almost
    16 percent between 1996 and 2000.
        The shortage of school nurse positions contributes to holes in the
    healthcare safety net for all children. The Institute of Medicine
    report, ``The Future of Nursing: Leading Change, Advancing Health'',
    points out that with an expected increase in the number of children who
    have complex medical, genetic and mental/behavioral health conditions
    that require more nursing oversight, school nursing provides the
    expertise and coordination to assure that children receive the care
    they need.
    Summary
        RNs, advanced practice registered nurses, and nursing faculty are
    all critically necessary to sustain an adequate supply of nurses
    available to deliver quality healthcare. The U.S. nursing shortage is
    part of a larger worldwide nursing shortage. The international scope of
    this problem makes it an immediate and critical need for our Nation to
    develop additional strategies to appeal to men and women to pursue
    nursing and teaching nursing as a profession. Congress specifies the
    mission of Title VIII is to ensure a sufficient national supply of
    nurses; Title VIII programs must be adequately funded to fulfill that
    important mission. ANSR requests $251 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
    2013.
                       list of ansr member organizations
    Academy of Medical-Surgical Nurses
    American Academy of Ambulatory Care Nursing
    American Academy of Nurse Practitioners
    American Academy of Nursing
    American Association of Nurse Anesthetists
    American Association of Nurse Assessment Coordination
    American Association of Occupational Health Nurses
    American College of Nurse-Midwives
    American Organization of Nurse Executives
    American Psychiatric Nurses Association
    American Society for Pain Management Nursing
    American Society of PeriAnesthesia Nurses
    American Society of Plastic Surgical Nurses
    Association for Radiologic & Imaging Nursing
    Association of Pediatric Hematology/Oncology Nurses
    Association of State and Territorial Directors of Nursing
    Association of Women's Health, Obstetric & Neonatal Nurses
    Citizen Advocacy Center
    Dermatology Nurses' Association
    Developmental Disabilities Nurses Association
    Emergency Nurses Association
    Infusion Nurses Society
    International Association of Forensic Nurses
    International Nurses Society on Addictions
    International Society of Nurses in Genetics, Inc.
    Legislative Coalition of Virginia Nurses
    National Association of Clinical Nurse Specialists
    National Association of Hispanic Nurses
    National Association of Neonatal Nurses
    National Association of Neonatal Nurse Practitioners
    National Association of Nurse Massage Therapists
    National Association of Nurse Practitioners in Women's Health
    National Association of Orthopedic Nurses
    National Association of Registered Nurse First Assistants
    National Association of School Nurses
    National Black Nurses Association
    National Council of State Boards of Nursing
    National Council of Women's Organizations
    National Gerontological Nursing Association
    National League for Nursing
    National Nursing Centers Consortium
    National Nursing Staff Development Organization
    National Organization for Associate Degree Nursing
    National Student Nurses' Association, Inc.
    Nurses Organization of Veterans Affairs
    Pediatric Endocrinology Nursing Society
    Preventive Cardiovascular Nurses Association
    RN First Assistants Policy & Advocacy Coalition
    Society of Gastroenterology Nurses and Associates, Inc.
    Society of Pediatric Nurses
    Society of Trauma Nurses
    Women's Research & Education Institute
    Wound, Ostomy and Continence Nurses Society
                                     ______

          Prepared Statement of the American Psychological Association
        The American Psychological Association (APA) appreciates that the
    Committee is accepting outside witness testimony addressing the fiscal
    year 2013 Labor-HHS-Education appropriations bill. APA is a scientific
    and professional organization representing psychology in the United
    States, with 154,000 members and affiliates. APA's mission is to
    advance the creation, communication, and application of psychological
    knowledge to benefit society and improve people's lives. Although APA
    and its members have broad interests in many of the programs under the
    Subcommittee's jurisdiction, in this statement we highlight critical
    activities and funding needs in five agencies: the National Institutes
    of Health, Administration on Aging, Centers for Disease Control and
    Prevention, the Health Resources and Services Administration, and the
    Substance Abuse and Mental Health Services Administration.
        Substance Abuse and Mental Health Services Administration
    (SAMHSA).--SAMHSA's three component agencies have the primary Federal
    responsibility to mobilize and improve mental health and addiction
    services in the United States. The Center for Mental Health Services
    promotes improvements in mental health services that enhance the lives
    of adults who experience mental illnesses and children with serious
    emotional disorders; fills unmet and emerging needs; bridges the gap
    between research and practice; and strengthens data collection to
    improve quality and enhance accountability.
        APA strongly recommends that the 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.
        Racial and ethnic minorities represent 30 percent of our Nation's
    population, but only 23 percent of doctoral recipients in psychology,
    social work and nursing. The Minority Fellowship Program (MFP) is a
    unique workforce development initiative that trains ethnic minority
    mental and behavioral healthcare professionals to provide services to
    underserved communities. APA urges the Congress to maintain level
    funding for MFP ($5.1 million). This funding is needed given the recent
    expansion of the program by granting eligibility to additional
    disciplines to participate.
        Administration on Aging (AoA).-- 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.
        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 the
    Congress to appropriate $5 million for this initiative.
        National Institutes of Health (NIH).--The APA supports the
    recommendation of the Ad Hoc Group for Medical Research that the
    Subcommittee recognize the National Institutes of Health (NIH) as a
    critical national priority by providing at least $32 billion in funding
    in fiscal year 2013. This recommendation represents the minimum
    investment necessary to avoid further loss of promising research and at
    the same time allows the NIH's budget to keep pace with biomedical
    inflation.
        While there are many programs at NIH worthy of being highlighted,
    we want to mention some initiatives that are critically important to
    APA's member scientists. Regarding the proposed reorganization of
    substance use, abuse and addiction research at NIH, APA has long been
    concerned that substance use, abuse and addiction research is
    significantly underfunded when weighed against the public health and
    public safety impact associated with alcohol, tobacco, and illicit
    substance use. Any newly reorganized entity must be greater than the
    sum of its parts. This Committee should encourage NIH to fully
    integrate the substance use and related research portfolios of all
    other NIH Institutes and Centers in order to develop a new
    infrastructure for conducting that research with particular attention
    to tobacco, comorbid mental health disorders, and other compulsive use
    behaviors. NIH should establish rigorous and transparent baselines to
    define current funding levels, and the allocation of those funds across
    the existing NIH Institutes and Centers to ensure the ability to assess
    the evolution of the portfolios and effectiveness of any organizational
    change. This Committee should encourage the continued active
    involvement of extramural scientists at every stage of this process as
    well as the Office of Behavioral and Social Sciences Research.
        To its credit NIH is moving quickly to identify the reasons,
    documented in a recent Science article, that black investigators are
    significantly less likely to receive RO1 awards than investigators from
    other racial groups. The Committee should encourage NIH to devote all
    necessary resources to this investigation and subsequent corrective
    action. Additional efforts should go toward enhancing the pipeline of
    minority investigators. The Office of Behavioral and Social Sciences
    Research should be commended for its support of a workshop addressing
    ways to establish a comprehensive and cohesive process to track the
    efforts of Government, universities, private foundations and
    associations to enhance minority participation in the sciences.
        APA is concerned that the budget of the Office of Behavioral and
    Social Sciences Research has been flat, at $27 million, for 3 years,
    and urges the Committee to provide an inflationary increase at a
    minimum.
        The National Institute on Aging (NIA) has been the focus of
    additional resources from the administration so that it may push
    forward its research on Alzheimer's disease, now that the Congress has
    passed legislation authorizing a National Plan for Alzheimer's
    research, care and services. The Committee is encouraged to give full
    support to the NIA budget.
        Biomedical approaches to HIV prevention are most effective when
    they are combined with behavioral approaches. With recent scientific
    advances demonstrating the promise of biomedical HIV prevention
    interventions, behavioral research is needed more than ever to bolster
    medication adherence and treatment uptake, to document real-world
    decisionmaking processes associated with biomedical interventions, and
    to better understand potential unintended and/or undesired consequences
    of biomedical interventions. APA encourages the Committee to continue
    to press the National Institute on Mental Health to support a robust
    HIV/AIDS behavioral prevention research agenda that examines these
    factors, and includes operations research to optimize combination HIV
    prevention.
        Health Resources and Services Administration (HRSA), Bureau of
    Health Professions.--The APA requests that the Subcommittee include
    $4.5 million for the Graduate Psychology Education Program (GPE) within
    HRSA. An exemplary ``two-for-one'' Federal activity, this nationally
    competitive grant program supports the training of psychology graduate
    students while they provide mental and behavioral health services. In
    rural and urban underserved communities, services are provided under
    supervision at no charge to underserved populations, such as children,
    older adults, chronically ill persons, victims of abuse or trauma,
    including returning military personnel, veterans and their families,
    and the unemployed. To date there have been 125 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 more than 80 percent will work in
    underserved areas immediately after completing the training.
        The GPE Program is specifically authorized at between $10 million
    and $12 million per year by the Public Health Service Act [Section
    756(a)(2)]. Also Section 755(b)(1)(J) provides broader additional
    authority. HRSA receives appropriations for the program under its
    ``Mental and Behavioral Health'' account in the Labor-HHS
    appropriations bill. GPE was included in the President's budget at its
    current funding level of $3 million.
        Established in 2002, GPE grants have supported the
    interdisciplinary training of more than 3,000 graduate students of
    psychology and other health professions to provide integrated
    healthcare services to underserved populations. The fiscal year 2013
    GPE funding request will focus especially on providing services to
    returning military personnel, veterans and their families, unemployed
    persons and others affected by the economic downturn, 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.
        Centers for Disease Control and Prevention (CDC).--As a member of
    the Centers for Disease Control and Prevention (CDC) Coalition, APA
    supports a minimum budget of $7.8 billion for CDC core programs in
    fiscal year 2013. CDC programs play a key role in maintaining a strong
    public health infrastructure, protecting Americans from public health
    threats and emergencies, and in reducing healthcare costs and
    strengthening the Nation's health system. The Prevention and Public
    Health Fund and other fund transfers heavily supplant program budgets
    in the fiscal year 2013 President's budget. The proposed $664 million
    cut to CDC's budget authority in the President's budget request would
    amount to a $1.4 billion decrease in CDC's budget authority since
    fiscal year 2010. APA urges the Subcommittee to restore this cut.
        APA is disappointed to see a decrease in funding of more than 10
    percent for the Prevention Research Centers (PRC) program in the
    President's budget request. A focus on prevention is essential to
    improving health in America and the PRC network of community, academic,
    and public health partners makes significant contributions to research
    on evidenced based approaches in health promotion. APA urges the
    Congress to designate specific funding for the program again in fiscal
    year 2013, including the resources necessary to support the Prevention
    Research Centers so that this network of academic institutions and
    organizations can continue to contribute widely and effectively to
    prevention science.
        As a member of the Friends of the National Center for Health
    Statistics (NCHS), APA endorses the President's fiscal year 2013
    request of $162 million in funding for the agency's base discretionary
    budget. The health data collected by NCHS, on chronic disease
    prevalence, healthcare disparities, emergency room use, teen pregnancy,
    infant mortality, causes of death, and rates of insurance, to name a
    few, are essential to the Nation's statistical and public health
    infrastructure. Your leadership in securing steady and sustained
    funding increases for NCHS over the last 5 fiscal years has helped NCHS
    rebuild after years of underinvestment and restored the collection of
    essential health data. In particular, APA is pleased with the Center's
    progress in the past year field testing data collection methods for
    sexual orientation, and hopes for the expedient incorporation of this
    data, as well as that on gender identity, into the National Health
    Interview Survey and other appropriate surveys.
        APA is pleased to see the increase in funding for the National
    Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention in the
    President's fiscal year 2013 budget, and in particular the $40.2
    million increase in funding for domestic HIV/AIDS prevention and
    research in line with the National HIV/AIDS Strategy. APA supports the
    maximum possible funding for HIV/AIDS prevention for fiscal year 2013
    to scale up combination HIV prevention. APA urges CDC to make
    additional funds available for screening for mental health and
    substance use disorders in HIV testing programs; behavioral
    interventions to optimize biomedical interventions; and operations
    research to inform implementation of high impact HIV prevention.
        As a member of the Injury and Violence Prevention Stakeholder
    Coalition, convened by the Safe States Alliance, APA supports
    restoration of the CDC Injury Center to its fiscal year 2011 level of
    $147 million and restoration of the Preventive Health and Health
    Services Block Grant to its fiscal year 2011 level of $100 million. The
    Injury Center and the Preventive Health and Health Services Block Grant
    are critical to the State and local injury and violence prevention
    efforts.
        Again, APA is grateful for the opportunity to present these
    recommendations for fiscal year 2013.
                                     ______

          Prepared Statement of the American Public Health Association
        The American Public Health Association 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
    regarding fiscal year 2013 funding for the Centers for Disease Control
    and Prevention, the Health Resources and Services Administration and
    school-based health programs. We urge you to take our recommendations
    into consideration as you work to develop the fiscal year 2013 Labor-
    HHS-Education appropriations bill.
    Centers for Disease Control and Prevention
        APHA believes that the Congress should support CDC as an agency--
    not just the individual programs that it funds. In our best judgment--
    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--CDC will require funding of at
    least $7.8 billion for CDC's programs in fiscal year 2013. We are
    deeply disappointed with the proposed $664 million cut to CDC's budget
    authority contained in the President's fiscal year 2013 budget
    proposal. In fact, when including the President's fiscal year 2013
    request, CDC's budget authority would have been decreased by a
    staggering $1.4 billion since fiscal year 2010. While CDC has received
    and the President's fiscal year 2013 budget proposal directs
    significant funding from the Prevention and Public Health Fund to CDC,
    we believe this funding is essentially supplanting many of the cuts
    made to CDC's budget authority. We urge you to restore this cut to
    CDC's budget authority and to support the $1 billion available through
    Prevention and Public Health Fund in fiscal year 2013.
        By translating research findings into effective intervention
    efforts, CDC is a critical source of funding for many of our State and
    local programs that aim to improve the health of our 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. We urge you to restore the proposed
    elimination of the Preventive Health and Health Services Block grant in
    the President's budget, which is a critical source of funding for State
    and local public health agencies.
        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, 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.
        CDC serves as the lead agency for bioterrorism and other public
    health emergency preparedness and response 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. Unfortunately, this is not a threat
    that is going away.
        The President's fiscal year 2013 budget proposes to consolidate a
    number of chronic disease programs within CDC to promote better
    coordination. If it is to be effective, we believe this proposal, the
    Coordinated Chronic Disease Prevention and Health Promotion program,
    must receive the resources needed to provide our States and communities
    increased and sustainable funding to effectively improve efforts to
    reduce the burden of chronic disease.
        We encourage the Subcommittee to restore funding for CDC's National
    Center for Environmental Health. Since 2009, NCEH funding has been cut
    by 25 percent. We urge the committee to restore funding for the Healthy
    Homes and Lead Poisoning Prevention program and to main the program and
    Asthma program as separate and distinct programs. We ask the
    Subcommittee to continue its recent efforts to maintain CDC's capacity
    to help the Nation prepare for and adapt to the potential health
    effects of climate change by providing CDC with level funding for
    climate change and health activities.
        We also urge you to restore funding for the Education and Research
    Centers and for the Agriculture, Forestry and Fishing Program (AFF)
    within the budget for the National Institute for Occupational Safety
    and Health which are proposed for elimination in the President's
    budget. These programs play an important role in protecting the health
    and safety of American workers.
    Health Resources and Services Administration
        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 nearly
    50 million Americans who were uninsured in 2010 and 60 million
    Americans who live in neighborhoods where primary healthcare services
    are scarce. To respond to these challenges, APHA believes that the
    agency will require an overall funding level of at least $7 billion for
    fiscal year 2013.
        Our request of $7 billion represents the 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, we remain concerned about the deep cuts the agency has
    endured over the past few years; HRSA's discretionary budget has been
    reduced by more than $1.2 billion since fiscal year 2010. Cuts of this
    magnitude have had a serious negative impact on the agency's ability to
    carry out critical public health programs and services for millions of
    Americans. Therefore, our requested level of funding is necessary to
    ensure HRSA is able to implement public health programs 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.
        Some of the major healthcare initiatives conducted by HRSA include:
      --Health Professions programs that support the education and training
            of primary care physicians, nurses, dentists, optometrists,
            physician assistants, public health personnel 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 that support more than 7,000 community health
            centers and clinics 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 programs including the Title V Maternal
            and Child Health Block Grant, Healthy Start and others support
            a myriad of initiatives designed to promote optimal health,
            reduce disparities, combat infant mortality, prevent chronic
            conditions, and improve access to quality healthcare for more
            than 40 million women and children, including children with
            special healthcare needs.
      --HIV/AIDS programs that 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 services that ensure access to a broad
            range of reproductive, sexual, and related preventive
            healthcare for more than 5.2 million poor and low-income women,
            men and adolescents at nearly 4,400 health centers nationwide.
            This program helps improve maternal and child health outcomes
            and promotes healthy families.
      --Rural Health programs improve access to care for the more than 60
            million Americans who live in rural areas. These programs
            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 that 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, which help people who need potentially life-
            saving transplants by connecting patients, doctors, donors, and
            researchers to the resources they need to live longer,
            healthier lives.
    School Health
        Nearly one-third of students in the United States do not graduate
    from high school, and for Black, Latino and American Indian students,
    the number is half. As indicated in Healthy People 2020, the leading
    indicator determining health status in the United States is graduation
    from high school. Thus, graduation from high school is not only a
    predictor of economic success but also of long-term health.
        Some of the social factors that influence whether or not a student
    remains in school and graduates simultaneously influence their health
    and vice versa. That is why these factors are also included in the
    adolescent health objectives of Healthy People 2020. A number of
    studies now recognize the cause and effect between social determinants
    of health and achievement. The October 2011 issue of the Journal of
    School Health identified seven educationally related health disparities
    that contribute to the achievement gap and ultimately school dropout:
    (1) hunger, (2) aggression and violence, (3) teen pregnancy, (4)
    asthma, (5) vision, (6) physical, and (7) inattention and
    hyperactivity.
        SBHCs can address these issues and improve educational success of
    at-risk students. Studies have also shown that SBHCs create the
    conditions needed for educational success by meeting student's physical
    and mental healthcare needs. They have been shown to reduce
    absenteeism, improve grade point average, and improve the overall
    school climate.
        We urge you to provide the $50 million in fiscal year 2013 for
    operation of school-based health centers as authorized in the Patient
    Protection and Affordable Care Act. We also urge you to consider the
    social factors that influence health and ultimately graduation and ask
    you to provide $120 million for programs in the Office of Safe and
    Healthy Students in the U.S. Department of Education.
    Conclusion
        In closing, we emphasize that public health programs require
    stronger financial investments at every stage. Funding for these
    programs makes up only a fraction of Federal spending and continued
    cuts to public health and prevention programs will not balance our
    budget, it will only lead to increased costs to our healthcare system.
    Successes in biomedical research must be translated into tangible
    prevention opportunities, screening programs, lifestyle and behavior
    changes and other population-based interventions that are effective and
    available for everyone. Without a robust and sustained investment in
    our Nation's public health programs and 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 2013.
        APPA has consistently supported an increase in the authorization
    level for LIHEAP. The administration's fiscal year 2013 budget requests
    $3 billion for LIHEAP--a cut of $452 million from fiscal year 2012
    levels. APPA supports extending the current level of $5.1 billion for
    the program.
        APPA is the national service organization representing the
    interests of more than 2,000 municipal and other State and locally
    owned utilities throughout the United States (all but Hawaii).
    Collectively, public power utilities deliver electricity to 1 of every
    7 electricity consumers (approximately 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 2013.
                                     ______

    Prepared Statement of the Association of Public Television Stations and
                        the Public Broadcasting Service
        On behalf of America's 361 public television stations, we
    appreciate the opportunity to submit testimony for the record on the
    importance of Federal funding for local public television stations.
    Corporation for Public Broadcasting--Fiscal Year 2015 Request: $445
            Million, 2-Year Advance Funded
        More than 40 years after the inception of public broadcasting,
    local stations continue to serve as the treasured educational and
    cultural institutions envisioned by their founders, reaching America's
    local communities with unique, essential and unsurpassed programming
    and services.
        Public television treats its audience as citizens rather than mere
    consumers. We provide essential services to all Americans, not just the
    18-49 year olds to whom advertisers hope to appeal to because of that
    age group's spending habits. We serve everyone, everywhere, every day,
    for free.
        Public broadcasting serves the public good--in education, public
    affairs, public safety, the preservation of the national memory and
    celebration of the American culture, and many other areas--and richly
    deserves public support. The overwhelming majority of Americans agree.
    In a recent bipartisan poll conducted by Hart Research Associates/
    American Viewpoint, nearly 70 percent of American voters, including
    majorities of self-identifying Republicans, Independents, and Democrats
    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.
        We seek Federal funding for public broadcasting because we are part
    of the Nation's public service infrastructure, just like public
    libraries, public schools and public highways.
        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. Funding from
    traditional sources such as individuals, corporate underwriters,
    foundations and State governments has become increasingly more
    challenging to secure in this difficult economy. Continued Federal
    support for public broadcasting is more important now than ever before.
        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, online and on-the-ground. This funding is
    particularly important to rural stations that 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.
        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 more than $6 from
    State legislatures, private foundations and corporations, and ``viewers
    like you.''
        A 2007 GAO report concluded that Federal funding, such as CSGs, is
    an irreplaceable source of revenue, and that ``substantial growth of
    non-Federal funding appears unlikely.'' It also found that ``cuts in
    Federal funding could lead to a reduction in staff, local programming
    or services.'' This study was conducted before the severe economic
    recession that struck in 2008, and its findings may be even more acute
    today.
        At an annual cost of about $1.37 per year for each American--
    compared with $68 in Japan and $83 in Great Britain--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 more than 24,000 jobs, and 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 fundamental 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 developed the
    American Graduate initiative, 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 are providing 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.
        Public television is the Nation's largest classroom. Local stations
    provide free, cutting edge, educational content for all Americans so
    that regardless of their family's income, children have access to safe,
    non-commercial media that helps prepare them for success in school and
    has been proven to help close the achievement gap.
        Stations are also responding to the needs of the 21st century
    classroom by expanding digital educational resources for teachers,
    students and parents alike. For example, stations are working together
    with PBS to create an online portal, PBS Learning Media, where
    educators can access standards-based, curriculum-aligned digital
    learning objects created from public television content as well as
    material from the Library of Congress, National Archives, and other
    contributors to the Department of Education's Learning Registry.
    Stations are also building homegrown learning platforms like Maryland
    Public Television's Thinkport online system, which the State
    superintendent of schools has credited with helping raise Maryland's
    students to the top of the student achievement rankings nationwide.
        Local public television stations have also embraced the
    opportunities of digital technology as a way to help address emergency
    response and homeland security issues in their communities. Stations
    like Las Vegas PBS have integrated their digital technology with local
    public safety officials to provide enhanced emergency communications
    that better aide the responders and provide citizens with needed
    information during a crisis. Vegas PBS is also the largest job trainer
    in Nevada, and this manifold mission of service is being emulated by
    public television stations nationwide.
        Local public television stations serve as essential communications
    hubs in their communities providing unparalleled local coverage of
    news, current events, and State legislatures that encourages every
    American to become a more informed citizen. Public television is the
    place for real public affairs programming, real news, real history,
    real science, real art that makes us think, teaches us useful things,
    and inspires us to be a better, more sophisticated, more civilized,
    more successful people. We bring the wonders of the world--Broadway
    shows, the finest museums, the best professors and much more--to the
    most remote places in our country.
        In order for our stations to continue playing this vital role in
    their communities, APTS and PBS respectfully request $445 million for
    CPB, 2-year advance funded for fiscal year 2015.
        Two-year advance funding is essential to the mission of public
    broadcasting. This longstanding practice, which was proposed by
    President Ford and embraced by the Congress in 1976, establishes a
    firewall insulating programming decisions from political interference,
    enables the leveraging of funds to ensure a successful public-private
    partnership, and provides stations with the necessary lead time to plan
    in-depth programming.
        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.
        Public television's history of editorial independence has paid off
    in unprecedented levels of public trust--for the ninth consecutive
    year, the American people have ranked public broadcasting as one of the
    most trusted national institutions. Advance funding and the firewall it
    provides is vital to maintaining this credibility among the American
    public.
        In addition, local public broadcasting stations are able to
    leverage the 2-year advance funding to raise State, local and private
    funds, ensuring the continuation of this strong public-private
    partnership. These Federal funds act as essential seed money for
    fundraising efforts at every station, no matter its size.
        Finally, the 2-year advance funding mechanism also gives stations
    and producers the critical lead time needed to plan and produce high-
    quality programs. The signature series that demonstrate the depth and
    breadth of public television, like Ken Burns' ``The Civil War'' and
    Henry Hampton's ``Eyes on the Prize'', take several years to produce.
    Ken Burns's documentary schedule is already planned through 2019, and
    it will educate the Nation on subjects ranging from the Dust Bowl to
    the Vietnam war to the history of country music.
        The fact that stations know they will have funding to support
    projects like these in advance is critical for producers to be able to
    actively develop groundbreaking projects. In addition to national
    programming, 2-year advance funding is essential to the creation of
    local programming over multiple fiscal years as stations convene the
    community to identify needs, recruit partners, conduct research,
    develop content and deliver services.
        The 2-year advance funding is essential for stations as they
    continue to plan the production of the unparalleled programming and
    local services that educate, inspire, inform and entertain the American
    people in the unique way only public broadcasting can.
    Ready To Learn--Fiscal Year 2013 Request: $27.3 Million (Department of
            Education)
        The Ready to Learn Television competitive grant 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 literacy 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 public media's Ready to Learn approach. 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, use of Ready to Learn
    curriculum has been proven to help close the achievement gap by
    enabling low-income students to catch up to their peers from high-
    income households as shown when comparing standardized reading
    assessments.
        Pivoting off of this success in literacy, public media will expand
    its Ready to Learn effort to include early math skills to continue
    helping bridge the achievement gap by further innovating educational
    media content, educating kids inside and outside the classroom, and
    engaging local communities. This will include developing new content
    like a PBS KIDS TV math series and three new math TV pilots. In
    addition to the content, new tools will be provided including a
    sophisticated progress tracking system that equips parents and
    educators with the means to measure student progress, in real time.
    Ready to Learn will continue to be rigorously evaluated for its appeal
    and efficacy, so that the program can continue to offer America's
    youngest citizens the tools they need to succeed in school and in life.
        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 5-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 funding would likely end.
        The President's budget proposes consolidating Ready to Learn into a
    larger grant program. APTS and PBS are concerned that the consolidation
    of this program could lead to the elimination of this critical program
    that has been the driving force behind the creation of public
    television's unparalleled children's educational programming. The
    proposed budget would significantly weaken Ready to Learn's unique
    local-national partnership between communities and their public media
    stations and PBS with its national scope and resources. This local-
    national partnership has made Ready to Learn tremendously efficient and
    effective and is a key element of the successful operation of the
    program. 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 critical
    resources provided by this program for children, parents and teachers.
        Ready to Learn symbolizes the mission of public media and is a
    shining example of a public-private partnership as Federal funds are
    leveraged to create the most appealing and impactful children's
    educational content that is supplemented by online and on-the-ground
    resources. Without the Ready to Learn 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 2013 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 2013.
        One hundred seventy million Americans regularly rely on public
    broadcasting--on television, on the radio, online, and in the
    classroom--because we provide them something they need that no one else
    in the media world provides: A place to think. A place to learn. A
    place to grow. A tool for the citizen. None of this would be possible
    without the Federal investment in public broadcasting.
        We request that the Congress continue its commitment to this highly
    successful public-private partnership by continuing to provide level
    funding for the 2-year advance of the Corporation for Public
    Broadcasting and the Ready to Learn Program.
                                     ______

         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 LHHS Appropriations Subcommittee regarding funding for nursing
    and rehabilitation related programs in fiscal year 2013. ARN represents
    nearly 12,000 rehabilitation nurses that work to enhance the quality of
    life for those affected by physical disability and/or chronic illness.
    ARN understands that the 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. We
    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. We
    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. We base our practice on rehabilitative and
    restorative principles by: (1) managing complex medical issues; (2)
    interprofessional collaboration 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.
        As we celebrate the 2 year anniversary of the Affordable Care Act
    (ACA)--which focused on creating a system that will increase access to
    quality care, emphasizes prevention, and decreases costs--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 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 meet these new
    demands, but we are destined to fall short of these lofty goals if
    there are not enough nurses to facilitate change.
    ---------------------------------------------------------------------------
        \1\ http://bhpr.hrsa.gov/healthworkforce/reports/nursing/
    rnbehindprojections/4.htm.
    ---------------------------------------------------------------------------
        According to the U.S. Bureau of Labor Statistics, nursing is the
    Nation's top profession in terms of projected job growth, with more
    than 581,500 new nursing positions being created through 2018.\2\ These
    positions are in addition to the existing jobs that healthcare
    employers have not been able to fill. Educating new nurses to fill
    these gaping vacancies is a great way to put Americans back to work and
    simultaneously enhance an ailing healthcare system.
    ---------------------------------------------------------------------------
        \2\ http://www.bls.gov/oco/ocos083.htm#outlook.
    ---------------------------------------------------------------------------
        ARN strongly supports the national nursing community's request of
    $251 million in fiscal year 2013 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 the Congress
    to provide the maximum possible fiscal year 2013 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
    interprofessional 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 $150 million in fiscal year 2013 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 the Congress to support the following fiscal year 2013
    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 2013 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 2013 funding levels detailed
    above, we believe the Subcommittee will be taking the steps necessary
    to ensure that our Nation has a sufficient nursing workforce to care
    for patients requiring rehabilitation from chronic illness and/or
    physical disability.
                                     ______

       Prepared Statement of the Association for Research in Vision and
                                 Ophthalmology
    Biomedical Research Investment
        Fiscal year 2013 is a pivotal time for the United States as the
    Nation's leaders work hard toward the goal of recovering from an
    historic economic recession. We agree with the President that education
    and innovation are crucial investments for growing the economy and
    creating jobs. We understand that difficult decisions have to be made
    about fiscal year 2013 appropriation priorities, with imposed counter
    pressures from the Budget Control Act. We urge the Congress to
    carefully consider the long term impact of not investing in research
    and development (R&D) while other nations (e.g., China and India)
    increase their investment, and while the United States faces a critical
    need to control inflating healthcare costs. We were happy to see the
    importance of R&D investment reflected in the President's budgets for
    the National Science Foundation, the Department of Energy, and the
    Department of Agriculture. We think the Presidential budget for NIH,
    which did not maintain funding levels, is a mistake. Our Nation faces
    unprecedented aging eye disease costs; these will radically increase
    without proper investment in research that leads to treatments and
    cures.
    Americans Want Biomedical Research Investment
        The American public recognizes the importance of biomedical
    research and is more likely to support candidates who support Federal
    biomedical research.\1\ Specifically, ``85 percent of likely voters are
    concerned about the impact of a decreased Federal investment in
    research, including the possibility of scientists leaving their
    profession or moving abroad to countries with a stronger research
    investment.'' \1\ Biomedical research investment is a long term
    strategy to ensure economic competitiveness of the United States. Each
    dollar NIH spends on research results in a two-fold economic return to
    local economies. NIH funding supports half a million U.S. jobs,
    including extramural research supported by 325,000 scientists at more
    than 3,000 institutions.\2\ In 2010, NIH funding ``directly and
    indirectly supported 487,900 jobs nationwide, leading to 15 States
    experiencing job growth of 10,000 or more.'' \2\ The spending results
    in complementary private investments,\2\ not even accounting for local
    growth near new research infrastructure (e.g., restaurants/other
    services). Unfortunately, 55,000 jobs were lost when American Recovery
    and Reinvestment Funding ended.\2\ Research is a marathon, not a
    sprint. Sustained investment over time is needed for progress. We urge
    elected representatives to consider what constituents value when making
    decisions about NIH funding appropriations.
    ---------------------------------------------------------------------------
        \1\ Research!America March 14, 2012 public opinion poll.
        \2\ United for Medical Research, May 2011, NIH Role in Sustaining
    the U.S. Economy.
    ---------------------------------------------------------------------------
        ARVO has two major requests for the Senate:
      --To recognize funding for the NIH as a national priority by funding
            NIH in fiscal year 2013 at least $32 billion.
      --To recognize vision health as a national priority by funding the
            NEI at $730 million.
        The requested funding levels will enable NIH and NEI to keep pace
    with inflation and continue extraordinary progress made toward
    improving vision health of the American public. Blindness prevention
    and vision restoration are crucial for reducing healthcare costs,
    maintaining productivity, ensuring independence, enhancing quality of
    life, enabling safe mobility and navigation of affected individuals and
    the community (e.g., driving safety). The $730 million requested for
    NEI is a small amount, considering the annual cost of eye disease
    (estimated in U.S. adults at $51.4 billion/year in 2007).\3\ The annual
    economic cost did not account for child eye care costs or the baby
    boomer demographic entered this decade, when the number of people
    turning 65-years-old each day rose from 1,000 people per day to 6,000
    people per day, continuing until 2029. Future eye care costs will be in
    proportion to the number of children affected by diabetic and other eye
    disease and the number of adults affected by aging eye diseases.\4\
    ---------------------------------------------------------------------------
        \3\ Prevent Blindness America, 2007, The Economic Impact of Vision
    Problems.
        \4\ Alliance for Aging Research, 2012, The Silver Book: Vision
    Loss, Volume II.
    ---------------------------------------------------------------------------
    Biomedical Infrastructure in Crisis
        Rep. Paul Ryan (R-WI) outlined a 10-year Federal spending reduction
    plan earlier this month that did not recognize the crucial role that
    biomedical research spending plays for the economic growth and well-
    being of our country. Meanwhile, the biomedical research institutions
    of our Nation, whose goal it is to address the national health needs
    through research are economically stressed from a variety of sources
    including: State budget restrictions, decreased availability of bridge
    and philanthropic funding, and added expenses from increased regulatory
    administrative costs detailed below.
    Salary Caps Derail Clinical Research, New Research Programs and Junior
            Researchers
        On January 20, 2012 NIH issued guidance on congressionally imposed
    salary caps, effectively reducing Executive Level II salaries by
    $20,000. This decision might look like an insignificant 1 percent
    budget reduction from a policy perspective. However, from a local
    perspective on individual institutions, this decision generated more
    interest than any other policy report by our organization in the past 4
    years. Below are some preliminary institutional administrative reports
    on the local impact.
      --The cap disproportionately affects clinician-scientists, who
            already make lower salaries than their colleagues in private
            practice and industry settings. Effectively, this cap pushes
            them out of research at a time when the United States is
            placing more emphasis on translational research.
      --Clinical departments are ceasing to offer seed money for new
            faculty to jumpstart new research programs.
      --Post-doctoral researchers in clinical departments are being let go
            (at the most vulnerable stage in their career) to address lost
            NIH salary reimbursements. Post-docs are highly trained,
            relatively poorly paid (around $40,000/year) junior
            investigators, who frequently fall between the cracks as they
            are not faculty, staff, or students.
      --John's Hopkins alone estimates the current salary cap will result
            in a loss of $6.8 million per year in recoverable facility and
            administration (F&A) costs, in addition to an earlier cap that
            resulted in a $10 million per year loss in recoverable F&A.
    Increased Costs and Reduced Capacity
        A set of new guidelines for the care and use of animals is being
    implemented by NIH. The spirit and intent of the guidelines are
    currently being followed in a manner consistent with the scientific
    community concerns to limit the number of animals used and ensure they
    are not subjected to unnecessary discomfort and pain. However, the
    prescriptive nature of the new guidelines have the potential to be
    interpreted as regulations that leave little room for professional
    judgment based on local infrastructure and study specific variables. An
    uncertainty about interpretation of the guidelines by inspectors is
    certain to initiate changes in housing at great expense and loss of
    capacity to individual institutions.
        Transportation of animals is also being targeted. Non-human
    primates, while infrequently used in vision research, are very
    important and critical for certain studies. Members are starting to
    rely on expensive charters to ship research animals, as airlines are
    being targeted by passionate anti-animal research advocates.
        The regulatory, public policies and transportation issues for
    animal research are initiating a shift for pharmaceutical companies to
    move pharmaceutical testing to countries with less stringent
    regulations and easier access to research animals, which will be
    unfortunate for the humane treatment of animals and will mean a loss of
    jobs in the United States.
    Approval Path to a Product Graveyard
        Members who conduct translational studies report that the Food and
    Drug Administration (FDA) has a lack of a defined approval process for
    ophthalmic drugs. They report that it is difficult to attract investors
    for clinical trials in part because prior endeavors failed due to
    inappropriate endpoints or measurements. Investors simply will not
    invest in trials when they have to guess what steps are necessary to
    achieve regulatory approval. We understand why such challenges exist
    within FDA as the FDA has had to move from regulatory oversight of U.S.
    drugs/devices/biologics to an international oversight environment with
    limited budget for additional staff/resources. Yet, the FDA approval
    process is a critical barrier to product approval, a process that
    European countries made more efficient. Some companies and investors
    now start their studies in Europe instead of the United States, with a
    resulting loss of U.S. jobs due to these differences in regulatory
    environments.
    So Much Vision Progress at Stake
        The very health of the vision research community is at stake with
    the proposed declines in NEI funding. Not only will funding for new
    investigators be at risk, but also that of seasoned investigators,
    which threatens the continuity of research and the retention of trained
    staff. When institutions must release staff due to lack of extramural
    funding, highly trained people are lost to the field. This is
    unfortunate. As NEI's fiscal year 2013 budget Director's overview
    stated, ``NEI made a considerable investment in basic research that is
    now creating unprecedented opportunities to develop new treatments that
    address the root cause of vision loss''. Examples of progress made with
    prior vision research investments include the following examples.
      --Better age-related macular degeneration therapies are expected to
            reduce the incidence of legal blindness by 72 percent and
            visual impairment by 37 percent in 2 years.\4\
      --Current treatments for abnormal blood vessel growth in diabetic
            retinopathy patients reduced the rate of legal blindness within
            5 years from 50 percent to less than 5 percent.\4\ Fifty
            percent of treated patients experienced improved visual
            function within 1 year. Laser treatment and vitrectomy reduced
            the risk of blindness in patients with severe diabetic
            retinopathy by 90 percent.\4\
      --Prescription eye drops delay or prevent 50 percent of glaucoma
            cases in African Americans.\4\
      --Treatments that delay/prevent diabetic retinopathy now save the
            United States $1.6 billion annually.\4\
        In summary, ARVO requests NEI funding at $730 million, reflecting
    biomedical inflation plus modest growth commensurate with that of NIH
    overall, since our Nation's investment in vision health is an
    investment in overall health. NEI's breakthrough research is a cost-
    effective investment, since it is leading to treatments and therapies
    that can ultimately delay, save, and prevent health expenditures,
    especially those associated with the Medicare and Medicaid programs. It
    can also increase productivity, help individuals to maintain their
    independence, and generally improve the quality of life, especially
    since vision loss is associated with increased depression and
    accelerated mortality.
    About the Association for Research in Vision and Ophthalmology
        ARVO is the world's largest international association of vision
    scientists (scientists who study diseases and disorders of the eye).
    More than 7,000 members are supported by NIH grant funding. Vision
    science is a multi-disciplinary field, but the NEI is the only
    freestanding NIH institute with a mission statement that specifically
    addresses vision research. ARVO supports increased fiscal year 2013 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 Autism Speaks
        Chairman Harkin, Ranking Member Shelby, and members of the
    subcommittee, thank you for the opportunity to offer testimony on the
    importance of continued funding for autism.
        My name is Peter Bell and I am executive vice president of programs
    and services for Autism Speaks. My responsibilities at Autism Speaks
    include overseeing the foundation's family services and Government
    relations activities. I also serve as an advisor to our science
    division. Autism Speaks is the world's leading autism science and
    advocacy organization. Since its inception in 2005, Autism Speaks has
    committed more than $173 million to autism research as well as
    developing innovative resources for individuals with autism and their
    families. Our mission is to change the future for those who live with
    autism. We do this through funding science, raising awareness, helping
    families, and advocating for those who live on the spectrum.
        I am also the proud father of a child with autism. His name is
    Tyler and he recently turned 19. In 1996 when my wife and I first heard
    the words ``your son has autism,'' we were stunned. Our only reference
    to autism at the time was from the Oscar-winning movie ``Rain Man.'' We
    had never known anyone with autism, nor did we know any families who
    had a child with autism. I suspect this would have been true for most
    of you on this committee. However, today, I'm willing to wager that
    every one of you personally knows someone or some family who is touched
    by autism. Each year, nearly 50,000 families hear those same words--
    ``your child has autism.''
        Twenty years ago, the experts estimated that 1 of every 2,500
    children had autism. The latest statistic, announced on March 29 by the
    Centers for Disease Control and Prevention (CDC), is 1 in 88, 1 in 54
    for boys. Increasingly we hear the word ``epidemic'' associated with
    autism in America. But we at Autism Speaks are hearing something else
    from the families in our community and it is getting louder by the day.
        And that is the question, ``what is our Government doing to
    confront this public health crisis?'' We are increasingly frustrated
    and frankly confused by what appears to be a lack of will from
    Washington. When the number of people on the spectrum is going up, why
    are the dollars for autism research and prevention going down?
        When Bob and Suzanne Wright founded Autism Speaks in 2005, they
    were shocked that a disorder as prevalent as autism commanded so little
    in terms of resources devoted to research and treatment when compared
    to other, less common disorders. Working together with thousands of
    families affected by autism, we were able to enact the Combating Autism
    Act of 2006. Signed by President Bush, this historic act was considered
    to be the most comprehensive piece of single-disease legislation ever
    passed by the Congress. Last year, working with many of you in
    bipartisan fashion, the Combating Autism Act was reauthorized when
    President Obama signed a 3-year reauthorization into law on September
    30.
        Autism Speaks and the 1 million plus members of our community are
    of course grateful for this funding. But we also recognize it provides
    but a fraction of the billion dollar a year commitment that had been
    promised by President Obama, a commitment that better reflects the
    actual need for funding meaningful research, treatment, and services.
    That disappointment has now been compounded by fears that the funding
    that was authorized just last September may now be in jeopardy as a
    result of this year's appropriations process.
        Funding for the CDC to continue prevalence research under the
    President's budget request was $700,000 below the $22 million
    authorized funding level and then inexplicably incorporated within the
    Prevention and Public Health Fund created under the Affordable Care
    Act. As you know, recent legislation reduces the fund by 20 percent in
    fiscal year 2013, further jeopardizing the CDC's autism surveillance
    activities. Since 2000, funding for this work has always been included
    within the CDC's total discretionary budget authority. It should
    continue there. Autism Speaks requests that you include $22 million for
    autism activities within the National Birth Defects Center, within
    CDC's discretionary budget authority.
        Further, we urge you to fully fund the basic and clinical research
    initiatives for autism at the levels called for under the Combating
    Autism Reauthorization Act (CARA). Specifically, we ask you to support
    at least $161 million for the NIH's autism research programs and $48
    million for HRSA's autism research, treatment, and training activities.
    We also urge the Subcommittee to fund CDC's autism activities within
    CDC's Discretionary Budget Authority.
        As I mentioned earlier, Autism Speaks has committed more than $173
    million through private fundraising to scientific research studies,
    fellowships, and scientific initiatives. Other private foundations have
    contributed in excess of $125 million. But we can't do this alone. We
    ask that the Congress restore full funding as authorized under CARA for
    autism research, surveillance and treatment. And we ask that Washington
    treat autism as the epidemic it has become.
                                     ______

            Prepared Statement of the American Society of Hematology
        The American Society of Hematology (ASH) thanks the subcommittee
    for the opportunity to submit written testimony on the fiscal year 2013
    Departments of Labor, Health and Human Services, and Education
    appropriations bill.
        ASH represents approximately 14,000 clinicians and scientists
    committed to the study and treatment of blood and blood-related
    diseases. These diseases encompass malignant disorders such as
    leukemia, lymphoma, and myeloma; life-threatening conditions, including
    thrombosis and bleeding disorders; and congenital diseases such as
    sickle cell anemia, thalassemia, and hemophilia. In addition,
    hematologists have been pioneers in the fields of bone marrow
    transplantation, stem cell biology and regenerative medicine, gene
    therapy, and the development of many drugs for the prevention and
    treatment of heart attacks and strokes.
        Over the past 60 years, American biomedical research has led the
    world in probing the nature of human disease. This research has led to
    new medical treatments, saved innumerable lives, reduced human
    suffering, and spawned entire new industries. This research would not
    have been possible without support from the National Institutes of
    Health (NIH). 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.
    Discoveries gained through basic research yield the medical advances
    that improve the fiscal and physical health of the country.
        Funding for hematology research has been an important component of
    this investment in the Nation's health. With the advances gained
    through an increasingly sophisticated understanding of how the blood
    system functions, hematologists have changed the face of medicine
    through their dedication to improving the lives of patients. As a
    result, children are routinely cured of acute lymphoblastic leukemia
    (ALL); more than 90 percent of patients with acute promyelocytic
    leukemia (APL) are cured with a drug derived from vitamin A; older
    patients suffering from previously lethal chronic myeloid leukemia
    (CML) are now effectively treated with well-tolerated pills; and
    patients with multiple myeloma are treated with new classes of drugs.
        Hematology advances also help patients with other types of cancers,
    heart disease, and stroke. Blood thinners effectively treat or prevent
    blood clots, pulmonary embolism, and strokes. Death rates from heart
    attacks are reduced by new forms of anticoagulation drugs. Stem cell
    transplantation can cure not only blood diseases but also inherited
    metabolic disorders, while gene therapy holds the promise of
    effectively treating even more genetic diseases. Even modest
    investments in hematology research have yielded large dividends for
    other disciplines.
    Fiscal Year 2013 Funding Request
        ASH supports the recommendation of the Ad Hoc Group for Medical
    Research that the Subcommittee recognize NIH as a critical national
    priority by providing at least $32 billion in funding in the fiscal
    year 2013 Labor-HHS-Education appropriations bill. This funding
    recommendation represents the minimum investment necessary to avoid
    further loss of promising research and at the same time allows the
    NIH's budget to keep pace with biomedical inflation.
        It is critically important that our country continues to capitalize
    on the momentum of previous investments to drive research progress to
    develop new treatments for serious disorders, train the next generation
    of scientists, create jobs, and promote economic growth and innovation.
    Adequate funding is necessary for NIH to sustain current research
    capacity and encourage promising new areas of science and cures.
    For Fiscal Year 2013, the American Society of Hematology Seeks
            Congressional Support for the Following Activities
        In fiscal year 2013, ASH also urges the Subcommittee to recognize
    the following areas of hematology research that have shown impressive
    progress and offer the potential of future advances:
                Stem Cells and Regenerative Medicine: Improving Current
                        Technologies to Cure Blood Disorders
        Hematologists have been at the forefront of research in stem cell
    biology by studying blood cell development and exploring stem cells'
    potential to repair damaged tissue, fight infections, and reduce
    autoimmune diseases. The techniques and principles used by
    hematologists in studying the blood system stem cells have been applied
    to stem cells from many other tissues with great success, spawning a
    huge research effort across all areas of medicine.
        Researchers have made significant progress in developing re-
    programmed adult cells, called induced pluripotent stem (iPS) cells,
    which can subsequently develop into any tissue of the body. iPS cells
    can be generated and used in patients who have genetic blood diseases
    as well as other complex diseases because they will not be attacked by
    a patient's own immune system, they serve as a continuous source of
    cells, and they are amenable to genetic manipulation.
        Recent research has suggested that iPS cells can be manipulated to
    become blood stem cells and can be used as a transplant source for
    patients who do not have a matched donor. This will greatly enhance
    bone marrow and cord blood stem cell transplantation for the treatment
    of blood cancers and other hematologic disorders and subsequently
    inform our understanding of transplantation-related morbidities for
    other organs. iPS-generated red blood cells from rare blood types also
    could be used in blood banking as reagents to identify patients and
    blood units suitable for transfusion.
        Future stem cell advances are highly dependent on the ability to
    transplant stem cells at high efficiencies and then have them perform
    well once transplanted. However, several barriers remain that currently
    prevent the clinical translation of iPS cell technology. Compared to
    other sources of stem cells, iPS cells have slower growth kinetics, are
    more genomically unstable, and have decreased efficiency for
    differentiation. These barriers are also important areas for future
    research.
        ASH applauds the efforts of the National Heart, Lung, and Blood
    Institute (NHLBI) to conduct further research in the development of
    blood stem cells from iPS cells and to address the barriers to the
    clinical translation of iPS cell technology.
                Research in Sickle Cell Trait and Exercise-Related Illness
        Sickle cell disease (SCD) is an inherited blood disorder that
    affects 80,000-100,000 Americans, mostly but not exclusively of African
    ancestry. SCD causes production of abnormal hemoglobin, resulting in
    severe anemia, pain, other devastating disabilities, and, in some
    cases, premature death.
        Eight to 10 percent of African-Americans have sickle cell trait.
    Individuals with sickle cell trait do not have SCD, but are carriers of
    one defective gene associated with SCD. Millions of Americans with
    sickle cell trait enjoy normal life spans without serious health
    consequences. At the same time, possible health risks have been
    reported for individuals with sickle cell trait including increased
    incidence of renal failure and malignancy, thromboembolic disorders,
    splenic infarction as a high altitude complication, and exertion-
    related sudden death.
        In April 2010, the National Collegiate Athletic Association (NCAA)
    adopted a policy requiring Division I institutions to perform sickle
    cell trait testing for all incoming student athletes. This policy has
    been controversial because there are no high quality (well-controlled,
    hypothesis-driven, prospective) studies on sickle cell trait and
    exertional collapse or evidence to justify it.
        There is a need for increased biomedical and population-based
    research on sickle cell trait and its relation to exertion-related
    illness as well as other conditions. Based on its 2010 Consensus
    Conference on this topic, NHLBI has identified a research agenda and
    ASH, the American Academy of Sports Medicine, and the NCAA have met to
    discuss potential studies to pursue. It is important that the research
    agenda is moved forward collaboratively under the direction of the
    NHLBI.
    Conclusion
        Hematology research offers enormous potential to better understand,
    prevent, treat, and cure a number of blood-related and other
    conditions. Recent investments have created dramatic new research
    opportunities, spurring advancements and precipitating the promise of
    personalized medicine that will yield far-reaching health and economic
    benefits. Trials to find new therapies and cures for millions of
    Americans with blood cancers, bleeding disorders, clotting problems,
    and genetic diseases are just a few of the important projects that
    could be delayed unless NIH continues to receive predictable and
    sustained funding.
        ASH urges the Subcommittee to continue to be a champion for
    research and support at least $32 billion in funding for NIH in fiscal
    year 2013. The American people are depending on you to ensure the
    Nation does not lose the health and economic benefits of our
    extraordinary commitment to medical research.
        Thank you again for the opportunity to submit testimony. Please
    contact Tracy Roades, ASH Research Advocacy Manager, at
    troades@hematology.org, or Ulyana Desiderio, PhD, ASH Senior Manager
    for Scientific Affairs, at udesiderio@hematology.org, if you have any
    questions or need further information concerning hematology research or
    ASH's fiscal year 2013 funding request.
                                     ______

          Prepared Statement of the American Society for Microbiology
        The American Society for Microbiology (ASM) is pleased to submit
    the following statement on the fiscal year 2013 appropriation for the
    Centers for Disease Control and Prevention (CDC). The ASM is the
    largest single life science organization in the world with
    approximately 38,000 members. The ASM strongly supports the leadership
    role of CDC, in partnership with State and local health departments and
    global organizations, in safeguarding the public health and protecting
    against infectious disease threats through surveillance, laboratory
    diagnosis, and control and prevention strategies.
        The ASM is greatly concerned that the proposed fiscal year 2013
    budget for CDC of $5.1 billion represents a decrease of $664 million,
    or 11.6 percent. The CDC budget may be reduced in fiscal year 2013 by
    an additional 8 percent as the result of an across-the-board,
    sequestration provision in the Budget Control Act. The fiscal year 2013
    decreases accelerate declines in CDC's funding that have occurred in
    the past several years. Such cuts will inevitably have a severe impact
    on CDC's ability to protect the Nation from disease threats and public
    health emergencies. CDC oversees programs that are critical to
    addressing vaccine preventable diseases, foodborne diseases, pandemic
    influenza, vector-borne and zoonotic diseases, high consequence
    pathogens, antimicrobial resistance, healthcare acquired infections,
    and outbreak response activities. Because of declining funding for CDC
    in recent years, its core infectious disease budget has eroded and
    these reductions threaten core epidemiology, laboratory and
    surveillance capacity, as well as modern technologies and methods to
    ensure that CDC laboratories, researchers and outbreak response teams
    are able to continue critical infectious disease activities. In the
    past, declines in resources for prevention and control of infectious
    diseases have resulted in disease reemergence, leading to significantly
    higher costs for the healthcare system and for disease containment
    efforts. The ominous increase in measles cases seen in the United
    States in 2011 is an example of the potential for disease reemergence
    when public health programs are not optimized.
        Although concerned about CDC's overall budget, the ASM does support
    those areas that have received funding increases. These include the
    proposed increase for the National Center for Emerging and Zoonotic
    Infectious Diseases (NCEZID) of $27 million and for the National Center
    for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Infections and
    Tuberculosis Prevention of $35 million. The NCEZD includes CDC's
    antimicrobial resistance activities for surveillance, data collection
    and stewardship which require additional resources to address the
    danger of pathogens resistant to antibiotics. The ASM is pleased to see
    the increase of $17 million for food safety activities to restore and
    improve State and local surveillance and outbreak response capacity and
    move toward implementation of CDC's provisions of the Food Safety
    Modernization Act including Centers of Excellence. The ASM also
    supports the increase of $12.6 million for the National Healthcare
    Safety Network (NHSN). This investment is needed as the number of
    hospitals, long term care facilities, and hemodialysis centers that are
    now using NHSN has risen dramatically in the last 2 years in response
    to State and Federal efforts to control healthcare associated
    infections. The additional funds for NHSN will allow CDC to maintain
    and update the system to meet the increased demands and optimally
    target prevention and control measures.
        The ASM is concerned about the proposed cut of $15.5 million in
    funding to State and local preparedness and response capacity which
    threatens the Nation's preparedness for infectious disease outbreaks
    and other hazards. The strategic national stockpile is reduced by $64
    million in the administration's proposed budget. CDC is one of the few
    Federal agencies providing continuous surveillance, detection and
    response for chemical, biological, radiological and nuclear threats, as
    well as natural disasters, outbreaks and epidemics. CDC fulfills this
    critical role by supporting State and local health departments,
    safeguarding deadly pathogens, managing the strategic national
    stockpile, creating national tracking and surveillance systems and
    overseeing the national laboratory network. The fiscal year 2013 budget
    represents a decrease of $54 million below fiscal year 2012 for these
    critical activities, including elimination of funding for the Academic
    Centers for Public Health Preparedness. We urge the Congress to reject
    these reductions and to restore funding for these important programs.
    Centers for Disease Control and Prevention Funding Supports Strategies
            to Protect Public Health
        CDC activities are critical to preventing disease and disability
    across the United States and abroad. Through partnerships with local,
    State, Federal, and international institutions, CDC has created disease
    prevention campaigns that combine scientific research, public education
    and training of health professionals, case surveillance systems, and
    prevention protocols. Only programs of wide scope and complexity like
    those administered by CDC can be effective against major health issues,
    such as drug resistant pathogens and microbial threats to the Nation's
    food supply.
        Antimicrobial Resistance.--Both United States and global health
    officials list microorganisms resistant to available drugs as one of
    their top priorities. According to the World Health Organization (WHO),
    there are about 440,000 new cases of multidrug resistant tuberculosis
    (MDR TB) each year and at least 150,000 MDR TB deaths. Drug resistant
    cases of malaria and cholera are rising in number, and healthcare
    facilities worldwide are beset by unacceptable rates of AR infections
    like methicillin resistant Staphylococcus aureus (MRSA) and Clostridium
    difficile infections (CDI). Recently CDC surveillance has collected
    case reports from across the United States of bacteria, including E.
    coli, that produce Klebsiella pneumoniae carbapenemase (KPC), an enzyme
    that makes bacteria resistant to most known treatments.
        In large part due to CDC partnerships and prevention initiatives,
    there has been a 60 percent reduction of MRSA in Veterans
    Administration facilities and a 2010 report demonstrated a significant
    MRSA decline in United States healthcare settings in general. CDC data
    also show that rates of MRSA bloodstream infections in hospitalized
    patients fell nearly 50 percent from 1997 to 2007. Last November, CDC
    initiated a new antibiotic tracking system within its National
    Healthcare Safety Network (NHSN) for monitoring in hospital antibiotic
    use electronically. Promotion of appropriate antimicrobial stewardship
    is a critical component of a comprehensive program to reverse the
    impact of antibiotic resistance.
        Healthcare Associated Infections (HAIs).--Pathogens like MRSA that
    are increasingly resistant to therapeutics are particularly alarming
    among vulnerable patients being treated for other medical conditions.
    Last year CDC expanded its NHSN surveillance system from 3,400 to 5,000
    hospitals, hemodialysis and long term acute care facilities, and other
    facilities faced with patient infections acquired in house. NHSN data
    are strong evidence that CDC education and surveillance programs
    achieve gains against these infections. For example, infections
    reported to NHSN that declined in 2010 included a 33 percent reduction
    in central line associated bloodstream infections and 35 percent among
    critical care patients. Such declines result in billions of dollars of
    cost savings to the healthcare system, although the economic and human
    costs of HAIs remain far too high. CDC estimates that 1 out of 20
    hospitalized patients will develop an infection while receiving
    treatment for other conditions. Continued investments in addressing
    other costly healthcare associated infections such as surgical site
    infections and ventilator associated pneumonia should have similar
    impacts to those seen with bloodstream infections.
        Immunization.--CDC campaigns have made impressive progress against
    childhood vaccine preventable diseases in the United States and,
    jointly with WHO and other stakeholders, worldwide. A recent CDC report
    listing the most significant global public health achievements in the
    past decade included various vaccination programs that prevent 2.5
    million deaths every year among young children, that is, measles,
    polio, and diphtheria tetanus pertussis vaccinations. Global mortality
    from measles has declined from an estimated 733,000 deaths in 2000 to
    164,000 in 2008. Since 1988, polio incidence has fallen by 99 percent,
    from more than 350,000 cases to 1,410 in 2010, with four remaining
    endemic countries. In December, CDC activated its Emergency Operations
    Center to strengthen its partnership with the Global Polio Eradication
    Initiative. However, more than 1 million infants and young children
    still die from vaccine preventable pneumococcal disease and rotavirus
    diarrhea every year, and multiple other diseases take lives that could
    be saved through immunization. However, as noted above, the increase in
    measles cases seen in the United States in 2011 and similar increases
    in pertussis in 2010-2011 demonstrates the importance of continued
    investment in vaccination programs to keep these diseases at bay.
        The CDC continues to make progress in raising immunization coverage
    levels for some of the newly available vaccines. In the United States,
    vaccinating infants against rotavirus has shown impressive gains
    against a major cause of severe diarrhea in infants and young children.
    Before introduction of the rotavirus vaccines in 2006, the pathogen was
    responsible for about 200,000 emergency room visits and 55,000-70,000
    hospitalizations per year. Intensive immunization campaigns resulted in
    high percentages of protected children, responsible for a 75 percent
    decline in rotavirus related hospitalizations in 2007-2008 compared
    with pre vaccine levels. Federal estimates indicate that for every
    dollar invested in immunizing Americans, we save $10.20 in direct
    medical costs.
        Food Safety.--Based on surveillance data, CDC believes that
    foodborne contaminants are responsible for about 128,000 United States
    hospitalizations annually. The 31 known microbial pathogens linked to
    foodborne illness account for an estimated 9.4 million of the roughly
    47.8 million illnesses yearly, the remaining blamed on ``unspecified
    agents.'' Five pathogens targeted by CDC account for more than 90
    percent of the identified agent cases: norovirus, Salmonella,
    Clostridium perfringens, Campylobacter, and Staphylococcus aureus. The
    agency's food safety activities utilize multiple tools that include
    case reporting systems, public and food processor education, and
    product recalls. CDC will support five Food Safety Centers of
    Excellence at State health departments across the country. A 2011 CDC
    report summarizing 15 years of case surveillance showed that illnesses
    from E. coli O157 have been cut nearly in half and the overall rates of
    six foodborne infections have been reduced by 23 percent, but warned
    that Salmonella caused infections have risen 10 percent. However,
    problems like the 2011 outbreak of listeriosis associated with
    cantaloupes, the deadliest foodborne outbreak in the United States in
    decades, demonstrates the importance of prompt recognition and response
    to foodborne disease, including laboratory capacity to make the
    diagnosis and fingerprint the strains.
        Public Safety and Preparedness.--The ASM is concerned that the
    administration's fiscal year 2013 budget decreases funding for some
    important CDC biodefense and emergency preparedness activities.
    Programs like the Strategic National Stockpile build our national
    capabilities against both intentionally released and naturally
    occurring infectious agent threats. The agency oversees a national
    laboratory network, develops science based expertise in numerous health
    threats, and serves as primary first responder during sporadic disease
    outbreaks, epidemics, and a broad spectrum of other crises. With State
    and local budgets strained economically, it is all the more important
    that CDC is able to fully support health departments across the
    country. The ASM also urges the Congress recognize that funding is
    needed to ensure CDC's own laboratories and personnel continue to serve
    as national and global leaders against infectious disease and other
    health threats.
    Centers for Disease Control and Prevention Funding Supports Research
            and Education to Prevent Infectious Disease
        The CDC Office of Infectious Diseases (OID), which oversees the
    National Center for Immunization and Respiratory Diseases, the National
    Center for Emerging and Zoonotic Infectious Diseases, and the National
    Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention addresses
    antimicrobial resistance, chronic viral hepatitis, food and water
    safety, healthcare associated infections, HIV/AIDS, respiratory
    infections, vaccine preventable diseases, and zoonotic and vectorborne
    diseases. The ASM strongly supports funding for OID efforts to
    identify, treat, and prevent a long list of infectious diseases that
    kill millions each year. CDC's infectious disease programs play a
    critical role in protecting all Americans from the dangers of microbial
    threats, and we cannot allow these important functions to continue to
    erode.
        The ASM urges the Congress to provide needed new resources in
    fiscal year 2013 for the CDC budget to strengthen science based
    programs that have so effectively investigated, controlled, and, most
    importantly, prevented disease and disability. This funding is critical
    to maintaining the CDC laboratories, expert personnel, education and
    prevention campaigns, and CDC supported collaborations that work
    together daily to protect people in this Nation and worldwide.
                                     ______

            Prepared Statement of the American Society for Nutrition
        The American Society for Nutrition (ASN) appreciates the
    opportunity to submit testimony regarding fiscal year 2013
    appropriations for the National Institutes of Health (NIH) and the
    Centers for Disease Control and Prevention's National Center for Health
    Statistics (NCHS). Founded in 1928, ASN is a nonprofit scientific
    society with more than 4,500 members in academia, clinical practice,
    Government and industry. ASN respectfully requests $32 billion for the
    National Institutes of Health, and we urge you to adopt the President's
    request of $162 million for the National Center for Health Statistics
    in fiscal year 2013.
        Basic and applied nutrition research on the relationship between
    nutrition and chronic disease, nutrient composition, and nutrition
    monitoring are critical for 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 the Nation's premier
    sponsor of biomedical research and is the agency responsible for
    conducting and supporting 86 percent (approximately $1.4 billion) of
    federally funded basic and clinical nutrition research. Nutrition
    research, which makes up about 4 percent of the NIH budget, is truly a
    trans-NIH endeavor, being conducted and funded across multiple
    Institutes and Centers. Some of the most promising nutrition-related
    research discoveries have been made possible by NIH support. In order
    to fulfill the full potential of biomedical research, including
    nutrition research, ASN recommends an fiscal year 2013 funding level of
    $32 billion for the NIH, a modest increase over the current funding
    level of $30.64 billion.
        The modest increase we recommend is necessary to maintain both the
    existing and future scientific infrastructure. The discovery process--
    while it produces tremendous value--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. It is imperative that we continue our commitment to
    biomedical research and continue our Nation's dominance in this area by
    making the NIH a national priority.
        Over the past 50 years, NIH and its grantees have played a major
    role in the growth of knowledge that has transformed our understanding
    of human health, and how to prevent and treat human disease. Because of
    the unprecedented number of breakthroughs and discoveries made possible
    by NIH funding, scientists are helping Americans to live 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
    basic and clinical research is required if we are to successfully
    confront the healthcare challenges associated with an older, and
    potentially sicker, population.
    Centers for Disease Control and Prevention National Center for Health
            Statistics
        The National Center for Health Statistics (NCHS), housed within the
    Centers for Disease Control and Prevention, 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), that serve
    as a gold standard for data collection around the world. Nutrition and
    health data, largely collected through NHANES, are essential for
    tracking the nutrition, health and well-being of the American
    population, and are especially important for observing nutritional and
    health trends in our Nation's children.
        Nutrition monitoring conducted by the Department of Health and
    Human Services in partnership with the U.S. Department of Agriculture
    Agricultural Research Service is a unique and critically important
    surveillance function in which dietary intake, nutritional status, and
    health status are evaluated in a rigorous and standardized manner.
    Nutrition monitoring is an inherently governmental function and
    findings are essential for multiple Government agencies, as well as the
    public and private sector. Nutrition monitoring is essential to track
    what Americans are eating, inform nutrition and dietary guidance
    policy, evaluate the effectiveness and efficiency of nutrition
    assistance programs, and study nutrition-related disease outcomes.
    Funds are needed to ensure the continuation of this critical
    surveillance of the nation's nutritional status and the many benefits
    it provides.
        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 ``nutrients of concern'' such as calcium, which are consumed in
    inadequate amounts by many subsets of our population. Data such as
    these are critical to guide policy development in the area of health
    and nutrition, including food safety, food labeling, food assistance,
    military rations and dietary guidance. For example, NHANES data are
    used to determine funding levels for programs such as the Supplemental
    Nutrition Assistance Program (SNAP) and the Women, Infants, and
    Children (WIC) clinics, which provide nourishment to low-income women
    and children.
        To continue support for the agency and its important mission, ASN
    recommends an fiscal year 2013 funding level of $162 million for NCHS.
    Sustained funding for NCHS can help to ensure uninterrupted collection
    of vital health and nutrition statistics, and will help to cover the
    costs needed for technology and information security upgrades that are
    necessary to replace aging survey infrastructure.
        Thank you for your support of the NIH and the NCHS, and thank you
    for the opportunity to submit testimony regarding fiscal year 2013
    appropriations. Please contact John E. Courtney, Ph.D., Executive
    Officer, if ASN may provide further assistance. He can be reached at
    9650 Rockville Pike, Bethesda, Maryland 20814 or
    jcourtney@nutrition.org.
                                     ______

            Prepared Statement of the American Society of Nephrology
                               executive summary
        The American Society of Nephrology (ASN) requests $32 billion in
    funding for the National Institutes of Health (NIH) and $2.03 billion
    in funding for NIH's National Institute of Diabetes and Digestive and
    Kidney Diseases (NIDDK) in the fiscal year 2013 Labor-HHS-Education
    appropriations bill.
        ASN is dedicated to the study, prevention, and treatment of kidney
    disease, and the society respects your leadership and commitment to
    both preventing illness and maintaining fiscal responsibility.
    Estimates of chronic kidney disease (CKD) in the United States suggest
    that it affects more than 26 million, or 1 in 9, Americans, and more
    than 550,000 of them have irreversible kidney failure.
        Without research funded by NIH broadly and NIDDK specifically,
    research leading to advances in the care and treatment of adults and
    children afflicted with kidney disease would not be conducted.
        For instance, hereditary diseases such as cystinosis--a metabolic
    disorder that affects the kidneys, eyes, thyroid, pancreas, and brain--
    can now be treated to prevent or delay its worst effects on children.
    Although cystinosis is a relatively rare disease, this achievement
    highlights that advancing understanding of the genetics of kidney
    diseases in children enables us to address a previously untreatable
    condition as well as gain significant insight into the mechanisms of
    other kidney conditions.
        In addition, investigative studies supported by NIH and NIDDK
    generated a groundbreaking discovery that helps explain racial/ethnic
    disparities that increase risks for kidney disease, which can lead to
    earlier detection and treatment. The recent finding that African-
    Americans with variant APOL1 genes are at increased risk of kidney
    disease is a crucial step in understanding why this sector of our
    population is four times more likely to have kidney failure than non-
    Hispanic whites.
        Funding from NIH and NIDDK also enabled research that could improve
    ESRD patients' heart health and physical wellness: patients receiving
    daily in-center dialysis had better outcomes compared to conventional
    thrice-weekly dialysis. The discovery of these advantages has
    significant implications for the future of dialysis care for patients
    with end-stage renal disease (ESRD).
        A funding increase of 4 percent for NIH and 4.5 percent for NIDDK
    would continue the important work that is necessary to move the model
    from curative healthcare, where interventions occur late in the natural
    history of a disease, to a preemptive model in which the onset of
    disease is significantly delayed or even prevented--saving taxpayer
    funds and creating a better quality of life for Americans.
        ESRD is covered by Medicare regardless of a patient's age or
    disability status. Consequently, preventing kidney disease and
    advancing the effectiveness of therapies for kidney failure--starting
    with innovative research at NIDDK--would have a greater impact at the
    highest level of costs within the Centers for Medicare and Medicaid
    Services. Perhaps most importantly, in human terms, the applied
    research will help prevent greater suffering among those who would
    otherwise progress to an even greater level of illness.
        Sustained, predictable investment in research is the only way that
    scientific investigations can be effective and lead to new discoveries.
    With funding from NIH and NIDDK, scientists have been able to pursue
    cutting-edge basic, clinical and translational research. While ASN
    fully understands the difficult economic environment and the intense
    pressure you are under as an elected official to guide America forward
    during these tough times, the society firmly believes that funding NIH
    at $32 billion and NIDDK at $2.03 billion will continue to create jobs,
    support the next generation of investigators, and ultimately improve
    public health.
        Several recent studies have concluded that Federal support for
    medical research is a major force in the economic health of communities
    across the Nation.
        It is critically important that the Nation continue to capitalize
    on previous investments to drive research progress, train the next
    generation of scientists, create new jobs, promote economic growth, and
    maintain leadership in the global innovation economy--particularly as
    other countries increase their investments in scientific research.
        Most important, a failure to maintain and strengthen NIH and
    NIDDK's ability to support the groundbreaking work of researchers
    across the country carries a palpable human toll, denying hope to the
    millions of patients awaiting the possibility of a healthier tomorrow.
        ASN strongly recommends that the fiscal year 2013 Labor-HHS-
    Education appropriations bill uphold its longstanding legacy of
    bipartisan support for biomedical research by providing funding of no
    less than $32 billion for NIH and $2.03 billion for NIDDK.
        Should you have any questions or wish to discuss NIH, NIDDK, or
    kidney disease research in more detail, please contact ASN Manager of
    Policy and Government Affairs Rachel Shaffer at rhaffer@asn-online.org.
                                   about asn
        The American Society of Nephrology (ASN) is a 501(c)(3) nonprofit,
    tax-exempt organization that leads the fight against kidney disease by
    educating the society's 13,500 physicians, scientists, and other
    healthcare professionals, sharing new knowledge, advancing research,
    and advocating the highest quality care for patients. For more
    information, visit ASN's website at www.asn-online.org.
                                     ______

         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; such research has
    contributed in innumerable ways to improving the lives of people
    throughout the world.
        ASPB 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.
        Despite the fact that foundational plant biology research underpins
    vital advances in practical applications in health, agriculture,
    energy, and the environment, the amount of money invested in
    understanding the basic function and mechanisms of plants is relatively
    small. This is especially true when considering the significant
    positive impact plants have on the Nation's economy and in addressing
    some of our most urgent challenges in health and nutrition.
        Understanding the importance of these areas and in order to address
    future challenges, ASPB organized the Plant Science Research Summit
    held in September 2011. With funding from the National Science
    Foundation, U.S. Department of Agriculture (USDA), Department of
    Energy, and the Howard Hughes Medical Institute, the Summit brought
    together representatives from across the full spectrum of plant science
    research to identify critical gaps in our understanding of plant
    biology that must be filled over the next 10 years or more in order to
    address the grand challenges facing our Nation and our planet. The
    grand challenges identified at the Summit include:
      --To feed everyone well, now and in the future, advances in plant
            science research will be needed for higher yielding, more
            nutritious crop varieties able to withstand a variable climate.
      --Innovations leading to improvements in water use, nutrient use, and
            disease and pest resistance that reduce the burden on the
            environment are needed and will allow for improved ecosystem
            services, such as clean air, clean water, fertile soil, and
            biodiversity benefits, such as pest suppression and
            pollination.
      --To fuel the future with clean energy--and to ensure that our Nation
            meets its fuel requirements--improvements are needed in current
            biofuels technologies, including breeding, crop production
            methods, and processing.
      --For all the benefits that advances in plant science bestow, to have
            lasting, permanent benefit they must be economically, socially,
            and environmentally sustainable.
        In spring 2012, a report from the Plant Science Research Summit
    will be published. This report will further detail priorities and needs
    to address the grand challenges.
    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 property known as RNA interference,
    which has potential application in the treatment of human disease, was
    first noted in plants. Upon further elucidation in other plants and
    animals, this research 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.'' Without good nutrition, there
    cannot be good health. Indeed, a World Health Organization study on
    childhood nutrition in developing countries concluded that more than 50
    percent of the deaths of children less than 5 years of age could be
    attributed to malnutrition's effects in exacerbating common illnesses
    such as respiratory infections and diarrhea. Strikingly, most of these
    deaths were not linked to severe malnutrition but only to mild or
    moderate nutritional deficiencies. Plant biology researchers are
    working today to improve the nutritional content of crop plants by
    increasing the availability of nutrients and vitamins such as iron,
    vitamin E, and vitamin A.
        By contrast, obesity, cardiac disease, and cancer take a striking
    toll in the developed world. 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 will help in addressing these concerns. Ongoing development
    of crop varieties with tailored nutraceutical content is an important
    contribution that plant biologists are making toward realizing the goal
    of personalized medicine, especially personalized preventative
    medicine.
        Drug Discovery.--Plants are also fundamentally important as sources
    of both extant drugs and drug discovery leads. In fact, more than 10
    percent of the drugs considered by the World Health Organization to be
    ``basic and essential'' are still exclusively obtained from flowering
    plants. A recent example of the importance of plant-based
    pharmaceuticals is the anti-cancer drug taxol, which was discovered as
    an anti-carcinogenic compound from the bark of the Pacific yew tree
    through collaborative work involving scientists at the NIH National
    Cancer Institute and plant biologists at the USDA. 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. Taxol is just
    one example of the estimated 200,000 secondary plant compounds that
    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 from NIH, plant
    biologists can lead the way to developing new medicines and biomedical
    applications to enhance the treatment of devastating diseases.
    Conclusion
        The NIH does recognize that plants help serve 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 asks the Subcommittee
    to 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. For more information about ASPB,
    please see www.aspb.org.
                                     ______

         Prepared Statement of the American Society for Pharmacology &
                           Experimental Therapeutics
        The American Society for Pharmacology and Experimental Therapeutics
    (ASPET) is pleased to submit written testimony in support of the
    National Institutes of Health (NIH) fiscal year 2013 budget. ASPET is a
    5,100 member scientific society whose members conduct basic,
    translational, 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.
        ASPET recommends a budget of at least $32 billion for the NIH in
    fiscal year 2013. Research funded by the NIH improves public health,
    stimulates 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 advances in medical research,
    jeopardizing potential cures, eliminate jobs, and threaten American
    leadership and innovation in biomedical research.
        A $32 billion budget for the NIH in fiscal year 2013 will provide a
    modest 4 percent increase to the agency and help restore NIH to more
    sustainable growth. Currently, the NIH cannot begin to fund all the
    high quality research that needs to be accomplished. After several
    years of flat funding and spending cuts enacted in 2011, the NIH's
    funding environment has reached a critical point:
      --Adjusted for inflation, the fiscal year 2012 budget and the
            President's fiscal year 2013 budget proposal are $4 billion
            lower than the peak year of fiscal year 2003;
      --The number of research project grants funded by NIH has declined
            every year since 2004, and NIH is projected to fund 3,100 fewer
            grants in fiscal year 2012-2013 than in fiscal year 2004; and
      --Success rates have fallen more than 14 percent in a decade and are
            projected to decline further in fiscal year 2012 and fiscal
            year 2013.
        If flat funding continues or if additional cuts are mandated to the
    NIH budget for fiscal year 2013 and beyond, research that improves the
    quality of life will be delayed or stopped, and fewer clinical trials
    will be conducted. 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 ongoing
    work, thus representing a waste of valuable research resources.
        An fiscal year 2013 NIH budget of $32 billion would help to begin
    to restore momentum to NIH funding. A $32 billion fiscal year 2013 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. Scientific
    research takes time. 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 2013 NIH budget of $32 billion will help
    NIH move to more fully exploit promising areas of biomedical research
    and translate the resulting findings into improved healthcare.
    Diminished Support for National Institutes of Health Will Negatively
            Impact 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 difficult Federal funding environment becomes more
    problematic as economic difficulties have led to less investment by the
    pharmaceutical industry and diminished venture capital needed by the
    biotech industry. Previous investments in NIH research have been
    instrumental in improving human health. However, a greater investment
    in research is needed to help improve the lives of many afflicted by
    chronic diseases:
      --Parkinson's disease is estimated to afflict more than 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 the disease, but more
            research is needed to identify the causes of the disease and
            help to 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.
      --One in eight older Americans suffer from Alzheimer's disease at
            annual costs of more than $200 billion. It is estimated that by
            2050 more than 14 million Americans will live with the disease
            with projected costs of $1.1 trillion (in 2012 dollars).
            Although there are new clinical candidates for Alzheimer's
            disease in development, more basic research is needed to focus
            on new molecular targets and potential cures for this disease.
            Inadequate funding will delay and prevent improved 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. Death rates from
            cardiovascular disease have fallen by 50 percent since 1970.
            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 more
            than $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 basic research built the foundation for one of the
            most revolutionary FDA approved new treatments for melanoma and
            helped launch the ear of modern personalized medicine.
      --NIH-funded investigators discovered an enzyme that may act as a
            tumor suppressor, therapeutic target, and clinical biomarker in
            patients with colorectal cancer. Clinical trials are now
            underway to study its role as a possible novel chemoprevention
            approach to prevent colorectal cancer and determine the utility
            of the enzyme as a prognostic and predictive marker for staging
            patients with disease. The enzyme is also being used as a
            vaccine target to prevent recurrent disease. Studies are
            underway evaluating this enzyme's role in regulating appetite
            and as a possible novel therapeutic target to prevent obesity,
            diabetes, and metabolic syndrome.
      --Finding new uses for existing drugs is difficult but could be life
            saving and cost effective. NIH-funded researchers using new
            bioinformatic approaches have discovered that a drug designed
            to treat heartburn also inhibited the growth of human lung
            tumors in laboratory mice. Without adequate support for NIH
            funding, this type of discovery may become impossible and
            potential clinical benefits will not be realized.
      --There are almost 7,000 rare diseases, each afflicting fewer than
            200,000 individuals. More than 350 drugs have been approved for
            rare diseases since passage of the Orphan Drug Act in 1983. The
            number of new drugs in development is increasing rapidly as
            researchers gain a better understanding of the underlying
            molecular and genetic causes of disease. Diminished support for
            NIH will prevent new and ongoing investigations into rare
            diseases that FDA estimates almost 90 percent are serious or
            life-threatening.
        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 5 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.
    Investing in National Institutes of Health Helps America Compete
            Economically
        A $32 billion budget in fiscal year 2013 will also help the NIH
    train the next generation of scientists. This investment will help to
    create jobs and promote economic growth. Limiting or cutting the NIH
    budget will mean forfeiting future discoveries to other countries.
        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 more than 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. The European Union, despite austerity
    measures and the severe debt problems of its member nations, has
    proposed to increase spending on research and innovation by 45 percent
    between 2014 and 2020.
        NIH research funding catalyzes private sector growth. More than 83
    percent of NIH funding is awarded to more than 3,000 universities,
    medical schools, teaching hospitals and other research institutions in
    every State. One national study by an economic consulting firm found
    that Federal (and State) funded research at the Nation's medical
    schools and hospitals supported almost 300,000 jobs and added nearly
    $45 billion to the U.S. economy. NIH funding also provides the most
    significant scientific innovations of the pharmaceutical and
    biotechnology industries.
        Inadequate funding for NIH means more than a loss of scientific
    potential and discovery. As we have noted, failing to help meet the
    NIH's scientific potential has led to a significant reduction in
    research grants and the resulting phasing-out of high quality research
    programs and jobs lost.
    Conclusion
        ASPET appreciates the many competing and important spending
    decisions the Subcommittee must make. The Nation's deficit and debt
    problems are great. However, NIH and the biomedical research enterprise
    face a critical moment. The agency's contribution to the Nation's
    economic and physical well-being 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 $32 billion fiscal year 2013 NIH budget
    will allow the agency to begin moving forward to full program capacity,
    exploiting more scientific opportunities for investigation, and
    increasing investigator's chances of discoveries that prevent, diagnose
    and treat disease. NIH should be restored to its role as a national
    treasure, one that attracts and retains the best and brightest to
    biomedical research and provides hope to millions of individuals
    afflicted with illness and disease.
                                     ______

      Prepared Statement of the American Society of Tropical Medicine and
                                    Hygiene
        The American Society of Tropical Medicine and Hygiene (ASTMH)--the
    principal professional membership organization representing, educating,
    and supporting scientists, physicians, clinicians, researchers,
    epidemiologists, and other health professionals dedicated to the
    prevention and control of tropical diseases--appreciates the
    opportunity to submit testimony to the Senate Labor, Health and Human
    Services, and Education Appropriations Subcommittee.
        The benefits of U.S. investment in tropical diseases are both
    humanitarian and diplomatic. With this in mind, we respectfully request
    that the Subcommittee provide at least $32 billion for the NIH, and
    fully fund CDC in the fiscal year 2013 LHHS appropriations bill to
    allow them to maintain their current activities and research priorities
    to ensure a continued U.S. Government investment in global health and
    tropical medicine research and development:
    National Institutes of Health
        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, neglected tropical diseases (NTDs), and
    diarrheal diseases through the Fogarty International Center.
    The Centers for Disease Control and Prevention
        The Center for Global Health, which includes CDC's work in malaria
    and NTDs; and
        The National Center for Emerging & Zoonotic Infectious Diseases,
    which houses the Emerging and Zoonotic Infectious Disease Program and
    the Vector-Borne Disease Program that are responsible for protecting
    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 creating lifesaving new drugs and diagnostics to some of
    the poorest, most at-risk people in the world.
                                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 and Parasitic Disease.--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 is the lead
    institute for malaria and NTD research.
        ASTMH encourages the subcommittee to:
      --Increase funding for NIH to expand the agency's investment in
            malaria, NTDs, and 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 2013 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 and Parasitic Disease.--Malaria has been eliminated as an
    endemic threat in the United States for over 50 years, and CDC remains
    on the cutting edge of global efforts to reduce the toll of this deadly
    disease. CDC efforts on malaria and parasitic disease 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
            and parasitic disease, including adequately funding the
            important contributions of CDC in malaria and parasitic disease
            at no less than $18 million.
        Neglected Topical Diseases.--CDC currently receives zero dollars
    directly for NTD work outside of parasitic diseases; 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,
            including but not limited to parasitic diseases; 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).--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 through the National Center for
            Emerging and Infectious Zoonotic Diseases.
                                   conclusion
        Thank you for your attention to these important United States and
    global health matters. We know the Congress and the American people
    face many challenges in choosing funding priorities, and we hope you
    will provide the requested fiscal year 2013 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..........................         32,000
        National Heart, Lung and Blood Institute...........          3,214
        National Institute of Allergy and Infectious                 4,701
         Disease...........................................
        1National Institute of Environmental Health                    717.7
         Sciences..........................................
        Fogarty International Center.......................             72.7
        National Institute of Nursing Research.............            151
    Centers for Disease Control and Prevention.............          7,800
        National Institute for Occupational Safety and                 293.6
         Health............................................
        Asthma Programs....................................             25.3
        Div. of Tuberculosis Elimination...................            243
        Office on Smoking and Health.......................            197.1
        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 members
    that focuses on respiratory and critical care medicine. The ATS's
    15,000 members help prevent and fight respiratory disease through
    research, education, patient care and advocacy.
    Lung Disease in America
        Diseases of breathing constitute the third leading cause of death
    in the United States, responsible for 1 of every 7 deaths. Diseases
    affecting the respiratory (breathing) system include chronic
    obstructive pulmonary disease (COPD), lung cancer, tuberculosis,
    influenza, sleep disordered breathing, pediatric lung disorders,
    occupational lung disease, sarcoidosis, asthma, and critical illness.
    The death rate due to COPD has doubled within the last 30 years and is
    still increasing, while the rates for the other three top causes of
    death (heart disease, cancer and stroke) have decreased by more than 50
    percent. The number of people with asthma in the United States has
    surged more than 150 percent since 1980 and the root causes of the
    disease are still not fully known.
                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. Due to the combination of funding
    that has not kept pace with biomedical research and inflation and the
    rising costs of doing research, the number of research project grants
    supported by the NIH is now at the lowest level since 2001. The success
    rate for NIH grants has plummeted to below 13 percent, meaning that
    more than 87 percent of meritorious research is not being funded.
    Without a funding increase 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 $32
    billion for the NIH in fiscal year 2013.
        Despite the rising lung disease burden, lung disease research is
    underfunded. In fiscal year 2011, lung disease research represented
    just 23.4 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 fraction of
    the money invested for the other leading causes of death.
                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 and occupational safety and health
    research and training. The ATS recommends a funding level of $7.8
    billion for the CDC in fiscal year 2013.
    Chronic Obstructive Pulmonary Disease
        COPD is the third leading cause of death in the United States and
    the third leading cause of death worldwide. 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 have
    a public health action plan on the disease. The ATS urges the 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) and the
    National Health Information Survey (NHIS).
    Tobacco Control
        Cigarette smoking is the leading preventable cause of death in the
    United States, responsible for 1 in 5 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 $197 million for the Office of Smoking and
    Health in fiscal year 2013.
    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. Many children with respiratory illness grow into
    adults with COPD. It is estimated that 7.1 million children suffer from
    asthma. While some children appear to outgrow their asthma when they
    reach adulthood, 75 percent will require life-long treatment and
    monitoring of their condition. 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 25 million Americans currently have asthma. 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 more than
    $50.1 billion per year. African-Americans have the highest asthma
    prevalence of any racial/ethnic group and the age-adjusted death rate
    for asthma in this population is three times the rate in whites.
        The President's fiscal year 2013 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 more than 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 ask that in your appropriations request for fiscal year
    2013 that funding for CDC's National Asthma Control Program be
    maintained at a funding level of at least $25.3 million and that the
    National Asthma Control Program remain as a distinct, stand-alone
    program.
    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 2013 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 1.4 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. Treatment costs
    for multidrug-resistant (MDR) TB range from $100,000 to $300,000. The
    global TB pandemic and spread of drug resistant TB present a persistent
    public health threat to the United States.
        Despite declining rates, persistent challenges to TB control in the
    United States remain. Specifically: (1) racial and ethnic minorities
    continue to suffer from TB more than majority populations; (2) foreign-
    born persons are adversely impacted; (3) sporadic outbreaks occur,
    outstripping local capacity; (4) continued emergence of drug
    resistance; and (5) there are critical needs for new diagnostics,
    treatment and prevention tools.
        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 $243 million in fiscal year 2013 for
    CDC's Division of TB Elimination, as authorized under the CTEA, and
    encourages the NIH to expand efforts 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 enormous, and 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. To put that in context, that is the approximately the
    number of deaths each year due to breast cancer, colon cancer, and
    prostate cancer combined. This disease can be triggered by a variety of
    causes, including infections, drowning, traumatic accidents, burn
    injuries, blood transfusions and inhalation of toxic substances.
    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. FIC has created
    supplemental TB training grants for these institutions to train
    international health professionals in TB treatment and research. The
    ATS recommends the Congress provide $72.8 million for FIC in fiscal
    year 2013, 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 ATS urges the subcommittee to provide at least level funding
    for the National Institute for Occupational Safety and Health (NIOSH).
    NIOSH, within the Centers for Disease Control and Prevention (CDC), is
    the primary Federal agency responsible for conducting research and
    making recommendations for the prevention of work-related illness and
    injury. NIOSH provides national and world leadership to avert workplace
    illness, injury, disability, and death by gathering information,
    conducting scientific research, and translating this knowledge into
    products and services. NIOSH supports programs in every State to
    improve the health and safety of workers.
        The ATS appreciates the opportunity to submit this statement to the
    subcommittee.
                                     ______

           Prepared Statement of the American Urogynecologic Society
        Founded in 1979, the American Urogynecologic Society (AUGS) is a
    professional organization of 1,400 physicians and allied health
    professionals who are dedicated to caring for women with pelvic floor
    disorders (PFD) that include pelvic organ prolapse, stress urinary
    incontinence, and defecatory disorders such as constipation and fecal
    incontinence.
        As the largest U.S. professional organization dedicated to caring
    for women with PFDs, AUGS is committed to advancing this vastly
    understudied field as a means to improve the quality of life of women
    worldwide. We are pleased to submit testimony to the Appropriations
    Subcommittee on Labor, Health and Human Services, Education, and
    Related Agencies requesting a greater commitment to biomedical research
    focused on female pelvic floor disorders, including incontinence.
    Impact of Pelvic Floor Disorders
        Female pelvic floor disorders (PFD) represent an under-appreciated,
    but major public health burden with high prevalence, impairment of
    quality of life, and substantial economic costs. These disorders, which
    include urinary and fecal incontinence as well as pelvic organ prolapse
    (POP) (pelvic organs protruding outside of the body), affect 25 percent
    of women aged 40-59. Women with PFDs suffer from pressure, pain,
    embarrassment, and frequently social isolation. However, because PFDs
    are rarely fatal and are underreported by those affected, public
    attention is sparse. While many of us take bladder and bowel control
    for granted, for those that suffer, day-to-day life is not routine.
    Prevalence dramatically increases with age; 50 percent of women over 80
    suffer from uncontrollable leakage of urine or stool and/or POP. As the
    United States population ages, PFDs will become an even greater public
    health issue that cannot be ignored.
        List of research priorities for PFDs:
      --Expand research into understanding what causes some women to suffer
            from PFDs, while other women are spared.
      --Foster collaborations between clinician scientists, basic
            researchers, and translational scientists.
      --Facilitate clinical effectiveness studies through the development
            of large practice-based networks, registries, or multi-
            institutional databases.
        Amount requested: $25 million in fiscal year 2013.
        Since fiscal year 1999 (14 fiscal years), the National Institute of
    Child Health and Human Development (NICHD), National Institute of
    Diabetes, Digestive, and Kidney Diseases (NIDDK) and the National
    Institute on Aging (NIA) have provided $150 million (or $10.7 million
    per annum) to PFD research (NIH Reporter query 4/21/12 [search criteria
    = ``pelvic floor'']). This funding has resulted in several important
    discoveries and programs, briefly summarized here:
      --The prevalence of the most common PFDs is better understood.
            (Nygaard, Brown, Bharucha, Guise)
      --Using increasingly well-characterized knockout mouse models, the
            role of modeling and remodeling of connective tissue
            constituents for pelvic floor support has been better
            elucidated. (Moalli, Word, Chen, Clark)
      --Utilizing magnetic resonance imaging and 3D ultrasound, the
            functional (and dysfunctional) anatomy of pelvic floor organ
            support by deep pelvic floor muscles is being explored.
            (Delancey, Ashton-Miller, Dietz)
      --The role of peripheral nerve injury in the function of sphincteric
            muscles has been evaluated in rodents, in some nonhuman
            primates, and in humans. (Damaser, Wai, Pierce, Kuehl, Weidner)
      --Genetic determination of disease expression is currently being
            explored in populations of families. (Norton)
      --Major NIH-funded networks (the Pelvic Floor Disorders Network and
            the Urinary Incontinence Treatment Network) have provided new
            insights from well-conceived clinical trials that are being
            incorporated into routine practice.
        Although these studies have led to important advances in PFD
    research, they have also unveiled a wealth of unanswered questions that
    only can be addressed with ongoing funded research. Given the potential
    for further critical research in this area and the large proportion of
    the population affected by these disorders, we respectfully request a
    significant increase in funding to $25 million in fiscal year 2013 in
    order to build on the work already done. By providing at least $32
    billion in funding to the National Institutes of Health in the fiscal
    year 2013 Labor-HHS-Education appropriations bill, there would be
    enough of an increase to also allow NICHD and NIDDK to appropriately
    provide for this requested increase in PFD research, as well.
    Further Detail Regarding Research Priorities for Pelvic Floor Disorders
        NICHD, NIDDK and NIA need to expand research into understanding
    what causes some women to suffer from PFDs, while other women are
    spared.
        Rationale.--Unlike many other disease processes, the underlying
    causes of PFDs are poorly understood, and thus, our ability to
    accurately determine which woman will be affected is rudimentary.
    Because of these significant knowledge gaps, efforts to develop
    effective preventive strategies and long-term treatment options remain
    empiric, rather than based on understanding of the underlying
    mechanisms of disease. This, in turn, likely contributes to the lack of
    long-term success of existing therapies. For example, women who suffer
    from urinary incontinence due to a condition called ``overactive
    bladder'' only achieve moderate improvements with currently approved
    medications. Furthermore, those that do get relief frequently
    discontinue medication because of equally bothersome side effects. An
    accurate understanding of disease mechanisms and varied expression of
    the disease is critical for advancing prevention strategies and
    developing new treatments. Better understanding of treatment failures
    will additionally serve to achieve our ultimate goal of improving the
    lives of millions of women who suffer from these highly prevalent
    disorders.
        Research Goal.--Encourage diverse research methodologies such as
    biomechanics, bioinformatics, genomics and proteomics, cellular biology
    and epidemiology. Below two research initiatives aimed at expanding
    research in the pathophysiology and phenotypes of PFDs are briefly
    outlined. To achieve this goal AUGS recommends the following:
          Pathophysiology.--Scientific understanding of tissue-specific
            abnormalities that underlie female PFDs is in its infancy with
            many competing concepts and hypotheses that do not have
            unifying themes. It is unclear whether the abnormalities
            presently associated with pelvic floor dysfunction are due to
            acute or repeated injury, deterioration, or inherent
            abnormalities of the structures studied. Investigations are
            urgently needed into the mechanisms underlying observed changes
            in the skeletal and smooth muscles of the pelvic floor;
            autonomic, peripheral and central nervous systems; and the
            connective tissues of the pelvic floor.
        --Create a multi-center discovery network of expert centers focused
                on the pathophysiology of PFD to develop coordinated
                research.
        --Publish RFAs to fund the required mechanistic research into the
                basic causes of the occurrence and progression of PFD.
          Phenotyping.--Accurate disease/disorder categorization is
            uniformly critical to high-quality research; however, current
            knowledge of various forms of urinary and fecal incontinence
            and POP is limited. The process of developing definitions of
            ``disease/disorder'' requires the use of epidemiologic,
            biologic, molecular and computational methodologies for complex
            processes such as PFDs. Therefore AUGS recommends:
        --Publish a specific RFA to fund multidisciplinary research on how
                to phenotype PFD.
        --Once the process has been defined, fund a consortium of centers
                focused on multidisciplinary approaches to accurately
                phenotype pelvic floor disorders.
        NIH Institutes need to foster collaborations between clinician
    scientists, basic researchers, and translational scientists.
        Rationale.--The Inaugural AUGS Research Summit 2010 recommended a
    variety of complex research topics to advance understanding in PFDs,
    all of which require multidisciplinary expertise. It is critical to
    prioritize enhancing partnerships between clinician scientists and
    basic/translational scientists to maximize the bi-directional flow of
    research.
        Research Goals.--We propose the following near-term action items to
    achieve this priority.
      --Using the RFA and PA mechanisms, include basic science research in
            ongoing and new large collaborative/network trials. This would
            allow basic scientists to create a tissue bank and access data
            and tissues collected from diverse yet well-characterized
            populations. Additionally, research grant requirements could be
            redefined so that large clinical studies are required to
            include a basic science component. This would encourage
            clinicians to think about the mechanisms leading to their
            observations and outcomes, and basic scientists to base their
            investigations on clinical perspective in their areas of
            expertise.
      --Develop seed funding mechanisms focused on bringing
            multidisciplinary experts together to plan and design studies
            in Female Pelvic Medicine and Reconstructive Surgery. Primary
            barriers preventing collaborative groups from receiving funding
            are the protected time necessary for investigators to plan and
            funds for them to generate pilot data together to produce
            meaningful proposals.
      --Increase ongoing communications between NICHD, NIDDK, NIA and
            Office of Research on Women's Health (ORWH) to align their
            goals and strategies in Female Pelvic Medicine and
            Reconstructive Surgery research. This also includes identifying
            scientific officers within these NIH Institutes and ORWH with
            specific responsibilities of advocacy for basic science/
            multidisciplinary research projects in Female Pelvic Medicine
            and Reconstructive Surgery. This organization at the level of
            the NIH would better focus research priorities and reduce
            redundancy, translating into better use of resources.
        NICHD, NIDDK and the Agency for Healthcare Research and Quality
    should work together and facilitate clinical effectiveness studies
    through the development of large practice-based networks, registries,
    or multi-institutional databases.
        Rationale.--Finding safe and cost-effective treatments for PFDs is
    of the utmost importance; however, the pipeline from bench to bedside
    is laborious. Women, in the meantime, continue to suffer from and seek
    treatment for PFDs. Research focused on comparative effectiveness,
    health behavior, cost-effectiveness and implementation science are
    crucial to provide safe, effective care to the many women who suffer
    from pelvic floor dysfunction in the immediate term. In order to make
    such research possible, it is imperative to develop an infrastructure
    that allows the study of treatment effectiveness or how treatments
    perform in a more ``real world'' setting. Broader participation in such
    efforts would be facilitated by the development of a system to
    encourage non-NIH funded investigators to contribute patients to
    ongoing multicenter trials or cohort studies. To achieve these goals,
    we recommend the following immediate actions:
          Establish Evidence-Based Outcome Measures.--Currently, clinical
            research is limited by the variability (across studies) in
            techniques for measurement of clinically relevant outcomes.
            Therefore, uniform evidence-based outcome measures should be
            selected or developed to allow cross-study comparisons and
            meta-analyses.
        --To select and develop this ``bank'' of measures, an
                interdisciplinary team should be convened and should
                include representatives from traditional Federal funding
                and oversight entities, as well as broad representation of
                other stakeholders including professional societies, and
                patients. The minimum data set proposed by the NIH
                Standardization of Terminology for Researchers in Female
                Pelvic Floor Disorders (2001) should be revised. The
                concept of a clinical outcome measure that balances
                improvement in pre-existing symptoms with the development
                of new symptoms and complications should be explored.
        --A library for clinical measurements in research should be
                established, including those that apply to both affected
                and unaffected individuals and including minority
                populations; such measures must be available in Spanish.
                Uniform measures across centers would promote comparisons
                of treatment outcomes in various settings and populations.
                In addition, this would facilitate the identification of
                quality indicators that assess the balance between benefits
                and harms.
          Practice-Based Networks.--The past 10 years has seen substantial
            progress with respect to high-quality clinical trials in the
            evaluation and treatment of PFDs. This will be crucial to
            ensure high quality as well as cost-effective care for our
            aging population.
        --Develop practice-based networks for clinical research for short
                and long-term (5 years or more) outcomes. The challenges
                are to engage practicing physicians in research, to
                encourage patients to participate in clinical trials, and
                to ensure best research practices in this context.
        --Develop a web-based comprehensive database for data collection.
                Ideally, this database would interface not only with the
                central repository, but also with the local medical record.
          Support a National Registry for Permanent Surgical Implants Used
            in POP Surgery.--The past decade has seen an unprecedented
            increase in the development of new surgical implants, many with
            uncertain long-term effects. Indeed, in 2008 the FDA issued a
            Public Health Notification and in 2011 a Safety Update
            regarding ``serious complications associated with transvaginal
            placement of surgical mesh''. Such a registry would allow the
            tracking and study of long-term efficacy and safety outcomes as
            well as the improved identification of rare adverse events
            associated with the use of these implants.
        We thank you, Mr. Chairman, and the Subcommittee, for your support
    of research regarding Pelvic Floor Disorders and thank you for the
    opportunity to share these comments.
                                     ______

               Prepared Statement of the Animal Welfare Institute
        We are grateful to the Animal Welfare Institute (AWI) subcommittee
    for this opportunity to offer testimony as you consider budget
    priorities for fiscal year 2013. This testimony addresses the National
    Institutes of Health (NIH), but does not make any funding requests.
        Thanks to the 2009 National Academy of Sciences (NAS) report
    ``Scientific and Humane Issues in the Use of Random Source Dogs and
    Cats in Research'', and to ongoing concern on the part of the Congress,
    the NIH has begun the process of prohibiting its extramural researchers
    from acquiring dogs and cats from random source Class B dealers. The
    ban on the acquisition of cats from these dealers will take effect on
    October 1, and the ban on the acquisition of dogs is scheduled to take
    effect in 2015.
        It should be clarified that the NAS report addressed extramural
    research funded by NIH, not NIH's internal research endeavors. There
    was no need--NIH had ceased using Class B dog and cat dealers in its
    own research over 20 years ago, recognizing the problems--both ethical
    and scientific--caused by acquiring animals from sources that treat
    dogs and cats inhumanely; fail to provide proper veterinary care and
    the basic necessities of life such as clean water, food, and shelter;
    acquire animals through fraud and deception; and are constantly under
    investigation for apparent violations of the Animal Welfare Act. In
    fact, in a 2010 article in Science (David Grimm, ``Dog Dealers' Days
    May Be Numbered,'' Vol. 327, 26 February 2010, p. 1076-1077), Dr.
    Robert Whitney, director of NIH's animal resources program for 20
    years, is quoted as saying, ``By using these animals, we risk losing
    our credibility with the public. It's an Achilles' heel for research.''
    Even so, and even in the face of congressional concern, NIH had
    steadfastly refused to hold its outside grant recipients to the same
    high standards it was requiring of its intramural researchers. We
    commend NIH for taking the NAS report recommendations and the Congress'
    concerns to heart and moving forward to end its support for the Class B
    dealer system.
        As a result of the NAS report, ongoing congressional interest,
    intensive (and overly expensive) oversight, and evaporating demand for
    their dogs and cats, very few of these dealers remain. Of the eight
    remaining random source Class B dog and cat dealers, one is still under
    a license suspension, one has received an Official Warning/Violation of
    Federal Regulations, and three others remain under investigation. Cases
    are still pending against two dealers who have given up their licenses;
    one of them was indicted on a number of Federal charges, including
    conspiracy, aggravated identity theft, mail fraud, and making false
    statements to a Federal agency.
        However, even with positive steps toward ending the Class B dealer
    system as a source of dogs and cats for research, it is too early for
    the Congress to take its eye off the ball. Until the Pet Safety and
    Protection Act is enacted, thus putting a permanent end to the supply
    of animals to research through Class B dealers, the potential will
    exist for the system to reconstitute itself. In light of this, it is
    vital that the Congress take every opportunity to underscore its
    continuing vigilance on this issue. We therefore respectfully ask the
    subcommittee to include the following language in its report:

        ``The Committee wishes to acknowledge that NIH has made progress in
    moving to end the use of Class B random source dealers as suppliers of
    dogs and cats to its grant recipients by recently announcing a ban,
    effective October 1, 2012, on the acquisition of cats from Class B
    random source dealers. The Committee urges NIH to move as expeditiously
    as possible to implement the ban on the acquisition of dogs from Class
    B random source dealers, preferably before, but certainly no later
    than, 2015, and to ensure that the ban covers not only future grant
    awards but also those in place at the time the ban goes into effect.
    Finally, the Committee requests that NIH provide regular reports to the
    Committee on the status of this process.''

        Thank you for your consideration of this request.
                                     ______

         Prepared Statement of the Brain Injury Association of America
        Chairman Harkin and Ranking Member Shelby, thank you for the
    opportunity to submit this written testimony with regard to the fiscal
    year 2013 Labor-HHS-Education appropriations bill. This 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 the 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; and
      --$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 21 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, the Congress
    should provide $11 million (+$1.5 million) in fiscal year 2012 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 Communities Advocating Emergency AIDS Relief
                                   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 1 of 7 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 345 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 2013 funding requests for Part A,
    Part B base and ADAP, and Part C reflect the amounts authorized by the
    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 2009
    the number of people living with AIDS grew 44 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 2012
    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:
      --$789.5 million for Part A to support grants to the cities where
            most people with HIV/AIDS live and receive their care and
            treatment.
      --$502.9 million for Part B base to provide additional needed
            resources to the States to bolster the public health response
            statewide regardless of location.
      --$1,123.3 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.
      --$285.8 million for Part C to support grants to faith- and
            community-based organizations, healthcare agencies, and
            clinics.
      --$42.2 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 2008 there were 1,178,350 persons living with HIV/AIDS in the
    United States. This represents an increase of approximately 7 percent
    from the previous estimate in 2006. Among persons initially diagnosed
    with HIV infection during 2008, one-third (33 percent) received an AIDS
    diagnosis within 12 months. These late diagnoses represent missed
    opportunities for treatment and prevention.
        The fiscal year 2013 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 20 percent
    of people living with HIV who do not know they are infected and
    therefore are not in care. Bringing these individuals into care will
    save large sums of money in the long run, but requires an initial
    investment now. Research clearly shows that averting a single HIV
    infection saves $221,365 in lifetime healthcare costs \1\, and getting
    people on anti-HIV treatment early lowers levels of HIV circulating in
    the body and reduces potential transmissions \2\--saving lives and
    money in the long term--but we must invest now in care and treatment to
    reap those rewards. Caring for individuals early in their disease will
    increase the cost of care by $2.7 billion over 5 years and the majority
    of those costs will fall to Federal discretionary programs like the
    Ryan White Program and will not be offset by entitlement programs.\3\
    ---------------------------------------------------------------------------
        \1\ Holtgrave DR, Briddell K, Little E, Bendixen AV, Hooper M,
    Kidder DP, et al. Cost and threshold analysis of housing as an HIV
    prevention intervention. AIDS & Behavior.(2007)11(Suppl 2), S162-S166.
        \2\ Montaner J, Lima VD, Barrios R, et al. Association of highly
    active antiretroviral therapy coverage, population viral load, and
    yearly new HIV diagnoses in British Columbia, Canada: a population-
    based study. The Lancet (2010) 376(9740): 532-539.
        \3\ Martin EG, Paltiel AD, Walensky, RP, Schackman BR, Expanded HIV
    Screening in the United States: What Will It Cost Government
    Discretionary and Entitlement Programs? A Budget Impact Analysis. Value
    in Health (2010) 13: 893--902.
    ---------------------------------------------------------------------------
        Community-based providers are stretched to provide high-quality
    care with the scarce resources available. CAEAR Coalition is concerned
    that many HIV expert medical staff are scheduled to retire and the
    persistent financial pressures may accelerate the loss of trained
    professionals in the field. This additional pressure on an already
    overburdened system will leave many of the more than 200,000 HIV-
    infected individuals who do not know their HIV status without access to
    the care they need.
        State budget cuts have created a continuing and growing ADAP
    funding crisis as a record number of people are in need of ADAP
    services due to the economic downturn. As of April 2012, there are
    3,079 people on ADAP waiting lists in 10 States. Additionally, ADAP
    waiting lists and other cost-containment measures, including limited
    formularies, reducing eligibility, or removing already enrolled people
    from the program, are clear evidence that the need for HIV-related
    medications continues to outstrip availability. ADAPs are forced to
    make difficult trade-offs between serving a greater number of people
    living with HIV/AIDS with fewer services or serving fewer people with
    more services. Additional resources are needed to reduce and prevent
    further use of cost-containment measures to limit access to ADAPs and
    to allow all State ADAPs to provide a full range of HIV antiretrovirals
    and treatment for opportunistic infections.
        The number of clients entering the 349 Part C community health
    centers and outpatient clinics has consistently increased over the last
    5 years. More than 255,000 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 the Congress to meet the
    challenges posed by the HIV/AIDS epidemic. In 2013, 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 the Congress for
    fiscal year 2013.
                                     ______

         Prepared Statement of the Council of Academic Family Medicine
                       fiscal year 2013 funding requests
        Concerning.--Health Resources and Services Administration (HRSA),
    Title VII Primary Care Training and Enhancement (Section 747 of Public
    Health Service Act (PHS)), Title VII, Sections 749A and B, the Teaching
    Health Center Development Grants and the Rural Physician Training
    Grants, the Agency for Healthcare Research and Quality (AHRQ) and its
    Primary Care Extension Program, and the National Health Workforce
    Commission.
        The member organizations of the Council of Academic Family Medicine
    (CAFM) are pleased to submit testimony on behalf of programs under the
    jurisdiction of the Health Resources and Services Administration (HRSA)
    and the Agency for Healthcare Research and Quality (AHRQ). The programs
    we support in our testimony are ones that deliver an investment in our
    Nation's workforce and health infrastructure. They are a down payment
    on a U.S. healthcare system with a foundation of primary care that will
    produce better health outcomes and reduce the ever rising costs of
    healthcare. We understand that hard decisions must be made in these
    difficult fiscal times, but even in this climate we hope the Committee
    will recognize that the production of a robust primary care workforce
    for the future is a necessary investment that cannot wait.
        Members of both parties agree there is much that must be done to
    support primary care provider production and to 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.
        We urge the Committee to appropriate at least $71 million for the
    health professions program, Primary Care Training and Enhancement,
    authorized under Title VII, Section 747 of the Public Health Service
    Act in order to allow for a new competitive cycle for physician primary
    care training grants.
    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, the 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.
        We urge you to support at least a $71 million appropriation for the
    Primary Care Training and Enhancement program funded through the Labor-
    HHS-Education appropriations bill. This funding level is necessary to
    permit a competitive grant cycle for physician primary care training
    grants. Without additional funding, this will be the second year in a
    row there are insufficient funds to conduct a grant cycle. In a time of
    increasing primary care need, we urge you to recognize the importance
    of maintaining and expanding the pipeline of primary care production
    and training. Funding for primary care training is an investment in the
    future restraint of healthcare spending, as well as in improved health
    outcomes.
        Level funding for primary care training is not enough. With the
    allocation of 15 percent of the appropriations of the Primary Care
    Training and Enhancement program line for physician assistant training,
    the Congress has taken steps to alleviate the shortfall in physician
    assistant training. However, not funding a competitive cycle for
    physicians stifles opportunities for inter-professional, team-based
    training. The Nation needs new initiatives relating to increased
    training in inter-professional care, the patient-centered medical home,
    and other new competencies required in our developing health system.
    Such initiatives will be impossible to implement without a competitive
    grant cycle. Now is the time to ensure that critical funding for the
    Primary Care Training and Enhancement program takes place. We cannot
    allow the primary care pipeline to dry up.
        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 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.''
        A recent study in the Annals of Family Medicine (Phillips and
    Turner, March/April 2012) stated that ``Meeting this increased demand
    [for primary care physician production] requires a major investment in
    primary care training.'' The study continues, ``Expansion of Title VII,
    Section 747 with the goal of improving access to primary care would be
    an important part of a needed, broader effort to counter the decline of
    primary care. Failure to launch such a national primary care workforce
    revitalization program will put the health and economic viability of
    our Nation at risk.''
        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.
        The evidence is clear:
      --Demonstration projects and international experiences that
            preferentially invest in primary care can reduce spending,
            particularly for inpatient and emergency department care
            (Health Affairs, March-April 2009).
      --``There is compelling evidence that healthcare outcomes and costs
            in the United States are strongly linked to the availability of
            primary care physicians. For each incremental primary care
            physician (PCP), there is 1.44 fewer deaths per 10,000 persons.
            Patients with a regular primary care physician have lower
            overall healthcare costs than those without one.'' (Council on
            Graduate Medical Education (COGME) December, 2010)
      --Hospital readmission after discharge is often a costly failing of
            the U.S. healthcare system to adequately manage patients who
            are ill. Increasing the number of family physicians (FPs) is
            associated with significant reductions in hospital readmissions
            and substantial cost savings. (Robert Graham Center, 2011)
    Agency for Health Care Research and Quality
        As mentioned above, the overall health of a population is directly
    linked to the strength of its primary healthcare system. Primary care
    research includes: translating science into the practice of medicine
    and caring for patients, understanding how to better organize
    healthcare to meet patient and population needs, evaluating innovations
    to provide the best healthcare to patients, and engaging patients,
    communities, and practices to improve health.
        Research related to the most common acute, chronic, and comorbid
    conditions that primary care clinicians care for on a daily basis is
    lacking. 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. And yet, the majority of research funding supports research of
    one specific disease, organ system, cellular, or chemical process--not
    for primary care.
        One cogent example of how AHRQ funded research is making a
    difference in primary care practices is a study on ``Care Coordination
    Accountability Measures for Primary Care Practice,'' published in
    January, 2012. This report builds on earlier work and presents measures
    ``that are well suited for use by health plans and insurers to assess
    the quality of coordination in primary care practices and by primary
    care practices themselves to assess their own performance.'' This type
    of research requires sufficient funding for AHRQ so it can help
    researchers address the problems confronting our health system today.
        We recommend the Committee fund AHRQ at a base, discretionary level
    of at least $400 million for fiscal year 2013.
    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 2013.
    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 2013 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.
        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.
    Teaching Health Center Development Grants
        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. In the first year of
    the program there were already 11 community-based entities from States
    across the country that committed to train 44 additional primary care
    residents: the second year of the program brought 11 additional
    grantees into the program, expanding both the scope of specialties
    trained and increasing the number of full-time equivalent residents
    trained to 143. This demonstration of early success of the program
    should not go unnoticed or unsupported. The limiting factor to the
    program is not the operating funds, but the ability of residencies to
    plan for the change in their sponsorship. Funding Teaching Health
    Center Development Grants will help fulfill the promise of these
    innovative programs.
        We recommend the Committee appropriate the full authorized amount
    for the Title VII Teaching Health Centers development grants of at
    least $10 million for fiscal year 2013.
    Workforce Commission
        We have recognized the need, and called for a national commission
    on health workforce issues for many years. We appreciate the work of
    this Committee in funding the National Workforce Commission at $3
    million for fiscal year 2012 and were disappointed the final bill
    didn't contain funding for the Commission.
        We ask the Committee to continue to recommend $3 million for the
    National Workforce Commission at $3 million for fiscal year 2013.
                                     ______

     Prepared Statement of the Centers for Disease Control and Prevention
                                   Coalition
        The CDC Coalition (c/o American Public Health Association) 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 critical 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 the 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 $7.8 billion for CDC's programs
    in fiscal year 2013. We are deeply disappointed with the proposed $664
    million cut to CDC's budget authority contained in the President's
    fiscal year 2013 budget proposal. In fact, when including the
    President's fiscal year 2013 request, CDC's budget authority would have
    been decreased by a staggering $1.4 billion since fiscal year 2010.
    While CDC has received and the President's fiscal year 2013 budget
    proposal directs significant funding from the Prevention and Public
    Health Fund to CDC, we believe this funding is essentially supplanting
    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. We urge you to
    restore this cut to CDC's budget authority and to support the $1
    billion available through Prevention and Public Health Fund in fiscal
    year 2013.
        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 serves as the command center for our Nation's public health
    defense system, conducting surveillance and detection of 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.
        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.
        Heart disease remains the Nation's No. 1 killer. In 2009, more than
    599,000 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 and stroke each year, and in 2009, females had higher
    rates of stroke mortality than males. Stroke is the fourth leading
    cause of death and is a leading cause of disability. In 2009, stroke
    killed almost 129,000 people (60 percent of them women), accounting for
    about 1 of every 19 deaths.
        Cancer is the second most common cause of death in the United
    States. There are 1,638,910 new cancer cases and 577,190 deaths from
    cancer expected in 2012. The financial cost of cancer is also
    significant. According to the National Institutes of Health, in 2007
    the overall cost for cancer in the United States was more than $226.8
    billion: $103.8 billion for direct medical costs, $123 billion for
    indirect mortality costs (cost of lost 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 all 50 States to
    develop Comprehensive Cancer Control 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.
        Arthritis is the most common cause of disability in the United
    States, striking 50 million Americans of all ages, races and
    ethnicities. CDC's Arthritis Program plays a critical role in
    addressing this growing public health crisis.
        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 3,800 young people initiate cigarette smoking.
    At the same time, according to CDC, only 1 out of 3 high school
    students participate in daily physical education classes. Seventy-eight
    percent of high school students do not eat the recommended number of
    servings of fruits and vegetables, while 1 in 3 children and
    adolescents are overweight or obese. And every year, more than 400,000
    teen girls give birth and nearly half of all sexually transmitted
    diseases occur in young people between the ages of 15 and 24. 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 619,400 in the United
    States 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 $17 billion annually. 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.
        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 more than 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 the
    majority of unintentional fatal injuries caused by motor vehicle
    traffic fatalities. 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 and ensuring
    widespread adoption of proven strategies.
        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.
        CDC's National Center for Environmental Health is essential to
    protecting 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. NCEH funds programs to reduce
    the burden of asthma in our States and communities and to track the
    impact of environmental exposures on our health. We ask you to support
    adequate funding for these vital programs which has been significantly
    reduced over the past several years.
        We thank you for your past support and urge you to adopt our fiscal
    year 2013 request of $7.8 billion for CDC's programs.
                                     ______

         Prepared Statement of the Christopher & Dana Reeve Foundation
        Senator Harkin, Ranking Member Shelby and Members of the
    Subcommittee, thank you for the opportunity to submit testimony in
    support of funding for the National Center on Birth Defects and
    Developmental Disabilities (NCBDDD) within the Centers for Disease
    Control and Prevention, as well as on the importance of a strong
    Federal investment in medical research at the National Institutes of
    Health (NIH).
        I am Matthew Reeve, the eldest son of Christopher Reeve, and I have
    served on the Board of the Christopher & Dana Reeve Foundation since
    2006. I also serve on the Foundation's Quality of Life Committee, which
    funds programs across all 50 States and around the globe to help people
    living with paralysis become more fully integrated members of society.
        The Foundation is dedicated to both curing spinal cord injury by
    funding innovative research and to improving the quality of life for
    nearly 6 million people currently living with paralysis and those that
    care for them. Since its inception, the Foundation has provided $100
    million in research grants to more than 750 researchers, and has
    provided more than $15 million to almost 2,000 organizations across the
    country through our Quality of Life grants program.
        It is a priority of the Reeve Foundation to ensure that individuals
    living with spinal cord injury and paralysis have access to the
    resources and tools necessary to live life to their fullest abilities.
    When my father suffered his injury in 1995, the world was a different
    place for those living with a spinal cord injury. I was 15 years old at
    the time of his accident, and I remember those first few weeks after
    his injury very clearly. I will never forget the sense of helplessness
    that we all felt, coupled with the knowledge that in an instant my
    father's life, as well as that of our entire family, had changed
    forever. Being active one day, and immobile the next, thrusts you and
    your family into an entirely new existence. Every day we found that
    there were more questions to be answered yet information and services
    were limited and difficult to locate. The unanswered issues we faced
    were outside the expertise of the doctors, nurses and staff at the
    Intensive Care Unit. We felt that we had nowhere to turn. Following our
    family's experience, my stepmother Dana was determined to do whatever
    she could to ensure that other families did not encounter the same
    problem.
        Led by her charge, over the past 10 years the Reeve Foundation has
    created a national resource center to help individuals and their
    families navigate a complicated healthcare system and to provide them
    with the tools and information they need to lead a productive and
    fulfilling life. The Paralysis Resource Center (PRC) funded through the
    NCBDDD, partners with organizations across the country to offer
    programs that promote independent and healthy living for all
    individuals living with paralysis. Currently, the PRC provides services
    to more than 500,000 individuals annually, and is indispensable in
    providing vital information and services that the paralysis community
    depends upon each day. The PRC provides patients with access to state-
    of-the-art therapies focused on improving health and mobility; guidance
    for evaluating rehab facilities and redesigning a home to make it wheel
    chair accessible; referrals to community support programs; and
    information and resources on a full range of topics related to
    paralysis and issues that arise from secondary complications.
        The Foundation is extremely proud of the infrastructure that has
    been built through support from NCBDDD, as well as the programs that
    serve the disability community beyond spinal cord injury and paralysis.
    NCBDDD was established by the Congress in 2000, and is the only entity
    within the Federal Government that focuses on the specific needs of
    many of our Nation's most fragile populations. The Foundation is very
    concerned about both the funding and structure of the Center in the
    President's budget. The President's fiscal year 2013 budget recommends
    a funding level of $126 million, a decrease of $11 million, for NCBDDD.
    To achieve these reductions, CDC has indicated that they plan to focus
    on cutting research, resource, surveillance programs, and information
    centers. These programs are a critical component of our Nation's public
    health infrastructure, and cutting them puts the infrastructure we have
    worked so hard to create at great risk. Second, in an effort to create
    efficiencies and cost savings, the President's budget proposes
    consolidation of funding for Federal agencies, including the CDC.
    Within the CDC is a proposal to consolidate the ten disability
    programs' funding lines that fall under the NCBDDD Division of Human
    Development and Disability into one.
        Last year, a similar consolidation of NCBDDD was proposed in the
    President's budget. In response, and under your leadership Chairman
    Harkin, the Congress included report language in the fiscal year 2012
    LHHS Appropriations Subcommittee conference report rejecting the
    proposed consolidation and directing the CDC to conduct a needs
    assessment before moving forward with future consolidation proposals.
    Members of the disability community came together to work with the
    Congress to stop consolidation from moving forward because we knew that
    consolidation of disability programs funded through NCBDDD would be
    devastating not only for the spinal cord injury and paralysis
    population, but for the entire disabled community. We are grateful for
    the support shown by you, Chairman Harkin, and your Subcommittee.
    However, despite the congressional direction, consolidation is back in
    this year's budget and is not accompanied by the conference committee's
    requests.
        On behalf of the Christopher & Dana Reeve Foundation, and the
    nearly 6 million individuals affected by spinal cord injury and
    paralysis, I ask that this Subcommittee once again reject the proposed
    NCBDDD consolidation included in the President's budget and direct CDC
    to conduct a needs assessment which reflects the impact of
    consolidation on the disability groups represented by NCBDDD.
        Programs funded through the NCBDDD are making an active difference
    in the lives of millions of individuals living with a disability. For
    the paralysis community, funding for the PRC is essential in the day-
    to-day lives of thousands of individuals living with paralysis. I am
    incredibly grateful for the ongoing support this committee has shown
    the disability community and for the relationships we have built on
    behalf of the Foundation.
        A core mission of the Reeve Foundation is to invest in research to
    develop effective treatments for acute and chronic spinal cord injury.
    But we cannot do it alone. A strong Federal investment in medical
    research at the NIH is critical in the quest for better cures and
    treatments for the paralysis community. The Foundation supports an
    appropriation of $32 billion for NIH in fiscal year 2013. The NIH funds
    some of the most groundbreaking research in the areas of spinal cord
    injury and paralysis and a strong Federal investment is critical so we
    can achieve our shared goal.
        NIH grants have supported the basic science of locomotor training
    and advanced the current research being conducted in epidural
    stimulation. NIH has also funded the Tongue Drive System, which is a
    wireless device that enables people with high-level spinal cord
    injuries to operate a computer and maneuver an electrically powered
    wheelchair simply by moving their tongues. These are examples of how
    NIH is turning research into reality and changing the lives of those
    living with paralysis. We need the support of this Subcommittee to
    ensure that NIH receives the necessary funding to continue to advance
    this critical research.
        As you move forward with the budget process we look forward to
    working with this Subcommittee to stop consolidation of the NCBDDD
    until the impact of the consolidation on the communities served by
    NCBDDD is addressed, as well as ensuring a strong Federal investment in
    medical research at the NIH.
        Thank you again, Mr. Chairman, for the opportunity to submit my
    testimony on behalf of the Foundation.
                                     ______

       Prepared Statement of the Children's Environmental Health Network
        The Children's Environmental Health Network (CEHN or the Network)
    providing testimony on fiscal year 2013 appropriations, especially
    appropriations for the Centers for Disease Control and Prevention (CDC)
    and the National Institute of Environmental Health Sciences (NIEHS), an
    institute within the National Institutes of Health (NIH).
        This year, the Children's Environmental Health Network is
    celebrating its 20th anniversary as a national nonprofit organization
    whose mission is to protect the developing child from environmental
    hazards and promote a healthier environment. The Network's Board and
    committee members include internationally recognized experts in
    children's environmental health science and policy who serve on key
    Federal advisory panels and scientific boards. We recognize that
    children, in our society, have unique moral standing.
        The Network is deeply concerned about the health of the Nation's
    children and urges the Subcommittee to help all children grow up in
    healthy environments by embracing its role in protecting our
    environment and our health.
        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.
        CEHN urges the Subcommittee to provide funding at or above the
    requested levels for the following CDC and NIEHS activities: National
    Center for Environmental Health; National Asthma Control Program and
    the Healthy Homes/Lead Poisoning Prevention Program; National
    Environmental Public Health Tracking Program; National Institute of
    Environmental Health Sciences; Children's Environmental Health Research
    Centers of Excellence; and National Children's Study.
    Centers for Disease Control and Prevention
        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 urges you to support a funding level of $7.8
    billion for CDC's core programs in fiscal year 2013.
        Within CDC, the National Center for Environmental Health (NCEH) is
    particularly important to protect 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 2013 budget. NCEH has absorbed a
    disproportionately large share of the imposed cuts. Since fiscal year
    2009, NCEH funding has been cut approximately 25 percent.
        We strongly recommend that the National Asthma Control Program and
    the Healthy Homes/Lead Poisoning Prevention Program remain separate and
    distinct programs. The National Asthma Control Program works to reduce
    the burden of asthma, which affects 25 million Americans including 7
    million children. The 36 State and territorial programs funded by the
    National Asthma Control Program include surveillance, environmental
    measures to reduce exposure to indoor and outdoor air pollutants,
    awareness and self-management education, and appropriate healthcare
    services.
        The Healthy Homes and Lead Poisoning Prevention Program, serves the
    12.3 million children with harmful lead levels. The 35 State programs
    funded by the program screen children for lead poisoning, track the
    incidence of the disease, inspect homes for environmental hazards, and
    conduct community lead poisoning prevention initiatives.
        The goals of the two programs as well as their target patient
    groups and methods of delivering services are markedly different. We
    strongly support maintaining the separation of these two programs to
    enable them to continue to fulfill their distinct missions.
        We support reinstatement of CDC's Healthy Homes and Lead Poisoning
    Prevention Program at $29 million (the same as fiscal year 2011 and
    support an additional valuable targeted increase (8.6 percent) to
    certain NCEH programs.
        CDC's National Environmental Public Health Tracking Program tracks
    environmental hazards and the diseases they may cause and coordinates
    and integrates 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 and 2012, which eliminated all budget authority for
    this vital program. We urge you to support additional funding for the
    program in fiscal year 2013. Its biomonitoring activities allow the
    measurement of 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
        The National Institute of Environmental Health Sciences (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.
        NIEHS' fiscal year 2013 President's budget is at $684 million
    (exclusive of Superfund amounts under Subcommittee on the Interior,
    Environment, and Related Agencies appropriations). This represents a
    reduction of $725,000 from NIEHS' fiscal year 2012 budget, which will
    have an impact on their program and research on children's
    environmental health. CEHN, therefore, urges you to set NIEHS' fiscal
    year 2013 budget at least to its fiscal year 2012 level.
    Children's Environmental Health Research Centers of Excellence
        The Children's Environmental Health Research Centers, jointly
    funded by the NIEHS and the U.S. Environmental Protection Agency (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 decisionmakers 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 Subcommittee 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
        The National Children's Study (NCS) is examining the effects of
    environmental influences on the health and development of more than
    100,000 children across the United States, following them from before
    birth until age 21. This landmark longitudinal cohort study--involving
    a consortium of agencies including NIEHS and CDC--will be one of the
    richest research efforts ever geared toward studying children's health
    and development and will form the basis of child health guidance,
    interventions, and policy for generations to come. We urge the
    Subcommittee to assure that the NCS retains on its original focus on
    environmental chemicals and assure that the communities most at risk
    are well represented in the cohort. While the NCS is housed at NICHD,
    it must be a multi-agency study and it must be responsive to its
    mission and to its partner agencies.
        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). Such cuts will reduce the number of exceptionally
    bright children.
        We understand that our Federal budget faces many long-term
    challenges, but we also believe strongly that a commitment to and
    strong investment in environmental public health activities will be
    critical to our Nation's long-term fiscal and physical health. We thank
    you for considering these recommendations.
        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.
                                     ______

       Prepared Statement of the Coalition of EPSCoR/IDeA States and the
                        Mississippi Research Consortium
        Mr. Chairman and Members of the Subcommittee; thank you for the
    opportunity to submit this statement regarding fiscal year 2013 funding
    for the National Institutes of Health's Institutional Development Award
    or ``IDeA'' Program. My name is Dr. David Shaw and I am the Vice
    President for Research and Economic Development at Mississippi State
    University. I submit this testimony on behalf of the Coalition of
    EPSCoR/IDeA States and the Mississippi Research Consortium (MRC) to
    include the following research institutions in our State: University of
    Southern Mississippi (USM), University of Mississippi (UM)/University
    of Mississippi Medical Center (UMMC), Mississippi State University
    (MSU), and Jackson State University (JSU).
    Impact of the IDeA Program on Mississippi
        Please allow me to describe how the INBRE and COBRE programs have
    dramatically impacted the biomedical landscape across the State of
    Mississippi.
                INBRE
        Mississippi's INBRE is located on the campus of the USM in
    Hattiesburg, Mississippi. A statewide network, the INBRE includes all
    five research-intensive institutions, six Partner Undergraduate
    Institutions (PUIs) and eight Outreach Institutions. The MS-INBRE
    represents the largest network of institutions in Mississippi with the
    mission to promote biomedical research and training in the State. The
    instrumentation core of the project includes the Genomics Facility
    located at the UMMC, the Imaging Facility located at the USM, and the
    Proteomics Core located at MSU. These facilities are available to all
    Mississippi scientists and students at no cost thus providing access to
    high cost equipment that promotes biomedical research in the State. The
    Bioinformatics Core is a new initiative through the INBRE that has
    brought together bioinformatics faculty from across Mississippi who
    serves as the backbone providing support and resources in research,
    training and education, and infrastructure.
        MS-INBRE continues to build on existing interdisciplinary
    collaborations, create new collaborative efforts, address the serious
    cyberinfrastructure needs in Mississippi, and train students in
    bioinformatics at the Partner Undergraduate Institutions. Particularly,
    many students would not have the opportunity to participate in
    biomedical research training without this funding which in turn means
    that we lose a lot of brain power and disenfranchise a lot of bright
    students in Mississippi.
        The established research labs at PUIs have made a great impact on
    the number of undergraduate students trained in biomedical research.
    The ``success rate'' is defined as the percentage successfully pursing
    biomedical career via graduate school, professional school, teaching or
    working in research.
      --Undergraduates trained via 12-week intensive summer internships =
            313 (success rate = 90 percent).
      --Undergraduates trained via working in MS-INBRE PUI labs = 127
            (success rate 94 percent).
      --Total Mississippi undergraduate students trained = 440.
        Please note the importance of the opportunity that this funding has
    provided for these students who otherwise would have not had the
    research training. These students are the future researchers,
    clinicians, scientists, teachers, policymakers, etc. If we do not
    continue to provide these opportunities, Mississippi, and our Nation,
    will fall even farther behind other countries in STEM areas.
      --Training our students to work with faculty and help write grant
            proposals has been successful: 54 funded projects with 14 more
            currently pending.
          Examples from NIH: 3 R01; 1 R21; 12 R15; 5 Publications: 119
            peer-reviewed pubs; 6-Presentations at scientific meetings:
            386.
                COBRE in Mississippi
        University of Mississippi (UM).--UM's first COBRE project, the
    Center for Psychiatric Neuroscience (CPN), was initiated 9 years ago at
    the University of Mississippi Medical Center in Jackson. The CPN is
    dedicated to generating knowledge about the relationships between
    neurobiology and clinical psychiatry. Over the past 9 years, CPN has
    made major strides toward its goal of becoming a depression research
    center that is innovative, multidisciplinary and increasingly
    independently funded; COBRE funding in the past 9 years has supported
    CPN-affiliated faculty in successfully competing for $9,082,910 in
    Federal grants and $923,702 in foundation grants. COBRE's support has
    been instrumental in achieving this--and continues to be instrumental.
        CPN has developed focuses in the areas of depression and alcohol
    dependence; both of these are recognized as highly prevalent, serious
    concerns in the United States. Of all mental illnesses, depression is
    the most common; it is a serious, persistent and potentially life-
    threatening medical illness affecting nearly 10 million American adults
    in any year (Healthy People 2010). It is estimated that lost
    productivity due to depression costs $44 billion per year in the United
    States (Stewart et al., 2003). Although antidepressant medications and
    psychotherapy provide some benefit to many people, depression continues
    to be a chronic and potentially life-threatening illness. New treatment
    strategies remain a high priority for many reasons: depression is a
    complex syndrome of variable symptoms; the sites of pathology in the
    brain appear to be multiple; and, most significantly, only about 50
    percent of individuals with depression show full remission in response
    to currently available therapies (Berton and Nestler, 2006). Alcohol
    use disorders are also very common in the United States, with
    approximately 7 percent of adults being alcohol dependent. There is a
    high correlation between alcohol use disorders and other psychiatric
    problems. Shrinkage of the brain is significantly present in alcohol-
    dependent subjects, and the development of new therapies is impeded by
    a lack of understanding of the precise mechanism leading to this
    pathological shrinkage.
        Projects funded by the CPN have been unique in describing the
    monoamine and excitatory amino acid neurotransmitter systems, and the
    contributions of vascular, gender-specific and aging-related risk
    factors to the pathophysiology of depression and alcohol dependence.
    Groundbreaking observations on the roles of neurons and glia, cerebral
    vasculature, aging, gender, transcription factors, serotonin and
    glutamate in depression as well as alcohol dependence have been
    reported by a critical mass of faculty of the CPN and its academic
    home, UMMC's Department of Psychiatry and Human Behavior. The CPN has
    provided an excellent environment for junior, mid-level and senior
    investigators working in close collaboration with leading national
    centers and scientists to carry out the projects building on these
    novel insights into the pathophysiology of depression and alcoholism.
        The University of Mississippi's second COBRE project, Center of
    Research Excellence in Natural Products Neuroscience (CORE-NPN), was
    initiated 5 years ago at the university's main campus in Oxford to
    evaluate the effects of natural products on the central nervous system
    (CNS). CORE-NPN has developed a multidisciplinary team committed to
    studying the neuroscientific properties of natural products and
    identifying potential new targets for the treatment of various
    disorders. CORE-NPN builds on UM's existing strengths at the National
    Center for Natural Products Research (NCNPR), the Nation's only
    university-affiliated research center devoted to improving human health
    and agricultural productivity through the discovery, development, and
    commercialization of pharmaceuticals and agrochemicals derived from
    natural products. With the development of the NIGMS COBRE CORE-NPN, the
    research capacity of NCNRP to discover new drugs for unmet therapeutic
    needs has skyrocketed. CORE-NPN has allowed UM's investigators to
    synergize their efforts with the resources provided through the
    existing NCNPR to develop an unmatched program in natural products
    neuroscience.
        CORE-NPN has allowed faculty in the NCNPR (and other UM
    departments) to develop expertise in a previously unavailable area.
    Expertise exists among the CORE-NPN faculty to extract and purify the
    chemical constituents of plants, microbes, and marine organisms; to
    perform bioassay-guided fractionation to rapidly identify active
    natural products from complex mixtures of metabolites; to elucidate the
    chemical structures of isolated natural products; to scale up these
    quantities for research; to perform in vitro characterization of their
    actions; and to perform in vivo behavioral studies to further evaluate
    their properties, therapeutic potential, and liabilities. Additional
    expertise exists to further modify promising leads into even better
    therapeutic compounds, perform limited toxicity tests, formulate drug
    delivery systems, and to conduct small-scale clinical trials in
    collaboration with UMMC. CORE-NPN participating faculty continue to
    increase their funding success rate. The growing number of faculty
    awards in natural product neuroscience has a strongly beneficial impact
    on UM (home of the State's only School of Pharmacy) and in turn on the
    reputations of the center's faculty and staff. Further, the CORE-NPN's
    research-intensive programs provide quality research and
    interdisciplinary training for students, enhance recruitment efforts,
    and further the development of novel natural products as potential
    therapeutic agents.
        A solid core of natural product researchers developed during Phase
    1 of the COBRE at UM are making cutting-edge discoveries on the
    endocannabinoid, opioid and sigma systems. The endocannabinoid system
    is regarded as a major regulatory system in the central and peripheral
    nervous systems and is involved in the modulation of a variety of
    physiological processes; among them is control of emotional behavior,
    suggesting the involvement of this system in the pathogenesis of mental
    disorders. The endocannabinoid system is also linked to appetite,
    emesis, pain, hypertension, and cardiac remodeling. CORE-NPN
    researchers have made novel observations of natural products from
    Cannabis on appetite in rodents; are evaluating the potential
    usefulness in treating depression with several novel phytocannabinoids;
    are developing computational models that can be used to predict a
    compound's ability to have affinity for the cannabinoid receptors; and
    have developed novel agents that attenuate the effects of cocaine and
    methamphetamine. The COBRE program funding has allowed UM to develop
    several pre-clinical candidates that might have utility in managing
    obesity, wasting syndrome, depression, anxiety, and drug addiction, and
    more. The critical mass of scientists working in the CNS area has
    increased from 5 to 23 scientists as a result of COBRE Phase 1 funding,
    and the significant rise in endocannabinoid-related publications
    reveals strong development by the CORE-NPN that is innovative,
    multidisciplinary, and moving toward the goal of independent funding
    for its programs.
        As part of the COBRE program, investigators are mentored to foster
    and facilitate their development as young scientists. The ability to
    secure external funding is the major index of success showing the
    transition from ``young investigator'' to ``independent scientist.''
    The graph below, of fiscal year Federal grant funding, outlines the
    year-to-year progression in external funding awards obtained since the
    inception of CORE-NPN. This effort resulted in a total of 38 grant
    awards and included: 13-R-type NIH grants, 1-ARRA Supplement, 5-NSF, 1-
    F32, 2-HRSA, 2-NOAA, 1-DOD, and 1-P50, among others.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        This increase in funding dollars is directly related to the number
    of applications the young faculty members made while enrolled in the
    COBRE Mentoring Plan. The 38 grant awards have been a result of 113
    Federal grant applications and 24 grant foundation applications
    submitted by the enrolled faculty. Overall, the mentorship has resulted
    in a success rate of 34 percent for NIH grant awards, which is much
    greater than the national average.
        Mississippi State University.--Mississippi State University was
    awarded a COBRE in 2002-2008 and the benefits of that center are still
    obvious. The funding supported research on the susceptibility of the
    dopamine neurons in the Nurr1-null heterozygous mice to neurotoxin
    exposure. The best lab space in the College of Veterinary Medicine is
    the Wise Center which was designed and renovated using COBRE funds.
    Frequently used equipment was obtained. Most importantly, the three
    faculty members who were involved by the end of the previous COBRE as
    junior investigators have received NIH funding, and one of them has
    been consistently averaging more than 5 peer reviewed publications per
    year.
        MSU currently has a pending COBRE application which involves an
    area of research that is already one of our strongest--infectious
    diseases. With the mentoring, research, and infrastructure funding from
    the COBRE, we expect to develop teams that will be competitive for
    center grants and individuals competitive for research grants from
    major funding agencies.
        The COBRE program is even more important to MSU and similar
    institutions in recent years than it was when the first one was awarded
    at MSU. Because the success rate for NIH grant applications is so low
    nationally, it is difficult for anyone to compete for this funding, and
    it is particularly difficult when the applicant is located at an
    institution that is not well known for its biomedical research. The
    COBRE will give five of MSU's most promising junior investigators an
    opportunity to build their scientific reputation by supporting their
    research, and it will give them formalized internal and external
    mentoring needed to teach them the skills and to help them build their
    professional networks needed for success. This will make our
    investigators better collaborators for other researchers in Mississippi
    and will enhance collaborations that already exist. It will also
    provide research support for investigators who have already shown
    interest and skill in commercializing their research ideas (two of our
    COBRE application leaders and one junior investigator have taken steps
    toward development of intellectual property, up to and including
    formation of a company).
        Despite these successes, our task is far from complete. Funding
    disparities between the States remain and may have a detrimental impact
    on our national self-interest. And that is why the IDeA program is so
    important. It is helping to ensure that all regions of the country
    participate in biomedical research and education. Citizens from all
    States should have the opportunity to benefit from the latest
    innovations in healthcare, which are most readily available in centers
    of biomedical research excellence.
        On behalf of the MRC, I express gratitude to this Subcommittee for
    the efforts it has made over the years to provide increased funding for
    IDeA, in particular this committee's work to ensure a funding increase
    in fiscal year 2012. I hope that you will continue to invest in this
    program, which is so important to almost half of the States in the
    Union. The importance of this program, especially to junior
    investigators who are starting to become competitive for NIH funding,
    should not be underestimated. They should not receive the wrong message
    by cutting or even possibly eliminating funding for their research
    after encouraging them to pursue a career in biomedical research.
        On behalf of the EPSCoR/IDeA Coalition, the MRC, and our partner
    institutions across Mississippi, I thank the Subcommittee for the
    opportunity to submit this testimony.
                                     ______

              Prepared Statement of the Cystic Fibrosis Foundation
        On behalf of the Cystic Fibrosis Foundation and the approximately
    30,000 people with cystic fibrosis (CF) in the United States, we are
    pleased to submit the following testimony to the Senate Appropriations
    Subcommittee on Labor, Health and Human Services, Education and Related
    Agencies requesting $32 billion for the National Institutes of Health
    (NIH) in fiscal year 2013. Particularly, the CF Foundation urges the
    Committee to support NIH's National Center for Advancing Translational
    Sciences (NCATS), programs under the NCATS umbrella including the
    Therapeutics for Rare and Neglected Diseases (TRND) program, and
    collaborative efforts by NIH and the Food and Drug Administration (FDA)
    such as the Regulatory Science Initiative and the FDA-NIH Joint
    Leadership Council.
                             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 CFTR
    gene, which causes the body to produce abnormally thick, sticky mucus
    that clogs the lungs and results in life-threatening lung infections.
    This mucus also obstructs the pancreas, preventing pancreatic enzymes
    from assisting in the breakdown of food and the absorption of
    nutrients.
        The mission of the Cystic Fibrosis Foundation is to find a cure for
    cystic fibrosis and improve the quality of life for people living with
    the disease. This is accomplished by funding life-saving research and
    working to provide access to quality care and effective therapies for
    people with CF. Through the Foundation's efforts, the life expectancy
    of a child with CF has doubled in the last 30 years. Although real
    progress toward a cure has been made, the lives of young people with CF
    are still cut far too short.
            sustaining the federal investment in biomedical research
        This Committee and the Congress are to be commended for their
    support for biomedical research through the years, particularly for
    increasing funding for the NIH and establishing the National Center for
    Advancing Translational Sciences (NCATS) in fiscal year 2012. It is
    vital that we continue to provide robust funding for the NIH, so that
    it can allow patients to benefit from scientific advances like the
    mapping of the human genome, and continue to train the next generation
    of scientists, create new jobs, and promote economic growth.
        We support the recommendation of the Ad Hoc Group for Medical
    Research that the Subcommittee recognize the National Institutes of
    Health (NIH) as a critical national priority by providing at least $32
    billion in funding in the fiscal year 2013 Labor-HHS-Education
    appropriations bill. This funding recommendation represents the minimum
    investment necessary to avoid further loss of promising research and at
    the same time allows the NIH's budget to keep pace with biomedical
    inflation.
        A report from United for Medical Research indicates that funding
    from the National Institutes of Health supported more than 432,000 jobs
    and generated more than $62.1 billion in economic activity in 2011.
    Cutting funding for NIH would not only curb this economic growth, but
    would impede the fight against many of the most serious diseases and
    stifle the scientific progress that makes the United States the
    worldwide leader in biomedical research.
        We urge this Committee and the Congress to maintain robust
    investment in biomedical research at the NIH so it can fund critical
    research today that will provide the cures of tomorrow.
              strengthening clinical research and drug development
        In the past two decades the Cystic Fibrosis Foundation has
    pioneered an innovative research approach resulting in a robust
    pipeline of potential therapies that target cystic fibrosis from every
    angle.
        As part of this approach the Foundation created a ``venture
    philanthropy'' model, through which CFF has raised and invested
    hundreds of millions of dollars to help fund cystic fibrosis drugs and
    therapies. Nearly every CF drug and therapy available today was
    supported by the CF Foundation. By providing upfront funding and
    reducing financial risk for drug companies like Vertex Pharmaceuticals,
    CFF has made sure that this rare disease has not been ignored.
        The Foundation has also created a Therapeutics Development Network
    (TDN) to achieve greater efficiency in clinical investigation.
    Challenges inherent in small patient populations, like the availability
    of participants for clinical trials, prompted the Foundation to create
    a network of academic centers and CF care centers that collaborate
    across sectors and share best practices, speeding clinical research on
    promising potential treatments.
        One such treatment developed through this approach is
    KalydecoTM, a groundbreaking new drug created by Vertex
    Pharmaceuticals in collaboration with the Cystic Fibrosis Foundation.
    Kalydeco is a breakthrough as it is the first treatment to address the
    underlying cause of cystic fibrosis in 1,200 patients with a particular
    genetic mutation. It has led to tremendous health gains for those who
    take the drug and has opened exciting new doors to research and
    development that may eventually lead to a cure for all people living
    with CF.
        While the CF Foundation has made great progress, still more needs
    to be done for cystic fibrosis and other rare diseases, many of which
    have no treatments available. We are hopeful that the Committee will
    bolster programs that support translating basic scientific research
    into therapies that can make a real difference to vulnerable patient
    populations.
    Advancing Translational Science at the National Institutes of Health
        The CF Foundation strongly urges this Committee to increase funding
    for NIH's newly established National Center for Advancing Translational
    Sciences (NCATS), which will catalyze innovation by improving the
    process by which diagnostics and therapeutics are developed, thereby
    diminishing obstacles to translating basic scientific research into
    treatments. This will make translational science more efficient, less
    expensive, and less risky.
        The specific programs housed in NCATS are integral to this mission,
    including the Clinical and Translational Science Awards (CTSA), the
    Cures Acceleration Network (CAN), and the Therapeutics for Rare and
    Neglected Diseases (TRND) program. They are designed to transform the
    way in which clinical and translational research is conducted and
    funded. NIH Director Dr. Francis Collins has cited the Cystic Fibrosis
    Foundation's successful Therapeutics Development Network as a model for
    TRND's innovative therapeutics development model.
        NCATS is already advancing a number of initiatives. For example,
    NCATS is working with the Defense Advanced Research Projects Agency
    (DARPA) and the FDA to design a tissue chip for drug screening. This
    chip, composed of diverse human cells and tissues, mimics how drugs
    interact in humans. If successful, this chip could make drug safety and
    efficacy assessments more accurate and even make them possible earlier
    in the development process--enabling investigators to concentrate on
    the most promising new drugs.
        Robust funding for NCATS will give industry, academia, and other
    stakeholders the tools and resources needed to speed the development of
    diagnostics and treatments.
    Increasing Collaboration
        The CF Foundation urges the Committee to support collaborative
    efforts by the Food and Drug Administration and the National Institutes
    of Health, such as the Regulatory Science Initiative and the FDA-NIH
    Joint Leadership Council. Collaboration between the NIH and FDA has the
    potential to help move innovative new drugs more quickly through the
    development process and into the hands of patients by ensuring that the
    FDA has the resources, strategies, and tools it needs to efficiently
    review and regulate drugs in this ever changing scientific landscape.
    As treatments like Kalydeco are being developed to target specific
    genetic mutations and smaller and smaller populations, it is important
    that the FDA has the expertise it needs to quickly move these drugs
    through the review process.
        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
    drug discovery effort comprised of early stage translational research
    into successful treatments for this disease. Several research projects
    at the NIH could eventually be the key to controlling or curing cystic
    fibrosis.
        For example, the CF Foundation commends NIH for issuing two
    Requests for Applications (RFAs) that specifically target cystic
    fibrosis--one on early lung disease and the other on cystic fibrosis
    related diabetes. The Cystic Fibrosis Foundation also encourages NIH to
    continue its 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 the National Heart, Lung, and Blood Institute
    (NHLBI) and the CF Foundation, bears great promise to help make
    significant developments in the search for a cure.
    Understanding CFTR Folding and Trafficking
        The data that emerged from Kalydeco Phase 2 and 3 clinical trials
    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 4 percent
    of the CF population. More research is needed to understand other
    genetic mutations, the most common of which 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 this
    more common mutation.
    Personalized Medicine
        Strong Federal and private investment in research is bringing
    personalized medicine to the forefront of drug research and
    development. Kalydeco, discussed above, is an outstanding example of
    the power of personalized medicine. If the 4 percent of the CF
    population for which Kalydeco is effective had not been properly
    identified and targeted for this therapy, the studies would have
    concluded that Kalydeco was not effective, because 95 percent of
    patients would not have responded.
        While exciting and promising for patients, the advancement of
    personalized medicine 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
    to be effective for cystic fibrosis when there is no formal clinical
    data to support it. This puts patients in a difficult position, as
    these clinical trials are unlikely to be performed by pharmaceutical
    companies because they are expensive and treat a very 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 support the advancement of exciting scientific discoveries.
        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 are vital to continuing these
    successes not only for CF but for all rare diseases.
        We urge the Committee to consider these factors as you craft the
    fiscal year 2013 Labor, Health and Human Services, and Education
    appropriations legislation. We stand ready to work with NIH and
    congressional leaders on the challenging issues ahead. Thank you for
    your consideration.
                                     ______

             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 (LHHS)
    appropriations subcommittee with a statement for the record on fiscal
    year 2013 funding levels for health agencies and programs. Since 1970,
    the Coalition 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.
        Every day, in important ways most Americans don't even realize, the
    Federal Government supports public health programs that keep them safe
    and secure. The agencies and programs of the LHHS: conduct health
    research and discover cures; prevent disease, disability, and injury;
    assure food, water, and drug safety; protect and respond in times of
    crisis; educate the next generation of scientists, healthcare
    providers, and public health professionals; and care for our Nation's
    most vulnerable.
        The Coalition's 76 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.
    In this regard, we are very concerned that deficit reduction efforts to
    date--both actual and those under consideration--have relied almost
    exclusively on cuts to public health and other discretionary programs
    to balance the budget. Public health programs have experienced 2
    straight years of funding cuts, and are facing a looming sequester that
    will cut even deeper--as much as $5.7 billion from health programs
    within the subcommittee's jurisdiction.
        These programs make up only a fraction of all Federal spending.
    They are not the root cause of our fiscal crisis, and cutting them
    further will not bring the budget into balance. On the contrary, with
    greater investment, public health programs are an integral part of the
    solution. 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. Healthy Americans drive our economic engine,
    and ultimately cost our Nation less in healthcare spending.
        The Coalition realizes the pressure the Congress and the
    administration face to balance the Nation's budget. However, our
    Nation's health has already borne more than its fair share of the
    responsibility for deficit reduction. A few weeks ago, the Coalition
    was joined by more than 900 national, State, and local organizations
    urging the Appropriations Committees to increase investments in public
    health and other programs within the subcommittee's jurisdiction. The
    following list summarizes the Coalition's fiscal year 2013 specific
    funding recommendations for these public health agencies.
                      national institutes of health (nih)
        The Coalition joins the Ad Hoc Group for Medical Research in
    seeking at least $32 billion for NIH in fiscal year 2013. This funding
    recommendation represents the minimum investment necessary to avoid
    further loss of promising research and at the same time allows the
    NIH's budget to keep pace with biomedical inflation. As the primary
    Federal agency responsible for conducting and supporting medical
    research, NIH drives scientific innovation and develops new and better
    diagnostics, improved prevention strategies, and more effective
    treatments.
        NIH 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.
                centers for disease control and prevention (cdc)
        The Coalition joins the CDC Coalition in seeking $7.8 billion for
    CDC in fiscal year 2013. This amount is representative of what CDC
    needs to fulfill its core mission in fiscal year 2013; 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 joins the Friends of HRSA in seeking $7 billion for
    HRSA in fiscal year 2013. 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. The requested level of
    funding for fiscal year 2013 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. In the long term, 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 joins the Mental Health Liaison Group and the
    addictions community in recommending an overall funding level of $3.5
    billion for SAMHSA in fiscal year 2013. According to results from a
    national survey conducted by SAMHSA, 45.1 million American adults in
    the United States experienced mental illness last year. However, only
    two-thirds of adults in the United States with mental illness received
    mental health services. In fact, suicide claims more than 36,000 lives
    annually, the equivalent of 94 suicides per day; 1 suicide every 15
    minutes. Last year, 8.7 million adults aged 18 or older thought
    seriously about committing suicide, 2.5 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 $3.6 billion reduction in State mental health funding for
    programs serving this vulnerable population.
               agency for healthcare research and quality (ahrq)
        The Coalition joins the Friends of AHRQ in recommending an overall
    funding level of $400 million in base discretionary funding for AHRQ in
    fiscal year 2013. 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 appreciates this opportunity to provide its fiscal
    year 2013 funding recommendations. During the coming months, our member
    organizations stand ready to work with Members of Congress in
    developing a balanced approach to deficit reduction that will prevent
    the harmful, indiscriminant cuts that will occur under sequestration.
                                     ______

         Prepared Statement of the Coalition of Northeastern Governors
        As the Subcommittee on Labor, Health and Human Services, Education,
    and Related Agencies begins to develop the fiscal year 2013 Labor, HHS,
    Education, and Related Agencies appropriations bill, the Coalition of
    Northeastern Governors (CONEG) urges you to fund the Low Income Home
    Energy Assistance Program (LIHEAP) at the most current authorized level
    of $5.1 billion, with at least $4.5 billion in the core block grant
    program and additional contingency funding for unforeseen emergencies.
    We urge you to provide these funds in a manner consistent with the 1994
    LIHEAP statute--``to assist low-income households, particularly those
    with the lowest incomes that pay a high proportion of household income
    for home energy, primarily in meeting their immediate home energy
    needs.''
        The Governors appreciate the Subcommittee's continued support for
    the Low Income Home Energy Assistance Program, and recognize the
    difficult fiscal challenges facing the Congress this year. However, the
    need that the LIHEAP program meets--immediate assistance that allows
    the most the vulnerable low-income households to pay their home energy
    bills--is great and continues to grow.
        LIHEAP is targeted to households whose income hovers near the
    Federal poverty level, which for a two-person household is less than
    $15,000 per year. More than 90 percent of LIHEAP households have at
    least one member defined as ``vulnerable''--elderly, disabled or a
    small child. In addition, a recent National Energy Assistance
    Directors' Association survey found that the number of households with
    veterans receiving LIHEAP assistance has increased by more than 150
    percent from 695,760 in fiscal year 2008 to 1.78 million in fiscal year
    2011.
        In the face of recent reductions in LIHEAP funding, the northeast
    States' LIHEAP programs faced a reduction of 20 to 25 percent in their
    fiscal year 2012 allocation compared to fiscal year 2011. This
    reduction creates considerable pressures and challenges in stretching
    the scarce LIHEAP dollars while still providing a meaningful benefit.
    States have responded to the reduced LIHEAP funds in a number of ways.
    For example, eligibility for LIHEAP assistance has been tightened. The
    application season has been reduced. The number of households served
    this season will be lower. Most critically, a number of States have had
    to reduce benefits. Many northeast States have also stretched their own
    limited budgets to provide millions of dollars in supplemental LIHEAP
    funds. Few northeast States will have carry-forward funds at the end of
    the current season. If the fiscal year 2013 appropriations are delayed,
    the lack of carry-forward funds creates an additional challenge for
    cold-weather States, where early winters create the need for benefits
    in the fall. A funding level of $4.5 billion in the block grant program
    provides the certainty that States need to plan and implement a cost-
    effective program.
        The threat of reduced LIHEAP funding comes as home heating oil
    prices continue their steady year-to-year rise. According to the most
    recent weekly price reports of the Energy Information Administration
    (March 19, 2012), residential heating oil prices now exceed $4 per
    gallon, and have risen steadily over the past month, even as winter
    temperatures moderate. These rising energy prices continue to erode the
    purchasing power of each LIHEAP dollar received by low-income
    households, particularly in the Northeast, which is more dependent on
    home heating fuel than any other region of the country. Almost 82
    percent of the 8 million U.S. households that use heating oil to heat
    their homes are located in this region, and they have limited options
    to switch to lower-cost residential fuels.
        At current prices, a typical LIHEAP benefit would pay for less than
    30 percent of the total heating expenditure for a household using 800
    gallons of heating oil during the season. Unlike most households that
    heat with natural gas or electricity, households that rely upon
    delivered fuels do not have the protection of a shut-off moratorium. If
    a household cannot afford to purchase home heating fuel, the delivery
    truck simply does not come, and the household is left in the cold.
    Adequate, predictable and timely Federal funding is vital for LIHEAP to
    assist these vulnerable, low-income households faced with increasing
    home energy bills.
        The CONEG Governors appreciate the Subcommittee's continuing
    support for LIHEAP, and urge that it fund the program at $5.1 billion,
    with a $4.5 billion funding level for the core LIHEAP block grant
    program and additional contingency funds provided to address unforeseen
    energy emergencies. An adequate and certain level of funding will help
    States to provide meaningful assistance to some of the Nation's most
    vulnerable low-income households as they attempt to pay their home
    energy bills.
                                     ______

    Prepared Statement of the Commissioned Officers Association of the U.S.
                             Public Health Service
        The Commissioned Officers Association of the U.S. Public Health
    Service, Inc. (COA), wishes to submit this statement for the record.
    The Association speaks for its members, all of whom are active-duty or
    retired officers of the Commissioned Corps of the U.S. Public Health
    Service (USPHS).
        The Association respectfully makes one request: support for a
    congressionally authorized (but unfunded) workforce program to recruit
    and train public health physicians, dentists, nurses, physician
    assistants, and mental health experts for public service careers in the
    USPHS Commissioned Corps. The program is called the United States
    Public Health Sciences Track. Its annual cost is estimated at $160
    million.
    Background and Rationale
        This program was authorized in Section 5315 of the Affordable Care
    Act (Public Law 111-148), which is now before the U.S. Supreme Court.
    Despite the intense controversy surrounding other aspects of this law,
    there has never been, to the Association's knowledge, any opposition
    expressed by any Member of Congress to the Public Health Sciences
    Track. Regardless of the Court's decision, our Nation will still need a
    way to replenish and grow the USPHS Commissioned Corps and its active-
    duty force of 6,500 health professionals.
        The Public Health Sciences Track means guaranteed jobs for all
    graduates. This is because there are thousands of unfilled positions,
    i.e., potential billets, for qualified clinicians who are willing to
    serve as uniformed public health professionals in Indian Country
    (especially Alaska and the American southwest) and in underserved urban
    and rural areas in nearly every State.
        USPHS health professionals 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 and Marines under fire in Afghanistan. At
    home, USPHS psychologists and other mental health specialists are
    detailed to the Department of Defense to treat returning soldiers and
    Marines suffering from traumatic brain injury and post-traumatic stress
    disorder. The USPHS Commissioned Corps is a public health and national
    security force multiplier.
        The Public Health Sciences Track, as set forth in Section 5315 of
    the ACA, would provide for 850 annual scholarships for medical, dental,
    nursing, and public health students who commit to public service in the
    USPHS. Such a program would be the first dedicated pipeline into the
    USPHS Commissioned Corps. The law would reserve ten slots at the
    Uniformed Services University of the Health Sciences (USUHS), which is
    the medical school and research institute for uniformed services
    personnel (Army, Navy, Air Force, Public Health Service). All the rest
    would be distributed among interested schools of medicine, dentistry,
    nursing, etc., based on recommendations of the U.S. Surgeon General.
    Funding
        The ACA provision authorizing the Public Health Sciences Track
    identified an existing source of funds. Full 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).
    That transfer of funds transfer never occurred, and we understand it is
    now precluded by language in the Continuing Resolution (CR). That is
    why an appropriation is necessary to keep this program alive.
        As the Association's Executive Director, I would be pleased to
    expand on these points or to answer any questions.
                                     ______

         Prepared Statement of the Council for Opportunity in Education
        Over the last several years, our Nation has struggled to overcome
    the greatest economic crisis since the Great Depression. More and more
    Americans are turning to education as a means to lift their families
    out of poverty and empower their local communities. The Federal TRIO
    Programs, which serve approximately 800,000 low-income, potential
    first-generation college graduates, presents a unique, yet ideal
    mechanism to achieve our mutual goals of increased college access and
    completion, enhanced employment prospects for veterans and adults
    returning to the workforce and strengthened status within the global
    marketplace. To that end, I am pleased to submit the following
    recommendations for increases in TRIO funding.
    Send Our Returning Veterans Back to the Classroom
        With the winddown of overseas military conflicts, several thousand
    servicemen and -women are returning home and need help to re-enter the
    classroom and re-engage in civilian life and their local communities.
    Yet, there are only 47 of TRIO's Veterans Upward Bound (VUB) programs.
    Through an increase of $13.5 million, the Congress could double the
    program's capacity and allow 12,000 veterans (total) to receive TRIO
    services. This is a more than worthwhile investment in those who have
    sacrificed so much for our Nation.
    Help More Out-of-Work Adults and Low-Wage Earners Boost Their
            Employability
        TRIO's Educational Opportunity Centers (EOC) target displaced and
    underemployed workers and guide these prospective students through the
    challenges of obtaining secondary education credentials, selecting and
    enrolling in appropriate postsecondary programs and/or navigating
    through the complex financial aid process. Currently, there are only
    128 EOC programs supporting approximately 192,000 adult learners across
    the country. By infusing just $14.9 million into the EOC program, the
    Congress could fund 38 additional programs--increasing the program's
    reach by 30 percent to serve an additional 58,000 students--and provide
    much needed relief to existing programs, which have sustained
    significant funding cuts in recent years.
    Increase Retention and Graduation Rates Among Low-Income College
            Students
        TRIO's Student Support Services (SSS) program helps low-income and
    first-generation students, including students with disabilities, to
    successfully begin and stay in college. Participants receive tutoring,
    counseling, and remedial instruction in order to achieve their goals of
    college completion. Serving nearly 203,000 students through just more
    than 1,000 programs on college campuses across the country, SSS is ripe
    for investment. By pouring $46.8 million into current programs, the
    Congress would allow the host colleges and universities to serve an
    additional 32,000 students within a matter of weeks. This would
    represent a 15 percent increase in the number of low-income college
    students served by SSS.
    Preserve Opportunity for Low-Income and Underrepresented Students to
            Pursue Graduate Education
        TRIO's Ronald E. McNair Postbaccalaureate Achievement program
    encourages and prepares low-income, first-generation and other
    underrepresented students to achieve doctoral degrees. The McNair
    program provides research opportunities, faculty mentoring and other
    supports necessary for such students to enter into and complete
    challenging degree fields. Recently, the Department of Education (DOE)
    cut funding for this program by $10 million (21 percent) and announced
    an intention to fund one-third fewer programs in the pending grant
    competition. By restoring this funding in fiscal year 2013, the
    Congress could restore services to approximately 2,000 students and
    allow these programs to build upon their track record of success in
    producing academics and other thought leaders in disciplines vital to
    our national interest, such as engineering and mathematics.
    Restore Services to Students in the Pipeline
        Due to funding cuts, several thousand low-income, potential first-
    generation college graduates have missed out on the opportunity to
    participate in TRIO. By infusing $71.4 million into the programs, the
    Congress could allow 55,000 middle and high school students to receive
    services through Talent Search, Upward Bound and Upward Bound Math-
    Science.
        With a longstanding history of helping low-income youth and adults
    become the first in their families to earn college degrees, the Federal
    TRIO programs are a ready resource to meet the needs of our veterans,
    adult learners, students with disabilities and other low-income
    students. Even during this time of austerity, it is critically
    important to make sound investments that put our Nation on a sound
    economic path and strengthen communities and families. This strategy
    proposes to do just that.
        In addition to these funding concerns, I would request that your
    subcommittee take particular action to remedy the Department of
    Education's mishandling of these programs.
        Imposing a Competitive Preference Priority that Moves Upward Bound
    grants from many States into Illinois--and particularly into Chicago.
    By adding ``competitive priorities''--and giving extra points to
    institutions and agencies that addressed those priorities--in the
    Upward Bound competition (and also, it is expected, in the Upward Bound
    Math/Science competition), the Department intends to reward
    institutions and agencies that address those priorities. The first of
    three competitive priorities awards applicants an extra 5 points out of
    a total possible of 125 by serving ``Persistently Lowest Achieving
    Schools'' (PLAS) as defined by the Department (and not the applicant's
    State). Because Upward Bound does not serve elementary school students,
    and since many States labeled more elementary schools than secondary
    schools as PLAS, applicants from certain States have a five point
    advantage over most applications from States that concentrated on
    elementary schools as PLAS. As a consequence, for example, institutions
    and agencies serving almost 60 schools in Chicago qualify for the extra
    five points. Meanwhile NO institutions and agencies serving schools in
    Idaho qualify and only a handful of institutions in Montana and
    Connecticut qualify.
        The Upward Bound competition closed Friday, March 16, but it is
    estimated that only about 25 percent of applications qualified for
    extra points under the first competitive priority, serving PLAS. Other
    applicants simply could not earn these points because there were no
    nearby PLAS. It is possible that this issue also raises civil rights
    concerns because among the applicants disadvantaged are those serving
    schools on Indian reservations and applicants serving schools in
    Southern States such as Alabama and West Virginia that have very low
    numbers of qualifying PLAS.
        Despite the fact that the Congress provided the Department of
    Education an extra year to prepare for and conduct TRIO competitions,
    and despite the fact that the Appropriations Committee gave specific
    direction to the Department to avoid delays in TRIO competitions in the
    fiscal year 2011 Omnibus, ED remains unable to announce grants in a
    timely fashion. In one (of two) TRIO competitions in fiscal year 2011,
    grants were so late that many expired before announcements were made.
    Those programs, Educational Opportunity Centers--which help unemployed
    and underemployed workers and other low-income adults get the education
    and training they need to prepare for good jobs--were forced to close
    down. Many educators were laid off, and many more left their employment
    given the uncertainty surrounding funding continuation. It is
    anticipated that this same problem will again occur all throughout the
    summer. The last time an Upward Bound competition was held, 5 years
    ago, applications had to be submitted in November and grant
    announcements were not made until May. This year, through a series of
    missteps, the Department closed and then re-opened the competition for
    Upward Bound with applications not being finally due until March 16.
    Although current grants to more than 300 institutions and agencies will
    have expired by June 1, the Department can provide no assurance that
    grant notifications will be made by that time. Upward Bound staff are
    already receiving termination notices, and very few colleges can plan
    summer programs with no assurance that funds will be available. The
    situation is compounded because--with the end of an infusion of
    mandatory monies--it is known that at least 150 previously funded
    Upward Bound programs will be discontinued.
        These acts demonstrate a lack of due care with the Federal funds
    with which your Subcommittee has entrusted the Department in the
    administration of the TRIO programs. Therefore, in addition to
    addressing the ever-pressing funding needs of TRIO, I respectfully
    request your leadership in remedying the administrative ills noted
    above.
        On behalf of the low-income, first-generation students served by
    TRIO, I thank you for your consideration of this testimony.
                                     ______

                   Prepared Statement of the COPD Foundation
                           summary of recommendations
        The Foundation requests that the National Institutes of Health,
    National Heart, Lung, and Blood Institute, National Institute of
    Allergy and Infectious Diseases and National Institute on Aging,
    increase the investment in Chronic Obstructive Pulmonary Disease and
    that the Centers for Disease Control and Prevention initiate a Federal
    partnership with the COPD community to achieve the following goals:
      --$32 billion for the NIH for fiscal year 2013--that is a 4.5 percent
            increase for the NIH over its fiscal year 2012 funding level;
      --Promotion of basic science and clinical research related to COPD;
      --Programs to attract and train the best young clinicians for the
            care of individuals with COPD;
      --Support for outstanding established scientists to work on problems
            within the field of COPD research;
      --Development of effective new therapies to prevent progression of
            the disease and control symptoms of COPD; and
      --Expansion of public awareness and targeted detection to promote
            early diagnosis and treatment.
        Mr. Chairman and members of the subcommittee thank you for the
    opportunity to submit testimony for the record on behalf of the COPD
    Foundation.
        The COPD Foundation has a clear mission: to develop and support
    programs, which improve the quality of life through research,
    education, early diagnosis, and enhanced therapy for persons whose
    lives are impacted by Chronic Obstructive Pulmonary Disease (COPD). The
    COPD Foundation was established to speed innovations which will make
    treatments more effective and affordable. It also undertakes
    initiatives that result in expanded services for COPD patients and
    improves the lives of patients with COPD through research and education
    that will lead to prevention and someday a cure for this disease.
                 copd: third leading cause of death and rising
        COPD is an umbrella term used to describe progressive lung diseases
    including emphysema, chronic bronchitis, refractory (non-reversible)
    asthma, and some forms of bronchiectasis. This disease is characterized
    by increasing breathlessness. The NIH, National Heart, Lung and Blood
    Institute estimates that 12 million adults have COPD and another 12
    million are undiagnosed. Smoking is not the only cause of COPD; second-
    hand smoke, occupational dust and chemicals, air pollution and genetic
    factors such as Alpha-1 Antitrypsin Deficiency also cause COPD. Dr.
    Susan Shurin, Acting Director, of NHLBI responsible for the Learn More
    Breathe Better COPD education and awareness program notes that, ``Half
    of the people living with COPD don't know it even though it is
    relatively simple to diagnose with spirometry.''
        COPD while chronic is often characterized by exacerbations that can
    cause considerable lung deterioration that possibly could be avoided
    with medication compliance and education. There are 500,000 to 1
    million hospitalizations for COPD each year, and because of these high
    rates of hospitalizations and readmissions the Affordable Care Act
    targeted COPD as an area of improvement in readmissions. Costs related
    to COPD are rising and estimated to be about $50 billion per year.
        A majority of patients with COPD also have at least one other
    chronic condition and receive care from more than one healthcare
    provider (primary care physicians, pulmonologists, nurses, or
    respiratory therapists). In 2006, the COPD Foundation presented the
    results of its study on co-morbidities at the American Thoracic Society
    International Conference. The COPD and Co-Morbidities Survey identified
    other chronic conditions and the extent of these illnesses, and also
    determine use of medications for these additional illnesses. 81 percent
    of the household sample with COPD described having over six co-morbid
    conditions. Thus it is critical that not only do individuals with COPD
    receive proper diagnosis and treatment but that it is also recognized
    that they will need proper diagnosis and treatment for co-morbid
    conditions that may also be chronic in nature.
        Utilization of Healthcare Services.--Individuals diagnosed with
    COPD and those with COPD who are undiagnosed seek treatment from
    Emergency Services when they find themselves in an episode of severe
    respiratory distress. (Survey: ``Confronting COPD in America'' found
    that in those age 45-54, 27 percent had at least one emergency room
    visit within the past year for their condition.) Common in emergency
    services is to treat the patient by relieving the present distress and
    discharging them with the directive to follow up with their personal
    physician. Relieved that the episode is past, individuals are eager to
    resume their usual schedule and are often unable to afford an office
    visit or don't even have a personal physician. Thus there is no medical
    follow up, leading them to repeat this scenario, requiring expensive
    emergency services again, within months, weeks, or even days.
    Improvement needs to be made in understanding transitions through the
    healthcare delivery system while continuing to meet the immediate
    clinical needs of the COPD patient.
        COPD Foundation Infrastructure Is Built for Research.--The COPD
    Foundation has worked with the FDA to establish biomarkers that will
    facilitate expedited drug development. The COPD Foundation has worked
    with the National Institutes of Health to encourage funding of research
    that looks at the relationship of COPD and genetics while exceeding its
    goal of recruiting 10,000 research subjects the largest COPD cohort
    ever organized. COPDGene has enrolled more than 10,000 smokers with and
    without COPD across the GOLD stages that includes traditionally
    underserved populations of both Non-Hispanic whites and African-
    Americans. The COPD Foundation Research Registry is a confidential
    database of individuals diagnosed with COPD or at risk of developing
    COPD. The Registry was established in 2007 by the COPD Foundation to
    help researchers learn more about COPD and to help people interested in
    COPD research find opportunities to participate. The Registry operates
    under the direction of the COPD Foundation's Board of Directors and is
    guided by an Oversight Committee comprised of leaders in the medical,
    ethical, scientific and COPD communities and ensures the strictest
    confidentiality of participant information.
            the medical needs of the copd community have gone unmet
        While smoking is a predominant cause of COPD it is not the only
    cause. Other significant factors are second hand smoke, occupational
    dusts and chemicals, air pollution, and a genetic cause called alpha-1
    antitrypsin deficiency. The other leading causes of death have seen
    great improvements over the past several decades. While the mortality
    of COPD rose by 163 percent from 1965-1998, the mortality of coronary
    heart disease decreased by 59 percent and the mortality of stroke
    decreased by 64 percent.
        And yet this third leading cause of death is a hidden, silent
    killer. There is a lack of awareness among the public that coughing and
    breathlessness is not a normal sign of aging. Those diagnosed with this
    disease are quick to blame themselves and are ashamed of their disease
    because of the current societal stigma. Many lack the information for
    proper disease self-management, which could easily prevent
    exacerbations and thusly, many hospital and emergency room visits.
        Currently, the only therapy shown to improve survival is
    supplemental oxygen. There are other therapies that can improve
    symptoms but they do not alter the natural history of the disease.
        COPD is Fairly Easy to Detect.--In addition to symptoms of
    breathlessness, cough and sputum production, spirometry is a
    quantitative test that measures air volume and air flow in the lung and
    is relatively easy and inexpensive to administer.
        The COPD Foundation believes that significant Federal investment in
    medical research is critical to improving the health of the American
    people and specifically those affected with COPD. The support of this
    Subcommittee has made a substantial difference in improving the
    public's health and well-being. While this is by no means an exhaustive
    list, the Foundation wishes to recognize and appreciate the efforts of
    the National Institutes of Health in creating the COPD Clinical
    Research Network, for conducting a COPD state of the science
    conference, and launching a national education campaign.
        Chronic disease have a profound human and economic toll on our
    Nation. Nearly 125 million Americans today are living with some form of
    chronic condition. The Foundation recognizes that the Centers for
    Disease Control and Prevention understands that COPD is one of the only
    top 10 causes of death that is on the increase, however, COPD has not
    been designated the resources to be a major focus of the CDC. The
    Foundation urges the Subcommittee to encourage the CDC to expand its
    data collection efforts and to expand programs aimed at education and
    prevention of the general public and healthcare providers.
        COPD is a condition that has a high probability of improvability
    via research with the potential for new evidence to improve patient
    health, well being, and the quality of care.
                 specific areas of concern and recommendations
        The Foundation requests that the National Institutes of Health,
    National Heart Lung, and Blood Institute, National Institute of Allergy
    and Infectious Diseases and National Institute on Aging, increase the
    investment in Chronic Obstructive Pulmonary Disease and that the
    Centers for Disease Control and Prevention initiate a Federal
    partnership with the COPD community to achieve the following goals:
      --Promotion of basic science and clinical research related to COPD;
      --Programs to attract and train the best young clinicians for the
            care of individuals with COPD;
      --Support for outstanding established scientists to work on problems
            within the field of COPD research;
      --Development of effective new therapies to prevent progression of
            the disease and control symptoms of COPD; and
      --Expansion of public awareness and targeted detection to promote
            early diagnosis and treatment.
                                     ______

        Prepared Statement of the College on Problems of Drug Dependence
        Mr. Chairman and Members of the Subcommittee, thank you for the
    opportunity to submit testimony to the Subcommittee in support of the
    National Institute on Drug Abuse. The College on Problems of Drug
    Dependence (CPDD), a membership organization with more than 800
    members, has been in existence since 1929. It is the longest standing
    group in the United States addressing problems of drug dependence and
    abuse. The organization serves as an interface among governmental,
    industrial and academic communities maintaining liaisons with
    regulatory and research agencies as well as educational, treatment, and
    prevention facilities in the drug abuse field. CPDD also often works in
    collaboration with the World Health Organization.
        Drug abuse is costly to Americans; it ruins lives, while tearing at
    the fabric of our society and taking a huge financial toll on our
    resources. Beyond the unacceptably high rates of morbidity and
    mortality, drug abuse is often implicated in family disintegration,
    loss of employment, failure in school, domestic violence, child abuse,
    and other crimes. Placing dollar figures on the problem; smoking,
    alcohol and illegal drug use results in an exorbitant economic cost on
    our nation, estimated at more than $600 billion annually. We know that
    many of these problems can be prevented entirely, and that the longer
    we can delay initiation of any use, the more successfully we mitigate
    future morbidity, mortality and economic burdens.
        Over the past three decades, NIDA-supported research has
    revolutionized our understanding of addiction as a chronic, often-
    relapsing brain disease--this new knowledge has helped to correctly
    situate drug addiction as a serious public health issue that demands
    strategic solutions. By supporting research that reveals how drugs
    affect the brain and behavior and how multiple factors influence drug
    abuse and its consequences scholars supported by NIDA continue to
    advance effective strategies to prevent people from ever using drugs
    and to treat them when they cannot stop.
        NIDA supports a comprehensive research portfolio that spans the
    continuum of basic neuroscience, behavior and genetics research through
    medications development and applied health services research and
    epidemiology. While supporting research on the positive effects of
    evidence-based prevention and treatment approaches, NIDA also
    recognizes the need to keep pace with emerging problems. We have seen
    encouraging trends--significant declines in a wide array of youth drug
    use--over the past several years that we think are due, at least in
    part, to NIDA's public education and awareness efforts. However, areas
    of significant concern, such as prescription drug abuse, remain and we
    support NIDA in its efforts to find successful approaches to these
    difficult problems.
        Recognizing that so many health research issues are inter-related,
    CPDD requests that the subcommittee provide at least $32 billion for
    the National Institutes of Health, which is a $1.3 billion or 4.3
    percent increase over fiscal year 2012. This will allow NIH to keep up
    with inflation. Because of the critical importance of drug abuse
    research for the health and economy of our Nation, we also request that
    you provide a proportionate increase for the National Institute on Drug
    Abuse.
        In addition, to highlight certain priority research areas within
    NIDA's portfolio, we respectfully request that you include the
    following language in the Committee report accompanying the fiscal year
    2013 funding recommendation for the National Institute on Drug Abuse:

        ``Medications Development.--With the recent reduction in the
    efforts of the pharmaceutical industry to develop new medications to
    treat diseases of the brain, the Committee encourages NIDA to continue
    to increase their efforts to develop medications to treat diseases of
    addiction. Reasonable success has occurred in the past and recent
    advances in knowledge support this effort.
        ``Translational Research.--The Committee encourages NIDA to
    continue its efforts to increase our knowledge of how genetics, age,
    environment and other factors affect the use of experimental drugs and
    the development of addiction.
        ``Education.--The educational efforts of NIDA to inform the public
    of the deleterious effects of abused substances and the life-
    threatening dangers of drug addiction are recognized and encouraged.
    Progress in this area has contributed to the decreased abuse of
    nicotine and its long term medical consequences, including death.
    Adolescents and returning veterans and their families are at a high
    risk for drug abuse and therefore should be areas of concentration for
    these educational efforts.
        ``Prevention and Treatment.--The Committee recognizes the reported
    increase in abuse of marijuana and prescription drugs and encourages
    NIDA to support innovative approaches to prevent and treat this abuse
    and the resulting harmful effects. The concentration in these areas
    should compliment efforts to prevent and treat addiction of all abused
    substances.
        ``Prescription Drug Abuse.--Prescription drug abuse has been the
    focus of much work by NIDA and its grantees and although significant
    progress has been made, the Committee encourages NIDA to maintain its
    comprehensive leadership role in the effort to halt this epidemic.
        ``Military Personnel, Veterans, and Their Families.--The Committee
    commends NIDA for its successful efforts to coordinate and support
    research with the Department of Veterans Affairs and other NIH
    institutes on substance abuse and associated problems among U.S.
    military personnel, veterans and their families. Many military
    personnel need help confronting war-related problems including
    traumatic brain injury, post-traumatic stress disorder, depression,
    anxiety, sleep disturbances, and substance abuse, including tobacco,
    alcohol and other drugs. Many of these problems are interconnected and
    contribute to individual health and family relationship crises, yet
    there has been little research on how to prevent and treat the unique
    characteristics of wartime-related substance abuse issues. The
    Committee encourages NIDA to continue work in this area.''

        The Nation's previous investment in scientific research to further
    understand the effects of abused drugs on the body has increased our
    ability to prevent and treat addiction. As with other diseases, much
    more needs be done to improve prevention and treatment of these
    dangerous and costly diseases. Our knowledge of how drugs work in the
    brain, their health consequences, how to treat people already addicted,
    and what constitutes effective prevention strategies has increased
    dramatically due to support of this research. However, since the number
    of individuals continuing to be affected is still rising, we need to
    continue the work until this disease is both prevented and eliminated
    from society.
        We understand that the fiscal year 2013 budget cycle will involve
    setting priorities and accepting compromise, however, in the current
    climate we believe a focus on substance abuse and addiction, which
    according to the World Health Organization account for nearly 20
    percent of disabilities among 15-44 year olds, deserve to be
    prioritized accordingly. We look forward to working with you to make
    this a reality. Thank you for your support for the National Institute
    on Drug Abuse.
                                     ______

     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 health careers. HRSA's own report, ``The Rationale for Diversity in
    the Health Professions: A Review of the Evidence,'' found that minority
    health professionals disproportionately serve minority and other
    medically underserved populations, minority populations tend to receive
    better care from practitioners of their own race or ethnicity, and non-
    English speaking patients experience better care, greater comprehension
    and greater likelihood of keeping follow-up appointments when they see
    a practitioner who speaks their language. Studies have also
    demonstrated that when minorities are trained in minority health
    professions institutions, they are significantly more likely to: (1)
    serve in medically underserved areas, (2) provide care for minorities
    and (3) treat low-income patients.
        Minority Centers of Excellence.--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 2013, 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 2013, 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 2013, an
    increase proportional to NIH's increase is recommended for NIMHD as
    well as additional FTEs.
        Research Centers at Minority Institutions.--RCMI, now at NIMHD, 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 2013.
    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 health
    careers, and supporting cooperative agreements with minority
    institutions for the purpose of strengthening their capacity to train
    more minorities in the health professions. For fiscal year 2013, 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 2013, 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 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, and Education, and
    Related Agencies for inclusion in the official subcommittee 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 for social workers at the Department of
    Health and Human Services (HHS).
        CSWE is a nonprofit national association representing more than
    3,000 individual members and more than 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.
        Recruitment and retention in social work continues to be a serious
    challenge that threatens the workforce's ability to meet societal
    needs. The 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 social workers specializing in mental health and substance use
    is expected to grow by almost 20 percent more than 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 March 28, 2012.
    ---------------------------------------------------------------------------
        CSWE understands the difficult funding decisions the Congress is
    faced with this year given the fragile state of the United States
    economy. In these challenging times, it is my hope that the
    subcommittee will prioritize funding for health professions training in
    fiscal year 2013 to help to ensure that the Nation continues to foster
    a sustainable, skilled, and culturally competent workforce that will be
    able to keep up with the increasing demand for social work services and
    meet the unique healthcare needs of diverse communities.
    health resources and services administration (hrsa) title vii and title
                        viii health professions programs
        CSWE urges the subcommittee to provide $520 million in fiscal year
    2013 for the health professions education programs authorized under
    titles VII and VIII of the Public Health Service Act and administered
    through HRSA. 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 funding from the suite of title
    VII health professions programs.
        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. 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). The Mental and Behavioral
    Health Education and Training Grants program 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 program received first-time
    funding of $10 million in the final fiscal year 2012 appropriations
    bill. The President's budget request for fiscal year 2013 would reduce
    funding to $5 million. CSWE urges the subcommittee to maintain funding
    for this new and critically needed program at $10 million in fiscal
    year 2013. 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.
      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 use fields.
    According to SAMHSA, minorities make up approximately one-fourth of the
    population, but only 10 percent of mental health providers come from
    ethnic minority communities. CSWE is one of six grantees of this
    critical program and administers funds to exceptional minority doctoral
    social work students. Other grantees include national organizations
    representing nursing, psychology, psychiatry, marriage and family
    therapy, and professional counselors. SAMHSA makes grants to these six
    organizations, who in turn recruit minority doctoral students into the
    program from the six distinct professions.
        CSWE urges the subcommittee to appropriate $5.7 million for the MFP
    in fiscal year 2013, which is equal to the fiscal year 2012 enacted
    level. The President's budget request for fiscal year 2013 proposes a
    23.4 percent cut to the program, which if appropriated would
    significantly reverse progress made over the last several years by
    bringing funding down to the lowest level in nearly 5 years. This cut
    would translate to a reduction in the number of minority mental health
    professions trained to serve vulnerable populations. Each of the MFP
    grantee organizations, including CSWE, would be forced to significantly
    scale back the support provided to minority doctoral students. With
    respect to the social work doctoral fellows, a 23 percent cut would
    have the following impacts:
      --The program would not have sufficient funds to cover the stipend
            increase for CSWE's current class of 25 fellows and would need
            to eliminate all other financial support to the fellows;
      --Fellows would not have funds to attend CSWE's Annual Program
            Meeting, which represents the only face-to-face meeting of
            fellows from doctoral programs located in different parts of
            the United States and is essential to professional development
            and collaborative networking; and
      --There would be no tuition support (currently set at $500 per
            student) to fellows to assist them in timely degree completion.

                           SAMHSA BREAKDOWN OF THE MINORITY FELLOWSHIP PROGRAM FUNDING REQUEST
                         [This program is funded through three separate accounts within SAMHSA]
    ----------------------------------------------------------------------------------------------------------------
                                                                         Requested      President's
                                                                          program       fiscal year     Fiscal year
                                                                          funding      2013 request    2012 funding
    ----------------------------------------------------------------------------------------------------------------
    Programs of Regional and National Significance, Center for            $5,089,000      $3,755,000      $5,089,000
     Mental Health Services (CMHS)..................................
    Programs of Regional and National Significance, Center for               546,000         546,000         546,000
     Substance Abuse Treatment (CSAT)...............................
    Programs of Regional and National Significance, Center for                71,000          71,000          71,000
     Substance Abuse Prevention (CSAP)..............................
                                                                     -----------------------------------------------
          Total, MFP funding........................................  ..............  ..............       5,706,000
    ----------------------------------------------------------------------------------------------------------------

        Since its inception, the MFP has helped support doctoral-level
    professional education for more than 1,000 ethnic minority social
    workers, psychiatrists, psychologists, psychiatric nurses, and family
    and marriage therapists. Still, the program continues to struggle to
    keep up with the demands that are plaguing these 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
    within Tribal communities, where mental illness and substance use 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 nonminorities.
    Furthermore, a direct positive relationship exists between the numbers
    of ethnic minority mental health professionals and the utilization of
    needed services by ethnic minorities.
        Level funding is needed simply to maintain the program's current
    capacities to provide education and training for minority mental health
    and substance use professionals. Much work is still needed in order to
    adequately address the mental health needs of minority populations;
    maintaining funding for the MFP is a small step the subcommittee can
    take in fiscal year 2013.
        Thank you for the opportunity to express these views. Please do not
    hesitate to call on CSWE should you have any questions or require
    additional information.
                                     ______

      Prepared Statement of the College of Veterinary Medicine, Nursing &
                       Allied Health, Tuskegee University
        Mr. Chairman and members of the subcommittee, thank you for the
    opportunity to present my views before you today. I am Dr. Tsegaye
    Habtemariam, dean of the College of Veterinary Medicine, Nursing, and
    Allied Health at Tuskegee University. The mission (purpose) of Research
    and Advanced Studies at the College of Veterinary Medicine, Nursing &
    Allied Health (CVMNAH) is to transform trainees into ambassadors of the
    Tuskegee tradition to benefit man and animals. Such a tradition is
    honed in the ``one medicine-one health'' concept that for decades has
    guided our academic mission, to expand biosciences and create bridges
    between veterinary medicine, agricultural and food sciences on one side
    and human health and welfare on the other.
        Mr. Chairman, 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 Tuskegee 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)--during the Bush administration--entitled ``The
    Rationale for Diversity in the Health Professions: A Review of the
    Evidence'' found that minority health professionals serve minority and
    other medically underserved populations at higher rates than 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 2013, funding for the Title VII Health Professions
    Training programs must be robust, 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 2013, 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 2013, 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), newly moved to the National
    Institute on Minority Health and Health Disparities 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 2013.
        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 its Centers of Excellence
    program. For fiscal year 2013, I recommend funded increases
    proportional with the funding of the overall NIH, with increased FTEs.
    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 health careers, and
    supporting cooperative agreements with minority institutions for the
    purpose of strengthening their capacity to train more minorities in the
    health professions.
        The OMH has the potential to play a critical role in addressing
    health disparities. For fiscal year 2013, 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 2013, 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. CVMNAH seeks to close the ever
    widening health disparity gap. If this subcommittee will give us the
    tools, we will continue to work toward 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 Dystonia Medical Research Foundation
        Summary of recommendations for fiscal year 2013:
      --$32 billion for the National Institutes of Health (NIH) and
            concurrent percentage increases across its institutes and
            centers.
      --Continue to support the Dystonia Coalition within the Rare Disease
            Clinical Research Network (RDCRN) coordinated by the Office of
            Rare Diseases Research (ORDR).
      --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), and the National Eye Institute (NEI).
        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
        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 Rare
    Diseases Research (ORDR).
        ORDR coordinates the Rare Disease Clinical Research Network (RDCRN)
    which provides support for studies on the natural history,
    epidemiology, diagnosis, and treatment of rare diseases. RDCRN includes
    the Dystonia Coalition, a partnership 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. The Dystonia Coalition has made tremendous
    progress in recruiting patients for clinical trials and funding four
    promising studies that hold great hope for advancing understanding and
    treatment of primary focal dystonias. The DMRF urges the subcommittee
    to continue its support for the Dystonia Coalition within the Rare
    Disease Clinical Research Network at ORDR.
        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. The DMRF urges the
    subcommittee to support NINDS in conducting and expanding critical
    research on dystonia.
        NIDCD and NEI also support research on 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. 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.
        In summary, the DMRF recommends the following for fiscal year 2013:
      --$32 billion for NIH and a proportional increase for its Institutes
            and Centers.
      --Continued support for the Dystonia Coalition within the Rare
            Diseases Clinical Research Network at ORDR.
      --Increased portfolio of dystonia research at NIH through NINDS,
            NIDCD, NEI, and ORDR.
    The Dystonia Medical Research Foundation
        The Dystonia Medical Research Foundation was founded over 30 years
    ago and has been a membership-driven organization since 1993. Since its
    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 a fiscal year 2013
    Labor-HHS, and Education appropriations bill. The EJC is a 3,000 member
    strong, nonpartisan organization dedicated to advocating for funding
    for the Elder Justice Act (EJA) and related elder abuse prevention
    legislation. The EJA was passed over 2 years ago and while authorized
    funding for the EJA is $195 million per year, for the second year in a
    row, zero funds have been appropriated for the EJA. Two years later,
    vulnerable older adults who should be protected by the law are
    confronted with the same threats of abuse, neglect, and exploitation.
        The President's fiscal year 2012 budget requested a total of $21.5
    million for the EJA. We strongly supported that level last year and
    continue to this year. This funding was targeted for State adult
    protective services (APS) operations and the Long-Term Care Ombudsman
    Program. APS workers are often the first responders to cases of abuse
    and neglect. They are faced with increasing and complex caseloads yet;
    there is no dedicated Federal funding stream for APS programs. The
    Long-Term Care Ombudsman Program provides resident advocacy to elders
    and adults with disabilities who live in long-term care settings. This
    program is consistently underfunded.
        According to the Department of Justice, 1 out of every 10 older
    adults are victims of elder abuse. A 2011 study on elder abuse
    prevalence indicated that out of 23.5 elder abuse cases, only 1 is
    reported. For financial exploitation, the ratio is an astounding 43.9
    to 1 reported. A 2011 study found that the annual financial loss by
    victims of elder financial abuse is at least $2.9 billion, a 12 percent
    increase from the $2.6 billion estimated in a similar 2009 study.
        We urge you to include a minimum appropriation of $21.5 million for
    the Elder Justice Act in your fiscal year 2013 Labor-HHS appropriations
    bill. We feel the President's fiscal year 2013 request of $8 million is
    simply inadequate. We ask you to consider the fact that funds we invest
    in elder abuse prevention today will save Medicaid and Medicare dollars
    that elder abuse victims might otherwise need.
        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
    29 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 2013, the
    Alliance \1\ asks that you consider $48.7 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:
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
      --$40.3 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.
        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.
        We appreciate President Obama's commitment to targeting resources
    to the programs which are most critical to meeting our Nation's
    challenges in a time of fiscal constraint. Funding included in his
    fiscal year 2013 budget for the Geriatrics Health Professions programs
    administered through the Health Resources and Services Administration
    (HRSA) under Title VII and Title VIII of the Public Health Service Act
    is one such critical target. His request represents a welcome, though
    still inadequate, investment in equipping the Nation's healthcare
    workforce to meet the needs of America's older adults. HRSA's budget
    justification recognizes the immediacy of the eldercare workforce
    crisis by identifying ``enhancing geriatric/elder care training and
    expertise'' as one of their top five priorities.
        At a minimum, EWA asks the Congress to support the full amount of
    the President's request for these programs, and to consider the
    importance of the additional investments needed in order to realize the
    healthcare workforce goals set forth in the recently released draft
    National Action Plan on Alzheimer's and the bipartisan commitment to
    enhancing the primary care workforce of which geriatrics is a part.
    According to a 2008 MedPAC report, among physicians who specifically
    train in and provide primary care, geriatricians spend the most time
    providing non-procedural primary care with 65 percent of their payments
    derived from primary care services such as office and home visits and
    visits to patients in non-acute settings.\2\ Geriatrics and
    gerontological health professionals typically care for the 20 percent
    of Medicare beneficiaries who account for 80 percent of Medicare costs.
    The Geriatrics Health Professions programs support geriatrics faculty
    and programs that we need to train other members of the care team to
    provide the type of multidisciplinary care that is the hallmark of
    geriatrics.
    ---------------------------------------------------------------------------
        \2\ Medicare Payment Advisory Commission, Report to the Congress:
    Reforming the Delivery System (Washington: MedPAC, June 2008), chap. 2,
    p.34.
    ---------------------------------------------------------------------------
        In light of current fiscal constraints, EWA specifically requests
    $48.7 million in funding for the following programs administered
    through the Health Resources and Services Administration (HRSA) under
    Title VII and VIII of the Public Health Service Act.
    Title VII: Geriatrics Health Professions Appropriations Request: $40.3
            Million
        Title VII Geriatrics Health Professions programs are the only
    Federal programs that: (1) seek to increase the number of faculty with
    geriatrics expertise in a variety of disciplines; and (2) offer
    critically important training for the healthcare workforce overall to
    improve the quality of care for America's elders.
        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 2010-2011, the GACA
            Program funded 68 full-time junior faculty awardees. These
            awardees provided interdisciplinary training in geriatrics to
            38,392 health professionals in clinical geriatrics; provided
            interdisciplinary team training to 6,617 clinical staff in
            various geriatric clinical settings; and provided geriatric
            services to 57,364 geriatric patients who are underserved and
            uninsured patients in acute care, geriatric ambulatory care,
            long-term care, and geriatric consultation services settings.
            HRSA, through the Affordable Care Act, expanded the awards to
            be available to more disciples. EWA strongly supports and
            requests adequate funding for future expansion. Currently, new
            awardees are selected only every 5 years and to meet the need
            for clinician educators in all disciplines, EWA believes that
            we need to invest more in this program in order to develop
            adequate numbers of faculty to provide this training.
            Specifically, these academic career development awards should
            be available to clinician educators annually. EWA's fiscal year
            2013 request of $5.5 million includes will support current GAC
            Awardees in their development as clinician educators.
        Geriatric Education Centers (GEC).--The goal of the Geriatric
    Education Centers is to provide quality interdisciplinary geriatric
    education and training to the health professions workforce including
    geriatrics specialists and non-specialists.
      --Program Accomplishments.--In Academic Year 2010-2011, the 45 GEC
            grantees developed and provided 2,103 education and training
            offerings to health professions students, faculty, and
            practitioners related to care of older adults.
            Interdisciplinary education and training was provided to 10,703
            interdisciplinary teams. The grantees provided education and
            training to 64,414 health professions students, faculty, and
            practitioners. The GECs provide much needed education and
            training. As part of the ACA, the Congress authorized a
            supplemental grant award program that will train additional
            faculty through a mini-fellowship program. The program provides
            training to family caregivers and direct care workers. Our
            funding request of $22.7 million includes support for the core
            work of 45 GECs and $2.7 million awarded to 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, (GTPD) and
    Behavioral and Mental Health Professions.--The goal of the GTPD is to
    increase the number and quality of clinical faculty with geriatrics and
    cultural competence, including retraining mid-career faculty in
    geriatrics.
      --Program Accomplishments.--In Academic Year 2010-2011, 13 non-
            competing continuation grants were supported. A total of 54
            physicians, dentists and psychiatry fellows provided geriatric
            care to 24,139 older adults across the care continuum.
            Geriatric physician fellows provided healthcare to 13,788 older
            adults; geriatric dental fellows provided healthcare to 4,834
            older adults; and geriatric psychiatric fellows provided
            healthcare to 5,516 older adults. 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.
            EWA's funding request of $8.8 million will support 13
            institutions to continue this important faculty development
            program.
        Geriatric Career Incentive Awards Program.--Congress authorized
    this new program through the ACA. It 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. EWA's
    funding request of $3.3 million supports implementation of this new
    program.
    Title VII Direct-Care Worker Training Program Appropriations Request:
            $3.4 Million
        Direct-care workers help older people carry out the basic
    activities of daily living and are critical to ensuring an adequate
    geriatrics workforce. More than 1 million additional direct-care
    workers will be needed by 2018, according to the latest employment
    projections.
        Training Opportunities for Direct Care Workers.--In the ACA
    Congress approved a program administered by HHS that will offer
    advanced training opportunities for direct care workers. While this
    vital training program was left out of President Obama's budget, EWA
    believes the Congress must fund it to create new employment
    opportunities by offering new skills through training. EWA's funding
    request of $3.4 million will support the Department of Labor to
    establish this unique grant program to support community colleges in
    increasing the geriatrics knowledge and expertise of this 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.
      --Program Accomplishments.--In Academic Year 2010-2011, 27 non-
            competing Comprehensive Geriatric Education (CGEP) grantees
            provided education and training to 3,645 registered nurses,
            1,238 registered nursing students, 870 direct service workers,
            569 licensed practical/vocational nurses, 264 faculty and 5,344
            allied health professionals. 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.
        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.
        EWA's funding request of $5 million supports the training of nurses
    who care for older adults and offer traineeships to nurses under the
    newly implemented traineeship program.
        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 supporting the geriatrics workforce at this
    critical time--for all older Americans deserve quality of care, now and
    in the future.
        Thank you for your consideration.
                                     ______

        Prepared Statement of the Federation of American Societies for
                              Experimental Biology
        The Federation of American Societies for Experimental Biology
    (FASEB) respectfully requests a fiscal year 2013 appropriation of $32
    billion for the National Institutes of Health (NIH) as the first step
    of a program of sustained growth that will keep pace with increasing
    scientific opportunities and return to the demonstrated capacity of the
    research enterprise.
        As a federation of 26 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.
        Research funded by NIH is essential for improving health, reducing
    human suffering, and protecting the Nation against new and emerging
    health threats. As a result of the prior investment in medical research
    at NIH, scientists have developed vaccines to protect our citizens from
    cervical cancer, flu, and meningitis; increased survival rates from the
    most common form of childhood leukemia, which are now at 90 percent;
    and combined effective medicines and a broad base of knowledge about
    lifestyle changes to reduce the death rate for heart disease by more
    than 60 percent and stroke by 70 percent. Many of these advances arose
    from non-medically targeted investigations designed to explain basic
    molecular, cellular, and biological mechanisms.
        More recently, researchers supported by NIH found that a saliva
    sample from a newborn can be used to quickly and effectively detect
    cytomegalovirus (CMV) infection, a major cause of hearing loss in
    children. CMV is the most common infection passed by a mother to her
    unborn child. As many as 30,000 children are infected with the virus at
    birth; and 10 to 15 percent of them are at risk for developing hearing
    loss. Monitoring infected children for signs of hearing loss as they
    grow is the best way to ensure they get early treatment, but they often
    show no symptoms. Better CMV screening at birth could help doctors
    determine which patients to monitor for symptoms so they can be treated
    as quickly as possible. NIH researchers also discovered that a
    noninvasive technique that uses light therapy to selectively destroy
    cancerous cells in mice without harming surrounding tissue could
    eventually be used to treat tumors in humans, a process known as
    photoimmunotherapy. Using photoimmunotherapy, scientists were able to
    dramatically shrink tumors in mice after a single dose of infrared
    light therapy. This method has the potential to replace some surgical,
    radiation, and chemotherapy treatments. Last year, an international HIV
    prevention trial funded by NIH was named the ``Breakthrough of the
    Year'' by the journal Science. Researchers found that if HIV-infected
    heterosexual individuals began taking antiretroviral medicines when
    their immune systems are relatively healthy, as opposed to delaying
    therapy until the disease has advanced, they are 96 percent less likely
    to transmit the virus to their uninfected partners. The study
    convincingly demonstrated that antiretroviral medications cannot only
    treat but also prevent the transmission of HIV infection among
    heterosexual individuals, adding to the existing base of public health
    strategies that can be used to make a significant impact on the HIV
    pandemic.
        These successes are the direct result of a vigorous medical
    research effort. Sustaining this robust enterprise is crucial for
    meeting the known and unknown challenges that are surely coming, such
    as the increasing numbers of Alzheimer's disease sufferers as the baby
    boomer generation ages, the increasing incidence of obesity-associated
    type 2 diabetes, and potential threats through bioterrorism.
        In addition to improving health, support for medical research
    contributes to the Nation's economy. More than 80 percent of NIH funds
    are distributed through competitive grants to more than 300,000
    scientists who work at universities, medical schools, and other
    research institutions in nearly every congressional district in the
    United States. It is critically important that the Nation continue to
    capitalize on previous investments to drive research progress, train
    the next generation of scientists, promote economic growth, and
    maintain leadership in the global innovation economy, particularly as
    other countries increase their investments in scientific research.
    Predictable and Sustainable Funding Will Drive Innovation and Progress
        The broad program of research supported by NIH is essential for
    improving our understanding of diseases and is a primary source of new
    innovations in healthcare and other areas, but because of the scale,
    scope, and time involved, it is the kind of investment that private
    industry could not afford to undertake. Unfortunately, due to several
    years of flat funding and spending cuts enacted in 2011, the NIH budget
    is insufficient to fund all of the critical research that needs to be
    done. Furthermore, the rising costs of research and a loss of
    purchasing power in the NIH budget have led to a decrease in the number
    of research grants awarded to investigators. Data \1\ from the NIH
    website recently analyzed by FASEB demonstrate how difficult times have
    become:
    ---------------------------------------------------------------------------
        \1\ http://www.faseb.org/
    LinkClick.aspx?fileticket=aDQlNW4adp0%3d&tabid=431.
    ---------------------------------------------------------------------------
      --In constant dollars (adjusted for inflation), the fiscal year 2012
            budget and the President's proposal for fiscal year 2013 are $4
            billion lower than the peak year (fiscal year 2003) and at the
            lowest level since fiscal year 2001.
      --The number of research project grants funded by NIH has declined
            every year since 2004. This trend is projected to continue in
            fiscal year 2012 and fiscal year 2013, when NIH will fund 3,100
            fewer grants than in fiscal year 2004.
      --Success rates have fallen more than 14 percentage points in the
            past decade and are expected to decline even further in fiscal
            year 2012 and 2013.
        This analysis clearly demonstrates that we have lost ground. If
    supplemental appropriations are considered, the decline is much
    greater. NIH reached a capacity of more than $35 billion in fiscal year
    2010-2011. The high demand for stimulus funding, and the exceptional
    research that it yielded, illustrate that the capacity of the research
    system is at least $35 billion.
        NIH needs sustainable and predictable budget growth in order to
    continue important scientific investigations that improve the health of
    all Americans. Advances in research will enhance our ability to respond
    quickly to new health threats and exciting NIH initiatives currently
    underway are poised to accelerate our progress in the search for cures.
    It would be tragic if we could not capitalize on the many opportunities
    before us. The discovery of a universal vaccine to protect adults and
    children against both seasonal and pandemic flu; nanomedicine that can
    target cancer cells precisely, with limited impact on healthy cells;
    and development of gene chips and DNA sequencing technologies that can
    predict risk for high blood pressure, kidney disease, diabetes, and
    obesity are just a few of the research breakthroughs that will be
    delayed if we fail to sustain the investment in NIH.
        Maintaining the current level of effort requires an increase equal
    to the biomedical research and development price index (BRDPI), which
    is projected to be 2.8 percent for fiscal year 2013, and additional
    funds are essential to take advantage of the exciting and urgent
    opportunities in science and medicine available today. A 1.7 percent
    increase above BRDPI could provide support for nearly 170 additional
    research grants. To prevent further erosion of the Nation's capacity
    for biomedical research, FASEB recommends an appropriation of at least
    $32 billion for NIH in fiscal year 2013.
        Thank you for the opportunity to offer FASEB's support for NIH.
                                     ______

      Prepared Statement of Friends of the Health Resources and Services
                                 Administration
        On behalf of the Friends of the Health Resources and Services
    Administration (HRSA), we write to respectfully request a minimum
    overall funding level of $7 billion for fiscal year 2013 for HRSA. As a
    national leader in providing health services for individuals and
    families, HRSA, operates programs in every State, territory, and
    thousands of communities across the country. The agency serves as a
    health safety net for the medically underserved, including the 50
    million Americans who were uninsured in 2010 and 60 million Americans
    who live in neighborhoods with scarce primary healthcare services.
        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.
        While we recognize the reality of the current fiscal climate, our
    request of $7 billion represents the minimum amount necessary for HRSA
    to continue meeting 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 Nation's most
    vulnerable citizens. Additionally, the Friends of HRSA remains
    concerned about the deep cuts the agency has endured over the past few
    years--HRSA's discretionary budget has been reduced by more than $1.2
    billion since fiscal year 2010. Cuts of this magnitude have had a
    serious negative impact on the agency's ability to carry out critical
    public health programs and services for millions of Americans, and as a
    result, have the potential to lead to significant increased costs to
    our healthcare system in the long term. Therefore, our requested level
    of funding is necessary to ensure support for the continued
    implementation of HRSA programs including:
      --Health Professions programs that support the education and training
            of primary care physicians, nurses, dentists, optometrists,
            physician assistants, nurse practitioners, clinical nurse
            specialists, 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 our complex health system.
      --Primary Care programs that support more than 7,000 community health
            centers and clinics 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 programs that include the Title V
            Maternal and Child Health Block Grant, Healthy Start, and
            others support a myriad of initiatives designed to promote
            optimal health, reduce disparities, combat infant mortality,
            prevent chronic conditions, and improve access to quality
            healthcare for more than 40 million women and children,
            including children with special healthcare needs.
      --HIV/AIDS programs that 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 services that ensure access to a broad
            range of reproductive, sexual, and related preventive
            healthcare for more than 5.2 million poor and low-income women,
            men, and adolescents at nearly 4,400 health centers nationwide.
            This program helps improve maternal and child health outcomes
            and promotes healthy families.
      --Rural Health programs that improve access to care for the more than
            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, among other programs 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 that 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, which help people who need potentially life-
            saving transplants by connecting patients, doctors, donors, and
            researchers to the resources they need to live longer,
            healthier lives.
        This investment is necessary to sufficiently fund these important
    HRSA services and programs that continue to face increasing demands. We
    urge you to consider HRSA's role in strengthening the foundation of
    health service delivery and safety net programs, which are critical
    components of any comprehensive plan to secure our Nation's progress
    and drive down long-term healthcare costs. By supporting HRSA today, we
    can build on the successes of the past to improve the public's health
    and achieve health equity through access to quality services, a skilled
    health workforce, and innovative programs in the future.
        The members of the Friends of HRSA thank you for considering our
    request for $7 billion for HRSA in the fiscal year 2013 Labor-HHS-
    Education appropriations bill and we appreciate the opportunity to
    submit our recommendation to the Subcommittee.
                                     ______

      Prepared Statement of the Friends of the National Institute on Aging
        Senator Harkin, Senator Shelby, and members of the Subcommittee, on
    behalf of the Friends of the National Institute on Aging (FoNIA) at the
    National Institutes of Health (NIH), thank you for the opportunity to
    provide testimony in support of the National Institute on Aging (NIA)
    and to comment on the need for sustained, long-term growth in aging
    research.
        The FoNIA is a coalition of more than 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 continues, the Coalition endorses the Ad Hoc Group
    for Medical Research in supporting $32 billion for NIH in fiscal year
    2013. Given the unique funding challenges facing the NIA, and the range
    of promising scientific opportunities in the vast, diverse field of
    aging research, the FoNIA ask the subcommittee to recommend that NIA
    receive $1.4 billion in fiscal year 2013.
    The National Institute on Aging 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 consists of four components:
      --Support and conduct genetic, biological, clinical, behavioral,
            social, and economic research on aging.
      --Foster the development of research and clinician scientists in
            aging.
      --Provide research resources.
      --Disseminate information about aging and advances in research to the
            public, healthcare professionals, and the scientific community,
            among a variety of audiences.
        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 38-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 will more than double between 2010 and 2050 to 88.5 million or 20
    percent of the population, 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 is leading the Alzheimer's Disease Research Summit on May 14 and
    15, 2012 at which officials representing Federal agencies, scientific
    researchers, providers, caregivers, patients and their families will
    convene to develop final recommendations to the National Alzheimer's
    Project Act Advisory Council.
        The NIA's support of important AD research has contributed to
    important recent advances. For example, the identification of relevant
    Alzheimer's Disease (AD) biomarkers through the groundbreaking
    Alzheimer's Disease Neuroimaging Initiative, along with a deeper
    understanding of the disease's pathology and clinical course, have
    facilitated the first revision of the clinical diagnostic criteria for
    AD in 27 years. These new criteria address for the first time the use
    of imaging and biomarkers in blood and spinal fluid, and unlike the
    previous guidelines they cover the full spectrum of the disease, from
    mild cognitive impairment (MCI) through clinical dementia. To expand
    and intensify the translation of basic research findings into clinical
    studies and human trials, NIA, the National Institute of Neurological
    Diseases and Stroke, and the National Institute of Mental Health
    support an AD Translational and Drug Discovery Initiative that
    currently funds more than 40 projects, including a number of pilot
    clinical trials. In a recent, highly promising pilot trial, a nasal-
    spray form of insulin delayed memory loss and preserved cognition in
    people with cognitive deficits ranging from MCI to moderate AD. A
    larger-scale study to confirm and extend these results is under
    development.
    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 2011, the NIA Division of Aging Biology led the formation of the
    Trans-NIH GeroScience Interest Group (GIG). This working group, which
    is comprised currently of 19 NIH Institutes and Centers was formed to
    encourage trans-NIH discussion and coordination of research activities
    focusing on mechanisms underlying age-related changes, including those
    that could lead to increased disease susceptibility (e.g. stress,
    inflammation, etc.). Another major goal of the GIG is to raise
    awareness both inside and outside the NIH of the relevant role aging
    biology plays in the development of age-related processes and chronic
    disease. To achieve this goal, the working group is planning seminars
    that will feature internal and external speakers, as well as symposia
    and workshops. With additional funding, the GIG could play an
    instrumental role in developing trans-NIH initiatives, including
    funding opportunities and Common Fund initiatives, to encourage
    research on basic biology of aging and its relationship to earlier life
    events, exposures, and diseases. The FoNIA believe the GIG is an
    important development that will result in greater coordination of aging
    research activities and resources across the NIH.
    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.
        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 more than 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. It is so respected that the study is being
    replicated in 30 other countries. In March 2012, HRS took an important
    step forward by announcing that genetic data from approximately 13,000
    individuals were posted to dbGAP, the NIH's online genetics database.
    The data are comprised of approximately 2.5 million genetic markers
    from each person and are immediately available for analysis by
    qualified researchers. These data will enhance the ability of
    researchers to track the onset and progression of diseases and
    conditions affecting the elderly.
        NIA also continues to support research on the economic implications
    of aging and healthcare reform. In an ongoing study, the State of
    Oregon randomly assigned 10,000 low-income uninsured adults to the
    State's Medicaid program (out of a pool of 90,000 individuals who
    applied). The initial results from this study indicate that enrollees
    increased use of healthcare services and therefore program costs, but
    also reported improved health and well-being and reduced financial
    strain.
    Funding Challenges
        Despite its ability to support important research projects and
    programs, the NIA faces unique funding challenges. While the current
    dollars appropriated to NIA seem to have risen significantly since
    fiscal year 2003, when adjusted for inflation, they have decreased
    almost 18 percent in the last 9 years. Further, according to the NIH
    Almanac, out of each dollar appropriated to NIH, only 3.6 cents goes
    toward supporting the work of the NIA-compared to 16.5 cents to the
    National Cancer Institute, 14.6 cents to the National Institute of
    Allergy and Infectious Diseases, 10 cents to the National Heart, Lung
    and Blood Institute, and 6.3 cents to the National Institute of
    Diabetes and Digestive and Kidney Diseases. Finally, despite enacting
    cost cutting measures, such as differing paylines for projects costing
    above and below $500,000 and a decrease in non-competing commitments,
    NIA's success rate remained below the average NIH success rate between
    2008 and 2011.
        The undeniable rise in the U.S. aging population is another factor
    justifying the need for increasing the NIA budget. 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. Aging is a major risk factor for numerous diseases and
    disorders. These factors justify the need to provide NIA with $1.4
    billion, an increase of $300 million over the Institute's fiscal year
    2011 level, in fiscal year 2013. It is important to note that this
    funding level is not only endorsed by the FoNIA and the Leadership
    Conference on Aging, but also was endorsed by more than 500 scientists
    nationwide who signed a letter to Dr. Collins in December 2011,
    requesting this amount.
    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 the Friends of the National Institute of Child
                          Health and Human Development
        The Friends of the National Institute of Child Health and Human
    Development (NICHD) is a coalition of more than 100 organizations,
    representing scientists, physicians, healthcare providers, patients,
    and parents, concerned with the health and welfare of women, children,
    families, and people with disabilities. We are pleased to submit
    testimony to support the extraordinary work of the Eunice Kennedy
    Shriver National Institute of Child Health and Human Development.
        We would like to urge all Members of Congress to continue sustained
    and predictable funding for the National Institutes of Health (NIH). To
    ensure that progress in basic, translational and clinical research is
    sustained, the Coalition joins the Ad Hoc Group for Medical Research in
    supporting a fiscal year 2013 appropriation of at least $32 billion for
    NIH.
        The Coalition has a particular interest in the important research
    conducted and supported by the NICHD. Since its establishment in 1963,
    the NICHD has made great strides in meeting the objectives of its broad
    biomedical and behavioral research mission. The NICHD mission and
    portfolio includes a focus on women's health and human development,
    including research on child development, before and after birth;
    maternal, child, and family health; learning and language development;
    reproductive biology and population issues; and medical rehabilitation.
        Although the NICHD has made significant contributions to the well-
    being of children, women, and families, much remains to be done. With
    sufficient resources, the NICHD could build upon the promising
    initiatives described in this testimony and produce new insights into
    human development and solutions to health and developmental problems
    for the world and for the Nation--including the families living in your
    districts. For fiscal year 2013, the Friends of NICHD support an
    appropriation of at least $1.37 billion for NICHD.
    New Discoveries
        Scientific breakthroughs supported by NICHD specifically serve to
    prevent and treat many of the Nation's most devastating health
    problems, such as infant mortality and low birthweight, birth defects,
    intellectual and developmental disabilities, pediatric AIDS, and the
    reproductive and gynecologic health of women throughout their
    lifespans. Adding to its strong record of progress over the past 50
    years, recent advances by the NICHD have contributed to the health and
    well-being of our Nation and world. Several highlights are:
        Prematurity.--Biomedical research is critically important to
    understanding the causes of prematurity and developing effective
    prevention and treatment methods. Prematurity rates have increased
    almost 35 percent since 1981 at a cost to the Nation of $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. A
    breakthrough study conducted by NICHD last year showed a significant
    reduction in preterm delivery among women with short cervixes who are
    administered vaginal progesterone. The results were especially positive
    in reducing births pre-28 weeks. The results of this study are expected
    to save the healthcare system $500 million a year. Additional research
    can help drive down our prematurity rates further, saving dollars and
    lives.
        Autism.--Scientists funded through an NICHD-funded Infant Brain
    Imaging Study have discovered patterns of brain development in the
    first 2 years of life that are distinct in children who are later
    diagnosed with autism spectrum disorder (ASD). The study results show
    differences in brain structure at 6 months of age, the earliest such
    structural changes have been recorded in ASDs. ASDs involve
    communication and social difficulties as well as repetitive behavior
    and restricted interests. Many early behavioral signs of ASDs are not
    apparent until the first year of age. Typically, ASDs are diagnosed at
    age 3 or older. According to the U.S. Centers for Disease Control and
    Prevention (CDC), ASDs affect 1 of 88 children in the United States (1
    in 54 for boys).
        Childhood Obesity.--According to the CDC, obesity now affects 17
    percent of all children and adolescents in the United States--triple
    the rate from just one generation ago and nearly one-third of all
    adults are now classified as obese, a figure that has more than doubled
    over the last 30 years. Health risks associated with being overweight
    or obese include type 2 diabetes, high blood pressure, high
    cholesterol, asthma, and arthritis, among other risks. While promoting
    healthy behaviors and physical activity is critical to child health,
    studies have also demonstrated that genetics could also play a factor.
    NIH-supported researchers have also identified locations at two genes,
    which, when mutated, appear to increase the likelihood of common
    childhood obesity. Earlier studies have identified genes associated
    with obesity in extremely obese youth and in adults, but the current
    study is the first to identify two genes associated with the less
    severe, more common form of obesity.
        Cognitive Development.--NICHD sponsors research on reading and
    reading disabilities, with the goal of identifying those factors that
    help English speaking children, bilinguals, and children who learn
    English as a second language become proficient in reading and writing
    in English. In 2009, 21 percent of U.S. children spoke a language other
    than English at home. According to a recent study sponsored by the
    NICHD, children who grow up learning to speak two languages are better
    at switching between tasks than are children who learn to speak only
    one language, which serves as an indicator of executive functioning
    skills such as the ability to pay attention, plan organize, and
    strategize. However, the study also found that bilinguals are slower to
    acquire vocabulary than are monolinguals, because bilinguals must
    divide their time between two languages while monolinguals focus on
    only one.
        Population Research.--In late 2011, an NICHD-supported analysis of
    more than 5 million medical records showed that pregnant women
    assaulted by an intimate partner are at increased risk of giving birth
    to infants at lower birth weights. Babies born at low birth weights are
    at higher risk for SIDS, heart and breathing problems, and learning
    disabilities. The American College of Obstetricians and Gynecologists
    used this information in developing physician training materials for
    screening patients for intimate partner violence.
    Future Research Opportunities
        Although the studies mentioned above have unquestionably made
    significant contributions to the well-being of our children and
    families, there is still much to discover about ways to improve health,
    learning, and quality of life. NICHD recently undertook a ``visioning''
    process to identify critical scientific opportunities and goals for the
    coming decade to explore how biomedical, social and behavioral research
    could improve public health and prevention across its research
    portfolio. We support the Institute's efforts to achieve their goals as
    well as those scientific opportunities below, all of which can only be
    achieved with adequate Federal investments.
        Learning to Read, Write and Compute.--There is valuable research
    underway at NICHD on behavioral science, genetics, trans-disciplinary
    topics examining issues related to etiology, classification and
    definition, and prevention and remediation of learning disabilities
    (LD) impacting listening, speaking, reading, writing and math with an
    emphasis on co-morbid conditions (e.g., ADHD). Because individuals with
    LD continue to represent the largest population of school-age students
    identified for special education services in K-12 schools and continue
    to struggle to read, write and compute at the same rate as their
    peers--yet individuals with LD do not have intellectual disabilities--
    NICHD continues to conduct innovative research to study the
    neurological processes of the brain with an integrative approach,
    including the use of fMRI and MRI. Such integration in the research
    includes pursuing answers to how the brain processes information
    including the underlying neurological processes that support learning
    to read, write and compute. NICHD's ongoing work continues to better
    inform best practices to improve classroom instruction and learning so
    that more struggling students successfully exit high school ready to
    attend college or receive career training.
        Intellectual and Developmental Disabilities.--Ongoing support of
    the research in intellectual and developmental disabilities being
    undertaken at the Eunice Kennedy Shriver Intellectual and Developmental
    Disabilities Research Centers (IDDRC) is essential. The IDDRCs have
    made outstanding contributions toward understanding the causes of a
    wide range of developmental disabilities including autism, Fragile X
    syndrome, Down syndrome, autism spectrum disorders (ASD), mitochondrial
    and other genetic/genomic disorders and environmentally induced
    disorders. IDDRCs have collaborated with each other to leverage
    resources and scientific capital on such efforts as developing a shared
    contact registry of individuals with Fragile X syndrome that will
    become a national resource to support investigators interested in
    studies involving this condition. Recent genetic and biomedical
    advances over the past few years hold the promise for understanding the
    threats to healthy and full development and ultimately to the
    prevention and amelioration of the impact of many disabilities.
    Additional resources are needed to help bring about progress in
    expanding registries to include larger samples across different
    disorders, support and mentor new investigators, and develop
    opportunities for translational research efforts to take advantage of
    recent findings.
        Contraceptive Research and Development.--Through its investment in
    contraceptive evaluation research, NICHD plays a key leadership role in
    ensuring acceptability and effective use of existing products in
    various settings and populations and in addressing behavioral issues
    related to fertility and contraceptive use. Specific opportunities and
    research priorities in the area of contraceptive evaluation include
    evaluation of the safety and effectiveness of hormonal contraceptive
    options for women who are overweight or obese. The Institute's
    investment in contraceptive development research is critical for
    producing new contraceptive modalities that offer couples options with
    fewer side-effects and additional non-contraceptive health benefits.
    Specific opportunities and research priorities in the area of
    contraceptive development include the need for non-hormonal
    contraception, post-coital contraception and multipurpose prevention
    technologies that would prevent both pregnancy and sexually transmitted
    infections.
        Reproductive Sciences.--Through its investment in reproductive
    science, NICHD conducts research to improve women's health by
    developing innovative medical therapies and technologies and improving
    existing treatment options for gynecological conditions affecting
    overall health and fertility. The Institute's reproductive science
    research makes a vital contribution to women's health by focusing on
    serious conditions that have been overlooked and underfunded, despite
    the fact that the impact many women. For example, the NICHD's Pelvic
    Floor Disorders Network is conducting research to improve treatment of
    extremely painful gynecological conditions that affect 25 percent of
    American women. Specific opportunities and research priorities in
    infertility research include the need for treatments for disorders such
    as endometriosis, polycystic ovarian syndrome (PCOS) and uterine
    fibroids which can prevent couples from achieving desired pregnancies.
        Rehabilitation Research.--The NICHD houses the National Center for
    Medical Rehabilitation Research (NCMRR). This Center fosters the
    development of scientific knowledge needed to enhance the health,
    productivity, independence, and quality-of-life of people with
    disabilities. A primary goal of Center-supported research is to bring
    the health related problems of people with disabilities to the
    attention of the best scientists in order to capitalize upon the myriad
    advances occurring in the biological, behavioral, and engineering
    sciences.
        Longitudinal Research.--NICHD's investments in longitudinal, large
    scale databases, provide rich, in-depth resources for researchers
    across the demographic, behavioral, social and population sciences. As
    public resources, these accessible databases enable scientists
    worldwide to conduct research on linkages between family, neighborhood
    and school environments, socio-economic status and behaviors that
    impact health outcomes in particular. Among the most important
    databases are the Add Health Study, the Panel Study of Income Dynamics,
    Fragile Families and Child Well Being.
        Building Scientific Capacity.--Adequate levels of research require
    a robust research workforce. The average investigator is in his/her
    forties before receiving their first NIH grant, a huge disincentive for
    students considering biomedical 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.
    Conclusion
        We deeply appreciate the consistent interest and support the
    Congress has shown for the NIH and NICHD. As your committee moves
    forward on the Labor, HHS Appropriations bill, we urge you to provide
    NIH and NICHD with funding levels that meet current needs for
    addressing health issues across the lifespan. Thank you in advance for
    your consideration of our views and we look forward to continuing to
    work with you on these critical issues.
                                     ______

      Prepared Statement of the Friends of the National Institute on Drug
                                     Abuse
        Mr. Chairman and Members of the Subcommittee, thank you for the
    opportunity to submit testimony to the Subcommittee in support of the
    National Institute on Drug Abuse. The Friends of the National Institute
    on Drug Abuse (FON) is a coalition of more than 150 scientific and
    professional societies, patient groups, and other organizations
    committed to, preventing and treating substance use disorders as well
    as understanding their causes through the research agenda of the
    National Institute on Drug Abuse (NIDA). We are pleased to provide
    testimony in support of the work carried out by scholars around the
    country whose work is supported by NIDA.
        Drug abuse is costly to Americans; it ruins lives, while tearing at
    the fabric of our society and taking a huge financial toll on our
    resources. Beyond the unacceptably high rates of morbidity and
    mortality, drug abuse is often implicated in family disintegration,
    loss of employment, failure in school, domestic violence, child abuse,
    and other crimes. Placing dollar figures on the problem; smoking,
    alcohol and illegal drug use results in an exorbitant economic cost on
    our Nation, estimated at more than $600 billion annually. We know that
    many of these problems can be prevented entirely, and that the longer
    we can delay initiation of any use, the more successfully we mitigate
    future morbidity, mortality and economic burdens.
        Over the past three decades, NIDA-supported research has
    revolutionized our understanding of addiction as a chronic, often-
    relapsing brain disease--this new knowledge has helped to correctly
    situate drug addiction as a serious public health issue that demands
    strategic solutions. By supporting research that reveals how drugs
    affect the brain and behavior and how multiple factors influence drug
    abuse and its consequences, scholars supported by NIDA continue to
    advance effective strategies to prevent people from ever using drugs
    and to treat them when they cannot stop.
        NIDA supports a comprehensive research portfolio that spans the
    continuum of basic neuroscience, behavior and genetics research through
    medications development and applied health services research and
    epidemiology. While supporting research on the positive effects of
    evidence-based prevention and treatment approaches, NIDA also
    recognizes the need to keep pace with emerging problems. We have seen
    encouraging trends--significant declines in a wide array of youth drug
    use--over the past several years that we think are due, at least in
    part, to NIDA's public education and awareness efforts. However, areas
    of significant concern, such as prescription drug abuse, remain and we
    support NIDA in its efforts to find successful approaches to these
    difficult problems.
        Recognizing that so many health research issues are inter-related,
    we request that the subcommittee provide at least $32 billion for the
    National Institutes of Health, which is a $1.3 billion or 4.3 percent
    increase over fiscal year 2012. This will allow NIH to keep up with
    inflation. Because of the critical importance of drug abuse research
    for the health and economy of our Nation, we also request that you
    provide a proportionate increase for the National Institute on Drug
    Abuse.
        In addition, to highlight certain priority research areas within
    NIDA's portfolio, we respectfully request that you include the
    following language in the committee report accompanying the fiscal year
    2013 funding recommendation for the National Institute on Drug Abuse:

        ``Medications Development.--With the recent reduction in the
    efforts of the pharmaceutical industry to develop new medications to
    treat diseases of the brain, the Committee encourages NIDA to continue
    to increase their efforts to develop medications to treat diseases of
    addiction. Reasonable success has occurred in the past and recent
    advances in knowledge support this effort.
        ``Translational Research.--The Committee encourages NIDA to
    continue its efforts to increase our knowledge of how genetics, age,
    environment and other factors affect the use of experimental drugs and
    the development of addiction.
        ``Education.--The educational efforts of NIDA to inform the public
    of the deleterious effects of abused substances and the life-
    threatening dangers of drug addiction are recognized and encouraged.
    Progress in this area has contributed to the decreased abuse of
    nicotine and its long term medical consequences, including death.
    Adolescents and returning veterans and their families are at a high
    risk for drug abuse and therefore should be areas of concentration for
    these educational efforts.
        ``Prevention and Treatment.--The Committee recognizes the reported
    increase in abuse of marijuana and prescription drugs and encourages
    NIDA to support innovative approaches to prevent and treat this abuse
    and the resulting harmful effects. The concentration in these areas
    should compliment efforts to prevent and treat addiction of all abused
    substances.
        ``Prescription Drug Abuse.--Prescription drug abuse has been the
    focus of much work by NIDA and its grantees and although significant
    progress has been made, the Committee encourages NIDA to maintain its
    comprehensive leadership role in the effort to halt this epidemic.
        ``Military Personnel, Veterans, and Their Families.--The Committee
    commends NIDA for its successful efforts to coordinate and support
    research with the Department of Veterans Affairs and other NIH
    Institutes on substance abuse and associated problems among U.S.
    military personnel, veterans and their families. Many military
    personnel need help confronting war-related problems including
    traumatic brain injury, post-traumatic stress disorder, depression,
    anxiety, sleep disturbances, and substance abuse, including tobacco,
    alcohol and other drugs. Many of these problems are interconnected and
    contribute to individual health and family relationship crises, yet
    there has been little research on how to prevent and treat the unique
    characteristics of wartime-related substance abuse issues. The
    Committee encourages NIDA to continue work in this area.''

        The Nation's previous investment in scientific research to further
    understand the effects of abused drugs on the body has increased our
    ability to prevent and treat addiction. As with other diseases, much
    more needs be done to improve prevention and treatment of these
    dangerous and costly diseases. Our knowledge of how drugs work in the
    brain, their health consequences, how to treat people already addicted,
    and what constitutes effective prevention strategies has increased
    dramatically due to support of this research. However, since the number
    of individuals continuing to be affected is still rising, we need to
    continue the work until this disease is both prevented and eliminated
    from society.
        We understand that the fiscal year 2013 budget cycle will involve
    setting priorities and accepting compromise, however, in the current
    climate we believe a focus on substance abuse and addiction, which
    according to the World Health Organization account for nearly 20
    percent of disabilities among 15-44 year olds, deserve to be
    prioritized accordingly. We look forward to working with you to make
    this a reality. Thank you for your support for the National Institute
    on Drug Abuse.
                                     ______

                  Prepared Statement of the FSH Society, Inc.
        Honorable Chairmen Inouye and Harkin and Ranking Members Cochran
    and Shelby, 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 49 years. For
    hundreds of thousands of men, women, and children the major consequence
    of inheriting this form of muscular dystrophy is a lifelong progressive
    loss of all skeletal muscles. FSHD is a crippling and life shortening
    disease. No one is immune. It is both genetically and spontaneously
    transmitted to children. It can affect multiple generations and entire
    family constellations.
        I have testified many times before the Congress. When I first
    testified, we did not know the mechanism of this disease. Now we do.
    When I first testified, we assumed that FSHD was a rare form of
    muscular dystrophy. Now we understand it to be one of the most, if not
    the most, prevalent form of muscular dystrophy. Congress is responsible
    for this success, through its sustaining support of the National
    Institutes of Health (NIH), enactment of the Muscular Dystrophy CARE
    Act and the collaborations of NIH, the Centers for Disease Control and
    Prevention (CDC), patient groups, and researchers, both here and
    internationally.
        I am testifying in order to document this success and call on the
    Congress to take advantage of the system of discovery it has set in
    motion.
    Mechanism of Facioscapulohumeral Muscular Dystrophy Has Been Described
        On August 19, 2010, Dutch and American researchers published a
    paper which dramatically expanded our understanding of the mechanism of
    FSHD.\1\ The front page story in the New York Times quoted the NIH
    Director, Dr. Francis Collins saying, ``If we were thinking of a
    collection of the genome's greatest hits, this would go on the list.''
    \2\
    ---------------------------------------------------------------------------
        \1\ Lemmers, RJ, et al, A Unifying Genetic Model for
    Facioscapulohumeral Muscular Dystrophy, Science 24 September 2010: Vol.
    329 no. 5999 pp. 1650-1653.
        \2\ Kolata, G., Reanimated ``Junk'' DNA Is Found to Cause Disease.
    New York Times, Science. Published online: August 19, 2010 http://
    www.nytimes.com/2010/08/20/science/20gene.html.
    ---------------------------------------------------------------------------
        Two months later, another paper was published that made a second
    critical advance in determining the cause of FSHD.\3\ The research
    shows that FSHD is caused by the inefficient suppression of a gene that
    may be normally expressed only in early development.
    ---------------------------------------------------------------------------
        \3\ Snider, L., Geng, L.N., Lemmers, R.J., Kyba, M., Ware, C.B.,
    Nelson, A.M., Tawil,R., Filippova, G.N., van der Maarel, S.M.,
    Tapscott, S.J., and Miller, D.G. (2010). Facioscapulohumeral dystrophy:
    incomplete suppression of a retrotransposed gene. PLoS Genet. 6,
    e1001181.
    ---------------------------------------------------------------------------
        On January 17, 2012, an international team of researchers led by
    Stephen J. Tapscott, M.D., Ph.D., of the Seattle Fred Hutchinson
    Center's Biology Division, published a third major advance further
    elucidating the mechanisms that can cause the disease genes and
    proteins that damage FSHD muscle cells. The research also discovered
    that one of the genes required for FSHD, called, DUX4 regulates cancer/
    testis antigens.\4\ Cancer and testis antigens are abnormally expressed
    in various tumor types, including melanoma and carcinomas of the
    bladder, lung and liver. This allows for the potential of using these
    antigens to create cancer vaccines.
    ---------------------------------------------------------------------------
        \4\ Geng et al., DUX4 Activates Germline Genes, Retroelements, and
    Immune Mediators: Implications for Facioscapulohumeral Dystrophy,
    Developmental Cell (2012), doi:10.1016/j.devcel.2011.11.013.
    ---------------------------------------------------------------------------
        This past week has brought five publications with significant
    developments on FSHD. On this day, April 26, 2012, another major
    breakthrough was announced. Researchers who began their careers with
    FSH Society fellowships reported in Cell of an epigenetic activatory
    long non-coding RNA (lncRNA) switch involved in FSHD and human genetic
    disease. This opens the potential to control FSHD by going after the
    master switch that regulates DUX4 and other genes that are necessary to
    cause FSHD. The master switch is a non-protein encoding lncRNA that has
    a normal developmental function and that can cause disease by allowing
    normally quiescent genes to produce too much protein at the wrong time
    and wrong place.\5\ This study published in Cell is important for
    several reasons. First, it further defines a mechanism of disease that
    could help explain the workings of diseases other than FSHD, including
    some forms of diabetes or cancer. Second, it clarifies the mechanism at
    work in FSHD and has identified specific therapeutic targets to achieve
    a treatment for FSHD.
    ---------------------------------------------------------------------------
        \5\ Cabianca et al., A Long ncRNA Links Copy Number Variation to a
    Polycomb/Trithorax Epigenetic Switch in FSHD Muscular Dystrophy, Cell
    (2012), doi:10.1016/j.cell.2012.03.035.
    ---------------------------------------------------------------------------
        I am proud to say that many of these researchers have started their
    efforts in FSHD with seed funding from the FSH Society and have
    received continued support from the FSH Society, the National
    Institutes of Health, and the Muscular Dystrophy Association and other
    partners. This shows the power of the collaboration among funders,
    patient groups and researchers to advance the search for cures and
    treatments.
        The renowned FSH Society Scientific Advisory Board (SAB) led and
    chaired by M.I.T. Professor David E. Housman, Ph.D. has made great
    strides in the past 20 years. FSHD had long been thought of as a
    Mendelian disease caused by a defect in a single gene inherited in an
    autosomal dominant fashion. Two decades of work by a small group of
    patients and scientists have shown that, FSHD, is free of damage from
    any protein-encoding gene on the chromosomes that define human life.
    FSH Society seed funding has allowed researchers to understand how FSHD
    works, first in the cell, then at the chromosome level, then at a
    specific address on the chromosome called 4q35, then by discovering
    that the diseases is associated with a shortening or modification of
    repetitive sequences of DNA at 4q35 called D4Z4, then by studying the
    expression of genes and different types of RNA messages from within
    each repeat of D4Z4, and finally how D4Z4 repeat sequences regulate
    gene expression and that mutations and changes of such elements can
    influence the progression of a human genetic disease.
        Even with these breakthroughs, much work remains to be done. Given
    the recent developments in our definition of FSHD, the current
    potential is even greater for intervention strategies, therapeutics,
    and the planning and conducting of trials. We need to be prepared for
    this new era in the science of FSHD by accelerating efforts in the
    following four areas: \6\
    ---------------------------------------------------------------------------
        \6\ 2011 FSH Society FSHD International Research Consortium, held
    November 7-8, 2011 at DHHS NIH NICHD Boston Biomedical Research
    Institute Senator Paul D. Wellstone MD CRC for FSHD. To read the
    expanded summary and recommendations of the group see: http://
    www.fshsociety.org/assets/pdf/
    IRCWorkshop2011WorkingConsensusOfPrioritiesGalley.pdf.
    ---------------------------------------------------------------------------
                Genetics/epigenetics
        It is now broadly accepted that the disregulation of the expression
    of D4Z4/DUX4 plays a major role in FSHD1 (FSHD1A) and FSHD2 (FSHD1B).
    Additional FSHD (modifier) loci are likely to exist.
        FSHD molecular networks.--The relaxation of the chromatin structure
    on permissive chromosome 4 haplotypes leads to activation of downstream
    molecular networks. Importantly, the upstream processes--triggering of
    activation--are equally important. Detailed studies on these processes
    are crucial for insight into the molecular mechanisms of FSHD
    pathogenesis and may contribute to explaining the large intra- and
    interfamily clinical variability. Importantly such work will lead to
    intervention (possibly also prevention) targets.
        Additional FSHD genes.--FSHD2 is characterized by hypomethylation
    of D4Z4 on chromosome 4 as well as chromosome 10. This also leads to
    bursts of DUX4 expression. Identification of the responsible factor
    (gene) and molecular mechanisms is of utmost importance.
                Clinical trial readiness
        It is now broadly accepted that disregulation of the expression of
    D4Z4/DUX4 is at the heart of FSHD1 and FSHD2. This finding opens
    perspectives for intervention along different avenues.
        Clinical Trial Readiness.--Intervention trials are envisaged within
    the next several years. The FSHD field needs to be prepared for this
    crucial step. To design and coordinate this important translational
    process, it was envisaged to install an international task force
    Clinical Trial Readiness (FSHD-CTR), with a proven FSHD-clinician as
    leader.
        Biomarkers.--Sensitive biomarkers are needed to monitor
    intervention: they may also improve diagnosis.
                Model systems
        There are a plethora of cellular and animal models, based on
    different pathogenic (candidate gene) hypotheses. Moreover, the
    phenotypes are very diverse and often difficult to compare with the
    human FSHD phenotype.
        FSHD Model Data Base.--The importance of a systematic database was
    recognized. This data base should contain detailed information on the
    molecular characteristics of the model (design and phenotype).
        Human Pathology and Bio-Banking.--Importantly, this data base
    should also contain well-documented muscle pathology data of patients--
    astonishingly difficult to find in the literature. Human cellular
    resources continuously deserve attention.
                Sharing
        Timely sharing of information and resources significantly
    contributes to the progress in the field. There are several initiatives
    that create large repositories of data and resources. Their websites
    should be used for sharing of information (e.g. protocols, guide to
    FSHD muscle pathology (images), model systems, contact information,
    reagents, and resources).
        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 multiple human diseases.
    Surveillance Systems Have Improved Understanding of Prevalence
        The consortium, Orphanet, has issued new prevalence data for
    hundreds of orphan diseases in Europe. That report ranks FSHD as the
    most prevalent form of muscular dystrophy.\7\
    ---------------------------------------------------------------------------
        \7\ Prevalence of rare diseases: Bibliographic data, Orphanet
    Report Series, Rare Diseases collection, November 2011, Number 1:
    Listed in alphabetical order of diseases, http://www.orpha.net/
    orphacom/cahiers/docs/GB/Prevalence_of_rare_diseases_by_alphabetical_
    list.pdf.
    ---------------------------------------------------------------------------
        Likewise, the U.S. Centers for Disease Control and Prevention (CDC)
    has presented new data on the prevalence of muscular dystrophies which
    shows FSHD with the second highest prevalence rate 4.4/100,000 (the
    first was myotonic muscular dystrophy.) \8\ \9\ This enhanced
    understanding is due to the Congress' foresight in charging CDC to
    enhance its surveillance of muscular dystrophy. We cannot say whether
    FSHD is becoming more prevalent, if the prevalence of other dystrophies
    such as Duchenne's 2.1/100,000 is declining or if older information was
    just inaccurate.\9\ But we can say that congressional action is
    producing better information enabling all of us to make decisions.
    ---------------------------------------------------------------------------
        \8\ Centers for Disease Control and Prevention. November 7-8, 2011,
    CDC meeting ``Defining a public health approach for muscular dystrophy:
    A model for conditions with high impact/low prevalence''.
        \9\ Centers for Disease Control and Prevention. Prevalence of
    Duchenne/Becker muscular dystrophy among males aged 5-24 years--four
    States, 2007. MMWR Morb Mortal Wkly Rep. 2009 Oct 16; 58(40): 1119-22.
    ---------------------------------------------------------------------------
    Funding Picture Has Improved but More is Needed
        Mr. Chairman, these major advances in scientific understanding and
    epidemiological surveillance are not free. They come at a cost. Since
    the Congress passed the MD CARE Act, research funding at NIH for
    muscular dystrophy has increased 4-fold. While FSHD research funding
    has increased 12-fold during this period, the level of funding is still
    exceedingly low.

                                                                      [Dollars in millions]
    --------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                              Fiscal Year
                                         -------------------------------------------------------------------------------------------------------------------
                                            2000      2001      2002      2003      2004      2005      2006      2007      2008     2009     2010     2011
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    All MD..............................     $12.6     $21       $27.6     $39.1     $38.7     $39.5     $39.9     $47.2      $56      $83      $86      $75
    FSHD................................      $0.4      $0.5      $1.3      $1.5      $2.2      $2.0      $1.7      $3         $3       $5       $6       $6
    FSHD (percent total MD).............       3         2         5         4         6         5         4         5          5        6        7        8
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    Source: National Institutes of Health (NIH) FSHD Funding and Appropriations.
    FSHD Research Dollars (in millions) and FSHD as a Percentage of Total NIH Muscular Dystrophy Funding.
    Sources: NIH/OD Budget Office and NIH OCPL and NIH RCDC RePORT.

        We request for fiscal year 2013, a doubling of the
    facioscapulohumeral muscular dystrophy (FSHD) or facioscapulohumeral
    disease research budget at the NIH to $12 million. This will allow an
    expansion of the DHHS NIH Senator Paul D. Wellstone Muscular Dystrophy
    Cooperative Research Centers, an increase in much needed research
    awards, expansion of post-doctoral and clinical training fellowships,
    and a dedicated center to design and conduct clinical trials on animal
    models of FSHD. We need to translate discoveries and treatments for
    FSHD that, according to Dr. Collins ``if we were thinking of a
    collection of the genome's greatest hits, this would go on the list,''
    \2\ can be rapidly realized if FSHD is one of the diseases that the NIH
    National Center for Advancing Translational Sciences (NCATS), chooses
    to work on.
        Mr. Chairman, the patients and researchers of the FSH Society are
    grateful for the support from the Congress and the tremendous efforts
    of many people at the NIH Office of the Director, the National
    Institute of Arthritis and Musculoskeletal and Skin Disease, the
    National Institute on Neurological Disorders and Stroke and the
    National Institute for Child Health and Human Development. We are aware
    of the great pressures on the Federal budget, but cutting the NIH
    budget and research funding for FSHD at this time would be the wrong
    decision. We have come so far with such modest funding. This is not the
    time to lessen our endeavor. This is the time to fully and
    expeditiously exploit the advances for which the American taxpayer has
    paid.
        As president of a patient organization which raises about $1
    million a year for research, I can tell you that the private sector
    cannot touch the level of funding NIH provides. And we fully appreciate
    your support.
        Thank you for this opportunity to testify before your committee.
                                     ______

         Prepared Statement of the Global Health Technologies Coalition
        Chairman Rehberg, Ranking Member DeLauro, and members of the
    subcommittee, thank you for the opportunity to provide testimony on the
    fiscal year 2013 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 promote the advancement of
    research and development (R&D) 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. My testimony reflects the
    needs expressed by our member organizations which include nonprofit
    advocacy organizations, policy think-tanks, implementing organizations,
    and many others.\1\ Also, one-third of our members are nonprofit
    product development partnerships (PDPs), which work with partners in
    the private biotechnology, 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 R&D by (1) sustaining and supporting the U.S. investment in
    global health research and product development, (2) instructing the 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 to document coordination efforts between agencies for the
    use of the Congress and the public, and (3) to encourage the newly
    formed National Center for Advancing Translational Sciences (NCATS) to
    explore supporting all stages of research.
    ---------------------------------------------------------------------------
        \1\ GHTC member list: http://www.ghtcoalition.org/coalition-
    members.php.
    ---------------------------------------------------------------------------
    Critical Need for New Global Health Tools
        Our Nation's investments have made historic strides in promoting
    better health around the world: nearly 6 million people living with
    HIV/AIDS now have access to life-saving medicines; new, cost-effective
    tools help us diagnose diseases quicker and more efficiently than ever
    before; and innovative new vaccines are making significant dents in
    childhood mortality. While we must increase access to these and other
    proven, existing health tools to tackle global health problems, it is
    just as critical that we continue to invest in developing the next
    generation of tools to stamp out disease and address current and
    emerging threats. For instance, newer, more robust, and easier to use
    antiretroviral drugs (ARV), particularly for infants and young
    children, are needed to treat and prevent HIV, and even an AIDS vaccine
    that is 50 percent effective has the potential to prevent 1 million HIV
    infections every year. Drug-resistant tuberculosis (TB) 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 too expensive. New tools are
    also urgently needed to address fatal neglected tropical diseases
    (NTDs) such as sleeping sickness, for which diagnostic tools are
    inadequate and the few drugs available are toxic or 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
    supported and sustained.
    Research and U.S. Global Health Efforts
        The United States is at the forefront of innovation in global
    health technologies. For example, in November 2010, the NIH announced
    the results of the iPrEx clinical trial, a large, multi-country
    research study examining pre-exposure prophylaxis (PrEP).\2\ The study
    found that a daily dose of two anti-retroviral drugs could provide an
    average of 44 percent additional protection to high-risk populations
    who also received a comprehensive package of HIV prevention services.
    Additional studies supported by the CDC and the University of
    Washington confirmed that a daily oral dose of ARV drugs used to treat
    HIV infection can reduce the risk of HIV acquisition among uninfected
    individuals by between 63 and 73 percent.
    ---------------------------------------------------------------------------
        \2\ iPrex trial. http://www.niaid.nih.gov/news/newsreleases/2010/
    Pages/iPrEx.aspx.
    ---------------------------------------------------------------------------
        The NIH is the largest funder of global health research in the U.S.
    Government, and the agency continues to demonstrate growing interest in
    global health issues, particularly in the area of translational
    research. NIH Director Francis Collins has made global health one of
    his top five priorities for the future of the NIH, and our coalition
    members have been pleased to see this implemented via the launch of a
    new Center for Global Health Studies at the Fogarty International
    Center, new initiatives on global health at the National Cancer
    Institute, and the creation of the new National Center for Advancing
    Translational Sciences (NCATS). Fogarty continues to collaborate with
    the U.S. Department of State's Office of the U.S. Global AIDS
    Coordinator and other agencies on the Medical Education Partnership
    Initiative (MEPI) to develop, expand, and enhance models of medical
    education. This includes enhancing the capacity of local individuals to
    conduct research on global health diseases. Additionally, the Model
    Non-Profit License Agreement for NTDs, HIV, TB, and Malaria
    Technologies was created for nonprofit institutions and PDPs with a
    demonstrated commitment to neglected diseases to apply for the use of
    patented inventions and non-patented biological materials from the NIH
    and the FDA intramural laboratories. Also very recently, a partnership
    between the NIH, the FDA, and GHTC member organization BIO Ventures for
    Global Health has proposed the Global Health Connector--a knowledge
    sharing system for scientists to improve access to valuable compound
    information and data to inform research into neglected tropical
    diseases. Each of these efforts built on the historic work carried out
    by the agency which contributes to improved health around the world.
        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 the 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. The CDC's Center for
    Global Health employs 1,100 staff members, and has people on the ground
    in 55 countries. The CDC is one of many partners providing support to
    research conducted on the PATH Malaria Vaccine Initiative's RTS,S
    vaccine candidate, as well as vaccine research for dengue and Rift
    Valley Fever. The CDC also conducts important global disease mapping
    and surveillance, including operational research on integrated mapping
    of NTDs over the past year. These activities also increase the
    reliability of estimates of disease burden, measure impact of NTD
    control efforts, and provide a planning tool for national control
    programs. To combat HIV/AIDS, the CDC was involved with the ground-
    breaking HIV Prevention Trials Network (HPTN) 052 study, which was the
    first randomized clinical trial to show that treating HIV-infected
    individuals with ART can reduce the risk of sexual transmission of HIV
    to their uninfected partners. Additionally, the CDC's involvement with
    expansion of rapid HIV testing has had a big impact in improving HIV/
    AIDS diagnostics. All of these efforts at the CDC and NIH also align
    with the new global health strategy developed by the Office of Global
    Affairs at the U.S. Department of Health and Human Services.
    Leveraging the Private Sector for Innovation
        The NIH, CDC, and other U.S. 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 in which private industries have not historically
    invested. This unique model has generated 16 new global health products
    and has enormous potential for continued success if robustly supported.
    NIH Director Francis Collins has stated that such partnership is key to
    the development of therapies and health tools based on NIH-funded
    research.
    Innovation as a Smart Economic Choice
        Global health R&D brings life-saving tools to those who need them
    most, however the benefits of 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 support 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 and that
            leaders at the CDC and NIH 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 that relevant agencies report on their progress to the
            Congress and that these reports be made publicly available.
            Past accounting of the health R&D activities at individual
            agencies, such as the Research, Condition, and Disease
            Categorization at the 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. The Committee should request that the CDC and NIH
            each develop comprehensive strategies to include global health
            research, product development, and regulation in their
            activities, in line with the recently released HHS Global
            Health Strategy.
      --Request that the new National Center for Advancing Translational
            Sciences (NCATS) explore the benefits of supporting all stages
            of research instead of stopping at stage two, and that
            neglected diseases be given the same priority as rare diseases,
            in order to realize the full potential of the NCATS.
        We respectfully request that the Committee consider inclusion of
    the following language in the report on the fiscal year 2013 Labor,
    Health and Human Services, and Education appropriations legislation:

        ``The Committee recognizes the urgent need for new global health
    technologies in the fight against neglected diseases that
    disproportionately affect low- and middle-income countries, and the
    critical contribution that the NIH, CDC, and FDA make to this through
    health research training operations, research, and regulatory
    capabilities. The Committee also acknowledges the urgent need to
    sustain and support 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. 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. The 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, the NIH also
    harnesses its wealth of expertise to train the next generation of
    health scientists. The Committee recognizes the important role that
    late-stage research has in fostering the development of urgently needed
    health tools, and encourages the new National Center for Advancing
    Translational Sciences (NCATS) to explore supporting all stages of
    research, particularly for neglected diseases.
        ``The Committee directs the CDC, FDA, and NIH to each develop
    concrete plans to prioritize and incorporate global health research,
    product development, and regulation into the U.S. global health and
    development strategies. These efforts should be undertaken in line with
    the new Health and Human Services (HHS) Global Health Strategy. The
    Committee directs the CDC, FDA, and NIH to work with 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 U.S. Government. The
    CDC, FDA, and NIH shall each make the documentation and results of
    these efforts available to the 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 fiscal year 2013
    priorities for funding programs administered by the U.S. Departments of
    Labor, Health and Human Services, and Education.
        In 2011, Goodwill raised approximately $4.4 billion in its retail
    stores and other social enterprises and invested 82 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 approximately 4.2 million people, placing nearly 190,000
    people in jobs and employing more than 105,000.
        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.
        While Goodwill is proud of these and other achievements, they are
    truly the result of a public-private partnership. As the recovery from
    the worst recession since the Great Depression continues and
    unemployment rates slowly decline from near 10 percent, Goodwill
    Industries 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.
        While local Goodwill agencies care about a range of Federal funding
    sources, Goodwill urges appropriators to demonstrate that employment
    and training programs are a top priority by providing adequate funding
    for the Workforce Investment Act's adult, dislocated worker, and youth
    funding streams; Community College Partnerships; and the Senior
    Community Service Employment Program (SCSEP).
        Goodwill understands that appropriators face a difficult challenge
    in stretching limited resources to cover an increasing and dynamic
    range of priorities; and Goodwill shares concerns about the Nation's
    mounting debt and the deficit. This year, in particular, Goodwill is
    very concerned that the Budget Control Act's sequestration provision
    could result in an automatic across-the-board cut of approximately 9
    percent. Over the past several years, funding for a number of
    Goodwill's funding priorities has declined significantly, stretching
    resources critically thin. Goodwill is very concerned that decreasing
    funding by an additional 9 percent would have a drastic effect on its
    programs and the people who participate in them.
                            workforce investment act
        Funding for the Workforce Investment Act's youth, adult, dislocated
    worker formulas is one of Goodwill's top funding priorities for fiscal
    year 2013. The U.S. Department of Labor estimates that WIA's three core
    funding streams will help more than 5.2 million people this year to
    receive help finding jobs and accessing education and training that
    aims to improve their future employment prospects. In 2011,
    approximately 125,000 people were referred to local Goodwill agencies
    for employment services through the Workforce Investment Act (WIA).
        Investing 82 percent of its privately raise revenues in 2011,
    Goodwill is doing all it can to supplement the Federal investment in
    job training, employment services, and services that support people's
    efforts to find jobs and advance in careers. In fact, some agencies
    have been doing more than they can by deliberately using their reserves
    in order to provide help to more people than their current revenues
    support. Nevertheless, WIA funds support many agencies' efforts to
    provide skills training, job placement and job retention services to
    people with employment challenges including people with disabilities,
    people who receive welfare, and other job seekers. In addition, several
    agencies are one-stop lead operators or operators in association with
    other service providers. Many agencies are also active on State and
    local workforce boards, and most Goodwill agencies have people referred
    to them through the workforce system.
        The administration's fiscal year 2013 budget proposes approximately
    $2.6 billion for WIA's three main funding streams, and an additional
    $100 million to pay the U.S. Department of Labor's portion 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.
        Goodwill continues to be alarmed by the steady erosion of funding
    for WIA's adult, youth, and dislocated worker funding streams. In 2002,
    when the unemployment rate was 5.8 percent, combined funding for WIA's
    youth, adult, dislocated worker, and funding streams was more than
    $3.67 billion. Ten years later, combined fiscal year 2012 funding for
    WIA's core funding streams and the Workforce Innovation fund is $2.65
    billion--more than $1 billion or 25 percent less than in 2002--yet at a
    time when unemployment remains stubbornly high at more than 8 percent.
        The workforce system is vastly underfunded and preservation of
    WIA's formula funding streams should be a high priority. Therefore,
    Goodwill urges the Congress to sustain WIA's adult, dislocated worker,
    and youth funding streams at current funding levels at a minimum. In
    addition, Goodwill supports the administration's proposal to increase
    funding for the Workforce Innovation Fund from $50 million in fiscal
    year 2012 to $100 million in fiscal year 2013.
                         community college partnerships
        Goodwill continues to hear employers express that it remains
    difficult to find workers that have the skills employers seek. In
    response, Goodwill launched the Community College/Career Collaboration
    (C\4\) in 2009 to enhance local agencies' collaboration with community
    colleges to combine their assets and resources to provide easy access
    to education, job training and other supportive services to individuals
    who lack a college or career credential that employers look for.
        Pell grants are an important component of C\4\ because they
    increase access to training and education that lead to high-growth and
    good paying jobs that sustain families and build vibrant communities.
    Therefore the importance of Pell grants has increased dramatically for
    Goodwill. As a result, Goodwill was concerned that the fiscal year 2012
    omnibus appropriations bill included provisions that reduced Pell
    eligibility for many students.
        As members of the subcommittee know, the administration's fiscal
    year 2013 budget proposes to slightly increase the maximum Pell Grant
    to $5,635. In addition, the budget proposes to include up to $8 billion
    for the U.S. Departments of Labor and Education to create a Community
    College Initiative ``to support State and community college
    partnerships with businesses to build the skills of American workers.''
    Goodwill is intrigued by the proposal and believes that such
    partnerships should leverage the expertise and resources of community-
    based organizations that provide the supports students need to develop
    the skills and earn the credentials that employers seek.
        Goodwill urges the Congress to protect Pell Grants from efforts to
    further reduce eligibility for many low-income students, and approve
    the President's proposal to increase the maximum Pell Grant to $5,635.
              senior community service employment program (scsep)
        Although the economy is now slowly starting to recover, in 2011,
    millions of people--including more than 2 million who are 55 and older
    were unemployed. Workers who are 55 and older have multiple barriers to
    employment and will be among the last rehired as the economy improves.
    The President's fiscal year 2013 budget again proposes to move SCSEP
    from DOL to the Department of Health and Human Services' Administration
    on Aging. Goodwill is interested in learning more about the move to HHS
    and encourages the Congress to debate the proposal when it considers
    reauthorization of the Older Americans Act.
        SCESP helps provide low-income older workers with community
    services employment and private sector job placements. Goodwill is one
    of the newest SCSEP grantees. In 2011, Goodwill's SCSEP participants
    contributed nearly 1.4 million community service hours. Private sector
    placements averaged a starting wage of $9.34 per hour. Individuals
    placed in unsubsidized employment worked an average of nearly 30 hours
    per week. In addition, nearly 35 percent of those placed were into
    positions that offered benefits including health, vacation, and
    retirement.
        Goodwill urges the Subcommittee to increase SCSEP funding by 12
    percent to $500 million. This increase would help absorb increased
    costs and account for an increasing number of people who are over age
    55. Goodwill urges the Congress to discuss the proposal to move SCSEP
    from DOL to HHS when it considers reauthorization of the Older
    Americans Act.
                                   conclusion
        Goodwill thanks you for considering these requests, and looks
    forward to working with you to help Government meet the serious
    challenges our Nation faces.
                                     ______

      Prepared Statement of the 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
    recommending $520 million in fiscal year 2013 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 national organizations (https://www.aamc.org/advocacy/
    hpnec/members.htm) dedicated to ensuring the healthcare workforce is
    trained to meet the needs of the country's growing, aging, and diverse
    population.
        The Title VII health professions and Title VIII 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. Authorized since 1963, the programs
    are designed to help the workforce adapt to Americans' changing
    healthcare needs. Through loans, loan guarantees, and scholarships to
    students, as well as grants and contracts to academic institutions and
    nonprofit organizations, they are the only Federal programs designed to
    train providers in interdisciplinary settings to meet the needs of the
    country's special and underserved populations, increase minority
    representation in the healthcare workforce, and fill the gaps in the
    supply of health professionals not met by traditional market forces.
        While HPNEC recognizes the Subcommittee faces difficult decisions
    in a constrained budget environment, a continued commitment to programs
    supporting healthcare workforce development should remain a high
    priority. HPNEC's recommendation of $520 million would support
    continuation of all Title VII and Title VIII programs at least at their
    fiscal year 2012 enacted levels, while accommodating additional
    investments recommended by HRSA and HPNEC member organizations based on
    assessments of the Nation's growing workforce needs.
        Residents of underserved rural and urban areas alike already
    struggle to access health providers. Currently, HRSA estimates that
    more than 31,000 additional health practitioners are needed to
    alleviate existing shortages. As the Nation's 77 million baby boomers
    age, they will only require more care; coupled with the millions of
    newly insured individuals entering the system, this increased demand
    for health services will only exacerbate the existing deficit of health
    professionals.
        Failure to fully fund the Title VII and VIII programs would
    jeopardize activities to fill these vacancies and to prepare health
    professionals: to coordinate care for the Nation's expanding elderly
    population; to meet the unique needs of sick and ailing children; to
    practice in rural and other underserved communities; and to improve the
    diversity and cultural competence of the workforce. Given the
    synergistic nature of the programs, significant cuts to or elimination
    of any of the Title VII and Title VIII programs may also reverse the
    progress to date in mitigating such challenges.
        The Title VII and Title VIII programs can be considered in seven
    general categories:
      --The Primary Care Medicine and Oral Health Training programs support
            education and training of primary care professionals to improve
            access and quality of healthcare in underserved areas. Two-
            thirds of Americans interact with a primary care provider every
            year. Approximately one-half of primary care providers trained
            through these programs work in underserved areas, compared to
            10 percent of those trained in other programs. The General
            Pediatrics, General Internal Medicine, and Family Medicine
            programs provide critical funding for primary care physician
            training in community-based settings and support a range of
            initiatives, including medical student and residency training,
            faculty development, and the development of academic
            administrative units. 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 remote
            areas, the Interdisciplinary, Community-Based Linkages cluster
            supports community-based training of health professionals.
            These programs are designed to encourage health professionals
            to return to such settings after completing their training and
            to encourage collaboration between two or more disciplines. The
            Area Health Education Centers (AHECs) offer 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 leverage 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, all designed to bolster the number and quality of
            healthcare providers caring for older generations. The Graduate
            Psychology Education program, which supports interdisciplinary
            training of doctoral-level psychology students with other
            health professionals, provides 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 Mental and
            Behavioral Health Education and Training Grant Program supports
            the training of psychologists, social workers, and child and
            adolescent professionals. These programs together work to close
            the gap in access to quality mental and behavioral healthcare
            services by increasing the number of trained mental and
            behavioral health providers since 2002.
      --The Minority and Disadvantaged Health Professionals Training
            cluster helps improve healthcare access in underserved areas
            and the representation of minority and disadvantaged
            individuals in the health professions. Minority Centers of
            Excellence support 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 to
            advise future decisionmaking on the health professions and
            nursing programs. The Health Professions Research and Health
            Professions Data programs have developed 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.
            Reflecting 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 such analyses.
      --The Public Health Workforce Development programs help increase the
            number of individuals trained in public health, 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. This cluster
            also includes 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 service in underserved areas.
      --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 2005 and 2010, supported more than 400,000 nurses and
            nursing students as well as numerous academic nursing
            institutions and healthcare facilities. 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
            nurses with advanced education, including clinical nurse
            specialists, 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 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 exchange for 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 disadvantaged health professions students. The
            Nursing Student Loan (NSL) is for undergraduate and graduate
            nursing students with a preference for those with the greatest
            financial need. The Primary Care Loan (PCL) program provides
            loans in return for dedicated service in primary care. The
            Health Professional Student Loan (HPSL) program provides loans
            for financially needy health professions students based on
            institutional determination. These 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 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 Nation's
    workforce needs, but also help to improve access to care across all
    populations. Further, with the Bureau of Labor Statistics projecting
    that the healthcare industry will generate 3.2 million jobs through
    2018 (more than any other industry), these programs can help
    individuals in reaching their career goals and communities in filling
    their health needs. The multi-year nature of health professions
    education and training, coupled with 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 the immense fiscal pressures facing
    the Subcommittee, we respectfully urge support for $520 million for the
    Title VII and VIII programs to ensure the next generation of health
    professionals is equipped to address the Nation's healthcare
    complexities. We look forward to working with the Subcommittee to
    prioritize the health professions programs in fiscal year 2013 and into
    the future.
                                     ______

               Prepared Statement of the Harm Reduction Coalition
        We thank you for the opportunity to submit testimony regarding
    fiscal year 2013 Appropriations. Our testimony focuses on the urgency
    of scaling up Federal overdose prevention efforts.
        The Centers for Disease Control and Prevention (CDC) reports that
    ``Drug overdose death rates in the United States have more than tripled
    since 1990 and have never been higher. In 2008, more than 36,000 people
    died from drug overdoses, and most of these deaths were caused by
    prescription drugs . . . there is currently a growing, deadly epidemic
    of prescription painkiller abuse . . . the misuse and abuse of
    prescription painkillers was responsible for more than 475,000
    emergency department visits in 2009, a number that doubled in just 5
    years.''
        In a recent CDC Morbidity and Mortality Weekly Report (MMWR),
    findings ``suggest that distribution of naloxone and training in its
    administration might have prevented numerous deaths from opioid
    overdoses . . . To address the substantial increases in opioid-related
    drug overdose deaths, public health agencies could consider
    comprehensive measures that include teaching laypersons how to respond
    to overdoses and administer naloxone to those in need.''
        Naloxone is a prescription medication and opioid antidote which
    effectively reverses the effects of an opioid overdose. Within moments
    of its administration, naloxone restores breathing to a normal rate.
    There is no potential for abuse of naloxone and it will cause no effect
    in a person who has not taken opioids. However despite the powerful
    life-saving properties of naloxone, it is underutilized. Many health
    professionals lack awareness of the value of layperson-administered
    naloxone, and do not prescribe it to their patients for whom they have
    prescribed opioids.
        Broader recognition of the signs and symptoms of an overdose--and
    knowledge of how to respond (e.g., rescue breathing, administering
    naloxone, calling emergency services, etc.)--are essential to saving
    lives. HHS, the Department of Justice, and other agencies have been
    working to address prescription drug misuse, abuse, and diversion, but
    there is no coordinated Federal public health effort focused on helping
    the public and health professionals understand the signs and risks of
    overdose and learn how to prevent deaths from drug overdose.
        To that end, as advocates dedicated to preventing deaths from
    opioid overdose, we request that the Subcommittee consider including
    report language in the fiscal year 2013 appropriations bill which urges
    the Department of Health and Human Services and appropriate Federal
    agencies to adopt the following priorities:
      --Take steps to increase awareness of--and access to--the use of
            Naloxone, a prescription drug that when administered can
            prevent opioid overdose death. Specifically:
        --All Federal agencies involved in research, policies, regulation,
                and programs related to opioid misuse should coordinate
                efforts and develop and disseminate information about
                naloxone to healthcare professionals, individuals, and
                families and otherwise take other steps to facilitate its
                use, so that lives can be saved.
        --The Department of Health and Human Services should coordinate a
                national public health campaign to increase awareness of
                the signs and symptoms of overdose and improve
                understanding of the steps that individuals can take to
                save the life of someone who is experiencing an overdose.
                Such a national campaign should include information
                regarding the use of naloxone, rescue breathing, and
                calling emergency services, such as 9-1-1 and/or poison
                control centers.
        --CDC, working in collaboration with the Substance Abuse Mental
                Health Services Administration (SAMHSA) and the Health
                Resources and Services Administration (HRSA), should enable
                best practices, by providing technical assistance and
                toolkits for community programs and health professionals
                who wish to distribute naloxone.
      --Increase Federal surveillance and data collection regarding opioid
            use, misuse, and deaths to ensure that policies and programs
            are designed to target the actual causes of opioid misuse and
            death and to monitor the impact of any new efforts on: access
            to pain management; incidence and prevalence of opioid misuse;
            and overdose deaths from opioids.
      --Support increased access to--and funding of--drug treatment and
            recovery.
      --Continue Federal investment in the basic, clinical, and
            translational research supported by the National Institute of
            Drug Abuse (NIDA).
        The Harm Reduction Coalition believes that these measures are
    critical to meeting the goal of reversing the overdose epidemic in the
    United States.
        We thank you for your consideration of the important issues.
                                     ______

          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
    interstitial cystitis (IC) public awareness activities and research.
        ICA was founded in 1984 and remains the only nonprofit organization
    dedicated to improving the lives of those affected by IC. The
    Association provides an important avenue for advocacy, research, and
    education relating to this painful condition. Since its founding, the
    ICA has acted as a voice for those living with IC, enabling support
    groups and empowering patients. The ICA advocates for the expansion of
    the IC knowledge-base and the development of new treatments, including
    investigator initiated research. Finally, ICA works to educate
    patients, healthcare providers, and the public at large about IC.
        IC is a condition that consists of recurring pelvic pain, pressure,
    or discomfort in the bladder and pelvic region; it is often associated
    with urinary frequency and urgency. This condition may also be referred
    to as painful bladder syndrome (PBS), bladder pain syndrome (BPS), and
    chronic pelvic pain. It is estimated that as many as 12 million
    Americans have IC symptoms, more people than Alzheimer's, breast
    cancer, and autism combined. Approximately two-thirds of these patients
    are women, though this condition does severely impact the lives of men
    as well. IC has also been seen in children; in fact, many adults with
    IC report having experienced urinary problems during childhood.
    However, there has been little information published about children and
    IC, therefore statistics on IC, diagnostic tools, and treatments
    specific to children and IC are very limited.
        The exact cause of IC is unknown and treatment options are limited.
    There is no diagnostic test for IC, so 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, anxiety, and sexual
    dysfunction.
        Some studies also suggest that certain conditions occur more
    commonly in people with IC than in the general population. Some of
    these include allergies, irritable bowel syndrome, endometriosis,
    vulvodynia, fibromyalgia, and migraine headaches. Chronic fatigue
    syndrome, pelvic floor dysfunction, and Sjogren's syndrome have also
    been reported.
    Interstitial Cystitis Public Awareness and Education
        As IC is a condition that often takes years diagnosis, patients
    live in pain with no answers for many years. The IC Education and
    Awareness Program at the Centers for Disease Control and Prevention
    (CDC) plays a major role in increasing the public's awareness of this
    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 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.
        This program is a source of information for patients whose doctors
    have limited time or information, and many doctors recommend it to
    their patients as a resource. Many doctors are hesitant to treat IC
    patients because of the amount of time it takes to treat the condition
    and the lack of answers available. For this reason, it is especially
    critical for this program to provide patients with information about
    what they can do to manage this painful condition and lead a normal
    life.
        In order to continue these vitally important initiatives, it is
    critical that the CDC IC Education and Awareness Program be continued
    and receive a specific appropriation of $660,000 for fiscal year 2013.
    The ICA also encourages continued support for the National Center for
    Chronic Disease Prevention and Health Promotion, through which the IC
    program is supported.
    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
    major studies that yielded 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 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) indicated promising results for a new therapy for IC patients.
        Research currently underway also holds great promise to increase
    our understanding of IC, and thus find new treatments and a cure. The
    Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP)
    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. Research at the
    Office of Research on Women's Health (ORWH), specifically through
    Specialized Centers of Research on Sex and Gender Factors Affecting
    Women's Health, also shows great promise for learning more about IC.
    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. Continued research will assist in
    the development of new treatment and therapies to relieve this
    condition.
        We applaud the recent establishment of the National Center for
    Advancing Translational Sciences (NCATS) at NIH. Housing translational
    research activities at a single Center at NIH will allow these programs
    to achieve new levels of success. Initiatives like CAN are critical to
    overhauling the translational research process and overcoming the
    research ``valley of death'' that currently plagues treatment
    development. In addition, new efforts like taking the lead on drug
    repurposement hold the potential to speed new treatment to patients. We
    ask that you support NCATS and provide adequate resources for the
    Center in fiscal year 2013.
        In order for positive IC research to reach its full potential, it
    is essential that 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 $32 billion for fiscal year 2013. We
    also recommend the continuation of the MAPP study and research focused
    on IC in children.
        Thank you for the opportunity to present the views of the
    interstitial cystitis community.
                                     ______

        Prepared Statement of the Infectious Diseases Society of America
        The Infectious Diseases Society of America (IDSA) represents more
    nearly 10,000 infectious diseases (ID) physicians and scientists
    devoted to patient care, prevention, public health, education, and
    research. Investment in ID research and public health efforts, through
    lead Department of Health and Human Services (HHS) agencies, can reduce
    healthcare costs, save lives, and create jobs. IDSA urges you to
    provide strong funding for the following agencies:
    National Institutes of Health
                National Institute of Allergy and Infectious Disease
        IDSA supports funding for NIH of at least $32 billion for fiscal
    year 2013, as well as an additional $500 million to support National
    Institute of Allergy and Infectious Disease's (NIAID) antibacterial
    resistance and antibacterial drug and diagnostics R&D program. NIAID
    conducts and supports needed research on antibiotic resistance as well
    as research and development (R&D) of new antibiotics and diagnostics.
    Infections are becoming increasingly resistant to existing antibiotics,
    and the number of new antibiotics in development has plummeted. NIAID
    is establishing a vital new clinical trials network on antibiotic-
    resistant infections and it needs sufficient funding. The Committee
    also should urge NIAID to form a blue ribbon panel of experts to create
    an antibacterial resistance strategic plan to assist in prioritizing
    research in this area.
        Advancements in diagnostic tools are needed as well. Rapid point-
    of-care diagnostics improve physicians' ability to prescribe
    antibiotics appropriately, which can improve patient care and survival,
    limit the development of resistance, contain healthcare costs, and
    identify patients eligible for antibiotic clinical trials. IDSA
    requests that the Committee report urge NIAID to consult with
    stakeholders to explore the feasibility of creating a biorepository of
    prospectively collected specimens (e.g., tissue, sputum, blood, urine)
    to ease diagnostics R&D by reducing redundant specimen collection and
    assuring quality specimens and data.
        NIAID also plays an important role in funding research leading to
    new types of treatments for tuberculosis, fungal and viral diseases, as
    well as vaccines.
        IDSA remains concerned with limiting the salary of NIH extramural
    researchers to Executive Level II ($179,700--a reduction of $20,000
    from the Executive Level I cap used the past 10 years). The reduction
    will disproportionately affect physician investigators and serve as a
    deterrent to their research careers at a time when we are already
    struggling to remain globally competitive. IDSA urges the Congress to
    restore the NIH grantee salary cap to Executive Level I.
    Centers for Disease Control and Prevention
        IDSA supports at least $7.8 billion in funding for the Centers for
    Disease Control and Prevention's (CDC) programs for fiscal year 2013.
                National Center for Emerging and Zoonotic Infectious
                        Diseases
        National Center for Emerging and Zoonotic Infectious Diseases
    (NCEZID) houses CDC's antimicrobial resistance activities. CDC should
    be commended for creating an advisory group of non-government experts
    on antimicrobial resistance. Funding reductions to State and local
    public health laboratories (which are part of the National
    Antimicrobial Resistance Monitoring System--NARMS) hamper efforts to
    track resistance and understand its causes. Public health laboratories
    and PulseNet are also vital to detecting and tracking foodborne disease
    and identifying opportunities to increase food safety. The Emerging
    Infections Program (EIP) is a national resource for surveillance,
    prevention, and control of emerging infectious diseases whose
    activities include bacterial and food borne disease surveillance,
    influenza activities, and efforts to track and prevent healthcare-
    associated infections, about 70 percent of which are caused by
    resistant pathogens.
        The United States must improve data collection on antibiotic use to
    define the overuse and misuse of antibiotics that drives resistance.
    Specifically, IDSA recommends that the Committee report encourage CDC,
    in coordination with its partners on the Interagency Task Force on
    Antimicrobial Resistance (ITFAR), to issue a report to the Congress
    comparing European and American antibiotic surveillance and data
    collection capacities, including recommendations for the collection of
    more comprehensive data in the United States.
        The adoption of antimicrobial stewardship programs is crucial to
    foster the appropriate use of antibiotics and preserve these drugs'
    effectiveness. The Committee report should urge CDC to work in
    partnership with the Centers for Medicare and Medicaid Services (CMS)
    to continue promoting the uptake of stewardship programs in all
    healthcare facilities.
                National Healthcare Safety Network and the EpiCenter
                        Program
        IDSA supports the President's request for $27.5 million for
    National Healthcare Safety Network (NHSN), which conducts high-quality
    tracking and monitoring of deadly healthcare-associated infections
    (HAIs), of which more than 70 percent are caused by resistant
    pathogens. NHSN also funds the EpiCenter Program--a CDC collaboration
    with five academic centers focused on developing, implementing, and
    evaluating strategies to improve healthcare quality and assure patient
    safety. Past investment has yielded significant healthcare cost-savings
    and produced more than 150 peer-review publications.
                National Center for Immunization and Respiratory Diseases
        Section 317 Immunization Program.--Support for CDC's Section 317
    must be sustained. Section 317 supports access to (including obtaining
    and storing) vaccines, establishment and maintenance of vaccine
    registries, education of providers and the public, and promoting
    vaccination of healthcare workers (HCWs). Of tremendous concern,
    vaccination rates for adults range from 26 percent to 65 percent.
    Registries are one vital tool to improve these rates. Forty-nine States
    have childhood vaccination registries, but only 20 percent of adults
    have immunization information in a registry. The Committee should urge
    CDC to continue helping States expand immunization registries with a
    focus on improving information-sharing about patients' vaccination
    histories across providers and generating vaccination reminders,
    especially for adults.
        It is critical that HCWs receive the influenza vaccination. During
    the last influenza season, 63.5 percent of healthcare workers received
    the influenza vaccination according to CDC. The Committee should urge
    CDC to work in partnership with CMS to ensure that all healthcare
    workers receive the annual influenza vaccination.
                Public Health Preparedness and Response Activities
        CDC plays a central role in public health emergency preparedness
    and response. Funding is needed to provide coordination, guidance and
    technical assistance to State and local governments; support the
    Strategic National Stockpile; strengthen epidemiologic and public
    health laboratory capacity; and provide effective communications during
    an emergency.
                The National Center for HIV, Viral Hepatitis, STD and TB
                        Prevention
        IDSA supports a minimum increase of $40.2 million for HIV
    prevention and $10 million for viral hepatitis at the CDC. CDC plays a
    vital role in reducing new HIV infections through evidence-based
    prevention, including routine HIV screening. Hepatitis B and C affect
    nearly 6 million Americans and can lead to chronic liver disease,
    cirrhosis, liver cancer and liver failure that claim 15,000 lives each
    year. Increasing rates of gonorrhea are a critical concern because drug
    resistant strains have reduced our ability to treat these infections.
    Outbreaks of tuberculosis (TB) continue to occur throughout the United
    States. Multi-drug-resistant TB poses a particular challenge due to the
    very high costs of treatment. Funding is needed to detect, treat, and
    prevent these infections.
    Prevention and Public Health Fund
        The PPHF has filled gaps in core public health funding that should
    be sustained in CDC's base appropriation. The PPHF should be maintained
    for its true purpose--investment in innovative public health efforts.
    The PPHF has made important new investments in epidemiology and
    laboratory capacity; public health workforce training; preventing HIV/
    AIDS and viral hepatitis; increasing immunization rates; and reducing
    health care-associated infections.
    Assistant Secretary for Preparedness and Response
                Biomedical Advanced Research and Development Authority
        IDSA supports the administration's proposed $547 million for
    Biomedical Advanced Research and Development Authority (BARDA). BARDA
    facilitates advanced R&D of medical countermeasures (MCMs), including
    new antibiotics for intentional attacks and naturally emerging
    infections. This funding is particularly needed for antibiotic R&D,
    given the plummeting private investment in this area.
                Independent Strategic Investment Firm
        IDSA also supports the administration's proposal to establish an
    MCM Strategic Investor with an initial funding level of $50 million.
    This new entity will fill a significant void by partnering with small
    ``innovator'' companies and private investors to address urgent needs,
    including novel antimicrobials for multidrug-resistant organisms and
    diagnostics.
    Designate Leads on Antibiotic Development and Resistance
        The Committee report should urge HHS to designate leaders to fill
    voids and facilitate coordination and expert input into Federal
    antimicrobial resistance efforts by: (1) designating a lead agency to
    explore antibiotic R&D public private collaborations similar to those
    being established in the European Union; (2) establishing a lead office
    and director for the Interagency Task Force on Antimicrobial Resistance
    (ITFAR) and providing funding for the ITFAR to implement its action
    plan; (3) creating an advisory board of non-government experts that
    would work with the ITFAR and its director to establish priorities and
    ensure progress toward achieving their goals; (4) permitting non-
    government experts to serve on the US/EU Trans-Atlantic Task Force on
    Antimicrobial Resistance.
                                     ______

       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 and
    motility disorders (FGIMD) research.
        Established in 1991, IFFGD is a patient-driven nonprofit
    organization dedicated to assisting individuals affected by FGMIDs, and
    providing education and support for patients, healthcare providers, and
    the public. IFFGD also works to advance critical research on FGIMDs in
    order to provide patients with better treatment options, and to
    eventually find cures. IFFGD has worked closely with NIH on many
    priorities, including the NIH State-of-the-Science Conference on the
    Prevention of Fecal and Urinary Incontinence in Adults through the
    National Institute of Diabetes and Digestive and Kidney Diseases
    (NIDDK), the National Institute of Child Health and Human Development
    (NICHD), and the Office of Medical Applications of Research (OMAR). I
    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 FGIMDs are close to
    my heart. My own personal experiences of suffering from FGIMDs
    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
    FGIMDs due to a lack of awareness and education.
        The majority of FGIMDs 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
    FGIMDs 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. FGIMDs do not discriminate, affecting all ages,
    races and ethnicities, and genders.
    Irritable Bowel Syndrome
        Irritable Bowel Syndrome (IBS) 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 tests and treatments, including surgery,
    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 often 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 and work, and
    may even 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 with over-the-counter medications. In order to
    overcome these barriers to treatment, ensure more timely and accurate
    diagnosis, and reduce costly, unnecessary procedures, outreach to
    physicians and the general public remains 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; it 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 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
    other diseases.
        Causes 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. Several of these injuries may occur as a result of
    military service. 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 significant 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.
    More research in these priority areas is necessary to improve the lives
    of those who suffer from fecal incontinence.
        NIDDK recently launched a Bowel Control Awareness Campaign (BCAC)
    to educate the public about fecal incontinence. This campaign provides
    resources for healthcare providers, information about clinical trials,
    and information about lifestyle changes and advice for individuals
    suffering from bowel control issues. The BCAC is an important step in
    reaching out to patients, and we encouraged continued support for this
    campaign. Further research on fecal incontinence is critical to improve
    patient quality of life and implement the research goals of the NCDD.
    Gastroesophageal Reflux Disease
        Gastroesophageal reflux disease, or GERD, is a common disorder
    affecting both adults and children, which results from the back-flow of
    stomach contents into the esophagus. GERD is often accompanied by
    persistent symptoms, such as chronic heartburn and acid regurgitation.
    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. 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 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 8 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 who have 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. In many
    patients, the cause of the gastroparesis cannot be found and the
    disorder is termed idiopathic gastroparesis.
    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) last 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. CVS 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 the Congress to fund the NIH at level of $32 billion
    for fiscal year 2013. 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 FGIMDs, particularly through NIDDK. Increased
    support for NIDDK will facilitate necessary expansion of the research
    portfolio on FGIMDs necessary to grow the medical knowledge base and
    improve treatment. Such support would expedite the implementation of
    recommendations from the NCDD. It is also vital for NIDDK to work with
    NICHD to expand its research on the impact these disorders have on
    pediatric populations. Following years of near level-funding at NIH,
    research opportunities have been negatively impacted across all NIH
    Institutes and Centers. Without additional funding, medical researchers
    run the risk of losing promising research opportunities.
        We applaud the recent establishment of the National Center for
    Advancing Translational Sciences (NCATS) at NIH. Housing translational
    research activities at a single Center at NIH will allow these programs
    to achieve new levels of success. Initiatives like Cures Acceleration
    Network (CAN) are critical to overhauling the research process and
    overcoming the gap in translating basic into clinical research that
    currently plagues treatment development. In addition, new efforts like
    taking the lead on drug repurposement hold the potential to speed new
    treatment to patients. We ask that you support NCATS and provide
    adequate resources for the Center in fiscal year 2013.
        Thank you for the opportunity to present these views on behalf of
    the FGIMD community.
                                     ______

         Prepared Statement of the Interstate Mining Compact Commission
        We are writing in opposition to the fiscal year 2013 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 reject MSHA's proposed reduction of $5 million 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. Over the past
    several fiscal years, MSHA's budget request for State grants was
    approximately $9 million, which approached the statutorily authorized
    level of $10 million but still did 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 sections 502 and 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 pace with
    inflationary impacts or increased demands for training. The situation
    will likely be further exacerbated by new statutory, regulatory and
    policy requirements that grow out of the various reports and
    recommendations attending the Upper Big Branch accident.
        In MSHA's own budget justification document (at page 72), the
    agency states that: ``Training plays a critical role in preventing
    deaths, injuries, and illnesses on the job. By providing effective
    training, miners are able to recognize possible hazards and understand
    the safe procedures to follow. MSHA will continue its increased
    visibility and emphasis on training because it is critically important
    to making progress in reducing the number of injuries and fatalities.''
    Furthermore, in a March 5, 2012 communication to State training grant
    recipients, MSHA specifically asked for the States' assistance ``by
    including in your training, as appropriate, information on the [``Rules
    To Live By'' campaign].'' In this same letter, MSHA went on to note
    that ``the number of miners you reach yearly through the training your
    program provides makes your contribution to the success of the program
    all that more important.''
        We are mystified about how MSHA intends to accomplish these stated
    objectives without the training programs that are provided by the
    States pursuant to the grants they receive from MSHA--as has been the
    case since the enactment of the Mine Safety and Health Act in 1977. By
    way of an explanation for the drastic cut to training grants, MSHA
    states on page 73 of its budget justification document that because of
    the ``higher priorities'' placed on its enforcement activities, $5
    million will be ``reallocated'' and that it will ``shift responsibility
    for training back to mine operators.'' As a follow on, MSHA recognizes
    that some training services now provided by States will be ``reduced or
    eliminated'' and that ``operators will become more actively involved
    with their training or find other resources to provide training.'' This
    appears to be an effort by MSHA to begin shifting training
    responsibilities and costs entirely to mine operators. While this idea
    may have merit, we are uncertain about the ability of the mining
    industry to accommodate these new costs (especially small operators)
    and suspect that any realignment of training responsibilities from the
    States to the industry will take considerable time and planning.
    Furthermore, our experience over the past 35 years has demonstrated
    that the States are often in the best place to design and offer this
    training in a way that insures that the goals and objectives of
    sections 502 and 503 of the Mine Safety and Health Act are adequately
    met.
        The first time that the States became aware of this effort to shift
    responsibilities for miner training (and to reduce State grants) was
    upon the release of the Department of Labor's budget on February 13.
    There have been no discussions with the States about the impacts that
    this proposal will have on State training programs or about any sort of
    transition in the way we are currently doing business. To propose such
    a dramatic shift without first consulting the States is inappropriate
    and a denigration of the role the States have played in protecting our
    Nation's miners. Furthermore, to expect such a drastic change in
    operations to occur within a single fiscal year is unrealistic and will
    only result in confusion and potential negative impacts to the
    availability and quality of miner training.
        While we can appreciate MSHA's desire to realign its resources to
    focus on inspection and enforcement, one of the most effective ways to
    insure miner health and safety in the first place is through
    comprehensive and excellent training. MSHA Assistant Secretary Main
    specifically spoke to this in a recent letter he sent to State grant
    recipients wherein he stated: ``As in the past, we are reaching out to
    the grantees, recognizing the positive impact you have in delivering
    training to miners. I am asking that you incorporate, as appropriate,
    training on these types of [fatal] accidents as well as measures needed
    to prevent them. Increased training and awareness is necessary if we
    are to prevent these types of deaths.'' The States have been in the
    forefront of providing this training for more than 35 years and are
    best positioned to continue that work into the future. Furthermore, the
    Federal Government's relatively modest investment of money in
    supporting the States to handle this training has paid huge dividends
    in protecting lives and preventing injuries. The States are also able
    to provide these services at a cost well below what it would cost the
    Federal Government to do so.
        As you consider our request to reject MSHA's proposed cut and
    instead 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. This has
    been a particular focus in those States where metal/non-metal mining
    operations predominate. These are often small operators who cannot
    afford to offer the comprehensive training that is required under
    Section 502 of the Mine Safety and Health Act. Given this
    administration's articulated concerns about the impacts of regulatory
    decisions on small businesses, it is surprising that MSHA would propose
    significant cuts to the training that States provide to these small
    operators. Some States have also recently received requests from the
    VFW to provide ``new miner training'' for returning war veterans in
    order to prepare them for potential employment in the mining industry.
    Without the funding provided to States by MSHA, this may be difficult
    to accomplish in a timely manner, if at all.
        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 Lummi Indian Business Council
        Good morning to the distinguished Committee Members. Thank you for
    this opportunity. I am honored to present the appropriations request of
    the Lummi Nation for fiscal year 2013.
                             background information
        The Lummi Nation is located on the northern coast of Washington
    State, and is the third largest Tribe in Washington State serving a
    population of more than 5,200. The Lummi Nation is a fishing Nation. We
    have drawn our physical and spiritual sustenance from the marine
    tidelands and waters for hundreds of thousands of years. Now the
    abundance of wild salmon is gone, and the remaining salmon stocks do
    not support commercial fisheries. Consequently, our fishers are trying
    to survive off the sale of shellfish products. In 1999 we had 700
    licensed fishers who supported nearly 3,000 tribal members. Today, we
    have about 523 remaining. This means that more than 200 small
    businesses in our community have gone bankrupt in the past 15 years.
    This is the inescapable reality the Lummi Nation fishers face without
    salmon. We were the last surviving society of hunters/gatherers within
    the contiguous United States, but we can no longer survive living by
    the traditional ways of our ancestors.
                  lummi specific requests--department of labor
        Direct the DOL Office of Indian Energy, Economic and Workforce
    Development to work with the Lummi Nation in support of its
    comprehensive Fisherman's Cove Harbor and Working Water Front Project
    which addresses Indian Energy, Economic and Workforce Development needs
    of the Lummi Nation membership.
        Unemployment on the reservation has been very difficult to address
    with limited on-reservation jobs. Tribal governments need to be able to
    meet the employment and training needs of our membership as well as the
    business development needs of our communities. This is the objective of
    the Lummi Nation Fisherman's Cove Harbor and Working Waterfront
    Project. We need financial assistance to enable our membership to get
    the job skills the local (Reservation and Non-Reservation) labor market
    demands. The Lummi Nation needs to fully develop the Working Waterfront
    Project for the benefit of and to create jobs for the Lummi Nation
    fishers, members and others invested in the marine economy of the
    extreme northwest corner of the United States.
        lummi specific requests--department of health and human services
        Implement ACA and IHCIA.--Direct the Department and the U.S. Indian
    Health Services to fully and completely implement the Indian Specific
    provision of the Affordable Care Act and the newly reauthorized Indian
    Health Care Improvement Act (IHCIA).
        Affordable Care Act and Newly Reauthorized Indian Health Care
    Improvement Act.--Tribes are dismayed by the lack of support they have
    received in the development and implementation of the following:
      --Long Term and Community Based Care.--The authorization of long term
            and community based care Tribal communities are among the last
            to receive access to this all important healthcare option.
      --Tribal Medicaid Program Demonstration Project.--The Act authorizes
            a demonstration project to enable Tribes to demonstrate their
            ability to successfully plan, develop, implement and operate
            Medicaid Programs for the benefit of their membership.
      --Healthcare Insurance Exchanges.--To support the planning
            development, implementation and operation of tribes as
            providers of healthcare insurance on the same basis as State
            are receiving this technical and financial assistance from the
            Department.
        Support for full and complete implementation of the Indian Specific
    provision of the Lummi Nation requests the committee support the SAMHSA
    Proposed Tribal Block Grant to combat Drug Epidemic among the Lummi
    Nation membership.
        Wellness is the #1 Priority of the Council in 2012-13.--Drug abuse
    is at epidemic proportions on the Lummi Reservation. The proximity of
    the Lummi Reservation to the United States and Canadian borders makes
    for a key ingredient in successful drug trafficking. With that prime
    ingredient add production, transportation, distribution, abuse and drug
    related crimes . . . this is our reality where my people are becoming
    prisoners in our own homes.
        What We Have Done: Our people are seeking a return to health
    through massive consumption of Lummi Nation Health Care resources. We
    have increased the number of Tribal members receiving substance abuse
    treatment and mental health counseling.
        What We Still Need: We are not equipped to keep pace with the
    increasing access and use of heroin and other opiate additive drugs
    that have besieged our ports, borders, communities and citizens. Lummi
    Nation and other Tribes cannot successfully compete with politically
    connected communities and interest groups which receive the majority of
    the funding that is available through the State block grant system. We
    need assistance to secure funding to plan develop, construct and
    implement, programs services and facilities needed to improve health
    and safety in our communities.
        Reauthorization of Head Start.--Lummi Nation is very interested in
    the process of reauthorizing the Head Start Act. Lummi has operated a
    Head Start programs since 1966. Several members of the current elected
    Lummi Nation Tribal Council are graduates of Lummi Nation Head Start.
        Self-governance Option.--Lummi Nation requests that Tribes have an
    option to receive their Head Start program funding as a transfer of
    funds from the Federal Government to the Tribal government on a
    government-to-government basis. All Head Start funding is allocated on
    a continuing basis consistent with the current operations of Self-
    Governance Tribes. The Head Start Program has evolved away from its
    original grant based allocation system but has yet to remove the grant
    documents from its award system. It is a grant that acts like a
    transfer of funds.
        Designation Issues.--Tribal governments must not be subject to the
    re-designation process as Grantees for Head Start Program. Due to the
    unique culture of Tribal people, only those competent in the local
    tribal culture are able to assess and assist in the development of
    Tribal children. This is not a job that can be performed by others. We
    ask that the regulations promulgated last year regarding re-designation
    of tribal programs be withdrawn and replaced with regulations that make
    it clear that only service providers who are known to the Tribe and
    approved by the Tribe are eligible participants, in any designation
    and/or re-designation process.
        Head Start Facility.--The Lummi Nation has successfully completed
    several quality improvement plans required as a result of the Head
    Start performance Reviews. Each time we have not been able to address
    the deficits of our Head start Facility. The Tribe has secured a loan
    in the amount of $4.2 million to build a new and expanded Head Start
    Facility. However to meet Head Start performance standards the Tribe
    needs another $1.2 million. This amount will insure that four
    classrooms in the proposed facility will be suitable for special needs
    children. This amount is beyond the Tribe's ability to increase its
    debt load and must be contributed by other sources. Lummi Nation needs
    additional financial assistance to complete this long over-due project.
                lummi specific requests--department of education
        Head Start for Tribal Development--New Head Start Facility.--The
    Lummi Nation requests that the Committee directs BIE and DHHS,
    Children's Bureau support the construction of a new Head Start/day care
    facility for the Lummi Nation membership with technical and financial
    assistance. Lummi has operated a Head Start program since 1966 in the
    same facility. Successive Head Start Performance reviews have
    consistently identified the building as not meeting Head Start
    Performance standards. The Tribe is seeking gap financing in the amount
    of $1.2 million to complete the proposed new facility. These additional
    costs are generated by Head Start Performance and tribal Child Care
    Facility Standards.
        Head Start Program.--Head Start is a development program which is
    supports many early educational objectives. But it is first and
    foremost a child and family development program. The Lummi Nation does
    not support the proposal to transfer the Head Start Program to the
    Department of Education.
        BIE Memorandum of Understanding.--The Lummi Nation is aware that
    the Bureau of Indian Education and the Department of Education are
    close to signing a memorandum of understanding regarding the role of
    the Department of Education in the Bureau operate school system. The
    Lummi Nation notes that no tribes were involved in the development of
    the MOU and that no tribes will be involved in the operation of the
    MOU. This is not acceptable. Tribal governments do not rely on the BIA
    or the BIE to operate their schools. Most of the school operated by the
    Bureau of Indian Education are contract or grant schools which are
    actually operated by Tribal governments. Tribal people sit on our Board
    of Education and Tribal parents participate in the education of their
    children. We firmly object to any action directed at us taken without
    us.
        Revise Federal education laws to strengthen teaching about family
    violence/children violence in a school curricula--initiate renewed
    America by strengthening family values to teaching that all forms of
    violence hurts everyone, not only children.
        Thank you for this opportunity to provide these appropriations
    priorities of the Lummi Nation.
                                     ______

       Prepared Statement of the Mesothelioma Applied Research Foundation
        Chairman Harkin and Members of the subcommittee, I am grateful for
    the opportunity to provide written testimony. My name is Bonnie
    Anderson and I suffer from peritoneal mesothelioma. I am testifying on
    behalf of the mesothelioma community composed of patients, physicians,
    caregivers and family members. I would like to take this time to stress
    the importance of increased funding for the National Institutes of
    Health (NIH), including the National Cancer Institute (NCI), and the
    Centers for Disease Control and Prevention (CDC), both of which play a
    critical role in finding and delivering treatments for mesothelioma.
        Mesothelioma is an aggressive cancer known to be caused by exposure
    to asbestos. Doctors say it is among the most painful and fatal of
    cancers, as it invades the chest, abdomen and heart, and crushes the
    lungs and vital organs.
        Early in 2001, I began to experience severe stomach pain, diarrhea
    and other general symptoms. These were treated as irritable bowel
    syndrome. Treatment, which included anti-spasmodics and pain
    medication, proved ineffective. I underwent a ridiculous amount of
    tests: blood work, gynecological work-ups, a scope of my bladder, both
    upper and lower GI colonoscopy and endoscopy. After performing the
    latter, my gastroenterologist suggested exploratory surgery, but the
    surgeon thought it unnecessary. A barium enema followed by an X-ray
    also revealed nothing. Another gastroenterologist ordered a CAT scan.
        Finally, in December 2001 my abdomen filled up with ascites. Again
    a CAT scan was ordered, and my gastroenterologist attempted to remove
    the fluid. The procedure was so painful the specialist had to end it
    before he was able to withdraw all of the fluid. Tests taken from the
    fluid returned negative for any cancer cells. But I was still in pain,
    the pressure was horrible and unreal. In February 2002, I was sent to a
    surgeon for a laparoscopy. The surgeon removed 6 liters of fluid and
    was able to see what he described as indoor-outdoor carpet spread all
    over the lining of the abdomen. Before I left the operating room, he
    asked the hospital's pathology department to confirm that he was indeed
    viewing what he suspected: mesothelioma. Pathology confirmed his
    assessment. Though he had been in practice for many years, the surgeon
    confessed he had never seen mesothelioma before--except in a textbook.
    When I woke up, he told my husband John and me the news.
        When we first heard the word ``mesothelioma,'' we didn't know what
    it was. Then the doctor explained it in one word: ``cancer.'' The harsh
    reality for patients with advanced primary peritoneal cancer is a
    median survival time of 12.3 months; 5 year survivals are rare.
    Peritoneal affects the lining of the abdomen. Patients with pleural
    mesothelioma, which affects the lining of the lungs, comprise 85
    percent of the mesothelioma population and face an even more grim
    survival time of only 9 months. Many never have the opportunity to
    speak for themselves like this. I am here 10 years after my diagnosis.
    Fortunately, I am the exception.
        At the time, I was told I had about 6 months to live. With that
    information, my decision was to go into a clinical trial. I
    participated knowing I could face devastating side effects but with the
    hope I could help doctors learn how to treat mesothelioma and possibly
    live a while longer. I am willing to do anything to save my life and
    add precious more minutes to my time with my family. I went through
    many agonizing rounds of appeals with my insurance company in order to
    cover my surgeries and experimental treatment, but I felt this was the
    best course of treatment. I knew if I was going to die from
    mesothelioma, I was going to put it to good use in a clinical trial.
        There are brilliant researchers dedicated to mesothelioma. The Food
    and Drug Administration (FDA) has now approved one drug which has some
    effectiveness, proving that the tumor is not invincible. Biomarkers are
    being identified. Two of the most exciting areas in cancer research--
    gene therapy and biomarker discovery for early detection and
    treatment--look particularly promising in mesothelioma. The
    Mesothelioma Applied Research Foundation has made a significant
    investment, funding a total of $7.6 million to support research in
    hopes of giving researchers the first seed grant they need to get
    started. We need the continued partnership with the Federal Government
    to develop the promising findings into effective treatments.
        There are currently several promising research initiatives that are
    giving hope to mesothelioma patients:
      --A vaccine is being developed that would induce an immune response
            against WT1, a tumor suppressor gene highly expressed in
            mesothelioma patients. A pilot trial is being conducted in
            patients with mesothelioma to show that it is safe and
            immunogenic.
      --The National Mesothelioma Virtual Bank has been established due to
            a grant from the Centers on Disease Control and Prevention's
            National Institute on Occupational Safety and Health. The
            Virtual Bank allows researchers to access a virtual biospecimen
            registry which supports and facilitates research and
            collaboration.
        It is efforts like these that give me faith. I am grateful for the
    Federal Government's investment in mesothelioma research and I want to
    see it continued and increased.
        In 2010, the National Cancer Institute funded $8.3 million in
    mesothelioma research. This is a 6 percent decrease from the 2009
    funding level, which had declined 14 percent from 2008. This steady
    decline in funding terrifies me as a patient anxiously awaiting
    development of new treatments. At this juncture unless researchers have
    the funds to continue, patients like myself will have run out of
    treatment options and will die from this disease.
        I pray that improved treatments are developed--ones that aren't so
    severe and work better! I hope that future patients don't have to
    suffer the trial and error approach to being properly diagnosed and
    treated that I endured. More than anything, I wish there was a cure.
        The mesothelioma community asks that the Subcommittee recognize the
    National Institutes of Health (NIH) as a critical national priority by
    providing at least $32 billion in funding in the fiscal year 2013
    Labor-HHS-Education appropriations bill. This funding recommendation
    represents the minimum investment necessary to avoid further loss of
    promising research and at the same time allows the NIH's budget to keep
    pace with biomedical inflation.
        I look to the Labor, Health and Human Services, Education and
    Related Agencies Appropriations subcommittee to provide continued
    leadership and hope to the people like me who develop this deadly
    cancer. You have the power to lead this battle against meso. Thank you
    for the opportunity to submit testimony and for funding the National
    Institutes of Health and the National Cancer Institute at the highest
    possible level so that patients receiving this deadly diagnosis of
    mesothelioma may survive.
                                     ______

              Prepared Statement of the March of Dimes Foundation
        The 3 million volunteers and 1,200 staff members of the March of
    Dimes Foundation appreciate the opportunity to submit Federal funding
    recommendations for fiscal year 2013. 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. The March of Dimes
    recommends the following funding levels for programs and initiatives
    that are essential investments in maternal and child health.
    Preterm Birth
        Preterm birth is a serious health problem that costs the United
    States more than $26 billion annually. In 2008, one in eight infants
    was born preterm (before 37 weeks gestation). 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). Among those who survive, one in five faces health problems that
    persist for life such as cerebral palsy, intellectual disabilities,
    chronic lung disease, blindness and deafness.
        In 2010, the National Center for Health Statistics (NCHS) announced
    that the Nation's preterm birth rate fell below 12 percent for the
    first time in nearly a decade. It represented the fourth consecutive
    year of decline, bringing the rate down 6 percent from the peak of 12.8
    percent in 2006. We believe one of the reasons for the decline was the
    result of legislation enacted in 2006, the PREEMIE Act (Public Law 109-
    450), which led to the development of a public-private agenda aimed at
    reducing preterm labor and delivery. The Act mandated a Surgeon
    General's conference to address the growing problem of preterm birth.
    In 2008, more than 200 of the country's foremost experts convened for 2
    days to develop a comprehensive, national 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. The March of Dimes' fiscal year 2013 funding requests
    regarding preterm birth are based on the recommendations from the 2008
    conference and the PREEMIE Act.
                National Institutes of Health (NIH)
        The March of Dimes supports the recommendation of the Ad Hoc Group
    for Medical Research and urges the Subcommittee to recognize the NIH as
    a critical national priority by providing at least $32 billion in
    funding in the fiscal year 2013 Labor-HHS-Education appropriations
    bill. This funding recommendation represents the minimum investment
    necessary to avoid further loss of promising research and at the same
    time allows the NIH's budget to keep pace with biomedical inflation.
        The March of Dimes commends members of the subcommittee for their
    continuing support of the National Children's Study (NCS). When fully
    implemented, this study will follow 100,000 children in the United
    States from before birth until age 21. The data 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. 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 2013, the March of Dimes recommends at least $1.37
    billion for the NICHD. This $46 million increase compared to the fiscal
    year 2012 enacted level will enable NICHD to sustain its support for
    intramural preterm birth-related research and clinical research
    conducted through the Maternal-Fetal Medicine Units, Neonatal Research
    Network, and Genomic and Proteomic Network for Preterm Birth Research.
    In addition, the March of Dimes urges the Subcommittee to request that
    NICHD identify the steps and resources necessary to establish one or
    more Transdisciplinary Research Centers for Prematurity, as recommended
    by the Institute of Medicine. The causes of preterm birth are multi-
    faceted and necessitate a coordinated and collaborative approach
    integrating many disciplines. In 2011, the March of Dimes and Stanford
    University School of Medicine launched the Nation's first
    transdisciplinary research center dedicated to identifying the causes
    of premature birth. The March of Dimes is committed to opening five
    transdisciplinary centers across the country. A public-private
    partnership combining the resources of NICHD and private organizations
    would significantly enhance the impact of this research.
                Centers for Disease Control and Prevention--Preterm Birth
        The CDC's National Center for Chronic Disease Prevention and Health
    Promotion's Safe Motherhood Program works to promote optimal
    reproductive and infant health. For fiscal year 2013, the March of
    Dimes recommends a sustained funding level of at least $44 million, and
    the inclusion of a $2 million preterm birth sub-line as authorized by
    the PREEMIE Act (Public Law 109-450), to strengthen our national data
    systems to monitor trends and investigate health issues related to
    pregnancy and promote the health of women before, during and after
    pregnancy.
                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, a 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--a $24 million increase over the fiscal year 2012
    enacted level, which will support States and territories as they
    implement the 2003 Certificates of Birth, Death, and Fetal Deaths and
    aid in the transition to electronic collection of vital events data.
    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. Additional Federal
    resources are sorely needed to support research to discover the causes
    of all birth defects and for the development of effective interventions
    to prevent or at least reduce their prevalence.
                Centers for Disease Control and Prevention--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 2013, the March of Dimes requests at
    least level funding of $137 million for NCBDDD. We also encourage the
    Subcommittee to provide sustained funding levels of at least $2 million
    to support folic acid education and $22 million to support birth
    defects research and surveillance--a $2 million increase from fiscal
    year 2012 enacted levels.
        Allocating an additional $2 million to birth defects research and
    surveillance will 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. This analysis would enable researchers to identify relevant
    mutations and potential risk factors, which would then lead to
    prevention strategies. 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.
        Further, allocating at least $2 million to folic acid education
    will allow the CDC to sustain 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. Sustained funding levels will ensure CDC can continue
    to educate women on the importance of folic acid.
        The March of Dimes is very concerned about the administration's
    request to consolidate NCBDDD's budget lines into three categories. 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) with the exception of Autism. 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, obscuring
    the urgency and importance of the need for ongoing support from the
    Congress. The March of Dimes urges modification of the administration's
    proposal by retaining the term ``Birth Defects'' as a sub-line under
    the category ``Child Health and Development.'' This adjustment is
    needed to ensure that essential activities to reduce birth defects are
    not undermined or otherwise put at risk.
    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
    experiencing significant budget shortfalls are considering
    discontinuing screening for certain conditions or postponing the
    purchase of necessary technology. This situation represents a serious
    threat that, if left unresolved, will put infants at risk of permanent
    disability or even death. For fiscal year 2013, the March of Dimes
    urges the subcommittee to provide at least $10 million for HRSA's
    heritable disorders program, as authorized by the Newborn Screening
    Saves Lives Act (Public Law 110-204).
                Agency for Health Care Research and Quality (AHRQ)
        AHRQ supports research to improve healthcare quality, reduce costs
    and broaden access to essential health services. For fiscal year 2013,
    the March of Dimes recommends $400 million 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 community-based programs aimed at decreasing
    infant mortality, preventing disabling conditions, increasing the
    number of children immunized and improving the overall health of
    mothers and children. Reduced funding threatens the ability of these
    programs to carry on this work. For fiscal year 2013, the March of
    Dimes recommends at least $645 million for the Maternal and Child
    Health Block Grant, level funding from the fiscal year 2012 enacted
    level.
                Centers for Disease Control and Prevention--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. Childhood immunizations are among the
    most cost-effective preventive health measures. Every dollar invested
    in immunizing a child saves $16.50 in medical and societal costs. 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 $720 million in fiscal year
    2013 for the Section 317 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. The March of Dimes is requesting
    $126.4 million in fiscal year 2013 for CDC's Polio Eradication Program,
    which would allow CDC to continue its immunization activities in the
    remaining endemic and high-risk countries in Africa and Asia and
    interrupt polio transmission in these regions.
    Closing
        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 2013 FEDERAL FUNDING PRIORITIES
                            [In thousands of dollars]
    ------------------------------------------------------------------------
                                                              March of Dimes
                             Program                            fiscal year
                                                               2013 request
    ------------------------------------------------------------------------
    National Institutes of Health (Total)...................      32,000,000
        National Children's Study...........................  ..............
        Common Fund.........................................         569,452
        National Institute of Child Health and Development..       1,370,000
        National Human Genome Research Institute............         534,381
        National Institute on Minority Health and                    292,524
         Disparities........................................
    Centers for Disease Control and Prevention (Total)......       7,800,000
        National Center for Birth Defects and Developmental          140,100
         Disabilities (NCBDDD)..............................
            Birth Defects Research and Surveillance.........          22,300
            Folic Acid Campaign.............................           2,800
        Immunization and Respiratory Diseases...............  ..............
            Section 317.....................................         720,000
        Polio Eradication...................................         126,400
        Safe Motherhood.....................................          44,000
            Preterm Birth...................................           2,000
        National Center for Health Statistics...............         162,000
    Health Resources and Services Administration (Total)....       7,000,000
        Maternal and Child Health Block Grant...............         640,098
        Heritable Disorders.................................          10,000
        Universal Newborn Hearing...........................          18,660
        Community Health Centers............................       1,500,000
        Healthy Start.......................................         103,532
        Children's Graduate Medical Education...............         317,500
    Agency for Healthcare Research and Quality (Total)......         400,000
    ------------------------------------------------------------------------

                                     ______

         Prepared Statement of the Medical Library Association and the
               Association of Academic Health Sciences Libraries
                summary of recommendations for fiscal year 2013
        Continue the commitment to the National Library of Medicine (NLM)
    by increasing funding levels to $372.6 million for fiscal year 2013.
        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 health care 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 2013
    appropriations for the National Library of Medicine (NLM), a division
    of the National Institutes of Health (NIH). 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 individual and institutional members.
    Founded in 1898, MLA provides lifelong educational opportunities,
    supports a knowledge base of health information research, and works
    with a 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 libraries of 124 accredited U.S. and
    Canadian medical schools, and 26 associate members. AAHSL supports
    academic health sciences libraries and directors in advancing the
    patient care, research, education and community service missions of
    academic health centers through visionary executive leadership and
    expertise in health information, scholarly communication, and knowledge
    management. 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 President's fiscal year 2013 budget
    proposal provides a funding increase NLM which will bolster its
    baseline budget. In today's challenging budget environment, we
    recognize the difficult decisions the Congress faces as it seeks to
    improve our Nation's fiscal stability. We appreciate and thank the
    Subcommittee for its long-time commitment to strengthening NLM's budget
    and encourage you to also consider increasing the NIH budget by
    providing at least $32 billion in your fiscal year 2013 Labor-HHS-
    Education appropriations bill.
        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 bio-medical information more accessible to other
    researchers, clinicians, business innovators, and the public, NLM
    enables such information to be used more efficiently and effectively to
    drive innovation and improve the Nation'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
    provide meaningful annual increases for NLM in the coming years and
    recommend an increase to $372.6 million for fiscal year 2013. Beyond
    fiscal year 2013, it is critical to continue augmenting NLM's baseline
    budget to accommodate expansion of its information resources, services,
    and programs which must collect, organize, and make readily accessible
    rapidly expanding volumes of biomedical knowledge.
    Growing Demand for the National Library of Medicine'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 that helps 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
    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. Earlier this year, NLM
    launched the Genetic Testing Registry (GTR), a new resource for quickly
    finding information about genetic tests and their providers. The
    registry includes detailed information about available tests, the
    test's purpose and its limitations; the name and location of the test
    provider; whether it is a clinical or research test; what methods are
    used; and what is measured. The registry will provide valuable
    information to healthcare professionals looking for answers related to
    their patients' diseases as well as researchers seeking to identify
    gaps in scientific knowledge.
        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 500,000 users download 1 million 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 are pleased that other efforts are underway to
    expand public access policies across Federal agencies. The Federal
    Research Public Access Acts, H.R. 4004 and S. 2096, would require
    agencies with annual extramural research portfolios of more than $100
    million to develop public access policies related to research conducted
    by employees of that agency. Passage of FRPAA would bring the benefits
    of public access to other research disciplines. Further, because
    research in other disciplines is increasingly relevant to biomedicine,
    broadening public access policies across agencies will support better
    patient care, biomedical research, education, and health information
    technology. We support the work of the Office of Science and Technology
    Policy (OSTP) to implement the scholarly publications requirements in
    Section 103 of the American Competes Reauthorization Act which will
    ensure long-term stewardship and broad public access to the peer-
    reviewed scholarly publications resulting from federally funded
    scientific research. MLA and AAHSL have observed firsthand the
    significant benefit of providing public access to publications arising
    from NIH funded research, including its positive benefit-cost ratio,
    return on investment, and efficacy and efficiency to fuel new research,
    discoveries, and therapies, and applaud efforts to further this work in
    other areas.
        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 sciences 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 citizens 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 essential to MLA and AAHSL membership
    and to the profession. 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 more than 6,300 members in communities across the
    country, the National Network of Libraries of Medicine (NN/LM) 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 900 topics in English and
    Spanish, and has become a top destination for those seeking information
    on the Internet, attracting more than 750,000 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 the 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 with 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 117,000 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 5,000 trials, and the Library receives approximately 50 new
    results submission each week. More than 50,000 users visit the site
    each 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 2013.
                      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. The Library responds to
    specific disasters worldwide with specialized information resources
    appropriate to the need, including information on bioterrorism,
    chemical emergencies, fires and wildfires, earthquakes, tornadoes, and
    pandemic disease outbreaks. Recently, the Library launched a Disaster
    Information Apps and Mobile Web sites page designed to provide mobile
    device users access to Web-based content. MLA and NLM continue to
    develop the Disaster Information Specialization (DIS) program aimed at
    building the capacity of librarians and other interested professionals
    to provide disaster-related health information outreach. Currently MLA
    is developing five courses on topics assigned by NLM and based on the
    NLM Disaster Information Curriculum and will include basic and advanced
    topics in Disaster Health Information.
        Working with libraries and U.S. 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. Over the last 2 years,
    this initiative has assisted 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 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
    benefit 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
    nationwide use (e.g., SNOWMED), NLM works closely with the Office of
    the National Coordinator for Health Information Technology (ONCHIT) to
    promote the adoption of inter-operable 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.
        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 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
    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 the Congress continues to face tremendous funding challenges
    in fiscal year 2013, 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 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 2013, 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 2013, 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) is now housed at the National
    Institute on Minority Health and Health Disparities (NIMHD). RCMI 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 2013.
        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 2013, I recommend
    that this Institute's funding grow proportionally with the funding of
    the NIH and add additional FTEs.
    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 health careers, and
      --Supporting cooperative agreements with minority institutions for
            the purpose of strengthening their capacity to train more
            minorities in the health professions.
        The OMH has the potential to play a critical role in addressing
    health disparities. For fiscal year 2013, 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 2013, 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 toward the goal of eliminating that
    disparity as we have done for 1,876.
        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. MSM 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 2013, 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 2013 I
    recommend a funding level of $22.133 million for HCOPs.
    National Institutes of Health
        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 2013, I recommend a funding
    increase proportional to any increase given to the NIH and additional
    FTE positions.
        Research Centers at Minority Institutions.--The Research Centers at
    Minority Institutions program (RCMI), newly moved to NIMHD, 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 2013.
    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 health careers;
    and (4) supporting cooperative agreements with minority institutions
    for the purpose of strengthening their capacity to train more
    minorities in the health professions. The OMH has the potential to play
    a critical role in addressing health disparities, and with the proper
    funding this role can be enhanced. For fiscal year 2013, 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 2013, 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 toward 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 Association of County and City
                                Health Officials
        The National Association of County and City Health Officials is the
    voice of the 2,800 local health departments that safeguard the health
    of approximately 300 million people across the country. These city,
    county, metropolitan, district, and tribal departments work every day
    to ensure the safety of the water we drink, the food we eat, and the
    air we breathe.
        Local health departments have a unique and distinctive role and set
    of responsibilities in the larger health system and within every
    community. The Nation's current financial challenges are compounded by
    those in State and local governments that have resulted in diminishing
    the ability of local health departments to address community health and
    safety needs. Repeated rounds of budget cuts and layoffs continue to
    erode local health department capacity. According to recent surveys of
    local and State health departments, since 2008 52,000 jobs have been
    lost due to budget reductions.
        To help protect the public's health, we urge the Subcommittee on
    Labor, Health and Human Services, Education and Related Agencies to
    consider the following fiscal year 2013 funding requests:
    Public Health Emergency Preparedness
    Center: Center for Public Health Preparedness and Response (CDC)
    Funding Line: State and Local Preparedness and Response Capability
    Sub-line: Public Health Emergency Preparedness Cooperative Agreements
            (PHEP)
    NACCHO request: $715 million
    Fiscal Year 2013 President's Budget: $642 million (including CDC
            Capacity)
    Fiscal Year 2012: $643 million (not including CDC Capacity)
        The Public Health Emergency Preparedness (PHEP) cooperative
    agreement program provides funding to support local and State public
    health department capacity and capability to effectively respond to
    public health emergencies including terrorist threats, infectious
    disease outbreaks, natural disasters, and biological, chemical,
    nuclear, and radiological emergencies. Local and State health
    departments work with the Federal Government, law enforcement,
    emergency management, health care, business, education, and religious
    groups to plan, train, and prepare for emergencies so that when
    disaster strikes, communities are prepared. NACCHO opposes the
    administration's proposal to eliminate the separate funding line for
    PHEP and to cut the program by $8 million to pay for CDC programmatic
    operating costs. PHEP grants have been cut by 28 percent since 2004;
    NACCHO supports a return to the fiscal year 2010 funding level of $715
    million.
    Hospital Preparedness Program
    Assistant Secretary for Preparedness and Response (DHHS)
    NACCHO request: $426 million
    Fiscal Year 2013 President's Budget: $255 million
    Fiscal Year 2012: $380 million
        Administered by the Assistant Secretary for Preparedness and
    Response, the Hospital Preparedness Program (HPP) provides funding to
    local and State health departments to enhance hospital preparedness and
    improve overall surge capacity in the case of public health
    emergencies. The preparedness activities carried out under this program
    strengthen the capabilities of hospitals throughout the country to
    respond to floods, hurricanes, or wildfires, and also include training
    for a potential influenza pandemic or terrorist attack. NACCHO opposes
    the administration's proposal to cut HPP by $120 million. While HPP and
    PHEP grants have been aligned, the first year of alignment is
    ``mechanical'' in terms of getting the grant year and the application
    process for both programs in the same funding period. NACCHO supports a
    return to the fiscal year 2010 funding level of $426 million.
    Medical Reserve Corps
    Office of the Surgeon General (DHHS)
    NACCHO request: $12.6 million
    Fiscal Year 2013 President's Budget: $10.9 million
    Fiscal Year 2012: $11.2 million
        Administered by the Office of the Surgeon General, the Medical
    Reserve Corps (MRC) is a national network of local groups of volunteers
    that work to strengthen their local public health infrastructure and
    preparedness capabilities. Over the past 10 years, the program has
    grown to more than 200,000 volunteers in nearly 1,000 units in 50
    States, the District of Columbia, and several territories. The network
    of MRC volunteers includes medical and public health professionals, as
    well as non-medical volunteers who provide leadership, logistic and
    other support. MRC units are community-based and focus on local needs.
    The workload for these volunteers will increase as a result of the
    reduced health department workforce due to preparedness cuts. NACCHO
    supports a return to the fiscal year 2010 funding level of $12.6
    million.
    Chronic Disease Prevention
    Center: Center for Chronic Disease Prevention and Health Promotion
            (CDC)
    Funding Line: Community Transformation Grants (CTG)
    NACCHO Request: $226 million (including health department eligibility)
    Fiscal Year 2013 President's Budget: $146 million
    Fiscal Year 2012: $226 million
        The Community Transformation Grant (CTG) program provides resources
    for local communities to address heart attacks, strokes, cancer,
    diabetes, and other chronic diseases which contribute to the soaring
    cost of healthcare in the United States. The grants focus on the
    implementation, evaluation and dissemination of evidence-based
    community preventive health activities in order to develop strategies
    and practices that will enable States, counties, cities and tribes to
    control chronic disease and health disparities. Grantees are charged
    with a 5 percent reduction in death and disability due to tobacco use,
    heart disease and stroke and the rate of obesity through nutrition and
    physical activity in 5 years. Local and State public health departments
    should remain eligible to apply for funding through this important
    initiative in fiscal year 2013 and subsequent fiscal years. NACCHO
    supports the fiscal year 2012 funding level of $226 million for
    Community Transformation Grants.
    Center: Center for Chronic Disease Prevention and Health Promotion
            (CDC)
    Funding Line: Coordinated Chronic Disease Prevention and Health
            Promotion Grant Program
    NACCHO Request: $379 million
    Fiscal Year 2013 President's Budget: $379 million (+$129 million from
            fiscal year 2012)
    Fiscal Year 2012: $250 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. Today's children are in
    danger of becoming the first generation to live shorter, less healthy
    lives than their parents. The Coordinated Chronic Disease Prevention
    and Health Promotion Grants, as proposed in the President's budget,
    will provide local and State health departments flexibility to
    streamline funding to prevent, control, and reduce the burden of
    chronic illness and to address the underlying causes of chronic
    diseases in a more integrated and coordinated fashion. Local health
    departments seek relief from duplicative administrative burden for the
    multiple siloed funding streams resulting in more funding going into
    programs and out to the community.
        At a minimum, NACCHO recommends that the Congress encourage CDC to
    provide greater coordination among chronic disease programs and reduce
    duplicative administrative burden. NACCHO recommends the continuation
    of funding for State coordination grants begun in fiscal year 2011 for
    this purpose if funds are not made available for the coordinated
    Chronic Disease Prevention and Health Promotion Grant Program.
    Food Safety
    Center: Center for Emerging and Zoonotic Infectious Diseases (CDC)
    Funding Line: Food Safety
    NACCHO Request: $44 million
    Fiscal Year 2013 President's Budget: $44 million (+$17 million from
            fiscal year 2012)
    Fiscal Year 2012: $27 million
        Foodborne illness affects 48 million Americans every year,
    resulting in 128,000 hospitalizations and 3,000 deaths. CDC's Food
    Safety program seeks to ensure food safety through surveillance and
    outbreak response. Local and State health departments are an essential
    part of the process that ensures that food is safe to eat at home, at
    community events, in restaurants, and in schools. NACCHO supports the
    administration's $17 million increase as it will advance implementation
    of the Food Safety Modernization Act by enhancing and integrating
    disease surveillance, improving outbreak and response timeliness and
    helping address deficits in local capacity to prevent and stop illness.
    This increase will enable CDC to enhance and integrate disease
    surveillance, improve outbreak response timeliness and help address
    local deficits in capacity to prevent and stop illness. The increase
    also expands the number of Foodborne Diseases Centers for Outbreak
    Response Enhancement (FoodCORE) sites.
    Public Health Performance Improvement
    Center: Center for Public Health Leadership and Support (CDC)
    Funding Line: National Public Health Improvement Initiative
    NACCHO Request: $40.2 million
    Fiscal Year 2013 President's Budget: $40.2 million
    Fiscal Year 2012: $40.2 million
        The National Public Health Improvement Initiative (NPHII) provides
    funding to 74 State, tribal, local and territorial health departments
    to make fundamental changes and enhancements in their organizations and
    practices that improve the delivery and impact of public health
    services. Local and State health departments currently face
    unprecedented financial challenges that threaten their ability to
    prevent disease and promote health in their communities. NPHII
    strengthens health departments by providing staff, training, tools, and
    technical/capacity building assistance dedicated to establishing
    performance management and evidence-based practices that drive improved
    service delivery and better health outcomes. NACCHO supports
    continuation of funding for this important quality improvement program
    for health departments.
    317 Immunization Program
    Center: National Center for Immunization and Respiratory Diseases (CDC)
    Funding Line: 317 Immunization Program
    NACCHO Request: $720 million
    Fiscal Year 2013 President's Budget: $562.2 million
    Fiscal Year 2012: $620.2 million
        The Section 317 Immunization Program provides funds to 50 States,
    six large cities and eight territories for vaccine purchase for at-need
    populations and immunization program operations, including support for
    implementing billing systems for immunization services at public health
    clinics to sustain high levels of vaccine coverage. Childhood
    immunizations are one of the most cost-effective public health
    interventions, saving 42,000 lives and preventing 20 million cases of
    disease annually with an estimated $10.20 in savings for every $1
    invested. Increased funding would expand vaccine purchase grants to
    State and local health departments to cover the many new vaccines and
    expanded recommendations of existing vaccines. Additional funding would
    also strengthen State and local infrastructure to support vaccination
    programs and increase vaccine uptake rates.
        NACCHO opposes the $58 million cut proposed in the President's
    budget. While provisions in the Affordable Care Act (ACA) will expand
    insurance coverage of vaccines recommended by the Advisory Committee on
    Immunization Practices, that doesn't necessarily translate to increased
    vaccination by private physicians. Many private insurers do not
    reimburse physicians for the full cost of vaccine, nor do they cover
    actual administration expenses, causing physicians to stop offering
    immunizations. Health departments will continue to need sufficient
    funding for vaccinations not covered by the ACA expansions, services to
    the underinsured and administrative expenses not reimbursed by
    insurance. Additionally, the ACA expansion will not be fully
    implemented until 2019 while cuts are being proposed now.
        As the Subcommittee drafts the fiscal year 2013 Labor-Health and
    Human Services-Education appropriations bill, NACCHO urges
    consideration of these recommendations for CDC programs critical to
    protecting people and improving the public's health.
                                     ______

      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 American health center
    community, including the more than 20 million patients served
    nationwide by health centers, the 131,660 full-time health center
    staff, and countless volunteer board members who serve our centers as
    well as the National Association of Community Health Centers, we want
    to offer our deep thanks and appreciation for this Subcommittee's
    strong bipartisan support of health centers. I also appreciate the
    opportunity to submit testimony for the committee to review as you
    craft the fiscal year 2013 Labor-Health and Human Services-Education
    and Related Agencies appropriations bill.
    Health Centers--General Background
        Health Centers are locally owned nonprofit entities that provide
    primary medical, dental, and behavioral healthcare, along with pharmacy
    and a variety of enabling and support services to more than 20 million
    patients today. Currently, there are more than 1,200 health centers
    serving as medical homes at more than 8,000 sites in rural and urban
    underserved communities nationwide, including as you know, in the
    States represented by the members of this Subcommittee.
        By statute and mission, health centers are located in a medically
    underserved area or serve a medically underserved population and
    provide comprehensive primary care services to all community residents
    regardless of insurance status or ability to pay, while offering care
    on a sliding fee scale. This has enabled health centers to become
    healthcare homes to the medically underserved and our Nation's most
    vulnerable populations
        Health centers also have a unique connection to the health needs of
    their communities as they are directed by patient-majority boards,
    ensuring that care is locally controlled and responsive to each
    individual community.
        Health centers specialize in providing high-quality, cost-effective
    primary and preventive healthcare to their patients. Utilizing the
    unique health center model, health centers are able to save the entire
    health system, including the Government and taxpayers, approximately
    $24 billion annually by keeping patients out of costlier healthcare
    settings, such as emergency departments. Indeed, countless published
    studies over many decades have demonstrated that health centers are a
    proven cost saver. Studies have also proven that health centers improve
    the health status in communities, reduce emergency room use, and
    eliminate health disparities amongst their patients. Additionally,
    health centers serve as small businesses and economic drivers in their
    communities creating 200,000 jobs in just 2009.
    Fiscal Year 2012 Funding Background
        Thanks to the tireless efforts of this Subcommittee, in fiscal year
    2012 health centers received $2.8 billion in total program funding.
    This includes $1.6 billion in discretionary funding and $1.2 billion in
    mandatory funding for health centers through the Affordable Care Act
    for a total increase of $200 million above fiscal year 2011.
        A portion of this increase will go toward funding some of the more
    than 1,800 applications for health center expansion currently pending
    at HRSA. We anticipate this will mean health centers opening in more
    than 200 communities where primary care is currently scarce or non-
    existent. We want to again thank the Subcommittee for their support
    which is now being translated into real healthcare for many of our
    fellow Americans who currently go without access to even basic
    healthcare.
    Overwhelming Demand for Accessible Primary Care
        And yet, even with this tremendous new investment, there is still a
    pressing need for access to primary care services in communities across
    the country. As we recently documented in a new report entitled: Health
    Wanted, the State of Unmet Need for Primary Health Care in America
    (``Health Wanted''), the demand for primary care far exceeds supply all
    across our Nation. Health Wanted documents the principal barriers to
    care: affordability, accessibility, and availability. Within these
    three categories, specific hurdles to accessing primary care include
    lack or type of insurance, limited income, distance, and other factors
    that leave individuals, or whole communities, without care. As Health
    Wanted demonstrates, when health centers locate in underserved areas,
    they overcome these barriers using the unique health center model,
    improving health and producing documented health system savings. The
    report also highlights the multiple indicators, including health
    outcomes, that make the case that many more communities still need a
    health center, and that many of those communities with a health center
    have greater needs than the health center can meet with existing
    funding levels.
        Recent application cycles bear out the research and show that
    health centers are striving to meet this demand for primary care. Right
    now, more than 1,800 health center expansion applications are pending
    at HRSA, including:
      --More than 700 new health center applications that remain unfunded.
            These are communities with no health center and a documented
            shortage of primary care access.
      --More than 1,100 applications from existing Health Centers for
            expanded medical, oral and behavioral health, pharmacy, and
            vision service capacity based on identified unmet need in their
            communities remain unfunded.
      --129 communities without a Health Center but with documented need
            have received funding for planning grants, and most will soon
            be ready to apply to be funded for a new Health Center in their
            community.
        Health centers are clearly ready to do more to ensure all Americans
    have access to primary and preventive healthcare services. We look
    forward to working with this Subcommittee to translate this readiness
    into a reality.
    Fiscal Year 2013 Request
        The President's proposed fiscal year 2013 Health Resources and
    Services Administration (HRSA) fiscal year 2013 budget proposal
    provides $1.58 billion in discretionary funding for the Health Centers
    program. Together with the $1.5 billion in fiscal year 2013 mandatory
    funding available for health centers, health centers could receive a
    net increase of $300 million in total programmatic funding for fiscal
    year 2013 equaling total funding of $3.1 billion.
        We strongly support the President's proposed funding level of $3.1
    billion for health centers, but we are very concerned about the
    administration's proposal to hold back $280 million of the total
    proposed increase of $300 million and instead spread out health center
    growth over a longer period of time. This proposal does not recognize
    the great need outlined above for access to the very primary care
    services provided in health centers. In addition, health centers are
    looking ahead to 2014, when the demand for primary care is expected to
    soar as millions receive health coverage for the first time, many of
    them living in the very communities we serve. The experience of health
    centers in Massachusetts tells us that health centers will become the
    healthcare home for many of these new patients. We must begin to create
    the capacity to serve these patients now. If primary care is not
    available in the communities where the newly insured live, they will
    access care elsewhere, most likely the emergency room or hospital, when
    they are sicker. This will mean poorer health for these patients and
    much higher costs for the system.
        Health centers do, however, share the concern of the
    administration, and many members of this Subcommittee, over the funding
    cliff facing the Health Centers program in fiscal year 2016 when the
    mandatory funding from ACA is slated to end. If not remedied, health
    centers and the thousands of communities and millions of patients they
    serve could face a serious threat. We want to work with members of this
    Subcommittee to forge a bipartisan solution that averts this scenario.
        Health Centers are respectfully requesting a total of no less than
    $3.1 billion in funding for the Health Center program. However, instead
    of holding back funding, we propose that the entire increase be used
    immediately to provide for the expansion of care to 2.5 million new
    patients. We also urge the Subcommittee to consider the long-term
    stability and viability of the program, and the coming cliff in
    funding, while ensuring its continued growth which is so desperately
    needed.
    Conclusion
        We understand this Subcommittee will have to make many difficult
    budgetary decisions as you work within the funding limits set for the
    fiscal year 2013 Labor-Health and Human Services-Education
    appropriations bill. We understand that will be no easy task, but we
    ask you to keep in mind that health centers have continually proven to
    be a worthwhile investment by delivering affordable healthcare to those
    who need it most, while generating savings to our health system. We are
    deeply grateful for your longstanding leadership and ask for the
    Subcommittee's continued support for the Health Center program.
        Thank you for your consideration.
                                     ______

       Prepared Statement of the National Association of Clinical Nurse
                                  Specialists
        The National Association of Clinical Nurse Specialists (NACNS) is a
    national organization that exists to enhance and promote the unique,
    high value contribution of the clinical nurse specialist to the health
    and well-being of individuals, families, groups, and communities, and
    to promote and advance the practice of nursing. There are an estimated
    72,000 registered nurses that have the education and credentials to
    practice as a clinical nurse specialist. NACNS supports funding for
    nursing education and training provided through the Nursing Workforce
    Development programs, authorized under Title VIII of the Public Health
    Service Act (42 U.S.C. 296 et seq.). NACNS also supports funding for
    research initiatives at the National Institute of Nursing Research
    (NINR) under the National Institutes of Health (NIH), and investment in
    the Nurse-Managed Health Clinics, authorized under Title III of the
    Public Health Service Act (42 U.S.C. 254c-1a.)
        Clinical Nurse Specialists (CNSs) are licensed registered nurses
    who have graduate preparation (Master's or Doctorate) in nursing as a
    Clinical Nurse Specialist. They are Advanced Practice Registered Nurses
    (APRNs) in a specialized area of nursing practice in many areas,
    including but not limited to: primary care, pediatrics, geriatrics,
    women's health, critical care, emergency room, specific conditions,
    such as diabetes or oncology, psychiatry and rehabilitation. In
    addition to providing direct patient care, Clinical Nurse Specialists
    influence care outcomes by providing expert consultation for nurses,
    physicians, hospital administrators and other colleagues to implement
    improvements in healthcare delivery systems. Their leadership has led
    to reduced costs and increased quality of care, such as:
      --Reduced Hospital Costs and Length of Stay;
      --Reduced Frequency of Emergency Room Visits;
      --Shortened Hospital Stays;
      --Improved Pain Management Practices;
      --Increased Patient Satisfaction with Nursing Care; and
      --Reduced Medical Complications in Hospitalized Patients.
                     nursing workforce development programs
        The Nursing Workforce Development programs have supported the
    supply and distribution of qualified nurses to meet our Nation's
    healthcare needs since 1964. Since its inception, Title VIII programs
    have supported over hundreds of thousands of nurses from entry-level
    preparation through graduate study, and provide support for
    institutions that educate nurses for practice in rural and medically
    underserved communities. Between fiscal year 2005 and fiscal year 2010
    alone, Title VIII programs have supported more than 400,000 nurses and
    nursing students as well as numerous academic nursing institutions and
    healthcare facilities. Today, the Title VIII programs are essential to
    solving the looming national nursing shortage.
        The National Association of Clinical Nurse Specialists respectfully
    request $251 million for the Nursing Workforce Development programs
    authorized under Title VIII of the Public Health Service Act in fiscal
    year 2013. Last year, your Subcommittee provided a significant funding
    boost for Title VIII that helped support the Loan Repayment program and
    Scholarship and Nurse Faculty Loan program. These increases will
    bolster the pipeline of nurses and nurse faculty, which is so critical
    to reversing the nursing shortage. We feel it is extremely important to
    fund these critical programs. This funding not only increases the much
    needed number of nurses but allows individuals to pursue a career in
    nursing, contribute to the healthcare needs of their community and
    build a career to support them and their families in the future.
        The Advanced Education Nursing, Nursing Workforce Diversity, Nurse
    Education, Practice, and Retention, and Comprehensive Geriatric
    Education programs expand nursing school capacity and increase patient
    access to care. Below is a description of these four critical programs.
      --Advanced Education Nursing (AEN) Grants (Sec. 811) support the
            preparation of RNs in master's and doctoral nursing programs.
            The AEN grants help to prepare our Nation's nurse
            practitioners, clinical nurse specialists, nurse midwives,
            nurse anesthetists, nurse educators, nurse administrators,
            public health nurses, and other nurse specialists requiring
            advanced education. In fiscal year 2008 (most current data
            available), these grants supported the education of 5,649
            students.
        --AEN Traineeships assist graduate nursing students by providing
                full or partial reimbursement for the costs of tuition,
                books, program fees and reasonable living expenses. In
                fiscal year 2008, this funding helped support 6,675
                graduate nurses and APRNs.
        --Nurse Anesthetist Traineeships (NAT) support the education of
                students in nurse anesthetist programs. In some States,
                Certified Registered Nurse Anesthetists (CRNAs) are the
                sole anesthesia providers in almost 100 percent of rural
                hospitals. Much like the AEN Traineeships, the NAT provides
                full or partial support for the costs of tuition, books,
                program fees, and reasonable living expenses. In fiscal
                year 2008, the program supported 2,145 future CRNAs.
      --Workforce Diversity Grants (Sec. 821) prepare disadvantaged
            students to become nurses. This program awards grants and
            contract opportunities to schools of nursing, nurse managed
            health centers, academic health centers, State or local
            governments, and nonprofit entities looking to increase access
            to nursing education for disadvantaged students, including
            racial and ethnic minorities under-represented among RNs. In
            fiscal year 2008, the program supported 11,638 students.
      --Nurse Education, Practice, and Retention Grants (Sec. 831) help
            schools of nursing, academic health centers, nurse-managed
            health centers, State and local governments, and healthcare
            facilities strengthen programs that provide nursing education.
            In fiscal year 2008, the priority areas under this program
            supported 42,761 with an additional 455 students supported by
            the Integrated Nurse Education Technology program.
      --Comprehensive Geriatric Education Grants (Sec. 855) are awarded to
            schools of nursing or healthcare facilities to better provide
            nursing services for the elderly. These grants are used to
            educate RNs who will provide direct care to older Americans,
            develop and disseminate geriatric curriculum, prepare faculty
            members, and provide continuing education. In fiscal year 2008,
            this program supported 6,514 nurses and nursing students.
                     national institute of nursing research
        The National Association of Clinical Nurse Specialists respectfully
    requests $150 million for the National Institute of Nursing Research in
    fiscal year 2013. The NINR funds research that lays the groundwork for
    evidence-based nursing practice. Nurse-scientists at NINR examine ways
    to improve models of care to deliver safe, high quality, and cost-
    effective health services to the Nation. It is critical that we look
    toward the prevention aspect of healthcare as the vehicle for saving
    our system from further financial burden, and the work of NINR supports
    this through research related to 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.
             nurse-managed health clinics: expanding access to care
        The National Association of Clinical Nurse Specialists respectfully
    requests $20 million for the Nurse-Managed Health Clinics authorized
    under Title III of the Public Health Service Act in fiscal year 2013.
    NMHCs are healthcare delivery sites managed by APRNs and are staffed by
    an interdisciplinary health provider team that may include physicians,
    social workers, public health nurses, and therapists. These clinics are
    often associated with a school, college, university, department of
    nursing, federally qualified health center, or independent nonprofit
    healthcare agency. NMHCs serve as critical access points to keep
    patients out of the emergency room, saving the healthcare system
    millions of dollars annually. The NMHCs provide care to patients in
    medically underserved regions of the country, including rural
    communities, Native American reservations, senior citizen centers,
    elementary schools, and urban housing developments.
        Without an adequate supply of nurses to care for our Nation,
    including our growing aging population, the healthcare system is not
    sustainable. The NACNS requests $251 million in fiscal year 2013 for
    the HRSA Nursing Workforce Development programs, $150 million for NINR
    and $20 million for the Nurse-Managed Health Clinics authorized under
    Title III of the Public Health Service Act in fiscal year 2013 to
    ensure access to quality care provided by America's nursing workforce
                                     ______

    Prepared Statement of the National Alliance for Eye and Vision Research
        The National Alliance for Eye and Vision Research (NAEVR) requests
    fiscal year 2013 NIH funding of at least $32 billion, which reflects a
    $1.38 billion, or 4.5 percent increase over fiscal year 2012, which
    consists of biomedical inflation of 2.8 percent plus modest growth, and
    is necessary since:
      --After nearly a decade of budgets below biomedical inflation, NIH's
            inflation-adjusted funding is close to 20 percent lower than
            fiscal year 2003.
      --Even before adjusting for inflation, enacted spending bills in
            recent years have cut the NIH budget. The looming sequestration
            mandated by the Budget Control Act threatens further cuts,
            estimated by the Congressional Budget Office (CBO) at 8 percent
            in fiscal year 2013 alone.
        NIH, our Nation's biomedical research enterprise, is unique in
    that:
      --Its basic and clinical research has helped to understand the basis
            of disease, thereby resulting in innovations in healthcare to
            save and improve lives.
      --Its research serves an irreplaceable role that the private sector
            could not duplicate.
      --It has been shown through several studies to be a major force in
            the economic health of communities across the Nation. The
            latest United for Medical Research report estimates that NIH
            funding supported more than 432,000 jobs in 2011, directly or
            indirectly, and generated more than $62.1 billion in economic
            activity.
        NAEVR requests National Eye Institute (NEI) funding at $730
    million, commensurate with the overall NIH funding increase, especially
    since:
      --Proposed fiscal year 2013 NEI funding of $693 million reflects
            little more than 1 percent of the $68 billion annual cost of
            eye disease/vision impairment in the United States.
      --The proposed $693 million level is a $14 million cut since fiscal
            year 2010, translating into 40 research project grants--any one
            of which could have cured blindness.
      --In 2009, the 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 Loomers will turn 65 years
            of age and face greatest risk of aging eye disease. A cut,
            level funding, or even an inflationary increase is not
            sufficient for NEI to meet the vision challenges presented by
            the ``Silver Tsunami.''
        Congress must improve upon the President's fiscal year 2013
    request, since it cuts NEI funding by $8.86 million, or 1.2 percent
    below fiscal year 2012, which results in funding close to the base
    fiscal year 2009 level.
        Although the President's budget request level-funds NIH, it
    proposes to cut NEI by $8.8 million. Although most of this cut reflects
    the NIH Office of AIDS Research pulling its funding from the NEI's
    Studies of Ocular Implications of AIDS (SOCA) clinical trials, which
    established the efficacy of combination antiviral drug therapy in
    treating cytomegalorvirus (CMV) retinitis, the resulting total NEI
    funding of $693 million reflects a level just slightly higher than that
    in fiscal year 2009, prior to the addition of American Recovery and
    Reinvestment Act (ARRA) funding. Although the NEI's congressional
    justification (CJ) notes that this funding level will still enable NEI
    to increase Research Project Grant (RPG) funding by $3 million, it will
    still cut training programs and Research and Development contracts.
        The fiscal year 2013 level also results in a net $14 million loss
    of NEI funding since its highest level in fiscal year 2010, which
    translates into about 40 research grants--any one of which could hold
    the promise of curing a blinding eye disease. NEI is already facing
    enormous challenges in this Decade of Vision 2010-2020. Each day, from
    2011 to 2029, 10,000 citizens will turn 65 and be at greatest risk for
    eye disease, the fast growing African-American and Hispanic populations
    will experience a disproportionately higher incidence of eye disease,
    and the epidemic of obesity will significantly increase the incidence
    of diabetic retinopathy.
        NAEVR requests NEI funding at $730 million, reflecting biomedical
    inflation plus modest growth commensurate with that of NIH overall,
    since our Nation's investment in vision health is an investment in
    overall health. NEI's breakthrough research is a cost-effective
    investment, since it is leading to treatments and therapies that can
    ultimately delay, save, and prevent health expenditures, especially
    those associated with the Medicare and Medicaid programs. It can also
    increase productivity, help individuals to maintain their independence,
    and generally improve the quality of life, especially since vision loss
    is associated with increased depression and accelerated mortality.
        The very health of the vision research community is also at stake
    with a decrease in NEI funding. Not only will funding for new
    investigators be at risk, but also that of seasoned investigators,
    which threatens the continuity of research and the retention of trained
    staff, while making institutions more reliant on bridge and
    philanthropic funding. If an institution needs to let staff go, 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 2013 NIH funding of at least $32 billion, NEI at $730
    million lets NEI build upon its past record of basic and translational
    research.
        In late June 2010, NIH Director Francis Collins, M.D., Ph.D.
    recognized NEI's leadership in translational research at an NEI-
    sponsored Translational Research and Vision Conference. Just 2 weeks
    earlier, Dr. Collins testified before the House Energy and Commerce
    Committee, stating 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 fiscal year 2013 funding at $730 million, NEI can build upon
    its past research, including:
      --Genetic Basis of Eye Disease.--As NEI Director Paul Sieving, M.D.,
            Ph.D. has stated, of the more than 2,000 genes identified to
            date, more than 500, or one-quarter, are associated with both
            common and rare eye diseases. By further understanding the
            genetic basis of eye disease, NEI can study underlying disease
            mechanisms and develop appropriate diagnostic and therapeutic
            applications for such blinding eye diseases as AMD, glaucoma,
            and retinitis pigmentosa (RP).
        --NEI's AMD Gene Consortium, which consolidates 15 international
                Genome Wide Association Studies (GWAS) representing more
                than 8,000 patients, has validated 8 previously known gene
                variants and identified 19 new variants.
        --NEI's Glaucoma Human Genetics Collaboration (NEIGHBOR) has
                identified the first risk variant in a gene thought to play
                a role in the development of the optic nerve head, the
                degeneration of which leads to glaucoma and loss of
                peripheral vision, and then ultimately blindness.
        --The NEI-led human gene therapy clinical trial for
                neurodegenerative eye disease Leber Congenital Amaurosis
                (LCA) has resulted to date in 15 patients being treated and
                experiencing visual improvement. NEI's pioneering work, as
                well as subsequent refinement of gene therapy techniques,
                is enabling further research into ocular gene therapy
                through the launch of NEI-funded clinical trials for AMD,
                choroideremia, Stargardt disease, and Usher Syndrome. The
                latter three neurodegenerative diseases occur in early
                childhood and progressively destroy the retina, leading to
                vision loss and blindness and resulting in a lifetime of
                direct medical and indirect support costs. NEI is also
                funding pre-clinical safety trials for human gene therapy
                for RP, juvenile retinoschisis (``splitting'' of the
                retina, resulting in vision loss), and achromatopsia
                (affecting color perception and visual acuity).
      --Diabetic Eye Disease.--NEI's Diabetic Retinopathy Clinical Research
            (DRCR) Network found that laser treatment for diabetic macular
            edema, when combined with anti-angiogenic drug treatment, is
            more effective than laser treatment alone and will
            revolutionize the standard of care in place the past 25 years.
            With the National Institute for Diabetes and Digestive and
            Kidney Diseases (NIDDK) leading a new NIH strategic plan to
            combat diabetes, NEI's research through its various diabetic
            eye disease networks over the past 40 years--in partnership
            with NIDDK--will be more important than ever.
        Blindness and vision loss is a growing public health problem that
    individuals fear and would trade years of life to avoid.
        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.
    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 proposed fiscal
    year 2013 funding of $693 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.
        Vision loss also presents a real fear to most citizens:
      --In public opinion polls over the past 40 years, Americans have
            consistently identified fear of vision loss as second only to
            fear of cancer.
      --NEI's ``Survey of Public Knowledge, Attitudes, and Practices
            Related to Eye Health and Disease'' reported that 71 percent of
            respondents indicated that a loss of their eyesight would rate
            as a ``10'' on a scale of 1 to 10, meaning that it would have
            the greatest impact on their day-to-day life.
      --In patients with diabetes, going blind or experiencing other vision
            loss rank among the top four concerns about the disease. These
            patients are so concerned about vision loss diminishing their
            quality of life that those with nearly perfect vision (20/20 to
            20/25) would be willing to trade 15 percent of their remaining
            life for ``perfect vision,'' while those with moderate
            impairment (20/30 to 20/100) would be willing to trade 22
            percent of their remaining life for perfect vision. Patients
            who are legally blind from diabetes (20/200 to 20/400) would be
            willing to trade 36 percent of their remaining life to regain
            perfect vision.
        NAEVR urges the Congress to fund NIH and NEI at funding levels of
    at least $32 billion and $730 million, respectively, which ensures the
    momentum of research and retention of trained personnel.
                                  about naevr
        The National Alliance for Eye and Vision Research (NAEVR), which
    serves as the ``Friends of the NEI,'' 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 Association of Nutrition and Aging
                               Services Programs
        On behalf of the National Association of Nutrition and Aging
    Services Programs (NANASP), we thank you for providing an opportunity
    to submit testimony as you consider an fiscal year 2013 Labor, Health
    and Human Services, Education, and Related Agencies appropriations
    bill. NANASP is a national membership organization of nearly 1,000
    members working to provide older adults healthful food and nutrition
    through community-based services. We have 5 members from Montana and
    about 30 members in Connecticut who in turn serve hundreds of older
    adults every day.
        We are writing today to urge you to provide a much needed increase
    in funding for the senior nutrition programs in the Older Americans
    Act. These programs consist of the congregate and home-delivered (Meals
    on Wheels) nutrition programs along with the Nutrition Services
    Incentive Program. Together, these programs are known as the Elderly
    Nutrition Programs and all three keep millions of vulnerable older
    adults healthy and independent in their homes and communities by
    providing nutritious meals and needed socialization.
        These programs were forced to endure level funding in fiscal year
    2012 and if the President's budget was to be adopted, the same fate
    would occur in fiscal year 2013. Level funding is fine if costs
    associated with a program and the need for a program stay level as
    well. That is not the case with the Elderly Nutrition Programs. USDA
    has estimated that food costs are expected to increase by 3 percent. In
    addition, the price of gasoline has risen dramatically (up 12 percent
    since last year) as well as related energy costs which go to the heart
    of the nutrition programs that operate in congregate sites and who
    provide home-delivered meals on a daily basis. These costs have also
    reduced the ranks of volunteers for our programs. On the need side,
    many of our programs continue to have waiting lists or unmet needs.
        We would also proudly point out that the Elderly Nutrition Programs
    represent a sound and solid investment of the Federal dollar. Our
    programs keep seniors at home and in the community and out of nursing
    homes and hospitals because they help prevent hunger and malnutrition.
    In the congregate and home-delivered meal programs, a senior can be fed
    for 1 year for about $1,300. This $1,300 is the same as the cost of 6
    days in a nursing home or 1 day of hospitalization. In addition, for
    every $1 spent on home-delivered meals, an additional $3.35 is
    contributed from State, local, and private funds.
        The Elderly Nutrition Programs celebrate their 40th anniversary
    this year. They have more than proven their value. It is not time to
    pull back on the commitment of the Older Americans Act. We urge you to
    provide the nutrition programs with a modest increase of at least 3
    percent to allow them to keep up with inflation. Level funding in
    reality is a reduction. Only if there is absolutely no other choice
    then do we urge level funding be maintained for fiscal year 2013.
        In closing, another important priority for NANASP is the Senior
    Community Service Employment Program SCSEP. The President's fiscal year
    2013 budget once again proposes funding SCSEP at $448 million, which
    represents a 45 percent cut which was first enacted in fiscal year
    2011. The SCSEP program, also authorized by the Older Americans Act, is
    the only Federal job training program targeted for older adults seeking
    employment and training assistance. Many SCSEP participants work in
    programs that serve older adults, including the Elderly Nutrition
    Programs. We urge you to restore funding for the SCSEP program to
    $600.4 million, the pre-American Recovery and Reinvestment Act funding
    level.
        Thank you for the opportunity to submit this testimony. Please feel
    free to contact us with any questions or if you need additional
    information.
                                     ______

              Prepared Statement of the National AHEC Organization
        The members of the National AHEC Organization (NAO) are pleased to
    submit this statement for the record recommending $33.145 million in
    fiscal year 2013 for the Area Health Education Center (AHEC) program
    authorized under Titles VII of the Public Health Service Act and
    administered through the Health Resources and Services Administration
    (HRSA). The NAO is the professional organization representing AHECs.
    The AHEC Program is an established and effective national primary care
    training network built on committed partnerships of 53 medical schools
    and academic centers. Additionally, 253 AHEC centers within 48 States
    and tens of thousands of community practitioners are affiliated with
    the AHEC's national clinical training network
        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, more than
    379,000 students have been introduced to health career opportunities,
    and more than 33,000 mostly minority and disadvantaged high school
    students received more than 20 hours each of health career exposure.
    More than 44,000 health professions students received training at
    17,530 community-based sites, and furthermore; more than 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
        The AHEC network is an economic engine that fuels the recruitment,
    training, distribution, and retention of a national health workforce.
    AHEC stands for JOBS.
      --Primary Care services improve the health of the population, and
            therefore increase productivity of the U.S. workforce, while at
            the same time, contain costs within the U.S. healthcare system.
            Primary care practitioners are the front-line in prevention of
            disease, providing cost savings in the United States healthcare
            system.
        --AHECs are critical in the recruitment, training, and retention of
                the primary care workforce.
      --Research has demonstrated that the community-training network is
            the most effective recruitment tool for the health professions
            and those who teach remain longer in underserved areas and
            communities.
        --AHECs are in almost every county in the United States.
      --With the aging and growing population, the demand for primary care
            workforce is far outpacing the supply.
        --AHECs continue to educate and train current workforce, as well as
                recruiting and preparing future workforce
      --In 2010, AHECs trained 476,585 Health Professionals in 48 States in
            13,842 Health Professions Shortage Areas (HPSAs)--26.4 percent
            of those trained were physicians (125,818).
        The AHEC network's outcomes are the backbone of the Nation's
    community-based health professions training, with a focus on training
    primary care workforce.
      --HRSA has encouraged functional linkage between Bureau of Primary
            Care and Bureau of Health Professions Programs. AHECs have
            partnerships with more than 1,000 Community Health Centers
            nationally to recruit, train, and retain health professionals
            who have the cultural and linguistic skills to serve in HRSA
            designated underserved areas.
      --AHECs via a cooperative agreement with HRSA are training 10,000
            primary care providers throughout the county to address OIF/
            OEF/OND Veteran's mental health, substance abuse, traumatic
            brain injury and post-traumatic stress for those not utilizing
            the VA system
                                     ______

    Prepared Statement of the National Assembly on School Based Health Care
        I am grateful for this opportunity to submit written testimony on
    behalf of the National Assembly on School Based Health Care (NASBHC),
    an organization representing the interests of school-based health
    centers and the children and adolescents who depend upon them.
        More than 1,900 school-based health centers provide comprehensive
    primary healthcare for nearly 2 million students--regardless of their
    ability to pay--and in a location that meets children and adolescents
    where they are: at school. School-based health centers are a common-
    sense solution to address the severe gaps in educational achievement,
    healthcare access, and future employment potential among children and
    adolescents. School-based health centers are on the frontlines tackling
    challenging and expensive health crises like diabetes, asthma, mental
    health and oral health. School-based health centers keep students
    healthy and learning.
        The Patient Protection and Affordable Care Act (Public Law 111-148;
    section 4101(b)), includes a Federal authorization for school-based
    health center operations. The success of a Federal school-based health
    center authorization was a huge and historical victory for vulnerable
    children and adolescents; now, the Nation's school-based health centers
    need funds to be appropriated in order to continue providing critical
    health services to our Nation's children and adolescents.
        The National Assembly on School Based Health Care respectfully asks
    the Subcommittee to provide $50 million in funding for school-based
    health centers for fiscal year 2013.
        At school-based health centers, developmentally appropriate health
    services are provided by qualified health professionals, incorporating
    the principles and practices of pediatric and adolescent healthcare
    recommended by the American Medical Association, the American Academy
    of Pediatrics, and the American Association of Family Physicians.
        School-based health centers are first-hand witnesses to factors
    that impact student health and academic achievement--including
    bullying, school violence, depression, stress, and poor eating habits--
    circumstances often missed by outside health providers. Working within
    the school building, school-based health center staff members are
    uniquely poised to address the many challenges students bring to the
    classroom. Access to competent and appropriate healthcare leads to
    positive academic outcomes as shown in a recent study proving that
    school-based health centers have positive impacts on student
    achievement--particularly increasing grade point averages and
    attendance.
        Sadly, many school-based health centers are struggling to keep
    their doors open. Diminished public and private support, layoffs, and
    hiring freezes have reduced the number of providers on site to deliver
    care. Additionally, school-based health centers have historically faced
    limited patient revenue streams despite decades of providing services
    to Medicaid and CHIP-covered children: the gap between cost and actual
    revenue paid by Medicaid is quite steep in some communities. Average
    payment rates for SBHC visits by Medicaid enrollees range widely. In
    addition, many developmentally appropriate services--mental health,
    heath education, and behavioral risk reduction counseling--are
    oftentimes either not reimbursed or, if so, at a fraction of the cost
    of actual care.
        Restricted and diminishing revenue to support the delivery of
    health services to kids through school-based health centers jeopardizes
    the health and well-being of our Nation's children. Examples of funding
    limitations include:
      --New York.--Suffolk County Department of Health Services suffered
            reduction in funding and needed to reduce operations. Eastern
            BOCES School Based Health Center, supported by the county,
            closed on July 1, 2011. Even worse, UHS Chenango Memorial
            Hospital decided to close 10 comprehensive school-based health
            centers which include 5 dental programs prior to the start of
            this school year.
      --Illinois.--A survey taken by the Illinois Coalition for School
            Health Centers found that seven school-based health centers in
            that State have cut programs or staff over the last 4 years due
            to financial constraints.
      --Arizona.--In January 2009, 10 rural school-based health care
            centers were shut down because of lack of funding support at
            the following schools: Aquila Elementary, Arlington Elementary,
            Buckeye High School, Harquahala Valley community, Liberty
            Elementary, Paloma Elementary, Palo Verde Elementary, Ruth
            Fisher Elementary, Rainbow Valley Elementary, and Tolleson High
            School.
        School-based health centers need direct Federal financial support
    for operations to continue delivering quality comprehensive services to
    our Nation's children and adolescents.
        Thanks to the school-based health center authorization and the path
    it creates toward future reform, if funded, fewer school-based health
    centers will be forced to shut their doors because of State and local
    budget cuts, and more communities that desire to open a health clinic
    at their school will have the critical resources to do so. In her
    statement at the Coalition for Community School's national forum,
    Secretary Sebelius agreed: ``We are thrilled that part of the [health
    reform] legislation calls for an expanded foot print of school-based
    health clinics . . .  I can't think of a better way to deliver primary
    care and preventive care to not only students but their families than
    through school-based clinics.''
        We are pleased that school-based health centers are, at last, a
    federally authorized program. Until funds are appropriated, however,
    there remains no Federal support for their operations. We ask that
    funds be allocated this year to enable school-based health centers to
    keep their doors open, and to give critical resources to communities
    that desire to open health clinics at their schools.
        We recognize that there has been some confusion about capital money
    allocated to school-based health centers in the Affordable Care Act
    under section 4101(a). These funds, although important, are limited to
    capital improvements, land acquisition, and equipment purchases.
    Expenditures for care and personnel are specifically excluded.
        We respectfully request that a $50 million appropriation be
    provided for the school-based health center authorization for fiscal
    year 2013.
                                     ______

     Prepared Statement of the National Association of State Comprehensive
                             Health Insurance Plans
        The National Association of State Comprehensive Health Insurance
    Plans (NASCHIP) submits this testimony to urge your support for a
    fiscal year 2013 appropriation of $55 million for the State High Risk
    Pool Funding Extension Act of 2006.
        This funding level would be what our programs received in fiscal
    year 2011. Our programs which operate in 35 States (including Iowa and
    Alabama) and serve more than 200,000 persons with pre-existing
    conditions have been growing consistently year over year. Even with the
    advent of the Pre-Existing Condition Insurance Plans (PCIP) authorized
    under the Patient Protection and Affordable Care Act to serve
    individuals with pre-existing conditions, State pool enrollment
    continues to grow across the country. This is in part due to continued
    erosion of employer-sponsored coverage.
        Fiscal year 2012 funding to support the 35 State high risk pools
    was cut by $11 million or 25 percent. These cuts resulted in higher
    premiums and some of our most vulnerable citizens finding themselves
    unable to afford the healthcare services they need. Nearly half of all
    State high risk pools depend on the funding to directly buy-down
    premiums and other cost shares for low income pool members. Continuing
    with such dramatic cuts to this critical funding will ensure that more
    low income plan members may have to drop coverage altogether as
    premiums will be unaffordable.
        Contrast this to the lagging enrollment numbers for the totally
    separate PCIP program under the Affordable Care Act (with $5 billion in
    funding). The simple fact is not only do our State high risk pool
    programs predate the PCIP program but they are also distinct from PCIP
    because of the subsidy we provide in one-third of our States to low-
    income individuals offering discounts of between 18 and 67 percent.
        The administration's budget proposal for fiscal year 2013 slashes
    funding to $22 million, another 50 percent reduction. The
    administration's justification for this draconian cut is based on the
    patently false premise that only 6 months of funding is needed for this
    program is fiscal year 2013 because State exchanges will be fully
    operational and there will no need for the State high risk pool
    program. That is a misreading on the reality of the situation.
    Individuals covered by high risk pools will not be able to access
    insurance in the Exchange marketplace until January 1, 2014 at the
    earliest. Therefore, our State high risk pools will require funding for
    the entire fiscal year 2013 as they will be operational until at least
    December 31, 2013. State exchanges will not be ready to insure State
    high-risk pools members until after the close of fiscal year 2013.
    Funding must be provided to ensure continuation of coverage through
    2013 and a safe transition for these needy individuals in 2014.
        The funding level we seek is to simply allow us to continue our
    important work for the duration of fiscal year 2013; therefore, our
    request is a funding level of $55 million. We suggest as an offset to
    support this funding level come with the authority to allow PCIP funds
    to be used to support State operational grants and low-income subsidies
    for those with preexisting conditions in the 35 States we serve.
        Thank you for your consideration and the opportunity to submit this
    testimony.
                                     ______

     Prepared Statement of the National Alliance of State and Territorial
                                 AIDS Directors
        The National Alliance of State and Territorial AIDS Directors
    (NASTAD) represents the Nation's chief State health agency staff who
    have programmatic responsibility for administering HIV/AIDS and viral
    hepatitis healthcare, prevention, education, and supportive service
    programs funded by State and Federal governments. On behalf of NASTAD,
    we urge your support for increased funding for Federal HIV/AIDS and
    viral hepatitis programs in the fiscal year 2013 Labor-Health-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 2013. 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 are 30 years into the HIV/AIDS epidemic, we must be mindful
    that HIV/AIDS is still a crisis in the United States, not just abroad.
    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
    approximately 50,000 new infections occur 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 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.
                      hiv/aids care and treatment programs
        The Health Resources and Services Administration (HRSA) administers
    the $2.4 billion Ryan White Program that provides health and support
    services to more than 500,000 Persons Living with HIV/AIDS (PLWHA).
    NASTAD requests a minimum increase of $270.1 million in fiscal year
    2013 for State Ryan White Part B grants, including an increase of $79.9
    million for the Part B base and $190.2 million for AIDS Drug Assistance
    Programs (ADAPs). 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 wrap-around 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 2010, more than 226,000 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. Due to emergency
    funding for ADAPs throughout fiscal year 2012, the waitlists have
    decreased; however, to eliminate waitlists and other cost containment
    measures completely, there is still a need for additional funding. As
    of April 19, 2012, there are 3,079 individuals are on waiting lists in
    10 States to receive their life-sustaining medications through ADAP:
      --Florida: 427 individuals;
      --Georgia: 1,058 individuals;
      --Idaho: 8 individuals;
      --Louisiana: 356 individuals;
      --Montana: 4 individuals;
      --Nebraska: 222 individuals;
      --North Carolina: 140 individuals;
      --South Carolina: 0 individuals;
      --Utah: 0 individuals; and
      --Virginia: 864 individuals.
                 hiv/aids prevention and surveillance programs
        One of the major goals of the NHAS is to lower the annual number of
    new infections by 25 percent from 56,300 to 42,225 by 2015. In order to
    meet this ambitious goal, NASTAD requests an increase of $100 million
    above fiscal year 2012 funding levels 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.
        NASTAD is gravely concerned about the unraveling of State public
    health HIV prevention infrastructure in an era where averting new HIV
    infections is paramount. NASTAD requests that of these funds, $41
    million ($27 million for core health department prevention programs and
    $14 million for expanded HIV testing) be used to restore funding to
    health departments who lost resources through PS12-1201: Comprehensive
    Human Immunodeficiency Virus (HIV) Prevention Programs for Health
    Departments to fiscal year 2010 levels. The funding should reinstate
    Category A: HIV Prevention Programs for Health Departments losses and
    Category B: Expanded HIV Testing for Disproportionately Affected
    Populations. NASTAD's analysis indicates that 40 jurisdictions
    (including 34 States, the District of Columbia, three cities and two
    territories) experienced decreases in their core HIV prevention awards
    between fiscal year 2011 and fiscal year 2012. In terms of expanded HIV
    testing 24 jurisdictions (including 20 States, the District of Columbia
    and three cities) experienced a decrease in their awards between fiscal
    year 2010 and fiscal year 2012.
        NASTAD supports targeting resources to where they are most needed
    and innovation in HIV prevention programming. However, since the
    funding levels were lower than the previous year and because funds were
    shifted to some jurisdictions as a result of a new formula based on
    reported HIV cases, dramatic decreases in resources have occurred for
    the majority of States. Unfortunately, cuts of this magnitude erode the
    capacity of many of States to drive down HIV incidence and link newly
    diagnosed individuals to care, both critical goals of the National HIV/
    AIDS Strategy. Many health departments are experiencing significant
    challenges as they restructure existing programs in reaction to these
    funding shifts.
        NASTAD also recommends that all jurisdictions be eligible for
    expanded testing resources. Additional analyses indicate that
    approximately $18 million in additional funds are needed for Category
    B, expanded HIV testing, to bring currently funded programs to their
    fiscal year 2010 levels (including the MAI and PPHF resources) and fund
    the remaining programs at tiered levels based on prevalence. If the
    NHAS is to be truly ``national,'' all jurisdictions should receive
    resources under Category B. Currently, expanded HIV testing activities
    serve disproportionately impacted populations: African-Americans,
    Latinos, gay and bisexual men of all races and ethnicities and persons
    who inject drugs. Moreover, 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 expanded
    with adequate funding to ensure that more individuals learn their HIV
    status and are linked to care.
        In addition, NASTAD believes an increase of $40 million should be
    directed toward critical HIV surveillance efforts. HIV surveillance has
    been chronically underfunded in most jurisdictions for over a decade.
    As a result, many States cobble together their HIV surveillance
    programs with resources leveraged from other programs. With the
    significant reallocation of resources to State and local health
    departments through FOA PS12-1201 Comprehensive HIV Prevention Programs
    for Health Departments, the ability of these health departments to
    continue supporting surveillance activities will be greatly diminished.
    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.
                      viral hepatitis prevention programs
        NASTAD requests an increase of $40 million for a total of $59.3
    million in fiscal year 2013 for the CDC's Division of Viral Hepatitis
    (DVH) for a national testing, education and surveillance initiative as
    outlined in the Division's professional judgment budget submitted to
    the Congress last year. We believe that testing to identify more than 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. DVH received an increase of $10
    million from the Prevention and Public Health Fund in fiscal year 2012
    for the development of a national screening initiative. NASTAD requests
    funding to continue to support the viral hepatitis screening and
    testing initiative and encourages the Division to make all currently
    funded health departments eligible for funding. Due to the lack of
    strong surveillance data for viral hepatitis, it would be impossible to
    adequately determine which jurisdictions have the highest incidence or
    prevalence of viral hepatitis. Developing a national surveillance
    system is the Division's second highest priority. Surveillance is
    needed to monitor disease trends and evaluate evidence-based
    interventions. Unlike other infectious diseases, viral hepatitis lacks
    a national surveillance system. NASTAD requests funding to State adult
    viral hepatitis prevention coordinators be increased from $5 to $10
    million. Adult Viral Hepatitis Prevention Coordinators are based in
    State health departments and 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.
        HHS' Viral Hepatitis Action Plan will improve the collaboration and
    coordination of the Federal Government's response and implement the
    Institute of Medicine's (IOM) expert recommendations on controlling and
    preventing viral hepatitis. Funding is needed to support increased
    capacity at the HHS Office of the Assistant Secretary for Health (ASH)
    for supporting the implementation of the HHS Viral Hepatitis Action
    Plan.
                           syringe exchange programs
        NASTAD supports the lifting of the ban on the use of Federal funds
    for syringe exchange programs and opposes any Federal actions which ban
    or increase the bureaucratic, regulatory and reporting requirements on
    syringe access beyond those already in place at the State and local
    level. Syringe exchange programs are a crucial aspect of comprehensive
    HIV and viral hepatitis prevention services. Sharing used syringes is
    the primary reason IDUs become infected with HIV and hepatitis C and
    morbidity and mortality rates among IDUs remain disproportionately
    high. People who inject drugs bear the highest burden of hepatitis C
    (HCV) infection and in some communities as many as 90 percent of IDUs
    are infected with chronic HCV. Research has provided overwhelming
    evidence that access to sterile syringes is effective in reducing
    transmission of HIV, without increasing drug use. The 21-year-old ban
    on the use of Federal funds for syringe exchange programs was lifted in
    December 2009 when the fiscal year 2010 appropriations bill was signed
    into law without this restriction. However, in the fiscal year 2012
    Consolidated Appropriations Act, the Federal ban on syringe exchange
    programs was reinstated in the Labor-HHS appropriations and Financial
    Services appropriations, barring the use of Federal funds for syringe
    exchange in the United States and the District of Columbia.
                            std prevention programs
        NASTAD supports an increase of $26.2 million for a total of $180
    million in fiscal year 2013 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 1
    year, the United States spends more than $8 billion to treat the
    symptoms and consequences of STDs. Untreated STDs contribute to infant
    mortality, infertility, and cervical cancer. Additional Federal
    resources are needed to reverse these alarming trends and reduce the
    Nation's health spending. The teen pregnancy prevention initiative,
    administered through the Office of Adolescent Health should be expanded
    to include prevention of HIV and STDs and funded at $130 million.
                       prevention and public health fund
        The Prevention and Public Health Fund (PPHF) tackles critical
    epidemics, such as HIV/AIDS and viral hepatitis. The fund is a unique
    opportunity to decrease healthcare spending related to HIV/AIDS
    treatment and care, and invest in viral hepatitis prevention and
    screening efforts. We encourage you to utilize the PPHF 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, as well as HIV/AIDS prevention initiatives.
        PPHF is urgently needed to address the many emerging health threats
    our country faces through a coordinated, comprehensive, sustainable and
    accountable approach to improving health outcomes and curbing costs. It
    is essential to the health of Americans that we capitalize on the
    opportunity to invest in prevention programs and transform our public
    health system. In order to accomplish this, we must maintain the PPHF.
    The PPHF was used to offset costs for the Middle Class Tax Relief and
    Job Creation Act of 2012, which cut approximately $6.25 billion from
    PPHF over the next 10 years. It is imperative that the Prevention and
    Public Health Fund is not cut further or used again as an offset for
    other programs.
        As you contemplate the fiscal year 2013 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 Nursing Community
        The Nursing Community is a forum comprised of 59 national
    professional nursing membership associations that builds consensus and
    advocates on a wide spectrum of healthcare and nursing issues
    surrounding practice, education, and research. These 59 organizations
    are committed to promoting America's health through the advancement of
    the nursing profession. Collectively, the Nursing Community represents
    nearly 1 million 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
    support a robust investment in the Nursing Workforce Development
    programs (authorized under Title VIII of the Public Health Service Act
    [42 U.S.C. 296 et seq.]), support research initiatives at the National
    Institute of Nursing Research (NINR), and secure authorized funding for
    Nurse-Managed Health Clinics (Title III of the Public Health Service
    Act) so that our Nation's population receives the highest-quality
    nursing services possible.
    Demand for Nurses Continues to Grow
        According to the Bureau of Labor Statistics' Employment Projections
    for 2010-2020, the expected number of practicing nurses will grow from
    2.74 million in 2010 to 3.45 million in 2020, an increase of 712,000 or
    26 percent. The projections further explain the need for 495,500
    replacements in the nursing workforce, bringing the total number of job
    openings for nurses due to growth and replacements to 1.2 million by
    2020.
        Two primary factors contribute to this overwhelming projection.
    First, America's nursing workforce is aging. According to the 2008
    National Sample Survey of Registered Nurses, more than 1 million of the
    Nation's 2.6 million practicing RNs are over the age of 50. Within this
    population, more than 275,000 nurses are over the age of 60. As the
    economy continues to rebound, many of these nurses will seek
    retirement, leaving behind a significant deficit in the number of
    experienced nurses in the workforce. Second, America's baby boomer
    population is aging. It is estimated that more than 80 million baby
    boomers reached age 65 last year. This population will require a vast
    influx of nursing services, particularly in areas of primary care and
    chronic illness management. A significant investment must be made in
    the education of new nurses to provide the Nation with the nursing
    services it demands.
    Addressing the Demand: Title VIII Nursing Workforce Development
            Programs
        For nearly 50 years, the Nursing Workforce Development programs,
    authorized under Title VIII of the Public Health Service Act, have
    helped build the supply and distribution of qualified nurses to meet
    our Nation's healthcare needs. 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 2005 and 2010 alone, the Title VIII
    programs supported more than 400,000 nurses and nursing students as
    well as numerous academic nursing institutions, and healthcare
    facilities.
        The American Association of Colleges of Nursing's (AACN) Title VIII
    Student Recipient Survey gathers information about Title VIII dollars
    and its impact on nursing students. The 2011-2012 survey, which
    included responses from more than 1,600 students, stated that the Title
    VIII programs played a critical role in funding their nursing
    education. The survey showed that 68 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 new
    nurses enter the workforce without delay. The programs also address the
    current demand for primary care providers. Over one-half 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, several
    respondents identified working in rural and underserved areas as future
    goals, with becoming a nurse faculty member, a nurse practitioner, or a
    nurse researcher as the top three nursing positions for their career
    aspirations.
        The Title VIII programs also address the need for more nurse
    faculty. Data from AACN's 2011-2012 enrollment and graduations survey
    show that nursing schools were forced to turn away 75,587 qualified
    applications from entry-level baccalaureate and graduate nursing
    programs in 2011, citing faculty vacancy as a primary reason. The Title
    VIII Nurse Faculty Loan Program aids in increasing nursing school
    enrollment capacity by supporting students pursuing graduate education
    provided they serve as faculty for 4 years after graduation.
        The Nursing Community respectfully requests $251 million for the
    Nursing Workforce Development programs authorized under Title VIII of
    the Public Health Service Act in fiscal year 2013.
    National Institute of Nursing Research: Foundation for Evidence-Based
            Care
        As 1 of the 27 Institutes and Centers at the National Institutes of
    Health (NIH), the NINR funds research that lays the groundwork for
    evidence-based nursing practice. Nurse-scientists funded by NINR
    examine ways to improve care models to deliver safe, high-quality, and
    cost-effective health services to the Nation. Our country must look
    toward the prevention aspect of healthcare as the vehicle for saving
    our system from further financial burden, and the work of NINR embraces
    this endeavor through research related to 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. Moreover, NINR helps to provide needed faculty to support
    the education of future generations of nurses. Training programs at
    NINR develop future nurse-researchers, many of whom also serve as
    faculty in our Nation's nursing school.
        The Nursing Community respectfully requests $150 million for the
    NINR in fiscal year 2013. This level of funding is on par with the Ad
    Hoc Group for Medical Research's $32 billion request for the total NIH
    budget in fiscal year 2013.
    Nurse-Managed Health Clinics: Expanding Access to Care
        NMHCs are healthcare delivery sites managed by APRNs and are
    staffed by an interdisciplinary team that may include physicians,
    social workers, public health nurses, and therapists. These clinics are
    often associated with a school, college, university, department of
    nursing, federally qualified health center, or independent nonprofit
    healthcare agency. NMHCs serve as critical access points to keep
    patients out of the emergency room, saving the healthcare system
    millions of dollars annually.
        NMHCs provide care to patients in medically underserved regions of
    the country, including rural communities, Native American reservations,
    senior citizen centers, elementary schools, and urban housing
    developments. The populations within these communities are the most
    vulnerable to chronic illnesses that create heavy financial burden on
    patients and the healthcare system. NMHCs aim to reduce the prevalence
    of disease and create healthier communities by providing primary care
    services and educating patients on health promotion practices.
    Furthermore, NMHCs serve as clinical education training sites for
    nursing students and other health professionals, a crucial aspect of
    NMHCs given that a lack of training sites is commonly identified as a
    barrier to nursing school enrollment.
        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 2013.
        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 $251 million for the Title VIII Nursing
    Workforce Development programs, $150 million for the National Institute
    of Nursing Research, and $20 million for Nurse-Managed Health Clinics
    in fiscal year 2013 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 Nurse Practitioners
    American Academy of Nursing
    American Association of Colleges of Nursing
    American Association of Nurse Anesthetists
    American Association of Nurse Assessment Coordination
    American College of Nurse Practitioners
    American College of Nurse-Midwives
    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
    Asian American and Pacific Islander Nurses Association
    Association of Community Health Nursing Educators
    Association of Nurses in AIDS Care
    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 of the U.S. Public Health Service
    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 Nurses in Genetics
    International Society of Psychiatric Nursing
    National American Arab Nurses Association
    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 Gerontological Nursing Association
    National Nursing Centers Consortium
    National Organization for Associate Degree Nurses
    National Organization of Nurse Practitioner Faculties
    Nurses Organization of Veterans Affairs
    Oncology Nursing Society
    Pediatric Endocrinology Nursing Society
    Preventive Cardiovascular Nurses Association
    Public Health Nursing Section, American Public Health Association
    Society of Urologic Nurses and Associates
    Wound, Ostomy and Continence Nurses Society
                                     ______

        Prepared Statement of the National Congress of American Indians
                    department of health and human services
    Introduction
        The National Congress of American Indians (NCAI) is the oldest and
    largest American Indian organization in the United States. In 1944,
    tribal leaders created NCAI as a response to termination and
    assimilation policies that threatened the existence of American Indian
    and Alaska Native tribes. Since then, NCAI has fought to preserve the
    treaty rights and sovereign status of tribal governments, while
    ensuring that Indian people may fully participate in the political
    system. As the most representative organization of American Indian
    tribes, NCAI serves the broad interests of tribal governments across
    the Nation.
        Tribal nations in the United States are vastly diverse--as are the
    citizens that comprise them--but in the modern era, the common element
    responsible for revitalizing tribal homelands is tribal sovereignty at
    work. Effective self-rule requires that the United States respect
    tribes' inherent rights of self-government and self-determination and
    that the Federal Government honor its trust obligations to Native
    peoples in the Federal budget. Addressing the healthcare needs of
    American Indians and Alaska Natives is one of the most important
    cornerstones of this Federal trust responsibility. The budget for the
    Department of Health and Human Services should carry forward the trust
    responsibility and support tribal self-determination as a key element
    of healthcare reform while continuing the Government's partnership with
    tribes to improve Indian health.
        The foregoing fiscal year 2013 tribal budget program requests have
    been compiled in collaboration with tribal leaders, Native
    organizations, and tribal budget consultation bodies. Tribes
    respectfully request that these recommendations be included in the
    Labor, Health and Human Services, Education, and related agencies
    appropriations process.
    Administration on Aging
                Older Americans Act--Title VI
        Provide $30 million for Parts A (Grants for Native Americans) and B
    (Grants for Native Hawaiians) of the Act.
        Provide $8.3 million for the Native American Caregiver Support
    Program, and create a line item for training for tribal recipients.
        Programs under Title VI of the Older Americans Act are the primary
    vehicle for providing nutrition and other direct supportive services to
    American Indian, Alaska Native, and Native Hawaiian elders and their
    caregivers. However, these programs cannot be effective if not
    adequately funded.
                Older Americans Act--Title VII
        Create a tribal set-aside of $2 million under Subtitle B of Title
    VII.
        Subtitle B of Title VII of the Older Americans Act authorizes a
    program for tribes, public agencies, or nonprofit organizations serving
    Native elders to assist in prioritizing issues concerning elder rights
    and to carry out related activities. A $2 million tribal set-aside
    should be created under Subtitle B to ensure that tribes have access to
    funds at a comparable level to States.
                Older Americans Act--Title IV
        Provide $3 million for national minority aging organizations to
    build the capacity of community-based organizations to better serve
    American Indian and Alaska Native seniors.
        Language and cultural barriers severely restrict Native elder
    access to Federal programs for which they are eligible, such as Social
    Security, Medicare, and Medicaid. Funding is needed to build capacity
    for tribal, minority, and other community-based aging organizations to
    serve Native elders and enroll them in programs to which they are
    entitled.
    Administration for Children and Families
                Head Start
        Exempt Head Start from budget-related reductions.
        The Indian Head Start program comprehensively integrates education,
    health, and family services in a manner that closely mirrors a
    traditional Indian education model, making Indian Head Start one of the
    most successful Federal programs operating in Indian Country. Despite
    these successes, inflation-adjusted Head Start funding has
    significantly declined in the past decade and as a result, less than 20
    percent of age-eligible Indian children are enrolled in Indian Head
    Start. Recognizing that achieving a significant funding increase in
    fiscal year 2013 will be difficult, Head Start should at least be held
    harmless from any reductions, just as other low-income programs are
    held harmless in the Budget Control Act of 2011.
                Language Preservation Programs
        Provide $12 million for Native language preservation, with $4
    million designated to fund the Esther Martinez Language Programs
    through the Administration for Native Americans.
        Nationwide, tribes are combating the loss of traditional languages
    through culture and language programs. Tribal students in immersion
    programs often perform substantially better academically than Native
    students who have not participated in such programs.\1\ As such, in
    2013, the Federal budget should include $12 million as part of the
    appropriation to the Administration for Native Americans for Native
    language preservation activities, with $4 million designated to support
    Esther Martinez Language Programs' Native language immersion
    initiatives.
    ---------------------------------------------------------------------------
        \1\ See for example the cases profiled in Pease-Pretty on Top, J.
    (2003). Native American Language Immersion: Innovative Native Education
    for Children & Families. Denver, Colorado: American Indian College
    Fund.
    ---------------------------------------------------------------------------
                Foster Care Initiative
        Provide $20 million to fund Children's Bureau foster care
    demonstration grants and track tribal awards.
        The goal of this Obama administration initiative is to identify
    innovative strategies that improve outcomes for children in long-term
    foster care. Twenty million dollars in demonstration grants should be
    provided to tribes, States, and localities to test new, innovative
    strategies for improving outcomes for foster care children.
                Child Welfare Services
        Increase the tribal allocation of Title IV-B, Subpart 1 by creating
    a 3 percent set-aside of the total appropriation.
        Provide $200 million for Title IV-B, Subpart 2--the full amount
    authorized for the discretionary component of the program that will
    benefit tribes and States.
        The bare minimum needed to establish a child abuse and neglect
    prevention program in any tribal community is approximately $80,000.
    Title IV-B, Subpart 1 supports a significant portion of this amount,
    yet tribes are hindered in their ability to effectively administer a
    program as the majority of them are only eligible for small grants
    (less than $10,000, in most cases). No other consistent, stable source
    of funding is available to tribal governments to provide basic,
    preventive child welfare services. A 3 percent tribal set-aside of
    Title IV-B, Subpart 1 funding (within a total appropriation of $281.7
    million for this capped entitlement program) will allow for larger
    tribal grants to provide basic child welfare services to support Native
    families and protect Native children.
        In order for tribal courts to advance new practices and improve
    outcomes with children under their jurisdiction, they need access to
    funding that will support capacity building and innovative practices.
    Currently, the Title IV-B, Subpart 1 program allows the use of funds
    for family preservation purposes, but Title IV-B, Subpart 2 (the larger
    of the two programs) does not focus on family preservation. Title IV-B,
    Subpart 2 should be funded at $200 million--the full amount authorized
    under the Act for the discretionary component of the program--so tribes
    will receive increased resources from the 3 percent set-aside.
                Child Abuse Prevention and Treatment Act (CAPTA)
        Provide a separate line item for tribal Title II grants and set-
    aside 3 percent of total funding for tribes and tribal consortia.
        Currently, tribes and migrant programs must compete with each other
    for a 1 percent set-aside of the total funding appropriated under Title
    II of CAPTA. Tribes and States have a governmental responsibility to
    ensure that foster care protections are provided to every child that is
    in an out-of-home placement under their jurisdiction and care. A 3
    percent tribal set-aside, listed as a separate line item in the budget,
    will provide a base level of funding for every tribe, regardless of
    size, and give every tribal community an opportunity to establish a
    quality child abuse and neglect prevention program.
                Low-Income Home Energy Assistance Program (LIHEAP)
        Maintain full funding levels for LIHEAP ($4.5 billion), with $51
    million to tribes.
        LIHEAP prevents families from having to make the choice between
    food and heat. With high unemployment and barriers to economic
    development, much of Indian Country cannot afford to pay for the rising
    costs of heat and power. Full funding of LIHEAP is crucial to address
    the extreme need for heating assistance in Indian Country.
    Substance Abuse and Mental Health Services Administration
                Behavioral Health
        Provide $40 million to fund the Behavioral Health--Tribal
    Prevention Grant (BH-TPG).
        This proposed SAMHSA grant program has been authorized to award
    grants to tribes to evidence-based prevention practices in tribal
    communities. Funded through the prevention fund (authorized by the
    Affordable Care Act), the BH-TPG will be used to implement
    comprehensive prevention strategies to address the most serious mental
    health and substance abuse issues in tribal communities.
                Suicide Prevention
        Provide a $6 million tribal set-aside for American Indian and
    Alaska Native suicide prevention programs under the Garrett Lee Smith
    Act.
        Suicide has reached epidemic proportions in some tribal
    communities. The Garrett Lee Smith Memorial Act of 2004 is the first
    Federal law to provide specific funding for youth suicide prevention
    programs, authorizing $82 million in grants over 3 years through
    SAMHSA. Currently, tribes must compete with other institutions to
    access these funds. To assist tribal communities in accessing these
    funds, a line-item for tribal-specific resources is necessary.
                              department of labor
        Tribal nations in the United States are vastly diverse--as are the
    citizens that comprise them--but in the modern era, the common element
    responsible for revitalizing tribal homelands is tribal sovereignty at
    work. Effective self-rule requires that the United States respect
    tribes' inherent rights of self-government and self-determination and
    that the Federal Government honor its trust obligations to Native
    peoples in the Federal budget. Investing in the education of American
    Indian and Alaska Native students is not only one most of the most
    important cornerstones of this Federal trust responsibility, but is
    also critical to economic revitalization for both Indian Country and
    the Nation as a whole.
        Research repeatedly demonstrates that investments in education
    contribute to economic growth while also expanding opportunities for
    individual advancement. Unfortunately, when faced with tough budgetary
    decisions, policymakers and elected officials often target education
    and other social welfare budgets that require more long-term
    investments. Even worse, Native youth and families are often the
    hardest hit by these cuts. As a result, schools in Indian Country face
    inadequate Federal support, which leads to a shortage of staff, lack of
    support services, dilapidated facilities, and, ultimately, lower
    student achievement and limited educational opportunities. The Federal
    Government must live up to its commitment to providing a quality
    education for American Indian and Alaska Native students and for all of
    the Nation's students.
        The foregoing fiscal year 2013 tribal budget program requests have
    been compiled in collaboration with tribal leaders, Native
    organizations, and tribal budget consultation bodies. Tribes
    respectfully request that these recommendations be included in the
    Labor, Health and Human Services, Education, and related agencies
    appropriations process.
                            department of education
    Culturally Based Education
        Provide $198.4 million for Title VII funding under the Elementary
    and Secondary Education Act.
        Title VII of the Elementary and Secondary Education Act, which
    provides essential support for culturally based education approaches
    for American Indian and Alaska Native students and addresses the unique
    educational and cultural needs of Native students, is severely
    underfunded. It is well-documented that Native students are more likely
    to thrive in environments that support their cultural identities.\2\
    Title VII has produced many success stories, but increased funding is
    needed in this area to close the achievement gap for Native students
    and to ensure continued support for Native cultures and language
    education.
    ---------------------------------------------------------------------------
        \2\ Demmert, W.G. & Towner, J.C. (2003). A Review of the Research
    Literature on the Influences of Culturally Based Education on the
    Academic Performance of Native American Students. Portland, Oregon:
    Northwest Regional Educational Laboratory.
    ---------------------------------------------------------------------------
                Impact Aid Funding
        Provide $1.395 billion for Impact Aid, Title VIII funding under the
    Elementary and Secondary Education Act.
        Impact Aid provides resources to public schools whose tax bases are
    reduced because of Federal activities, including the presence of an
    Indian reservation. Thousands of American Indian and Alaska Native
    youth are served by reservation and other schools eligible for Impact
    Aid, including those located on or near tribal lands and those living
    on military bases.\3\ Yet, Impact Aid funding has not kept pace with
    inflation. Past budgets have also failed to provide appropriate
    allocations for facilities construction, causing a tremendous backlog
    in new construction and leaving many public schools on reservations in
    desperate need of repair.
    ---------------------------------------------------------------------------
        \3\ DeVoe, J. & Darling-Churchill, K. (2008). Status and Trends in
    the Education of American Indians and Alaska Natives. Washington, DC:
    U.S. Department of Education, National Center for Education Statistics
    (Publication Number NCES 2008-084).
    ---------------------------------------------------------------------------
                Tribal Education Departments
        Provide $5 million to fund Tribal Education Departments (TEDs).
        Five million dollars should be appropriated to the Department of
    Education to support Tribal Education Departments (TEDs). The
    Elementary and Secondary Education Act of 2001 authorizes this
    appropriation. Congress provided the first appropriation of $2 million
    in the Department of Education's Indian Education National Activities
    line for TEDs in the fiscal year 2012 Consolidated Appropriations Act.
    With continued funding, the impact on Indian education would be
    significant.
        Currently, most tribes fund TEDs with non-Federal sources of
    funding, Federal funding from Johnson O'Malley, and sometimes limited
    Title VII Indian education formula grants from the Elementary and
    Secondary Education Act. TEDs have a wide range of budgets depending
    upon the tribe's overall budget and priorities. TEDs serve thousands of
    American Indian and Alaska Native students nationwide in Bureau of
    Indian Education, tribal, and public schools. TEDs must have adequate
    financial support so they can serve the educational needs of these
    students at a comparable level to the students served by State
    education departments and agencies.
                Tribal Colleges and Universities
        Provide $36 million for Title III-A grants under the Higher
    Education Act.
        Titles III and V of the Higher Education Act, known as Aid for
    Institutional Development programs, support institutions with a large
    proportion of financially disadvantaged students and low cost-per-
    student expenditures. Tribal Colleges and Universities (TCUs) clearly
    fit this definition. The Nation's 36 TCUs serve Native and non-Native
    students in some of the most impoverished areas in the Nation, yet they
    are the country's most poorly funded postsecondary institutions.
    Congress recognized the TCUs as emergent institutions, and as such,
    authorized a separate section of Title III (Part A, Sec. 316)
    specifically to address their needs. Additionally, a separate section
    (Sec. 317) was created to address similar needs of Alaska Native and
    Native Hawaiian institutions. Section 316 is divided into two
    competitive grants programs: formula-funded basic development grants
    and competitive single-year facilities construction grants. Thirty-six
    million dollars should be provided in fiscal year 2013 to fund these
    two competitive grant programs.
                Vocational Rehabilitation Services Projects for American
                        Indians with Disabilities
        Increase Vocational Rehabilitation Services Projects to $67 million
    and create a line item of $5 million for providing outreach to tribal
    recipients.
        According to the U.S. census, 24 percent of American Indians and
    Alaska Natives have a disability. High rates of diabetes, heart
    disease, and preventable accidents are among the issues that contribute
    to this troubling reality. This creates an extraordinary need for
    tribes to support their disabled citizens in becoming self-sufficient.
    Further, tribes have had limited access to funding for vocational
    rehabilitation and job training--such as funds made available under the
    American Recovery and Reinvestment Act (ARRA)--compared to States. An
    increase to $67 million would begin to put tribes on par with State
    governments.
                              department of labor
    YouthBuild
        Restore the rural and tribal set-aside in the YouthBuild program
    and create a dedicated 5 percent tribal set aside of at least $4
    million.
        The YouthBuild program assists disadvantaged, low-income youth ages
    16-24 in obtaining education and work skills to be competitive
    candidates in the job market. When the program was transferred to
    Department of Labor in September 2006, the 10 percent set-aside for
    rural and tribal programs was eliminated. Given significant
    unemployment challenges and the growing Native youth population, it is
    essential that the 10 percent tribal and rural set-aside be restored,
    including a dedicated set-aside of 5 percent. Based on fiscal year 2011
    and fiscal year 2012 appropriations, we request a set-aside of at least
    5 percent ($4 million) for tribal programs.
                                   conclusion
        Thank you for your consideration of this testimony. For more
    information, please contact Ahniwake Rose, NCAI Director of Human
    Service Policy, at arose@ncai.org and Amber Ebarb, NCAI Legislative
    Associate, at aebarb@ncai.org.
                                     ______

    Prepared Statement of the National Council for Diversity in the Health
                                  Professions
        Mr. Chairman and members of the subcommittee, thank you for the
    opportunity to present my views before you today. I am Dr. Wanda
    Lipscomb, President of the National Council for Diversity in the Health
    Professions (NCDHP) and the Director of the Center of Excellence for
    Culture Diversity in Medical Education at Michigan State University.
    NCDHP, established in 2006, is a consortium of our Nation's majority
    and minority institutions that once house the Health Resources and
    Services (HRSA) Minority Centers of Excellence (COE) and Health Careers
    Opportunities Programs (HCOP) when there was more funding. These
    institutions are committed to diversity in the health professions. In
    my professional life, I have seen firsthand the importance of health
    professions institutions promoting diversity and the Title VII Health
    Professions Training programs.
        Mr. Chairman, time and time again, you have encouraged your
    colleagues and the rest of us to take a look at our Nation and evaluate
    our needs over the next 10 years. I want to say that minority health
    professional institutions and the Title VII Health Professionals
    Training programs address a critical national need. Persistent and
    severe staffing shortages exist in a number of the health professions,
    and chronic shortages exist for all of the health professions in our
    Nation's most medically underserved communities. Furthermore, our
    Nation's health professions workforce does not accurately reflect the
    racial composition of our population. For example while blacks
    represent approximately 15 percent of the U.S. population, only 2-3
    percent of the Nation's health professions workforce is black. Mr.
    Chairman, I would like to share with you how your committee can help
    NCDHP continue our efforts to help provide quality health professionals
    and close our Nation's health disparity gap.
        There is a well established link between health disparities and a
    lack of access to competent healthcare in medically underserved areas.
    As a result, it is imperative that the Federal Government continue its
    commitment to minority health profession institutions and minority
    health professional training programs to continue to produce healthcare
    professionals committed to addressing this unmet need.
        An October 2006 study by the Health Resources and Services
    Administration (HRSA), entitled ``The Rationale for Diversity in the
    Health Professions: A Review of the Evidence'' found that minority
    health professionals serve minority and other medically underserved
    populations at higher rates than 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, like the
    NCDHP members, have been particularly hard-hit as a result of the cuts
    to the Title VII Health Profession Training programs in fiscal year
    2006, fiscal year 2007, and fiscal year 2008. Given their historic
    mission to provide academic opportunities for minority and financially
    disadvantaged students, and healthcare to minority and financially
    disadvantaged patients, minority health professions institutions
    operate on narrow margins. The cuts to the Title VII Health Professions
    Training programs amount to a loss of core funding at these
    institutions and have been financially devastating. We have been
    pleased to see efforts to revitalize both COE and HCOP in recent fiscal
    years, but it is important to fully fund the programs at least at the
    fiscal year 2004 level so that more diversity is achieved in our health
    professions.
        Earlier this year with the passage of health reform, the Congress
    showed the importance of the many of the Title VII programs, including
    the Minority Centers of Excellence (COE) and Health Careers
    Opportunities Program (HCOP), by reauthorizing the programs.
        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 2013, I recommend a funding level of $24 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.
        Collectively, the absence of HCOPs will substantially erode the
    number of minority students who enter the health professions. Over the
    last three decades, HCOPs have trained approximately 30,000 health
    professionals including 20,000 doctors, 5,000 dentists and 3,000 public
    health workers. For fiscal year 2013, I recommend a funding level of
    $23 million for HCOPs.
        Mr. Chairman, please allow me to express my appreciation to you and
    the members of this subcommittee. With your continued help and support,
    NCDHP member institutions and the Title VII Health Professions Training
    programs can help this country to overcome health and healthcare
    disparities. Congress must be careful not to eliminate, paralyze or
    stifle the institutions and programs that have been proven to work.
    NCDHP seeks to close the ever widening health disparity gap. If this
    subcommittee will give us the tools, we will continue to work towards
    the goal of eliminating that disparity everyday.
        Thank you, Mr. Chairman, and I welcome every opportunity to answer
    questions for your records.
                                     ______

             Prepared Statement of the National 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. In fiscal year 2011,
    the program helped an estimated 9 million low-income households afford
    their energy bills.
    ---------------------------------------------------------------------------
        \1\ 42 U.S.C. Sec. Sec. 8621 et seq.
    ---------------------------------------------------------------------------
        One of the fastest growing segments of LIHEAP recipients is
    veterans. The number of LIHEAP recipient households with a veteran
    increased from 12 percent of all households served in fiscal year 2008
    to 20 percent of all LIHEAP households in fiscal year 2011.\2\
    ---------------------------------------------------------------------------
        \2\ LIHEAP Recipients by Veteran Status, NEADA (Dec. 8, 2011).
    Available at www.neada.org.
    ---------------------------------------------------------------------------
        Unemployment and poverty forecasts for 2013 indicate that the
    number of struggling households will remain at record 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
    2013.
    Low Income Home Energy Assistance Program 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 2013 is essential in light of the sharp increase in poverty and
    unemployment. It is telling that even with unusually warm winter
    temperatures, the size of home heating bills still remains beyond the
    ability to pay for struggling households.\3\ Ohio was hard hit by the
    great recession, losing 430,500 jobs.\4\ In that State, the total
    number of disconnections for gas and electric service for the year
    ending December 31, 2011 was 454,445. While the number of
    disconnections in 2011 represents a modest increase over 2010
    disconnections, this growth is cause for concern. Ohio strengthened its
    Percentage of Income Payment Program (PIPP) and other payment plans
    designed to help struggling low-income households afford their energy
    bills,\5\ yet the State faced a 30 percent reduction in LIHEAP funding
    from fiscal year 2011. LIHEAP assistance is critical for helping these
    struggling families afford their heating bills.
    ---------------------------------------------------------------------------
        \3\ See e.g., Steve Gravelle, Thousands of Iowans Facing Utility
    Shutoff Despite Mild Winter, The Gazette, Mar. 22, 2012. Available at
    http://thegazette.com/2012/03/22/thousands-of-iowans-facing-utility-
    shutoff-despite-mild-winter/.
        \4\ The State of Poverty in Ohio: A Path to Recovery, Ohio
    Association of Community Action Agencies (May 2011) at p. iv.
        \5\ Office of the Ohio Consumers' Counsel.
    ---------------------------------------------------------------------------
        Despite milder winter temperatures this winter and lower natural
    gas bills in Iowa, a record number of low-income households have fallen
    behind on their energy bills. In February 2012, the number of low-
    income households with past due energy accounts was the second highest
    on record for this time of year since these data have been tracked. The
    Iowa LIHEAP program estimates that demand for assistance will remain
    strong and that it will be serving close to last year's number of
    applicants, about 95,000 households. However, the size of the energy
    assistance has been cut back 25 percent due to the substantial cuts to
    the LIHEAP funding in fiscal year 2012. Thus, as the data shows, the
    need for LIHEAP remains strong in this sluggish economy despite the
    milder temperatures and the mitigation in natural gas prices.\6\
    ---------------------------------------------------------------------------
        \6\ Iowa Bureau of Energy Assistance.
    ---------------------------------------------------------------------------
        Data from Pennsylvania also demonstrate that an unusually mild
    winter cannot make up for cuts to vital energy assistance. Pennsylvania
    experienced a steady increase in enrollment for the regular LIHEAP
    program from fiscal year 2008 to fiscal year 2010, with 371,000
    households served in 2008, 547,000 in fiscal year 2009, and 587,000 in
    fiscal year 2010. However, due to the decreased LIHEAP funds, the
    projection for fiscal year 2012 is down to 425,000. Utilities in
    Pennsylvania that are regulated by the Pennsylvania Public Utility
    Commission (PA PUC) have established universal service programs that
    assist utility customers in paying bills and reducing energy usage.
    Even with these programs, electric and natural gas utility customers
    find it difficult to keep pace with their energy burdens. The PA PUC
    estimates that more than 20,034 households entered the current heating
    season without heat-related utility service. This number includes about
    2,559 households who are heating with potentially unsafe heating
    sources such as kerosene or electric space heaters and kitchen ovens.
    One harmful impact of unaffordable home energy is the abandonment of
    property that is no longer habitable. In mid-December 2011, an
    additional 13,136 residences where electric service was previously
    terminated were vacant and more than 5,977 residences where natural gas
    service was terminated were vacant. In 2011, the number of terminations
    increased 60 percent compared with terminations in 2004. As of December
    2011, preliminary data shows that 19.4 percent of residential electric
    customers and 15.8 percent of natural gas customers were overdue on
    their energy bills.\7\
    ---------------------------------------------------------------------------
        \7\ Pennsylvania Public Utilities Commission.
    ---------------------------------------------------------------------------
        Unfortunately, the number of households around the country that are
    struggling to make ends meet remains very high due to the slow recovery
    from the great recession. According a Pew Fiscal Analysis Initiative
    report, as of December 2011, 4 million jobless workers (which is more
    than the population of Oregon) have been unemployed for a year or
    longer.\8\ While long-term unemployment has affected all age groups,
    older workers have been hit particularly hard by this downturn.\9\
    CBO's budget and economic outlook report projects that unemployment
    will average 9.1 percent in 2013,\10\ far from the 5.3 percent that CBO
    estimates is the natural rate of unemployment.\11\ The U.S. Census
    reports the largest number in poverty in 52 years, 46.2 million people
    in 2010.\12\
    ---------------------------------------------------------------------------
        \8\ Pew Economic Policy Group Fiscal Analysis Initiative, Five
    Long-Term Unemployment Questions, February 1, 2012 at Question 1.
        \9\ Id at Question 3. (``However, among people without jobs,
    unemployed older workers were the most likely to have been jobless for
    a year or more. For example, in the fourth quarter of 2011, more than
    42 percent of unemployed workers older than 55 had been out of work for
    at least a year, a higher percentage than any other age category.'')
        \10\ CBO, The Budget and Economic Outlook: Fiscal Years 2012 to
    2022, Chpt. 2 The Economic Outlook Table 2-1. CBO's Economic
    Projections for Calendar Years 2012 to 2022 (Jan. 2012) at p.27.
        \11\ CBO, The Budget and Economic Outlook: Fiscal Years 2011 to
    2021, Summary (Jan. 2011) at Summary Table 2.
        \12\ U.S. Census, Income, Poverty, and Health Insurance Coverage in
    the United States: 2010 (Sept. 2011) at p.14.
    ---------------------------------------------------------------------------
        Thus indications are that the demand for LIHEAP in fiscal year 2013
    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.
    Low Income Home Energy Assistance Program 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.\13\ The U.S. Department of Agriculture has
    released a study that shows that low-income households, especially
    those with elderly persons, experience very low food security during
    heating and cooling seasons when energy bills are high.\14\ 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.\15\ 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.\16\
    ---------------------------------------------------------------------------
        \13\ See e.g., National Energy Assistance Directors' Association,
    2011 National Energy Assistance Survey (Nov. 2011) (to pay their energy
    bills, 24 percent of LIHEAP recipients went without food, 37 percent
    went without medical or dental care, 34 percent did not fill or took
    less than the full dose of a prescribed medicine). Available at http://
    www.neada.org/news/nov012011.html.
        \14\ 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.
        \15\ 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).
        \16\ 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.\17\ 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.\18\ The CDC
    also notes that air-conditioning is the number one protective factor
    against heat-related illness and death.\19\ 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.
    ---------------------------------------------------------------------------
        \17\ 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.
        \18\ CDC, ``Heat-Related Deaths--United States, 1999-2003'' MMWR
    Weekly, July 28, 2006.
        \19\ 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 \20\ 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 2013 in light of
    unaffordable, but essential heating and cooling needs of millions of
    struggling households due to the record high unemployment levels during
    the slow recovery from the great recession.\21\
    ---------------------------------------------------------------------------
        \20\ States can only spend 10 percent or less of their LIHEAP grant
    in administrative and planning costs. 42 U.S.C. Sec. 8624(b)(9).
        \21\ ``A large portion of the economic and human costs of the
    recession and slow recovery remain ahead . . . Those costs fall
    disproportionately on people who lose their jobs, who are displaced
    from their homes, or who own businesses that fail.'' CBO, The Budget
    and Economic Outlook: Fiscal Years 2012 to 2022, Chpt. 2 The Economic
    Outlook at p.26.
    ---------------------------------------------------------------------------
                                     ______

         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 2013 funding for the Social
    Security Administration (SSA). We respectfully request your support of
    full funding of the President's fiscal year 2013 budget request on
    behalf of SSA and the American public we serve.
        NCSSMA is a membership organization of more than 3,500 SSA managers
    and supervisors who provide leadership in nearly 1,300 community-based
    Field Offices and Teleservice Centers throughout the country. We are
    the front-line service providers for SSA in communities throughout the
    Nation. We are also the Federal employees who work with many of your
    staff members to resolve problems and issues for constituents who
    receive Social Security benefits. For over 42 years, NCSSMA has
    considered a strong and stable Social Security Administration that
    delivers quality and prompt locally delivered service to the American
    public a top priority. We also consider it a top priority to be good
    stewards of the taxpayers' monies.
        SSA is cost-efficient and appropriations to the agency are an
    excellent investment and return on taxpayer dollars. We are very
    appreciative of the support for SSA that 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.
    However, budgetary constraints in fiscal years 2011-2012 have resulted
    in vital service reductions and many public service repercussions.
        NCSSMA strongly supports the President's fiscal year 2013 budget
    request for SSA, which includes $11.760 billion for the agency's
    administrative expenses through the Limitation on Administrative
    Expenses (LAE) account. We respectfully request the Subcommittee
    provides no less than the President's full SSA budget request in fiscal
    year 2013. Full funding for SSA is critical to maintain staffing in
    front-line components, cover inflationary increases, continue efforts
    to reduce hearings and disability backlogs, and increase deficit-
    reducing program integrity work.
    Current State of Social Security Administration Operations
        NCSSMA has significant concerns about the dramatic growth in SSA
    workloads. We strongly believe that SSA must receive adequate 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 8 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
    ongoing 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! By
    fiscal year 2013, retirement and survivor claims will have increased by
    more than 30 percent and disability claims will have increased by
    nearly 25 percent since fiscal year 2007.
        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 2.6
    million SSI redeterminations in fiscal year 2012, an increase of more
    than 100 percent from fiscal year 2008. Nationally, visitors to Field
    Offices increased from 41.9 million in fiscal year 2007 to 44.9 million
    in fiscal year 2011. SSA continues to experience unprecedented
    telephone call volumes. In fiscal year 2011, SSA completed 62 million
    transactions over the 800 Number network. NCSSMA estimates Field Office
    telephone contacts to be more than 32 million during the same time
    period. The result is a combined total of more than 92 million
    telephone contacts annually for SSA.
    Social Security Administration Funding for Fiscal Year 2012
        NCSSMA strongly supported the President's fiscal year 2012 budget
    request of $12.522 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 ensured 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 2012 appropriation for administrative
    funding through the LAE account was $11.446 billion, only $22 million
    above the fiscal year 2011 enacted level.
        Inadequate funding of SSA in fiscal year 2013 would have major
    repercussions for SSA, including a continued hiring freeze, reduction
    of overtime, and postponement of initiatives to improve efficiency.
    Reducing resources at the same time SSA workloads are dramatically
    increasing is a prescription for significant service deterioration and
    workload backlogs. In addition, inadequate fiscal year 2013 funding
    levels will have a collateral negative impact on fiscal year 2014.
    Field Office Service Delivery Challenges
        SSA Field Offices are experiencing tremendous stress because of
    ever-increasing workloads and additional customer contacts. The fiscal
    year 2011 and fiscal year 2012 enacted funding levels exacerbated the
    situation and the impact on local Field Offices around the country is
    significant.
      --Frontline feedback from our busiest urban offices indicates that
            some are seeing 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
            budget constraints. The agency expects to lose 3,000 employees
            in fiscal year 2012 and 2,000 more in fiscal year 2013. This is
            in addition to 4,000 lost in fiscal year 2011 resulting in a
            total loss of 9,000 employees in just 3 years. SSA will have
            approximately the same number of employees in fiscal year 2013
            as it did in fiscal year 2007, even though workloads have
            increased dramatically.
      --SSA projects 45 percent of its employees, including 60 percent of
            supervisors, will be eligible to retire by fiscal year 2020.
            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 have occurred with uneven
            attrition leaving some offices significantly understaffed. This
            is especially problematic for rural SSA Field Offices, whose
            customers often live vast distances away, may have no Internet
            service, and lack access to public transportation.
    Social Security Administration Online eServices Assist with Service
            Delivery Challenges
        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, Internet services are not keeping pace with the
    increasing demand for service. High-volume transactions, such as
    requests for Social Security cards and benefit verifications are not
    yet available on the Internet, or are only being used to a limited
    degree. Requests for Social Security cards and benefit verifications
    represent about 35 percent of all transactions completed in SSA Field
    Offices in fiscal year 2011.
        NCSSMA believes that SSA must be appropriately funded in fiscal
    year 2013 and beyond for continued investment in improved, user-
    friendly Internet services allowing for more online transactions. If
    individuals were able to successfully conduct SSA business online, the
    results would include fewer contacts with Field Offices and the 800
    Number network, improved efficiencies, and enhanced public service.
    Disability Workload Processes
        Nationwide, more than 3.3 million new disability claims were
    processed and sent to State Disability Determination Services in fiscal
    year 2011, the highest in our history. This surge of increased claims
    has created backlogs. We expect that pending initial disability claims
    will rise to nearly 861,000 in fiscal year 2012 and to more than 1.1
    million in fiscal year 2013. 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 March 2012, 822,757 hearings were pending, which is 117,390
    more than at the end of fiscal year 2010, and a new all-time high.
        Despite these unprecedented challenges, SSA continues to make
    progress. In fiscal year 2012 (through March), the average processing
    time for a hearing was 350 days, the lowest average time since fiscal
    year 2003. Unfortunately, the number of claims and hearings pending is
    still not acceptable to Americans who need Social Security to support
    their families. Budget constraints in fiscal year 2011 and fiscal year
    2012 impeded progress and prevented SSA from opening eight planned
    Hearing Offices. This significantly threatens to prevent SSA from
    achieving its goal of 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 years 2004 through
    2007.
    President's Fiscal Year 2013 Budget Request for Social Security
            Administration
        NCSSMA strongly supports the President's fiscal year 2013 budget
    request for SSA and requests that the Congress provide full funding to
    maintain public service levels and to allow the agency to:
      --Cover fixed cost increases of $300 million (rent, guards, postage,
            and employee compensation).
      --Replace about one out of four employees lost in our Field Offices
            and Processing Centers.
      --Process more than 3 million disability and SSI claims along with 5
            million retirement, survivor, and Medicare claims.
      --Eliminate the disability hearings backlog by conducting hearings
            for 960,000 cases, 75 percent more than in fiscal year 2007,
            and reduce processing time for a hearing to 270 days.
      --Complete additional program integrity workloads yielding billions
            in savings--650,000 medical Continuing Disability Reviews
            (CDRs) and 2.622 million SSI redeterminations.
        SSA issues more than $60 billion in monthly benefit payments to
    more than 60 million people and the agency takes its stewardship
    responsibilities seriously. The fiscal year 2013 budget request
    includes $1.024 billion 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 disability benefits should be ceased because
            of medical improvement. SSA medical CDRs yield $9 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 $6 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 2013 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 (WISP),
    quarterly Federal wage reporting, workers compensation automatic
    reporting, and development of an automated system to report State and
    local pensions.
    Conclusion
        NCSSMA recognizes in the current budget environment that it may 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. 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 2013 budget request on behalf of our agency and the
    American public we serve. We 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.
        On behalf of NCSSMA members nationwide, thank you for the
    opportunity to submit this written testimony.
                                     ______

        Prepared Statement of the National Energy Assistance Directors'
                                  Association
        The members of National Energy Assistance Directors' Association
    (NEADA), representing the State directors of the Low Income Home Energy
    Assistance Program (LIHEAP) would like to first take this opportunity
    to thank the members of the subcommittee for considering our funding
    request for fiscal year 2013. The program is facing key challenges this
    year as we address the high level of demand for program services as a
    result of continuing weakness in the Nation's economy and high
    unemployment rates.
        LIHEAP is the primary source of heating and cooling assistance for
    some of the poorest families in the United States. In fiscal year 2012,
    the number of households receiving heating assistance remained at
    record levels of about 8.9 million. In addition, close to 600,000 are
    expected to receive cooling assistance. Of these households,
    approximately 20 percent contain at least one member who served in the
    military, a major increase from about 12 percent in 2008.
        Veteran households in fact accounted for almost 35 percent of total
    growth in the program between fiscal year 2008 and 2011. Of specific
    interest, 12 percent of all veterans receiving LIHEAP have served in
    Iraq or Afghanistan. Seven percent of military families are currently
    serving in the military. The increase in veterans' families mirrors the
    overall increase in LIHEAP across the country. It also clearly
    demonstrates that LIHEAP is reaching some of the Nation's poorest
    families--including those who have served their Nation in times of
    peace as well as war.
        Federal funding was decreased in fiscal year 2012 by 25 percent
    from the comparable appropriation level in fiscal year 2011. During
    this period, the average cost of home heating declined by 9.4 percent,
    considerably less than the reduction in funding. The purchasing power
    of the average home heating benefit declined from 42.1 percent to 34.7
    percent. The President's request would further decrease the purchasing
    power of LIHEAP, reducing the average grant to about 30 percent of the
    cost of home heating.

           ESTIMATE AVERAGE PERCENT OF HOME HEATING PURCHASED WITH LIHEAP (FISCAL YEAR 2008-FISCAL YEAR 2012)
                                                      [Percentage]
    ----------------------------------------------------------------------------------------------------------------
               Fiscal year              Heating oil     Natural gas       Propane       Electricity      All fuels
    ----------------------------------------------------------------------------------------------------------------
    2008............................            15.6            38.6            17.5            38.7            32.5
    2009............................            27.4            55.5            27.5            52.6            47.8
    2010............................            26.2            64.0            28.7            50.5            49.7
    2011............................            18.1            57.6            22.9            43.4            42.1
    2012............................            13.8            49.0            18.6            33.8            34.7
    ----------------------------------------------------------------------------------------------------------------

    fiscal year 2013 funding request and fiscal year 2014 advanced funding
                                    request
        For fiscal year 2013 we are requesting that the subcommittee
    restore funding for LIHEAP to the authorized level of $5.1 billion to
    maintain services for the 8.8 million households that received heating
    assistance and the 600,000 expected to receive cooling assistance, and
    provide $600 million in emergency funding authority. The additional
    funds would allow States to restore the average benefit to about 42
    percent of home heating costs plus provide sufficient flexibility in
    the event that heating oil prices remain at record levels and other
    fuel prices increase as a result of the continuing recovery in the
    Nation's economy.
        In addition, to these funding requests, we are concerned that
    States will be hampered in their ability to administer their programs
    efficiently due to the lack of advanced funding. The lack of a final
    program appropriation prior to the beginning of the fiscal year creates
    significant administrative problems for States in setting their program
    eligibility guidelines. In order to address this concern, we are
    requesting advance appropriations of $5.1 billion for fiscal year 2014
    and $600 million in emergency contingency fund authority.
      liheap families are among the nation's poorest and most vulnerable.
        In order to obtain a comprehensive demographic picture of LIHEAP
    recipients and the characteristics of those who are helped as well as
    who would be hurt by the program cuts, NEADA conducted a survey of
    approximately 1,800 households that received LIHEAP benefits in fiscal
    year 2011. The results show that LIHEAP households are among the
    vulnerable in the country.
      --40 percent have someone age 60 or older;
      --72 percent have a family member with a serious medical condition;
      --26 percent use medical equipment that requires electricity;
      --37 percent went without medical or dental care;
      --34 percent did not fill a prescription or took less than their full
            dose of prescribed medication;
      --19 percent became sick because the home was too cold; and
      --85 percent of people with a medical condition are seniors.
        Many LIHEAP recipients were unable to pay their energy bills:
      --49 percent skipped paying or paid less than their entire home
            energy bill;
      --37 percent received a notice or threat to disconnect or discontinue
            their electricity or home heating fuel;
      --11 percent had their electric or natural gas service shut off in
            the past year due to nonpayment, 24 percent were unable to use
            their main source of heat in the past year because their fuel
            was shut off, they could not pay for fuel delivery, or their
            heating system was broken and they could not afford to fix it;
            and
      --17 percent were unable to use their air conditioner in the past
            year because their electricity was shut off or their air
            conditioner was broken and they could not afford to fix it.
        LIHEAP's impact in many cases goes beyond providing bill payment
    assistance by playing a crucial role in maintaining family stability.
    It enables elderly citizens to live independently and ensures that
    young children have safe, warm homes to live in. Although the
    circumstances that lead each client to seek LIHEAP assistance are
    different, LIHEAP links these stories by enabling people to cope with
    difficult circumstances with dignity.
                              the faces of liheap
        Households of all varieties receive LIHEAP assistance. However, the
    positive impact on the most vulnerable members of society, including
    the elderly, disabled, and very young children, is striking. LIHEAP
    agencies in every State have continued to receive new requests for
    assistance from families struggling in the most difficult economy we
    have seen in decades. Finally, as many of these examples demonstrate,
    LIHEAP is administered in many places by Community Actions Agencies
    with deep ties to the people that they serve. Through their knowledge
    and connection to their communities, in many cases they are able to
    assist people in need at multiple levels, creating backward and forward
    linkages that enable people to regain their footing and start fresh.
    Help for the Elderly and Disabled
        The elderly and disabled constitute some of the most vulnerable
    members of society and a large number of those receiving energy
    assistance. Many elderly and disabled clients are in poor health and
    most live on small, fixed incomes. One such recipient, living in
    Oklahoma, relies on LIHEAP throughout the year in order to prevent
    utility shutoff, even planning her expenses around her small benefit.
    After her rent, she is left with approximately $165/month to pay
    electric, phone, natural gas, and water. This $165 must also be used to
    pay for medications not covered by Medicare or Medicaid, and other
    household expenses. She also knows she is eligible for winter heating
    assistance in December, which although it does not cover the entire
    bill, does cover enough to keep her utilities on until the next small
    payment is made in January or February. She is unable to pay all of her
    utilities and purchase medications each month so she alternates the
    utilities she pays. LIHEAP is her lifeline for keeping her utilities
    connected. Without it, she would likely go without medications in order
    to keep her heat and electricity connected.
        Back in December, the Illinois LIHEAP program received a request
    for assistance from an 84 years old woman with no heat. She hadn't had
    a working furnace for more than 2 years. Her daughter brought her in to
    apply for LIHEAP. As her story unfolded the program staff learned that
    she was heating her home with her cook stove and oven. She lives on
    $612 a month social security, and relies on food pantries and LIHEAP to
    make ends meet. Through LIHEAP, she was able to receive a new 90-
    percent efficient furnace in December and a payment toward her
    utilities. Representatives from the local community action agency went
    to her home on the final inspection of the furnace and she met both
    with a smile and a hug. She said that she was warm and doing well and
    looking forward to having her house weatherized.
        In Minnesota, an elderly couple was living on only social security
    benefits, totaling $998 a month. They had prided themselves on being
    self-sufficient for many years by keeping their thermostat set at 57
    degrees and dressing in many layers. However, after they were referred
    to the Minnesota Energy Assistance Program, they were able to heat
    their home to a safer temperature, and afford better food. They thanked
    the agency for giving them ``one of the best winters in many years.''
        Those living with disabilities often face seriously challenges in
    affording basic home necessities. One terminally ill 50-year old man
    from Utah who applied for assistance had been hospitalized and released
    several times for his severe health condition and had already had his
    power shut off when he contacted the LIHEAP agency. His utility bill
    had been transferred to his apartment complex's name, which they were
    charging him for, and he was also in danger of eviction. He was living
    on a fixed and limited social security income and a pension. Although
    his income was higher than many LIHEAP recipients, he too was faced
    with making the difficult choice between utility bills, doctor bills,
    food, or medication. His local agency was able to see him through this
    emergency and restore his utility connections, which were vital to
    providing him heat during the cold winter months. LIHEAP allowed him to
    afford the medications he needs without sacrificing heat in his home.
        This past heating season also highlighted how dangerous it can be
    for people living with disabilities to go without heat. In Maine, a
    disabled woman was running out of heating oil. To conserve supplies she
    was forced to turn her heat down extremely low. Her poorly insulted
    home leaked warm air and moisture, eventually resulting in her door
    freezing over completely. Her disability prevented her from removing
    the ice and she became trapped inside her home. Through LIHEAP
    assistance and Maine's Weatherization program, contractors were sent to
    her home to melt the ice from around her door, seal the leaks that
    contributed to her high energy bills, and provide her with fuel to heat
    her home.
        Finally, LIHEAP has been instrumental in improving the lives of
    those faced with challenging health conditions. One Minnesota woman, a
    longtime nurse in St. Paul, Minnesota, was diagnosed with degenerative
    blindness in 2004. She was an avid jogger who completed marathons with
    friends and enjoyed her career as a nurse. As her condition
    deteriorated however, she found it dangerous to drive and nursing
    became too difficult. She was devastated and worried about how she
    would make ends meet without her job. She lived off her retirement
    savings until they were almost exhausted, finally moving into an
    assisted living apartment for low-income residents. Although she had
    always prided herself on being frugal, conserving energy, keeping bills
    low, and maintaining her credit score, she could no longer make it
    without help. With the help of a health assistant, she applied for
    energy assistance. She still lives in her small apartment, still prides
    herself on being frugal and conserving energy.
    Children
        LIHEAP is critical for many families with small children and new
    babies. A warm home is a pre-requisite for hospitals to release babies
    and mothers after birth. The following family reached out for energy
    assistance when their child was born during the winter and they could
    not afford to heat their home. The mother had been employed as a full-
    time nurse in a nursing home but had been let go when her doctor
    ordered her to rest because her blood pressure was too high. Her
    husband worked in the remodeling business, which was hit hard in the
    recession.
        The family was not able to pay their gas bill and by the time their
    child was born the house was down to 40 degrees. Although they were
    reluctant to ask for help, they contacted the Green Hills Community
    Action Agency. Their energy assistance application was processed within
    a day and the gas was turned back on. In their letter to the agency,
    the family notes how helpful the staff was during a difficult time. The
    mother has since gone back to work and they no longer need energy
    assistance, but they said they would never forget how desperate they
    felt and how much it meant to them to be able to bring their new child
    home to a safe and warm house.
        Older children are also impacted by shut-off notices. One mother
    from Wisconsin had two school age children at home and was facing
    electricity shut-off. The Wisconsin Crisis Assistance payment stopped
    her impending disconnection. The mother's primary concern was the
    effect the disconnection would have on children, who would not be able
    to do their school work at home.
        Illinois was also able to help a single mother of two to restore
    her heat after her gas and electricity were shut off. This recipient
    was forced to send her children to live with family members because the
    home was too cold for them. After she received assistance from LIHEAP
    both of the utilities were restores and her children were able to come
    home. She was so thankful that she even sent the agency a thank you
    card. In it she stated, ``I appreciate your role in helping to turn my
    electricity and gas back on so my kids could come back home. For that
    there are simply not enough ways to say thank you.''
    Economic Conditions
        Many families have found themselves in shut-off situations as a
    result of the recession, including many that have never before sought
    energy assistance. One such family in Georgia was living on $330 a week
    in unemployment benefits. A single mother of two children, she was not
    receiving child support and did not have close family members who could
    assist her with bills. Her Georgia Power bill for 2 months was $651,
    and it was scheduled for disconnection when she reached out for energy
    assistance. The amount she owed was clearly unmanageable considering
    her income. The help she received through LIHEAP allowed her to keep
    her power on.
        Another story from Iowa highlights how complicated it can be to
    provide assistance to families whose assets have been completely
    diminished. A single father of two children had been out of liquid
    petroleum for a substantial amount of time. He had tried to deal with
    the situation by shutting off the entire house to just two rooms and
    using space heaters to heat those rooms. His hot water heater was
    fueled by propane, so the family also did not have hot water. They were
    boiling water on the stove for hot water for cleaning and bathing. His
    kids were making the best of the situation and had draped blankets over
    the furnishings to make tents and keep the heat in the enclosed areas.
    Despite these difficult circumstances, he did not reach out for
    assistance until his pipes froze and burst.
        The father was employed, and was working long hours through a temp
    agency but was not making enough to afford the $500 minimum fill for
    his propane company. Although he was qualified for LIHEAP assistance,
    the propane vendor told the agency that because the family was
    completely out of fuel, they would have to have to pay for a leak test,
    and pay a fee for same day delivery. If they did not order a full 250
    gallons, there would be an additional ``under the minimum'' fee.
    Because they were only eligible for $500 of assistance, the fees would
    not allow them to fill to 250 gallons. However, the agency stepped in
    to negotiate with the vendor, and was able to have some of the fees
    removed. Although the family did not receive a full fill, they were
    able to get substantial help, and have their heat and hot water
    restored.
                              the need for liheap
        Households reported enormous challenges despite the fact that they
    received LIHEAP. However, they reported that LIHEAP was extremely
    important. About 64 percent reported that they would have kept their
    home at unsafe or unhealthy temperatures and/or had their electricity
    or home heating fuel discontinued if it had not been for LIHEAP. Almost
    98 percent said that LIHEAP was very or somewhat important in helping
    them to meet their needs. In addition, 53 percent of those who did not
    have their electricity or home heating fuel discontinued said that they
    would have if it had not been for LIHEAP.
        The members of NEADA recognize the difficult budget decisions that
    you face as you consider funding levels for LIHEAP for fiscal year 2013
    and advance funding for fiscal year 2014. We appreciate your interest
    and continued support for LIHEAP. Please feel free to call upon us if
    we can provide you with additional information.
                                     ______

                         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 2013 Labor, Health an 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 is an internationally recognized children's health system
    that owns and operates the Nemours/Alfred I. duPont Hospital for
    Children in Wilmington, Delaware, along with major pediatric specialty
    clinics in Delaware, Florida, Pennsylvania, and New Jersey. In 2012, it
    will open the full-service Nemours Children's Hospital in Orlando,
    Florida. Established as The Nemours Foundation through the legacy and
    philanthropy of Alfred I. du Pont, Nemours offers pediatric clinical
    care, research, education, advocacy, and prevention programs to all
    families in the communities it serves.
        In addition to its investments in clinical care, education and
    treatment, Nemours has made significant investments 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, an operating division in Newark, Delaware, as well
    as the Florida Prevention Initiative, lead Nemours' prevention work.
    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. More than 20 percent of preschoolers are obese or
    overweight, an alarming statistic. We know that 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 (Fund) and the potential it holds to address obesity
    and chronic disease. We are disappointed that to help finance the
    Sustainable Growth Rate (SGR), the Congress made significant cuts to
    the fund. Physician reimbursement and prevention should not be pitted
    against one another. Instead, physicians must be enlisted in the fight
    to prevent disease and should be working closely with other community-
    based partners to help families and children lead healthy, active
    lifestyles, as is the case with Nemours-employed physicians. We urge
    the subcommittee to utilize the resources provided from the 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 (CDC)
        Community Transformation Grants (CTGs) 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. CTGs 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. We urge the subcommittee to provide $226
    million for CTGs in fiscal year 2013, the level of support provided in
    fiscal year 2012.
    Children's Hospital Graduate Medical Education (HRSA)
        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 (CHGME) provides support
    for Graduate Medical Education (GME) to freestanding children's
    hospitals that train resident physicians. The program was created to
    correct an unintended inequity in the level of Federal Graduate Medical
    Education funding for pediatric teaching hospitals, as opposed to other
    types of hospitals that are tied to the number of Medicare
    beneficiaries being treated at the hospital. Free-standing children's
    hospitals generally do not provide care to Medicare-eligible patients,
    and were largely left out of the GME financing system. While CHGME has
    helped address this inequity, support for children's hospitals still
    lags behind Medicare support for adult teaching hospitals.
        CHGME supports 55 free-standing children's hospitals in 30 States.
    Of the 8,111 general pediatric residents in this country, approximately
    45 percent of them train at a CHGME institution. Of the 4,883 pediatric
    subspecialist residents in the country, 51 percent of them train at a
    CHGME institution. In 2010, CHGME supported the training of almost
    6,000 pediatric resident physicians. Upon completion of their training,
    pediatric resident physicians become the primary care, specialty, and
    subspecialty physicians that care for our children in the community.
    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), now Children's
    Hospital Association, 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.
        More than 300 residents are trained each year at the Alfred I.
    duPont Hospital for Children (AIDHC). They are on the front line for
    families at our hospital, caring for patients 24 hours a day. They are
    also training to become future clinicians who will practice
    independently in general pediatrics specialties and subspecialties. In
    the outpatient department, they become the primary care physicians
    (under attending supervision) for numerous children. These trainees are
    also learning to become researchers to advance pediatric medicine in
    the future.
        The residents at AIDHC engage in many learning and volunteer
    opportunities. During daily conferences, medical students, residents,
    and attending physicians all come together to share knowledge and
    discuss complex cases. Residents participate in retreats where our
    attending physicians teach them about important topics such as patient
    safety, reducing medical errors, end of life care, and communicating
    with families. Along with an attending physician, residents volunteer
    on Wednesday evenings to provide care at homeless shelters in
    Wilmington. Some volunteer internationally, providing health education,
    medical care and immunizations in Haiti and Guatemala. These training
    components require the active participation of and close oversight by
    the attending physician.
        Unfortunately, the President's budget proposes reducing funding for
    this program to $88 million in fiscal year 2013. We urge the 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. In fiscal year 2013, Nemours urges the
    subcommittee to provide flat funding for the CHGME program ($265
    million), at a minimum.
    Child Care and Development Block Grant--Child Care Quality Initiative
            (ACF)
        From high obesity rates to poor literacy levels, children in the
    United States face a host of obstacles to achieving the goal of living
    healthy, happy, and productive lives. It is alarming that more than 20
    percent of pre-school aged children are obese or overweight, and
    reading failure affects 30 percent of our Nation's children. In order
    to ensure the healthy development of our children, we must reach them
    in as many settings as possible, including the places where they live,
    learn, and play. Approximately 12 million children in the United States
    spend time in child care outside their homes, making it a critical
    setting affecting the health and development of our Nation's children.
    To that end, we must ensure that we are providing the highest quality
    early care and education possible.
        The President's budget proposal includes $300 million for a Child
    Care Quality Initiative within the Child Care and Development Block
    Grant (CCDBG) to help ensure that children enter kindergarten ready to
    succeed. This initiative seeks to build on the progress of the Race to
    the Top--Early Learning Challenge (RTT-ELC). Nemours supports
    investments in improving the quality of child care programs by ensuring
    that child care providers have the training to help them meet higher-
    quality standards. Nemours supports funding the President's request for
    a Child Care Quality Initiative to improve the quality of early
    childhood programs in the United States, promote positive child
    outcomes, and ensure that our children enter kindergarten healthy and
    ready to learn.
                                   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, quality and the healthcare
    workforce will remain priorities of the subcommittee in fiscal year
    2013.
                                     ______

                 Prepared Statement of the Nephcure Foundation
        Summary of recommendations for fiscal year 2013:
      --$32 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.
        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 developed as an
    evolutionary response to African sleeping sickness and are common in
    African-Americans.
        FSGS has a large social impact in 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. For this reason,
    and on behalf of the thousands of families that are significantly
    affected by this disease, we recommend the following:
      --$32 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 (NEPTUNE) 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.
    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
    developing a database of NS patients who are interested in
    participating in clinical trials which would alleviate the problem
    faced by many rare disease groups of not having access to enough
    patients for research. We urge the subcommittee to continue its support
    for RDCRN and for NEPTUNE, which has tremendous potential to make
    significant advancements in NS and FSGS research.
        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 2007 and utilizes 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. 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
    to undertake culturally appropriate efforts aimed at educating minority
    populations about glomerular disease.
                                     ______

          Prepared Statement of the National Hispanic Council on Aging
        The National Hispanic Council on Aging (NHCOA)--the leading
    national organization working to improve the lives of Hispanic older
    adults, their families, and caregivers--thanks you for the opportunity
    to submit written testimony. Wisely investing in the future and
    implementing programs that will strengthen our country is a
    particularly daunting task given the limited resources and constraints
    at hand. Therefore, NHCOA recognizes the difficult decisions that lie
    ahead for your committee. We write to you today to express our support
    for the fiscally sensible programs created by the Older Americans Act,
    and to request they be appropriated sufficient funds to ameliorate the
    impending cuts of the Budget Control Act of 2011.
        For more than 30 years, NHCOA has been a strong voice dedicated to
    ensuring our Nation's Hispanic seniors--the fastest growing segment of
    the United State's rapidly expanding aging population--can age
    healthily and with dignity. Alongside its Hispanic Aging Network of
    nearly 40 community-based organizations across the country, NHCOA
    reaches 10 million Hispanics each year. NHCOA integrates research,
    policy, and practice to tackle the unique challenges Latino seniors
    face as they age, and by educating and empowering them to be better
    advocates for themselves. As an integral part of this mission, NHCOA
    incorporates a special focus on families and caregivers of Hispanic
    older adults in all its programmatic priorities, recognizing the
    paramount importance of family in the Latino community.
        Older Americans Act programs, implemented by the Administration on
    Aging, effectively serve older adults across the country, while also
    providing a wide variety of services that are flexible enough to meet
    the needs of every community. The Older Americans Act authorizes
    programs that train families to support their loved ones, put people
    back to work, put food on the table, eliminate elder abuse, and help
    communities develop the policies they need to help their older adults
    age with dignity. Because of programs that provide basic necessities
    like Meals on Wheels, there are fewer older adults having to choose
    between putting food on the table and filling their prescription. As
    appropriators, your support is critical for the continued success of
    these lifesaving programs.
        The population of Hispanic older adults, as well as the population
    of older adults in general, is growing rapidly. Every 7 seconds, today,
    and for the next 20 years, someone in the United States will turn 60.
    In terms of the Hispanic community, we have about 3 million Latino
    elders. By 2050, that number will increase to 17 million. Moreover, the
    Hispanic community as a whole is projected to grow to 30 percent of the
    entire U.S. population by 2050. That means nearly 1 in 3 people will be
    Hispanic. By 2019, the Latino senior population will become the largest
    non-White elder population in the United States.
        Funding for the programs of the Older Americans Act has not grown
    to match this population increase. Therefore, the impending cuts of the
    Budget Control Act of 2011 will decrease its ability to keep pace with
    the growth of the U.S. aging population. A reduction in these services
    will mean that fewer people will have access to home delivered meals,
    communities will have less funding to operate senior centers, and
    families will have less support in caring for their loved ones. These
    programs make a vital difference in communities across the country, but
    to keep effectively serving the growing population, an adequate level
    of funding is imperative.
        Hispanics face a variety of challenges that make aging particularly
    difficult. Many Hispanic older adults have spent their lives in jobs
    that have not helped them prepare for their later years. Low-wage,
    physically demanding jobs are all too common in the Latino community,
    and these jobs offer little in the way of healthcare and pension
    benefits. As a result, many Hispanics enter their golden years with
    little money saved and little or no previous access to health
    insurance. Cultural and linguistic differences are additional barriers
    to accessing needed services. All of these economic, physical, and
    social factors combined result in Hispanic older adults earning below
    average Social Security benefits, enduring chronic health problems at
    disparate rates, and having a harder time gaining access to needed
    services.
        Last year, an organization called Hispanics in Philanthropy
    released a study about the programs of the Older Americans Act and the
    difficulties those programs faced in serving Hispanic communities. The
    study found that many communities were unable to deliver the services
    and information necessary to help Hispanic older adults, despite being
    readily available. Many communities lack the financial resources to
    hire and train new workers to serve the rapidly aging Hispanic
    population. Appropriating more money for Older Americans Act programs
    will allow communities to better serve their older adults and also to
    embrace their growing diversity.
        NHCOA has worked and spoken with Hispanic older adults and their
    families across the country, and though the needs and concerns of the
    population are diverse, they were unified in their support for the
    Older Americans Act as a main vehicle to address the struggles of
    simply making ends meet in their community. Every day, Hispanic older
    adults must decide what to sacrifice--food on the table, rent and
    utilities, or medications. Family members juggle multiple jobs to care
    for older adults in their families and are unaware of existing
    opportunities for caregiver training. Incidents of elder abuse are not
    reported because older adults do not know where to turn. Hispanic older
    adults also suffer disproportionately from chronic medical conditions
    like diabetes, are less likely to manage hypertension, and are
    significantly more likely to suffer from HIV/AIDS. With sufficient
    funding, however, the Older Americans Act is unequipped to adequately
    address these problems.
        Funding Older Americans Act programs is a wise investment in the
    future. Nutrition and health management programs, which are proven
    effective at reaching Hispanic older adults, can keep minor health
    problems from becoming chronic, or even life threatening conditions.
    The National Family Caregiver Support Program offers trainings and
    services that are flexible enough to meet the needs of every community.
    Elder abuse prevention programs have the potential to save lives.
    Through small investments that help older adults age in dignity, we can
    achieve real savings in more costly programs, such as Medicare and
    Medicaid. Furthermore, making an investment to train service providers
    on how to effectively work with a diversifying older adult population
    is a necessary preemptive measure and cannot happen at a better time.
        NHCOA respectfully asks that your committee provide increased
    funding to Older Americans Act programs to help them withstand the
    impending cuts from the Budget Control Act of 2011. This increased
    appropriation will not only allow communities to maintain the services
    and supports they already offer, but it will also improve their
    capacity to serve the rapidly growing diverse older adult population in
    the United States.
                                     ______

           Prepared Statement of the National Head Start Association
        Chairman Harkin, Ranking Member Shelby, thank you for allowing the
    National Head Start Association (NHSA) submit testimony in support of
    funding for Head Start and Early Head Start in fiscal year 2013. 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. Today, as our Nation's children face greater
    obstacles than ever, 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. NHSA is grateful that the
    Congress and the President made a solid commitment to quality early
    childhood education in fiscal year 2012 by providing funding to
    maintain services for children currently served by Head Start and Early
    Head Start programs.
        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. But the economy has taken a toll on the program as well.
    During this most recent recession, Head Start and Early Head Start
    directors have experienced rapidly rising operating costs that may
    eventually affect their ability to maintain program size.
        NHSA hopes that this Subcommittee will support the administration's
    drive to improve accountability, as well as account for the rising cost
    of maintaining programs. Though we appreciate the President's request
    for an $85 million increase over the fiscal year 2012 enacted level,
    after extensive conversations and input from the field we recognize
    that it is not enough. The Head Start community is proposing an
    increase of $325 million over fiscal year 2012 to provide the funding
    necessary to ensure that Head Start centers can meet the rising costs
    of service for an additional school year, improve access for vulnerable
    infants, and meet the requirements of the 2007 Head Start
    Reauthorization Act.
    Head Start Fixed Costs Rising
        Though funding for Head Start has increased significantly 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. In some areas, rent on facilities
    alone has gone up between 5-10 percent. It is an enormous task to keep
    costs low for what is a very comprehensive model.
        Though center directors have some flexibility to streamline and try
    to be more efficient, there are limits to how far they can go. Most
    centers have already laid off staff, closed facilities and consolidated
    programs to save costs, and are leaning more than ever on other
    community partners to help provide health, employment, and other
    services that are required by the model. The Head Start community is
    reaching its limit on how far it can take this practice, given
    statutory quality standards. The only logical next step for many
    programs may in fact be to change their service delivery method which
    can result in moving from full-day to part-day service, or worse,
    reducing the number of children it can enroll.
        Energy costs have gone up significantly, and an overwhelming
    majority of programs are finding it difficult to keep up with fuel
    costs for the transportation of kids to and from the center. This is
    particularly challenging in rural areas. One Idaho Tribal Head Start
    program spends an astonishing $1,000 per month on gasoline. They
    believe that they must continue to provide transportation because, as
    the director says, ``Many of our families can barely afford gas for
    work, let alone transport their child to Head Start.''
        Deferred maintenance of Head Start centers poses its challenges as
    well. At one Western Iowa Head Start, they spent $53,000 on one bus
    that only holds 16 kids--to replace one of their buses among a fleet
    that is nearly 20 years old. Many other centers, operating in older
    facilities, hope the roof will hold out one more year, or that the
    playground equipment will remain solid and safe. Most programs must
    wait until the end of a program year to decide what can be fixed within
    the budget. Regardless, the centers are judged by frequent monitors who
    have the ability to demand change when they see a potential hazard--
    with the additional funds being requested, Head Start directors could
    do more to prevent potential safety hazards.
        Head Start programs also need to adapt to changing regulations. The
    Consumer Product Safety Commission released new rules regarding crib
    safety and Early Head Start programs must now replace all their cribs.
    Head Start centers also must implement new data systems that will track
    more nuanced child outcomes data. Even the smallest programs report
    costs upwards of $5,000 just for the tracking software. The City of
    Chicago Head Start program is spending an unexpected $12,000 on new
    cribs this year, and has spent a staggering $3,000,000 on new data
    collection systems.
        Finally, Head Start centers must provide health insurance for
    staff. These costs have increased rapidly. In Louisiana, the Iberville
    Parish Council Head Start, which serves 360 children and employs 61
    teachers and staff at 6 centers, has struggled to make ends meet
    because of rising health insurance and other costs. Ultimately, the
    Parish Council voted to relinquish control of the program entirely and
    turn it over to the Federal Government rather than tell families they
    could not serve their children because it, as a local entity, could not
    afford to continue subsidizing the increasing costs. The director said
    of the decision, ``The Federal Government wants you to run a Cadillac
    program on Chevrolet prices.''
    Head Start Salaries Are Noncompetitive
        Another pressing cost concern that is directly related to a child's
    progress is the quality of teachers. Five years ago, a bipartisan
    Congress passed, and President George W. Bush signed, the Improving
    Head Start for School Readiness Act of 2007 (Public Law 110-134).
    Included in this reauthorization were a number of welcomed quality
    improvement measures for Head Start and Early Head Start programs;
    particularly, requirements for more-qualified teachers.
        Specifically, by September 30, 2013, at least 50 percent of Head
    Start teachers nationally are required to have a Bachelor's Degree, an
    Advanced Degree, or an equivalent degree in a field related to early
    childhood education. I am pleased to share that the Head Start
    community has already met this requirement.
        In order to achieve compliance, Head Start directors encouraged
    their staff to obtain degrees. When possible they helped supplement
    tuition and costs in order to ensure that staff would stay on once the
    degree was obtained. But the market for early childhood teachers with
    college degrees is very competitive and it has become extremely
    difficult to keep these credentialed employees in place. Qualified
    staff comes at a price, a price the Head Start budget does not easily
    afford.
        According to data collected by the PIR, in 2010, a Head Start
    teacher with a CDA made on average $22,329 per year; a teacher with a
    graduate degree $35,194. The average across all Head Start teachers is
    $27,880. This is, according to the Center for Law and Social Policy,
    considerably less than the average salary for a preschool teacher in
    elementary in secondary schools, which was $42,150 in 2010. Young
    graduates of education schools, moreover, are not choosing early
    education as a viable career path.
        A Bachelor's degree qualifies them for any number of jobs outside
    of early education. Some employees leave to work for the local bank or
    another business, where the salaries and benefits much more competitive
    and better for their families. After all, many of these newly
    credentialed individuals were once Head Start parents themselves, due
    to the early focus on ``parents as teachers.'' We cannot and do not
    fault them for rising out of poverty to make a better life for
    themselves and their families.
        This constant turnover is disruptive to Head Start children and
    families, and is another burden on center directors who must find
    qualified individuals to take their place, complete background checks
    and have them fully oriented to the complicated expectations of the
    program. With noncompetitive salaries, this is very difficult. In rural
    areas, it is nearly impossible--the labor pool is limited, and
    relatively unchanging.
    Designation Renewal System
        One of the most anticipated provisions of the 2007 Head Start Act
    will require Head Start grantees designated as low-performing to
    compete for the continuation of their grant. Different from the Head
    Start grant termination process, this additional accountability
    measure, the Designation Renewal System, is an enormous undertaking for
    the Office of Head Start (OHS) and will certainly require additional
    funds to execute. NHSA supports the Administration for Children and
    Families' request for additional staff to ensure that the renewal
    competitions are executed in a fair, transparent, and effective manner.
        Last December, OHS began the first stages of the DRS by informing
    an initial 132 grantees that would recompete for their funding. We are
    very concerned with the potential impacts of transitioning a Head Start
    program from one organization to another, in particular the impact on
    children and families.
        We therefore appreciate the administration's request for $40
    million as a ``rainy day fund'' and understand these funds may indeed
    be necessary. However, we hope that if any of these funds are not
    utilized that they will be reinvested in the training and technical
    assistance activity funds available to grantees. During this time of
    change in the program, especially as new organizations may become Head
    Start grantees; it will be helpful to assist everyone in our continued
    drive to sustain excellence and remain compliant with all of the more
    than 1,700 separate Head Start regulations.
    The Gap Between Early Head Start and Head Start
        When NHSA talks to the dedicated Head Start directors across the
    country about how they could better serve their communities, so many of
    them say they wish they could get to more children earlier. Across all
    Head Start programs, centers are only able to serve less than 3 percent
    of eligible infants.
        The waiting lists are increasingly long, especially as the economy
    continues to present significant challenges to the poor. Today, one in
    five children are born into poverty--and eligible for Early Head Start.
    In one center in Burien, Washington, the Early Head Start program
    serves 30 infants, 10 of which are homeless, and 7 of which are
    ``special needs'' children. There are currently more than 50 families
    on the waitlist. Knowing all we know about the effectiveness of
    intervention in these early years, NHSA strongly supports even a small
    investment in increasing access to Early Head Start.
    Centers of Excellence
        Last, the National Head Start Association supports continued
    investment in the now 20 Centers of Excellence in Early Childhood that
    were named, but only partially funded, over the last 2 years--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; Dunkirk, New York; Laguna, New Mexico; Rock Island, Illinois;
    Reno, Nevada; Modesto, California; Marshalltown, Iowa; Elmsford, New
    York; Tulsa, Oklahoma; Hugo, Oklahoma; Mayaguez, Puerto Rico; and
    Chattanooga, Tennessee. The resources and tools these Centers have
    designed and provided to the Head Start community are effective, well-
    designed, and serve as models for other Early/Head Start programs to
    emulate. Their innovative practices and peer-learning approaches will
    be much more in 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.
    Research shows that Head Start has genuine cost benefits--
    conservatively, it is estimated to yield 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 hard-earned tax dollars by decreasing the need for
    children to receive special education services in elementary
    schools.\2\ Data analysis of a recent Montgomery County Public Schools
    evaluation found that a MCPS child receiving full-day Head Start
    services when in Kindergarten 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 person that they don't need
    to 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.
    ---------------------------------------------------------------------------
        A study released by the National Bureau of Economic Research shows
    that Head Start parents are more actively engaged in their children's
    academic careers long after the child has entered kindergarten, a key
    ingredient of a learning environment that leads to future success.\5\
    The Baltimore Education Research Consortium (BERC) released findings in
    March 2012 related to chronic absenteeism in Kindergarten--which
    studies have shown to relate to poorer overall academic achievement as
    late as 5th grade. BERC's research shows that students who had attended
    Head Start showed the highest attendance rates in kindergarten and the
    lowest level of chronic absence in first through third grades.\6\ These
    non-test-score findings help illustrate the long-term viability of the
    program--today, the more than 27 million Head Start graduates are
    working every day in our communities to make our country and our
    economy strong.
    ---------------------------------------------------------------------------
        \5\ National Bureau of Economic Research. (2011, December).
    Children's Schooling and Parents' Investment in Children: Evidence from
    the Head Start Impact Study (Working Paper No. 17704). Cambridge, MA:
    A. Gelber & A. Isen.
        \6\ Baltimore Education Research Consortium (2012, March). Early
    Elementary Performance and Attendance in Baltimore City Schools' Pre-
    Kindergarten and Kindergarten. Baltimore, Maryland: F. Connelly &
    Olson, L.
    ---------------------------------------------------------------------------
        Head Start families with their increased health literacy also show
    immediate healthcare benefits, including lower Medicaid costs-on
    average $232 per family. The program has also reduced mortality rates
    from preventable conditions for 5- to 9-year olds by as much as 50
    percent.\7\ Studies have shown that the program reduces healthcare
    costs for employers and individuals because Head Start children are
    less obese,\8\ 8 percent more likely to be immunized,\9\ and 19 to 25
    percent less likely to smoke as an adult.\10\
    ---------------------------------------------------------------------------
        \7\ 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.
        \8\ Frisvold, D. (2006, February). Head Start participation and
    childhood obesity. Vanderbilt University Working Paper No. 06-WG01.
        \9\ Currie, J. and Thomas, D. (1995, June). Does Head Start Make a
    Difference? The American Economic Review, 85 (3): 360.
        \10\ 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.
    ---------------------------------------------------------------------------
        The Head Start community understands the budgetary pressures the
    Federal Government is facing and is so very grateful for the commitment
    shown by this the Congress and the President to keep early learning,
    and Head Start in particular, a priority. 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 invest in Head
    Start and Early Head Start to improve accountability, increase access,
    and ensure that we have a stable and prosperous workforce for
    generations to come.
                                     ______

              Prepared Statement of the National Kidney Foundation
        End Stage Renal Disease (ESRD), which requires dialysis or
    transplantation for survival, is the only disease-specific coverage
    under Medicare, regardless of age or other disability. At the end of
    2009, the number of Americans with ESRD totaled 558,239, including
    113,908 new patients that year. Furthermore, CKD represented almost 8
    percent of the Medicare population age 65 and over in 2009, but 22
    percent of Medicare costs for this age group. Complicating the cost and
    human toll is the fact that CKD is a disease multiplier; patients are
    very likely to be diagnosed with diabetes, cardiovascular disease, or
    hypertension.
        Despite this tremendous social and economic impact, no national
    public health program focusing on early detection and treatment existed
    until fiscal year 2006, when the Congress provided $1.8 million to
    initiate a Chronic Kidney Disease Program at the Centers for Disease
    Control and Prevention (CDC). Congressional interest regarding kidney
    disease education and awareness also is found in section 152 of the
    Medicare Improvements for Patients and Providers Act of 2008 (MIPPA,
    Public Law 110-275), which 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. Cost-effective 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 $2.2 million for the Chronic Kidney Disease
    Program at CDC. 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 section 152 of
    MIPPA.
        The prevalence of CKD in the United States is higher than a decade
    earlier. This is partly due to 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\. Kidney disease is the 8th
    leading cause of death in the United States, after having been the 9th
    leading cause for many years. 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.
    ---------------------------------------------------------------------------
        CKD is often asymptomatic, especially in the early stages, and,
    therefore goes undetected without laboratory testing. In fact, some
    people remain undiagnosed until they have reached CKD Stage 5,
    requiring dialysis or a kidney transplant. 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.'' Screening and early detection provides opportunity for
    interventions to foster awareness, adherence to medications, risk
    factor control, and improved outcomes. Additional data collection is
    required to precisely define the incremental benefits of early
    detection on kidney failure, cardiovascular events, hospitalization and
    mortality. 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. As a result of consistent congressional support, 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. Congress rejected the administration's
    proposal to consolidate funding for chronic disease programs for fiscal
    year 2012 and we urge you to oppose it for fiscal year 2013 as well.
        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 has consisted 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
    have included the following:
      --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.
      --Establishing a surveillance system for Chronic Kidney Disease in
            the U.S. Development of a surveillance system by collecting,
            integrating, analyzing, and interpreting information on CKD
            using a systematic, comprehensive and feasible approach will be
            instrumental in prevention and health promotion efforts for
            this chronic disease. The CDC CKD surveillance project has
            built a basic system from a number of data sources, produced a
            report and beta-tested a website. The next steps include
            exploring State-based CKD surveillance data ideal for public
            health interventions through the State department of health.
        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.
        In summary, undetected Chronic Kidney Disease can lead to costly
    and debilitating irreversible kidney failure. However, cost-effective
    interventions are available if patients are identified in the early
    stages of CKD. With the continued expressed support of the Congress,
    the National Kidney Foundation is confident a feasible detection,
    surveillance and treatment program can be established to slow, and
    possible prevent, the progression of kidney disease.
        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,
    36,000 individual members, and 27 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 $251.099
            million in fiscal year 2013; and
      --The Nurse-Managed Health Clinics, as authorized under Title III of
            the Public Health Service Act, at $20 million in fiscal year
            2013.
                      nursing education is a jobs program
        According to the U.S. Bureau of Labor Statistics (BLS), the
    registered nurse (RN) workforce will grow by 26 percent from 2010 to
    2020, resulting in 711,900 new jobs. This growth in the RN workforce
    represents the largest projected numeric job increase from 2010 to 2020
    for all occupations. The April 6, 2012, BLS Employment Situation
    Summary--March 2012 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 8.2 percent for March 2012, the
    employment in healthcare increased in March with the addition of 26,000
    jobs at ambulatory healthcare services, hospitals, and nursing and
    residential care facilities.
        Nursing is the predominant occupation in the healthcare industry,
    with more than 3.854 million active, licensed RNs in the United States
    in 2010. 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 365,800 jobs, or an average of 30,480 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. The 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.
        The current Federal funding 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 14-year nurse and
    nurse faculty shortage felt throughout the entire United States health
    system.
                   the nurse pipeline and education capacity
        Although the recession resulted in some stability in the short-term
    for the nurse workforce, policymakers must not lose sight of the long-
    term growing demand for nurses in their districts and States. The NLN's
    findings from its 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. Key findings include:
      --Expansion of nursing education programs impeded by shortage of
            faculty and clinical placements. The overall 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. 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 will
            grow more severe. Without faculty to educate our future nurses,
            the shortage cannot be resolved.
      --Yield rates continued to grow. Yield rates--a classic indicator of
            the competitiveness of college admissions--remain
            extraordinarily high among 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.
      --Faculty Staffing Deficit Expected to Intensify as Workforce Reaches
            Retirement Age.--The percentage of faculty ages 30 to 45 and
            ages 46 to 60 both dropped by 3 percent between 2006 and 2009.
            At the same time the percentage of full-time educators over age
            60 grew dramatically from only 9 percent in 2006 to nearly 16
            percent in 2009. Overall, 57 percent of part-time educators and
            nearly 76 percent of full-timers were over the age of 45 in
            2009.
                       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 2011, NEPQR funded 106 infrastructure grants, including the
    Nursing Assistant and Home Health Aide 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 2010-2011, 27 non-competing CGEP grantees provided
    education to 3,645 RNs, 1,238 RN students, 870 direct service workers,
    569 licensed practical/vocational nurses, 264 faculty, and 5,344 allied
    health professionals.
        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 academic year 2010-11, the
    ANE Program supported 151 advanced nursing education projects and
    enrolled 7,863 advanced nursing education students.
                      nurse-managed health clinics (nmhc)
        NMHCs are defined as a nurse-practice arrangement, managed by
    advanced practice registered nurses, that provides primary care or
    wellness services to underserved or vulnerable populations. NMHCs are
    associated with a school, college, university, or department of
    nursing, federally qualified health center, or independent nonprofit
    health or social services agency.
        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. While providing
    access points in areas where primary care providers are in short
    supply, expansion of NMHCs also increases the number of structured
    clinical teaching sites available to train nurses and other primary
    care providers. Appropriating $20 million in fiscal year 2013 to NMHCs
    would increase access to primary care for thousands of uninsured people
    in rural and underserved urban communities.
        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 health care 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 $251.099
    million in fiscal year 2013. 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 2013.
                                     ______

             Prepared Statement of the National Minority Consortia
        The National Minority Consortia (NMC) \1\ submits this statement on
    the fiscal year 2015 advance appropriations for the Corporation for
    Public Broadcasting (CPB). The NMC is a coalition of five national
    organizations dedicated to bringing unique voices and perspectives from
    America's diverse communities into all aspects of public broadcasting
    and other media, including content transmitted digitally over the
    Internet. Our role has been crucial to public broadcasting's mission
    for over 35 years. We are unique in the services we provide minority
    producers for access, training and support. The NMC delivers important
    and timely public interest content to our communities and to public
    broadcasting. We ask the committee to:
    ---------------------------------------------------------------------------
        \1\ Center for Asian American Media; Latino Public Broadcasting;
    National Black Programming Consortium/Black Public Media; Native
    American Public Telecommunications; Pacific Islanders in
    Communications.
    ---------------------------------------------------------------------------
      --Direct CPB to increase its efforts for diverse programming with
            commensurate increases for minority programming and for
            organizations and stations located within underserved
            communities;
      --Include 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 other viewers. As communities in the Nation
                welcome increased numbers of citizens of diverse ethnic
                backgrounds, 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.''; and

      --Provide fiscal year 2015 advance appropriation for CPB of $445
            million, in order to develop content that reaches across
            traditional media boundaries, such as those separating
            television and radio. We feel strongly that 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 the 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.
        While public broadcasting continues to uphold strong ethics of
    responsible journalism and thoughtful examination of American history,
    life and culture, 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 programming and oversight levels within and
    in content production. 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 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, 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 the 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.
        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.
    We also provide numerous hours of programming to individual public
    television and radio stations, programming that is beyond the 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.
        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 systemwide within public
    broadcasting. The programming funds are re-granted to producers, used
    for purchase of broadcast rights and other related programming
    activities. Each organization solicits applications from our
    communities for these funds. A brief description of our organizations
    follows:
      --Center for Asian American Media.--CAAM's mission is to present
            stories that convey the richness and diversity of Asian
            American experiences to the broadest audience possible. We do
            this by funding, producing, distributing and exhibiting works
            in film, television and digital media. Over our 32-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 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 more than $8 million to Latino Independent Producers,
            and provided more than 150 hours of compelling programming to
            public television. LPB supports more than 300 Latino filmmakers
            per year through professional development initiatives. LPB also
            produces ``Voces'', the only Latino anthology series on public
            television. In addition, LPB presented the PBS 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).
            Currently LPB is working on ``The Latino Americans'', a
            bilingual 6 part series about the history of Latinos in the
            United States. 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.
      --NBPC/Black Public Media works to increase capacity in diverse
            communities to create, distribute and use public media.
            Throughout its history, its mission has been two-fold: building
            capacity in new generations of creators of social issue media
            and broadening the pool of stakeholders in public media
            institutions. Over the past 5 years, in addition to supporting
            producers who create programming for public television and
            other platforms, NBPC/Black Public Media has convened and
            mentored more than 500 digital media professionals and created
            the Public Media Corps (PMC) to address an urgent need in our
            communities at the grassroots level. Currently entering its
            third year, the PMC, in partnership with K-12 schools,
            libraries and universities, is a framework for supporting
            creative, sustainable and community-initiated methods for using
            media and media-technology in underserved communities by
            deploying public media content and tools. In 2012, we presented
            the fourth season of its critically acclaimed series ``AfroPop:
            the Ultimate Cultural Exchange'', which features independent
            perspectives from the African diaspora, including the African
            continent, the Caribbean and the Americas, as well as numerous
            hours of prime-time television programming to PBS. Currently,
            NBPC/Black Public Media is in production on a television
            special and related engagement activities that support CPB's
            American Graduate initiative to combat the drop out crisis in
            American public schools and two new web-exclusive content
            series by emerging black filmmakers.
      --Native American Public Telecommunications.--NAPT shares Native
            stories with the world. We advance media that represents the
            experiences, values, and cultures of American Indians and
            Alaska Natives. Founded in 1977, through various media--public
            television and radio and the Internet--NAPT brings awareness of
            Indian and Alaska Native issues. In 2011 NAPT presented seven
            Native American documentaries to PBS stations nationwide and
            offered producers and educators numerous workshops related to
            media maker topics including ``Media for Change: Documentary
            Film in Education and Social Issues'' that allowed NAPT to
            build learning objects to teach Native American History and fit
            all of its curricular materials to the set of core standards.
            In addition, NAPT continues to target and work and with
            stations to bring new voices into the public broadcasting
            system using new media civic engagement technology and support.
            NAPT is currently developing curriculum and community
            engagement strategies to support CPB's American Graduate
            initiative that extends the reach of the Nebraska Educational
            Telecommunications' documentary ``Standing Bear's Footsteps''
            through a partnership with NBPC's Public Media Corps, Southern
            Ponca Tribe of Oklahoma and Northern Ponca Tribe of Nebraska.
      --Pacific Islanders in Communications.--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. This year the PIC
            series Pacific Heartbeat premieres on American Public
            Television.
        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 the
    Congress for support of our work on behalf of our communities.
                                     ______

              Prepared Statement of the National Marfan Foundation
    National Marfan Foundation Fiscal Year 2013 LHHS Appropriations
            Recommendations
        $7.8 billion for CDC, an increase of $1.7 billion over fiscal year
    2012, including proportional increases for the National Center for
    Chronic Disease Prevention and Health Promotion (NCCDPHP) and the
    National Center on Birth Defects and Developmental Disabilities
    (NCBDDD) to facilitate critical Marfan syndrome and related connective
    tissue disorders education and awareness activities.
        $32 billion for NIH, an increase of $1.3 billion over fiscal year
    2012, including proportional increases for the National Heart, Lung,
    and Blood Institute (NHLBI); National Center for Advancing
    Translational Sciences (NCATS); National Institute of Arthritis and
    Musculoskeletal and Skin Diseases (NIAMS); and other NIH Institutes and
    Centers to facilitate adequate growth in the Marfan syndrome and
    related connective tissue disorders research portfolios.
        Chairman Harkin, Ranking Member Shelby, and distinguished members
    of the Subcommittee, thank you for the opportunity to submit testimony
    on behalf of NMF. It is my honor to represent the estimated 200,000
    Americans who are affected by Marfan syndrome or a related condition
    before you.
        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 a 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.
        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. Early surgical
    intervention can prevent a dissection and strengthen the aorta and the
    aortic valves, especially when preventive surgery is performed before a
    dissection occurs.
        The NMF is a nonprofit voluntary health organization founded in
    1981. NMF is dedicated to saving lives and improving the quality of
    life for individuals and families affected by the Marfan syndrome and
    related disorders. The Foundation has three major goals: (1) To provide
    accurate and timely information about the Marfan syndrome to affected
    individuals, family members, physicians, and other health
    professionals; (2) to provide a means for those with Marfan syndrome
    and their relatives to share in experiences, to support one another,
    and to improve their medical care; and (3) to support and foster
    research.
        NMF is deeply appreciative of this Subcommittee's historic support
    for critical public health programs at CDC and NIH, particularly
    programs focused on addressing life-threatening genetic disorders such
    as Marfan syndrome. Under your leadership NIH through NHLBI and NIAMS
    has been able to expand research in this area and advance our
    scientific understanding of the condition. In addition, CDC through
    NCCDPHP and NCBDDD has the resources necessary to implement life-saving
    awareness and education activities that can prevent thoracic aortic
    aneurysms and dissections. We urge you to once again prioritize funding
    for public health programs in fiscal year 2013 to ensure that these
    activities can continue to improve the quality of life for Americans
    affected by Marfan syndrome and related connective tissue disorders.
        To follow, please find NMF's fiscal year 2013 appropriations
    recommendations for CDC and NIH. Thank you for your time and your
    consideration of these recommendations.
    Centers for Disease Control and Prevention
        NMF joins the other voluntary patient and medical organizations
    comprising the public health community in requesting that you support
    CDC by providing the agency with an appropriation of $7.8 billion in
    fiscal year 2013. Such a funding increase would allow CDC to undertake
    critical Marfan syndrome and related connective tissue disorders
    education and awareness activities, which would help prevent deadly
    thoracic aortic aneurysms and dissections.
        In 2010, the American College of Cardiology and the American Heart
    Association issued landmark practice guidelines for the treatment of
    thoracic aortic aneurysms and dissections. 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. The TAD Coalition is presently comprised of 10 organizations
    that are coordinating efforts to help promote the Guidelines to
    healthcare professionals and to raise public awareness of various
    aortic diseases and the associated risk factors.
        The CDC would be an invaluable partner in the ongoing campaign to
    save lives and improve health outcomes by promoting the new Guidelines
    to healthcare providers and raising public awareness of risk factors.
    In this regard, we ask the Subcommittee encourage CDC to identify
    appropriate staff at the NCCDPHP and NCBDDD to participate in TAD
    Coalition activities. It is our hope that involving CDC in the
    activities of the TAD Coalition will lead to a lasting partnership and
    collaboration on critical outreach campaigns.
    National Institutes of Health
        NMF joins the other voluntary patient and medical organizations
    comprising the public health community in requesting that you support
    NIH by providing the agency with an appropriation of $32 billion in
    fiscal year 2013. This modest 4 percent funding increase would ensure
    that biomedical research inflation does not result in a loss of
    purchasing power at NIH, critical new initiatives like the Cures
    Acceleration Network (CAN) are adequately supported, and the Marfan
    syndrome research portfolio can continue to progress.
        National Heart, Lung, and Blood Institute.--First and foremost, NMF
    applauds NHLBI 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.
        Marfan syndrome patients (age 6 months to 25 years) are now
    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.
        NMF is proud to actively support the losartan clinical trial in
    partnership with PHN. 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. The Foundation asks for your
    continued support to ensure this critical study continues to move
    forward.
        Secondarily, NMF is 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 recently 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. In this regard, we ask that you
    encourage NHLBI to consider working with the Genetically Triggered
    Thoracic Aortic Aneurysms and Cardiovascular Conditions Registry or
    GenTAC to identify ways we can partner moving forward to facilitate
    continuation of the aforementioned outcomes study.
        Finally, in 2007, NHLBI convened a ``Working Group on Research in
    Marfan Syndrome and Related Conditions.'' 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.
        In addition to laying out a roadmap for research, the working group
    found that, ``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 research recommendations, which are also
    consistent with goals and challenges identified in the NHLBI Strategic
    Plan.
        National Center for Advancing Translational Sciences.--The
    Foundation applauds the recent establishment of NCATS at NIH. Housing
    translational research activities at a single Center at NIH will allow
    these programs to achieve new levels of success. Initiatives like CAN
    are critical to overhauling the translational research process and
    overcoming the research ``valley of death'' that currently plagues
    treatment development. In addition, new efforts such as taking the lead
    on drug repurposement hold the potential to speed new treatment to
    patients, particularly patients who struggle with rare or neglected
    conditions. NMF asks that you support NCATS and provide adequate
    resources for the Center in fiscal year 2013.
        National Institute of Arthritis and Musculoskeletal and Skin
    Diseases.--NMF is proud of its longstanding partnership with NIAMS. 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
    the program project entitled, ``Consortium for Translational Research
    in Marfan Syndrome,'' which has enhanced our understanding of the
    disorder and increased the ability to stop the disease progression
    using a drug-based therapy. 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. NMF would
    welcome an opportunity to partner with NIAMS on this and other
    research. In this regard, we ask that you encourage NIAMS to expand its
    support for research aimed at identifying effective therapies for
    heritable connective tissue disorders to reduce the number of premature
    deaths from these chronic and complex conditions.
        Thank you again for your time and your consideration of our fiscal
    year 2013 appropriations requests. Please contact me if you have any
    questions or if you would like any additional information.
                                     ______

         Prepared Statement of the National Multiple Sclerosis Society
        Mr. Chairman and members of the subcommittee, thank you for this
    opportunity to provide testimony regarding funding of critically
    important Federal programs that impact those affected by multiple
    sclerosis. Multiple sclerosis (MS) is an unpredictable, often disabling
    disease of the central nervous system that 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.
        MS stops people from moving. The National MS Society exists to make
    sure it doesn't. The National MS Society sees itself as a partner to
    the Government in many critical areas. As we advocate for NIH research,
    we do so as an organization that funds approximately $40 million
    annually in MS research through funds generated through the Society's
    fundraising efforts. And as we advocate for lifespan respite funding,
    we do so as an organization that works to provide some level of respite
    relief for caregivers. So while we're here to advocate for Federal
    funding, we do it as an organization that commits tens of millions of
    dollars each year to similar or complementary efforts as those being
    funded by the Federal Government. Through these efforts, our goal is to
    see a day when MS has been stopped, lost functions restored, and a cure
    is at hand.
        The National MS Society recommends the following funding levels for
    agencies and programs that are of vital importance for the lives of
    Americans living with MS.
                         lifespan respite care program
        Many caregivers are family members who provide care full time
    because of the needs of the patient. As you can imagine, the caregivers
    get worn out and need a break once in a while. That's why respite care
    services are so important--to provide caregivers with a chance to have
    a break and get refreshed. These 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 $5 million in the fiscal year 2013 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. According
    to a 2011 AARP report, 61.6 million family caregivers provided care at
    some point during 2009 and the value of their uncompensated services
    was approximately $450 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 $5 million for
    Lifespan Respite in fiscal year 2013 would 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 caregiver strain
    currently has on American businesses.
                         national institutes of health
        We urge the Congress to continue its investment in innovative
    medical research that can help prevent, treat, and cure diseases such
    as MS by providing at least $32 billion for the National Institutes of
    Health (NIH) in fiscal year 2013.
        The NIH is the country's premier institution for medical research
    and the single largest source of biomedical research funding in the
    world. The NIH conducts and sponsors a majority of the MS-related
    research carried out in the United States. Approximately $122 million
    of fiscal year 2011 and American Recovery and Reinvestment 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. Twenty
    years ago there were no MS therapies or medications. Now there are
    eight, with the first oral medication now available and other new
    treatments in the pipeline. The NIH provided the basic research
    necessary so that these therapies could be developed. Had there been no
    Federal investment in research, it's doubtful people living with MS
    would have any therapies available. 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 more than 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 that the Congress provide at least $32 billion for the
    NIH in fiscal year 2013.
                    centers for medicare & medicaid services
    Medicaid
        The National MS Society urges the Congress to maintain funding for
    Medicaid and reject proposals to cap or block grant the program.
        Medicaid provides comprehensive health coverage to more than 8
    million persons living with disabilities and 6 million persons with
    disabilities who rely on Medicaid to fill Medicare's gaps.
    Approximately 10 percent of people living with MS rely on Medicaid.
        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 decision Olmstead and integrating and keeping people with
    disabilities in their communities.
        While the economic situation demands leadership and thoughtful
    action, the National MS Society urges the 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 the Congress to provide $13.4 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.
        The wave of increased disability claims--in part due to the
    distressed economy--continues to have a very significant impact on the
    Disability Determination Services (DDSs). In the 35-month period ending
    in August 2011, the number of claims pending for a disability medical
    decision rose from 556,670 to 755,058--an increase of 36 percent. SSA
    faces an unprecedented backlog of disability hearings. In fiscal year
    2011, 859,514 hearings were filed, which is 270,065 (45.8 percent) more
    than in fiscal year 2008. Despite these challenges, eliminating the
    disability hearings backlog remains SSA's top priority and processing
    time has been reduced from 491 days in fiscal year 2009 to 340 days in
    October 2011. If SSA does not receive adequate funding for fiscal year
    2013 this progress will regress. The reduced SSA funding level in
    fiscal year 2011 for example resulted in the suspension of opening
    eight planned hearing offices, which diminishes SSA's ability to
    eliminate the backlog by fiscal year 2013. To support continued
    progress to eliminate the backlog and to help ensure that persons with
    disabilities relying on SSDI or SSI receive entitled benefits in a
    timely manner, the National MS Society urges the Congress to provide
    $13.4 billion for the SSA's LAE in fiscal year 2013.
                          food and drug administration
        The FDA is the United States' pre-eminent public health agency and
    its role as the regulator of the country's pharmaceutical industry
    provides invaluable support and encourages vital progress for people
    living with MS and other diseases. In its capacity as the industry's
    regulator, the FDA ensures that drugs and medical devices are safe and
    effective for public use and provides consumers with confidence in new
    technologies. Because of the tremendous impact the FDA has on the
    development and availability of drugs and devices for individuals with
    disabilities, the NMSS requests that the Congress provide a 6 percent
    increase over the fiscal year 2012 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 $1 invested in the life-science research regulated by the FDA has
    the potential to save upwards of $10 in health gains. Breakthroughs in
    medications 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 in 2010 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. Entire industries are
    working to enhance the lives of Americans with new medical devices and
    pharmaceuticals with tens of billions of dollars being spent annually
    by the NIH and industry in pursuit of new breakthroughs. The FDA has a
    comparatively small budget yet is charged with ensuring the safety and
    efficacy of these new products. The answer to the backlog is to provide
    adequate funding to FDA, not, as some have suggested, to lessen the
    rigorous protocols in place to ensure safety. Therefore, the National
    MS Society urges the Congress to provide the FDA with a 6 percent
    increase to address this backlog.
                                   conclusion
        The National MS Society thanks the subcommittee for the opportunity
    to provide written testimony and our recommendations for fiscal year
    2013 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 subcommittee to help move us closer to a
    world free of MS. Please don't hesitate to contact me with any
    question.
                                     ______

              Prepared Statement of the Neurofibromatosis Network
        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 research on Neurofibromatosis (NF), a
    genetic disorder closely linked too many common diseases widespread
    among the American population.
        On behalf of the Neurofibromatosis (NF) Network, 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
    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.
        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. In addition, approximately one-half of children with NF
    suffer from learning disabilities. NF is the most common neurological
    disorder caused by a single gene and three times more common than
    Muscular Dystrophy and Cystic Fibrosis combined. 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.
        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.
        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.
        The enormous promise of NF research, and its potential to benefit
    more than 175 million Americans who suffer from diseases and conditions
    linked to NF, has gained increased recognition from the Congress and
    the NIH. This is evidenced by the fact that 11 institutes are currently
    supporting NF research, and NIH's total NF research portfolio has
    increased from $3 million in fiscal year 1990 to an estimated $24
    million in fiscal year 2012. Given the potential offered by NF research
    for progress against a range of diseases, we are hopeful that the 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 2013 Labor, Health and Human Services, Education
    appropriations bill.

        ``Neurofibromatosis [NF].--The Committee supports efforts to
    increase funding and resources for NF research and treatment at
    multiple NIH Institutes. NF affected children and adults are at
    significant risk for the development of many forms of cancer; the
    Committee encourages NCI to increase its NF research portfolio in
    fundamental basic science, translational research and clinical trials
    focused on NF. The Committee also encourages the NCI to support NF
    centers, NF clinical trials consortia, NF preclinical mouse models
    consortia, and biospecimen repositories. The Committee urges NHLBI to
    expand its investment in NF based on the increased prevalence of
    hypertension and congenital heart disease in this patient population.
    Because NF causes brain and nerve tumors and is associated with
    cognitive and behavioral problems, the Committee urges NINDS to
    continue to aggressively fund fundamental basic science research on NF
    relevant to nerve damage and repair, learning disabilities and
    attention deficit disorders. In addition, the Committee encourages the
    NICHD and NIMH to expand funding of basic and clinical NF research in
    the area of learning and behavioral disabilities. Children with NF1 are
    prone to the development of severe bone deformities, including
    scoliosis; the Committee therefore encourages NIAMS to expand its NF1
    research portfolio. Since NF2 accounts for approximately 5 percent of
    genetic forms of deafness, the Committee encourages NIDCD to expand its
    investment in NF2 basic and clinical research. Based on the increased
    incidence of optic gliomas, vision loss, cataracts, and retinal
    abnormalities in NF, the Committee urges the NEI to expand its NF
    research portfolio. Finally, the Committee encourages NHGRI to increase
    its investment in NF, given that NF represents a tractable model system
    to study the genomics of cancer predisposition, learning and behavior
    problems, and bone abnormalities translatable to individualized
    medicine.''

        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 National Nursing Centers Consortium
        The National Nursing Centers Consortium (NNCC) is a 501(c)(3)
    member organization of nonprofit, nurse-managed health clinics,
    sometimes called nurse-managed health centers or NMHCs. The Affordable
    Care Act defines the term ``nurse-managed health clinic'' as a nurse
    practice arrangement, managed by advanced practice nurses, 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 (FQHC), or
    independent nonprofit health or social services agency. Currently there
    are about 200 NMHCs in operation throughout the United States. Title
    III of the Public Health Service Act established the Nurse Managed
    Health Clinic Grant Program to provide NMHCs with a stable source of
    Federal funding that would place them on footing similar to other
    safety-net providers. Although authorized, to date the Grant Program
    has received no appropriations.
    The Value of Nurse-Managed Health Centers: Interdisciplinary Training
            in an Academic Setting
        Many of the Nation's leading nursing schools operate NMHCs. Since
    the clinics are affiliated with academic institutions, they naturally
    become workforce development sites and can provide clinical training
    opportunities for health profession students. In addition to training
    registered nurses and advance practice registered nurses (mostly nurse
    practitioners), many NMHCs have interdisciplinary partnerships with
    other academic programs allowing them to also provide learning
    opportunities for medical, pharmacy, dental, social work, public
    health, and other health profession students. NMHCs easily blend
    community healthcare with healthcare provider training and development.
        In October 2010, HRSA released $14.8 million in Prevention and
    Public Health Fund dollars to fund 10 NMHC grants. Since receiving
    funding, the NMHC grantees have provided interdisciplinary clinical
    training to more than 800 students of nursing, medicine, public health,
    and other health professions. In May 2009, the NNCC conducted a survey
    of its members to measure their contribution to health professions
    education in the United States. Forty-four NMHCs in a mix of urban,
    rural, and suburban communities reported providing educational
    opportunities for nearly 3,100 students annually. The contribution by
    these clinics to the healthcare workforce is undeniable.
    The Value of Nurse-Managed Health Centers: Expanding Access to Care at
            a Lower Cost
        NMHCs act as essential safety-net providers in rural, urban, and
    suburban communities across the country. For many patients in medically
    underserved areas, NMHCs and nurse practitioners are the only primary
    care providers in the area. These critical access points provide care
    to patients regardless of ability to pay and insurance status and keep
    patients out of the emergency room, saving the healthcare system
    millions of dollars annually. NMHCs also improve access by helping to
    build the capacity of the Nation's primary care workforce. As the
    number of medical students going into primary care continues to stay at
    an alarmingly low rate, the United States is in serious need of quickly
    and well-trained primary care providers. By training nurse
    practitioners as community-based primary care providers, NMHCs are
    perfectly positioned to increase the number of providers while
    simultaneously providing needed primary care.
        By the end of 2011, the NMHC grantees that received Federal funding
    in October 2010 had served 27,000 patients and recorded more than
    72,000 patient encounters. Additionally, the grantees are providing
    care in communities with unprecedented need. For instance, one of the
    grantees provides care to residents of Galveston, Texas, a community
    still recovering from a devastating natural disaster. All this
    indicates that any Federal funds provided to NMHCs will go to provide
    quality primary care in very needy communities.
        Finally, having nurse practitioners provide primary care in NMHCs
    is cost-effective, which is critical in this time of fiscal
    uncertainty. In 1981, the Office of Technology Assessment first
    demonstrated that nurse practitioners perform comparable medical care
    tasks at a lower total cost than physicians.\1\ Many studies have since
    reaffirmed that nurse practitioners provide high quality care for a
    lower overall cost.\2\
    ---------------------------------------------------------------------------
        \1\ LeRoy, L. & Solowitz, S. (1981). The Costs and Effectiveness of
    Nurse Practitioners. Office of Technology Assessment.
        \2\ Coddington J. (2010). Quality of Care and Policy Barriers to
    Providing Health Care at a Pediatric Nurse-Managed Clinic. Journal of
    Pediatric Healthcare, 24 (5):e9; Eibner, E et al. (2009). Controlling
    Health Care Spending in Massachusetts: An Analysis of Options. RAND
    Health; Mehrota, A. et al. (2009). Comparing Costs and Quality of Care
    at Retail Clinics with that of Other Medical Settings for 3 Common
    Illnesses. Annals of Internal Medicine, 151, 321-323; Chenoweth, D. et
    al. (2008). Nurse Practitioner Services: Three-Year Impact on Health
    Care Costs. Journal of Occupational and Environmental Medicine, 50,
    1293-1298.
    ---------------------------------------------------------------------------
    The Challenge in Sustaining Nurse-Managed Health Centers
        The patient population and payor mix of NMHCs is similar to that of
    federally Qualified Health Centers. However, because many NMHCs are
    directly affiliated with academic schools of nursing, they cannot meet
    the governance requirements for Community Health Center funding.
    Without a stable source of funding to offset the cost of caring for the
    uninsured, several NMHCs have had to close, leaving many vulnerable
    patients without care.
    Request
        Because NMHCs are vital interdisciplinary training sites, help fill
    the gap in the primary care provider shortage by training primary care
    providers, and provide quality, affordable care to the most vulnerable
    people in their communities, the NNCC respectfully requests $20 million
    in fiscal year 2013 for the Nurse-Managed Health Clinic Grant Program,
    as authorized under Title III of the Public Health Service Act.
                                     ______

          Prepared Statement of the National Postdoctoral Association
        Mr. Chairman and Members of the Subcommittee: Thank you for this
    opportunity to testify in regard to the fiscal year 2013 funding for
    the National Institutes of Health (NIH). We are writing today in regard
    to support for postdoctoral researchers, specifically in support of
    fiscal year 2013 funding for the National Institutes of Health at the
    2012 level of $30.86 billion and in support of the 2 percent increase
    in the Ruth L. Kirschstein National Research Service Award (NRSA)
    training stipends for postdoctoral researchers, as requested in the
    President's proposed fiscal year 2013 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 31 percent of those with a pre-1972 doctorate to 46 percent
    of those receiving their doctorate in 2002-05 \2\. According to the
    2012 Science and Engineering Indicators, an increase in those taking
    postdoc positions is evident across most disciplines:

        \1\ National Science Foundation Division of Science Resource
    Statistics. (January 2010, chapter 3, pp.44-46). Science and
    engineering indicators 2010. Arlington, Virginia: National Science
    Board.
        \2\ National Science Foundation National Center for Science and
    Engineering Statistics (NCSES). (January 2012, chapter 3, p. 39).
    Science and engineering indicators 2012. Arlington, Virginia: National
    Science Board.
    ---------------------------------------------------------------------------
        ``In traditionally high-postdoc fields such as the life sciences
    (from 46 percent to 60 percent) and the physical sciences (from 41
    percent to 61 percent), most doctorate recipients now have a postdoc
    position as part of their career path. Similar increases were found in
    mathematical and computer sciences (19 percent to 31 percent), social
    sciences (18 percent to 30 percent), and engineering (14 percent to 38
    percent). Recent engineering doctorate recipients are now almost as
    likely to take a postdoc position as physical sciences doctorate
    holders were 35 years ago.'' \3\

        \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 Academy of Science (NAS), 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, p. 10). Enhancing the postdoctoral
    experience for scientists and engineers. Washington, DC: National
    Academy Press.
    ---------------------------------------------------------------------------
      --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 scientific and health 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 receive varying
    benefits depending on the institution where they work. The National
    Postdoctoral Association (NPA) advocates for policies that support and
    enhance postdoctoral training on the national level and also within the
    research institutions that host postdoctoral scholars. Low compensation
    remains one of the most 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 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 the 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 and 2012. The 2012 entry-level training stipend
    remains low, at $39,264, the equivalent of a GS-8 position, step 2 in
    the Federal Government in 2012 \5\, despite the postdocs' advanced
    degrees and specialized technical skills and experience. Furthermore,
    this stipend remains far short of the promised $45,000. Please see
    Figure 1 for a summary of the stipend amounts since 2000 and Figure 2
    for a comparison of the actual stipend growth with the NIH recommended
    growth.
    ---------------------------------------------------------------------------
        \5\ U.S. Office of Personnel Management Salary Tables 2012. http://
    www.opm.gov/oca/12tables/html/gs.asp.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        \6\ Figure created by Lorraine Tracey, Ph.D., on behalf of the
    ---------------------------------------------------------------------------
    National Postdoctoral Association.

        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 strongly suggested that the NIH training
    stipends are used as a benchmark by research institutions across the
    country for establishing compensation for postdoctoral scholars.\7\
    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, the NPA is
    hearing from many postdocs, who say they 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 the Congress appropriate
    funding for the 2-percent increase in training stipends, as a moderate
    yet substantial step toward reaching the recommended entry-level
    stipend of $45,000.
    ---------------------------------------------------------------------------
        \7\ Johnson Phillips, C. (April 2012). National Postdoctoral
    Association Institutional Survey on Postdoctoral Compensation,
    Benefits, and Professional Development Opportunities: Highlights.
    Washington, DC: National Postdoctoral Association.
    ---------------------------------------------------------------------------
    Solution: Keep the NIH's Original Promise to Raise the Minimum Stipends
        We respectfully request that the Subcommittee appropriate funding
    of $30.86 billion for the fiscal year 2013 NIH budget, which would in
    turn allow the NIH to appropriate $775 million to training grants and
    implement a 2 percent NRSA stipend increase, as per the President's
    proposed fiscal year 2013 budget:
      --Support for the training mechanism would decline by 0.4 percent
            compared to fiscal year 2012. This reflects a 1.8 percent
            reduction in the number of trainees supported. Stipend rates,
            however, would increase at the same pace as for fiscal year
            2012 at 2 percent, continuing a long-term strategy that NIH has
            used to try and keep stipend levels closer to salaries that
            could be earned in related occupations, to ensure that
            outstanding individuals continue to pursue biomedical research
            careers.'' \8\
    ---------------------------------------------------------------------------
        \8\ Department of Health and Human Services National Institutes of
    Health. (pp. ES25-ES26). NIH Congressional Justification: Overview.
    http://officeofbudget.od.nih.gov/pdfs/FY13/FY2013_Overview.pdf.
    ---------------------------------------------------------------------------
        The NPA believes it is 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 National Public Radio
        Dear Chairman Harkin, Senator Shelby and Members of the
    Subcommittee: Thank you for this opportunity to urge the Subcommittee's
    support for a Federal investment in America's distinctive public
    broadcasting system. Public broadcasting's continuing service to
    communities in every corner of America is dependent on a diversified
    revenue base, including Federal funding. For less money per American
    per year than a single cup of coffee, public broadcasting stations have
    become local community cornerstones that reflect local values and are
    built upon local control and local programming decisions. And this
    outstanding locally focused public service is widely supported by
    Americans from all walks of life.
        As the President and CEO of NPR, I offer this testimony on behalf
    of the public radio system, a uniquely American public service, not-
    for-profit media enterprise that includes NPR, our more than 950 public
    radio station partners, other producers and distributors of public
    radio programming including American Public Media (APM), Public Radio
    International (PRI), the Public Radio Exchange (PRX), and many
    stations, both large and small, that create and distribute content
    through the Public Radio Satellite System (PRSS). With your continued
    support for an annual Federal appropriation of $445 million to the
    Corporation for Public Broadcasting (CPB), every American will continue
    to have free access to the best in educational, news, information and
    cultural programming.
        Funding provided by the Congress to the CPB supports the entire
    foundation of a system that has been one of America's most successful
    models of a community-centric grant program. The revenue base provided
    by the Congress enables stations to raise $6 for every Federal grant
    dollar. And for every $1 that public radio stations invest in NPR
    programming, they are able to raise $3 locally from audiences and local
    businesses. This enables local stations to invest more deeply in their
    own local news and cultural programming. The essential Federal
    investment enables the American public to receive an enduring and daily
    return on investment that is heard, seen, read and experienced in
    public radio broadcasts, apps, podcasts, and on online.
    Public Radio: It's All Local
        Local is the cornerstone and watchword of public radio as stations
    connect with their communities and localize civil and civic discussions
    on reporting from across the street and around the world. Public radio
    stations are independently owned and operated, and are licensed to
    colleges, universities, community foundations, and other nonprofit
    organizations. Stations serve their local communities by determining
    their own schedules. They are managed locally by professionals who are
    accountable to community leaders and listeners who represent the
    diverse backgrounds of that community. Decisions about programming and
    services are made by people who live within the local community. That's
    the way it used to be throughout much of the broadcast industry, and we
    think it's the way it should be. Public radio stations set their own
    policies, make their own program decisions, and answer questions when
    their local listeners call or write. They respond to their listeners
    and respond to their needs because an actively engaged audience is
    public radio's calling card. Most of our system's revenue is audience-
    sensitive, coming either from individual local contributors or from
    local businesses and foundations that support the work of our stations.
        Consider these recent statistics . . . Roughly 38 million Americans
    listen to public radio each week, more than the total combined
    circulation of the country's top 64 newspapers, including USA Today,
    The Wall Street Journal, and the New York Times. Additionally, some 20
    million visitors a month find public radio's digital platforms, with
    some 30 million podcast downloads occurring each month. According to
    the Pew Research Center, NPR and public radio are the only news sources
    to see a meaningful increase in audience trust over the last 12 years.
        As the country's largest nonprofit news organization, public radio
    is uniquely positioned to respond to the ever evolving nature of
    delivering news, music and cultural affairs programming. Our network of
    local public radio stations reaches diverse communities, from the
    largest urban areas to the smallest rural enclaves. Public radio
    programming is rooted in the fundamentals of accuracy, transparency,
    independence, balance, and fairness that foster understanding for
    millions of Americans seeking information, context and insight.
        As a network of stations that produce local news and cultural
    programming and, with regional, national and international reporting
    capabilities that NPR, APM and others contribute, we are making a
    difference in the world beginning in each community you represent. On
    average, 44 percent of daily programming is locally produced by station
    staff, 28 percent is produced by NPR, and 28 percent comes from other
    public radio station producers and national distributors. Throughout
    the public radio station community, local and regional talk shows are
    mainstays of daily programming. Recent surveys show that the number of
    public radio stations carrying local news/talk programming rose from
    595 to 681 stations, with hours aired each week increasing by more than
    10 percent. On average, 1,400 programming segments produced by local
    public radio stations were included in programming distributed
    nationally by NPR.
        Roughly 90 percent of stations produce local newscasts, airing both
    newscast and non-newscast content primarily in weekday drive time,
    especially morning drive-time. About half of all stations carry local
    news content during the weekends. Most stations--74 percent--are
    producing stories other than newscasts each week to insert into
    ``Morning Edition'' and ``All Things Considered'' locally; and, most
    news stations--88 percent--are producing and inserting stories, with a
    majority of these stations inserting five or more stories per week.
    Stations devote the most local news coverage and their reporters'
    specific beat assignments to State-local-politics, schools and
    education, arts and cultural events, and environmental, health, and
    business issues. News format stations provide added coverage on local
    politics, education, and business, whereas music stations focus on arts
    and cultural affairs events.
    Public Radio: Music and Culture in Communities
        Public radio also provides an important and growing contribution to
    America's music culture and America's music economy. Some 480 public
    radio stations offer a mixed news and music programming format, with
    another 180 stations engaged entirely in music. Every year, public
    radio stations host and broadcast more than 3,000 in-studio and
    community-based performances. And every year, public radio stations
    broadcast more than 4.8 million hours of music programming. More than a
    third of all public-radio listening is to music.
        Classical, jazz, folk, independent, bluegrass, world and eclectic
    are music formats offered by public radio stations in cities large and
    small, and all are being eliminated as economically unsustainable in
    the commercial market. As a result, in dozens of communities
    nationwide, the local public radio station is the only free and
    universally available source of music from these genres. This
    preservation role is complemented by the important promotional role
    public radio stations play in music today. Local stations actively
    highlight in-studio performances by emerging artists and local music
    events spanning all music genres. Audiences increasingly are turning to
    their local public radio stations as trusted sources for information on
    new artists and events.
    Public Radio: Information in Times of Crisis and Emergency
        By ensuring that public radio is widely available throughout the
    country, Federal funding helps ensure that citizens have access to
    emergency and public safety information during national or local
    disasters. Public radio is a communications lifeline during times of
    emergencies, especially when the power grid is down. 98 percent of the
    U.S. population has access to a public radio signal. There are an
    estimated 800-900 million radios in the United States and more than 38
    million people listen to public radio each week. Radio is the most
    effective medium for informing a community of weather forecasts,
    traffic issues, services available, evacuations, and other emergency
    conditions. Everyone has access to a radio; they are portable and
    battery operated. In Indian Country, radio stations provide essential
    life saving information in many Native communities that do not have
    available or effective 9-1-1 services and have limited or no telephone
    access or broadband (one-third have no telephone and less than 10
    percent have Internet access).
        The Federal Emergency Management Agency (FEMA) routinely advises
    the public to make sure that radios with batteries are on hand when
    major storms approach. When people are instructed to evacuate due to
    local crisis situations such as hurricanes, flooding, tornados,
    wildfires, ice storms, earthquakes and terrorist attacks, car radios
    become a primary instrument for receiving information about the
    emergency situation including evacuation routes and evacuation center
    locations. Effective emergency warnings allow people to take actions
    that save lives, reduce damage, and reduce human suffering.
        Dedicated public radio personnel have worked and continued
    broadcasting through multiple crises such as the 9/11 attacks,
    Hurricanes Andrew, Hannah, Katrina, Rita and Gustav, blackouts,
    wildfires, ice storms, earthquakes and floods. During the 9/11 tragedy,
    WNYC 93.9 FM/820 AM served as a 24/7 lifeline to hundreds of thousands
    of people, while in the days that followed station personnel provided a
    calm and recognizable voice that helped survivors cope. The station
    kept reporting even while its FM transmitter located on the World Trade
    Center was destroyed in the first attack.
    Public Radio: Service to Everyone
        Many public radio stations also provide critical services to
    disabled Americans. Radio reading services in every major market in the
    United States provide millions of visually impaired persons the ability
    to function more independently in their communities. Our Nation's
    elderly and military veterans returning home injured or disabled from
    foreign combat duty depend on these broadcasts for their only access to
    current print-based news and information.
        Everyone with a visual impairment, physical disability or learning
    disability has a right to equal access to all forms of information
    available to the general public. Audio information services provide
    access to printed information for individuals who cannot read
    conventional print because of blindness or any other visual, physical
    or learning disability. Many audio information services provide service
    to institutions as well as to individuals, such as hospital rooms,
    assisted living facilities, low vision clinics, senior centers and
    other institutional care facilities where qualified listeners may
    reside or frequent.
    Public Radio: A Sound Investment
        At a time when the Federal Government is running a large deficit,
    every program and function of the Government deserves to be
    scrutinized. A review of Federal funding to public broadcasting is fair
    and to be expected. But the truth remains that the Federal investment
    in the public radio and public broadcasting system provides one of the
    most effective returns of any program authorized by the Congress. For a
    modest Federal investment of just $1.39 per person per year, the
    country is provided with exceptional journalism and culturally
    enriching programming that elevates the national dialogue and leads to
    a more informed citizenry.
        In closing Chairman Harkin and Senator Shelby, I encourage you,
    members of the subcommittee and your staffs to visit and tour your
    local public radio stations to view first-hand how Federal dollars are
    at work locally serving your constituents.
                                     ______

          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 $32 billion for NIH in
    fiscal year 2013, which represents a 4.2 percent increase above the
    fiscal year 2012 level. Within this proposed increase, the NPRCs also
    respectfully request that the Subcommittee provide strong support for
    the NIH Office of Research Infrastructure Programs (ORIP), housed
    within the NIH Office of the Director, which is the new administrative
    home of the 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 interventions, treatments,
    cures, and ultimately to overall better health of the Nation and the
    world. The NPRCs collaborate as a transformative and innovative network
    to develop and 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 and 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 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 fiscal year 2013 NIH congressional justification underscores
    the vital role that the NPRCs play in NIH translational science efforts
    and the broader biomedical research enterprise. With the recent
    creation of the National Center for Advancing Translational Sciences
    (NCATS), the NPRCs see a great opportunity to further integrate the
    consortium as a trans-NIH resource on topics such as colony management,
    training, genetics and genome banking. The NPRC consortium will
    continue to engage as a resource for the Clinical and Translational
    Science Award (CTSA) network to help clinical researchers increase
    their knowledge of and access to nonhuman primates as animal models.
        Outlined below are a few of the overarching goals and priorities
    for the NPRCs, 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 an NIH CTSA program through
    their host institution. Specifically, the nonhuman primate models at
    the NPRCs often provide the critical translational link between
    research with small laboratory animals and studies involving humans. As
    the closest genetic model to humans, nonhuman primates serve in the
    process of developing new drugs, treatments, and vaccines to ensure
    safe and effective use for the Nation's public.
        It is neither cost effective nor feasible to reproduce these
    specialized facilities and expertise at every research institution, so
    the NPRCs are a valuable resource to the research community. Major
    areas of research benefiting from the resources of the NPRCs include
    AIDS, avian flu, Alzheimer's disease, Parkinson's disease, autism,
    cardiovascular disease, diabetes, obesity, asthma, and endometriosis.
    To facilitate these and other studies, the NPRC have developed a
    resource of more than 26,000 nonhuman primates, 70 percent of which are
    rhesus monkeys, the most widely used nonhuman primate for HIV research
    and a wide range of translational studies.
        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 more than 2,000 NIH funded investigators around
    the country.
        The NPRCs are also supportive of students interested in the
    biomedical research at an early age. For example, the Yerkes NPRC
    supports a program that connects with local high schools and colleges
    in Atlanta, Georgia, and provides high school science students and
    teachers with summer-long internships to participate in research
    projects taking place at their center. Other NPRCs have similar
    programs that help develop a pipeline of aspiring science students and
    teachers.
        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.
    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 are dependent on
    strong support for the P51 base grant program which is essential for
    the operational costs, and the C06 and G20 programs which support
    construction and renovation of animal facilities. Without proper
    infrastructure, the ability for animal research facilities, including
    the NPRCs, to continue to meet the high demand of the biomedical
    research community will be unsustainable.
        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. We thank you for your support
    of NIH and urge you to provide $32 billion for the agency in the fiscal
    year 2013 appropriations bill.
                                     ______

              Prepared Statement of the National Respite Coalition
        Mr. Chairman, I am Jill Kagan, Chair of the National Respite
    Coalition (NRC), a network of respite providers, family caregivers,
    national, State and local agencies and organizations who support
    respite. Thirty State respite coalitions are also affiliated with the
    NRC. This statement is presented on behalf of these organizations. The
    NRC also facilitates the Lifespan Respite Task Force, a coalition of
    more than 200 national, State and local groups who support the Lifespan
    Respite Program and its continued funding. We are requesting that the
    Subcommittee include $5 million for the Lifespan Respite Care Program
    administered by the U.S. Administration on Aging in the fiscal year
    2013 Labor, HHS, and Education appropriations bill. Given the serious
    fiscal constraints facing the Nation, this request is only one-tenth of
    the request the NRC made last year. 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, about 61.6 million family caregivers provided care at some
    time during the year. The estimated economic value of their unpaid
    contributions was approximately $450 billion, up from an estimated $375
    billion in 2007. This amount is more than total 2009 Medicaid spending,
    including both Federal and State contributions for healthcare and long-
    term services and supports ($361 billion). Including caregiving for
    children with special needs in the total would add at least 4 to 8
    million additional caregivers and another $50 to $100 billion to the
    economic value of family caregiving (Feinberg, L.; Reinhard, S., et al,
    Valuing the Invaluable: 2011 Update, The Growing Contributions and
    Costs of Family Caregiving, AARP Public Policy Institute, 2011).
        Family caregiving is not just an aging issue, but a lifespan one.
    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 care for someone under age 50 (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, military personnel who returned
    from Iraq and Afghanistan with traumatic brain injuries and other
    serious chronic and debilitating conditions, don't have full access to
    respite. Even with enactment of the new VA Family Caregiver Support
    Program, the need for respite will remain high for 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 (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, 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 lists of respite providers in their 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 (The
    Arc, 2011; National Family Caregivers Association, 2011). 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.
        An estimated 80 percent of all long-term care in the United States
    is provided at home. This percentage will only rise in the coming
    decades with greater life expectancies of individuals with disabling
    and chronic conditions living with their aging parents or other
    caregivers, 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 respite or 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, it has been well documented that family caregivers
    experience physical and emotional problems directly related to their
    caregiving responsibilities. In a 2009 survey of family caregivers, a
    majority (51 percent) who are caring for someone over age 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 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. 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 U.S. 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 family caregiver stress, most importantly
    respite, are too often out of reach or completely unavailable.
    Restrictive eligibility criteria also preclude many families from
    receiving services or continuing to receive services for which they
    once were eligible. Children with disabilities will age out of the
    system when they turn 21 and they will lose many of the services, such
    as respite. A recent survey of nearly 5,000 caregivers of individuals
    with intellectual and developmental disabilities (I/DD) conducted by
    The Arc found: the vast majority of caregivers report that they are
    suffering from physical fatigue (88 percent), emotional stress (81
    percent) and emotional upset or guilt (81 percent) some or most of the
    time; 1 out of 5 families (20 percent) report that someone in the
    family had to quit their job to stay home and support the needs of
    their family member; and more than 75 percent of family caregivers
    caring for adult children with developmental disabilities could not
    find respite services (The Arc, 2011). Respite may not exist at all in
    some States for individuals with Alzheimer's, those under age 60 with
    conditions such as ALS, MS, spinal cord or traumatic brain injuries, or
    children with serious emotional conditions.
                  respite benefits families and is cost saving
        Respite has been shown to be an effective way to reduces stress and
    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. Researchers
    at the University of Pennsylvania studied the records of more than
    28,000 children with autism ages 5 to 21 who were enrolled in Medicaid
    in 2004. They concluded that for every $1,000 States spent on respite
    services in the previous 60 days, there was an 8 percent drop in the
    odds of hospitalization (Mandell, David S., et al, 2012). 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)
        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). Another 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 2009-2012. Since 2009, 30 States have received 3-year
    $200,000 Lifespan Respite Grants from AoA since 2009. Last year, seven
    States and the District of Columbia received one-time $150,000
    expansion grants to focus on direct services, especially for those who
    are currently unserved.
        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, defined as a coordinated system of community-
    based respite services, helps States use limited resources across age
    and disability groups more effectively. Provider pools can be
    recruited, trained and shared, administrative burdens reduced by
    coordinating resources, and savings used to fund new respite services
    for families who do not qualify for any Federal or State program. The
    Government Accountability Office summarized the innovative activities
    undertaken by the first 24 States to implement Lifespan Respite Systems
    in its report to the Congress, Respite Care: Grants and Cooperative
    Agreements Awarded to Implement the Lifespan Respite Care Act. GAO-11-
    28R, Oct. 22, 2010.
              how is lifespan respite program making a difference?
        With limited funds, Lifespan Respite grantees are engaged in
    innovative activities such as:
      --In Tennessee and Rhode Island, the Lifespan Respite program is
            building respite capacity by expanding volunteer networks of
            providers by recruiting University students or Senior Corps
            volunteers or expanding the national TimeBanks model for
            establishing voluntary family cooperative respite strategies.
      --In Texas, the Lifespan Respite program has established a statewide
            Respite Coordination Center, and an online database.
      --In North Carolina, South Carolina, and Alabama, the State respite
            coalition and the Lifespan Respite programs are partnering in
            new ways with the untapped faith community to provide respite,
            especially in rural areas.
      --The North Carolina Lifespan Respite Program has challenged each of
            its 100 counties to come up with a strategy, no matter how
            great or how small, to improve respite service delivery
            locally.
      --In New Hampshire, new providers have been recruited and trained
            through partnerships with the New Hampshire National Alliance
            on Mental Illness, New Hampshire Family Voices, and the College
            of Direct Support with funding from the Department of Labor to
            expand the pool of respite providers to work with teens and
            older individuals with mental health conditions or other groups
            where respite is in short supply.
      --In Illinois and Arizona, State grantees and their partners are
            working with child and adult protective services to ensure
            respite is available on an emergency basis for the most
            vulnerable families.
        Across the board, States are building respite registries and ``no
    wrong door systems'' in collaboration with State respite coalitions and
    Aging and Disability Resource Centers to help family caregivers access
    respite and funding sources. Oklahoma, Alabama, Nevada, Tennessee and
    others are using Lifespan Respite grants to expand or implement
    participant-directed respite through coordinated voucher systems so
    that family caregivers have greater control over the type and quality
    of the respite they select. All State grantees secure commitments from
    partnering State agencies to share information and coordinate resources
    to build a seamless Lifespan Respite system for accessing respite.
        Even with these State efforts, current funding is wholly
    inadequate. Close to 90 percent of the Nation's family caregivers still
    are not receiving respite. More than half of them are caring for
    someone under age 75 with early Alzheimer's, MS, ALS, traumatic brain
    or spinal cord injury, mental health conditions, developmental
    disabilities or cancer. The goal of Lifespan Respite System is to
    coordinate respite services and funding, maximize existing resources
    and leverage new dollars in both the public and private sectors to
    build respite capacity and serve the unserved; $5 million in fiscal
    year 2013 could allow new States to start Lifespan Respite Programs and
    ensure that the 2010-2012 grantees be able to complete the work that
    they have started. As it is, given the inadequate funding for fiscal
    year 2012, only up to 5 of the original 12 2009 grantees will be funded
    again before they have had a chance to make a lasting impact.
        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 at least $5 million in the
    fiscal year 2013 Labor, HHS, Education appropriations bill so that
    Lifespan Respite Programs can be replicated and sustained in the States
    and more families, with access to respite, will be able to continue to
    play the significant role that they are fulfilling today.
                                     ______

    Prepared Statement of the National Technical Institute for the Deaf and
                       Rochester Institute of Technology
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the fiscal year 2013 budget request for NTID, one of nine
    colleges of RIT, in Rochester, New York. Created by the 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. NTID students live, study and
    socialize with more than 15,000 hearing students on the RIT campus.
    Budget Request
        On behalf of NTID, for fiscal year 2013 I would like to request
    $70,577,000, of which $68,577,000 would be for Operations and
    $2,000,000 for Construction. This funding is necessary to allow us to
    continue to support record levels of enrollment, respond to increased
    demand for access services, and address strategic initiatives.
    Construction funds will be used for major renovations to a building
    designed more than 30 years ago that houses two major NTID programs.
        I make this request within the context of definitive actions taken
    by NTID to recognize the difficult economic times in which we operate.
    In fiscal year 2012, NTID operated with essentially the same level of
    Federal support as in fiscal year 2011. We accomplished this through
    the sound management of resources that were available as well as
    reducing 3 percent of our headcount. We have continued to increase
    tuition and fees, as these are our primary sources of non-Federal
    support. Over the past 6 years, tuition and fees have increased by 40
    percent. These non-Federal revenues now represent 27 percent of our
    operating budget--up from 9 percent in 1970.
    Enrollment
        In fiscal year 2012 (Fall 2011), we attracted the largest
    enrollment in our history--1,547 students. Truly a national program,
    NTID has enrolled students from all 50 States. Over the last 6 years,
    our enrollment has increased 24 percent (297 students). By granting
    this request for fiscal year 2013, NTID will be able to serve this
    record high enrollment level. Our enrollment history over the last 6
    years is shown below:

                                                               NTID ENROLLMENTS: SIX-YEAR HISTORY
    --------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                          Deaf/Hard-of-Hearing Students                 Hearing Students
                                                                  --------------------------------------------------------------------------------   Grand
                             Fiscal Year                                                                       Interpreting                          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      1,343
    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
    2012.........................................................      1,281         42         31      1,354          160          33        193      1,547
    --------------------------------------------------------------------------------------------------------------------------------------------------------

    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. More than 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.
    Student Accomplishments
        For our graduates, over the past 5 years, an average of 92 percent
    have been placed in jobs commensurate with the level of their
    education. Of our fiscal year 2010 graduates (the most recent class for
    which numbers are available), 57 percent were employed in business and
    industry, 27 percent in education/nonprofits, and 16 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. The
    studies show that NTID graduates over their lifetimes are employed at a
    much higher rate, 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. Considering the reduced dependency on
    these Federal income support programs, the Federal investment in NTID
    not only makes a positive difference in individual earnings, but also
    returns significant societal dividends.
    Access Services
        NTID provides an access services system to meet the needs of a
    large number of deaf and hard-of-hearing students enrolled in
    baccalaureate and graduate degree programs in RIT's other colleges as
    well as students enrolled in NTID programs who take courses in the
    other colleges of RIT. Access services also are provided for events and
    activities throughout the RIT community. Access services include sign
    language interpreting, real-time captioning, classroom notetaking
    services, captioned classroom video materials, and Assistive Listening
    Services.
        As enrollments have steadily increased, so has the demand for
    access services. In fiscal year 2011, 131,065 hours of interpreting
    were provided--an increase of 18 percent compared to fiscal year 2007.
    In fiscal year 2011, 21,493 hours of real-time captioning were provided
    to students--a 39 percent increase over fiscal year 2007. The increase
    in demand is partly a result of the increase in the number of students
    enrolled in baccalaureate programs at RIT and the number of students
    with cochlear implants. In fiscal year 2012, there were 515 deaf and
    hard-of-hearing students enrolled in baccalaureate programs at RIT--a
    17 percent increase compared to fiscal year 2007. In fiscal year 2012,
    there were 331 students with cochlear implants--a 56 percent increase
    over fiscal year 2007. We will be able to address this growing demand
    with our fiscal year 2013 funding request.
    Strategic Decisions 2020
        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;
      --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; and
      --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.
    Construction Needs
        On behalf of NTID, I am requesting $2,000,000 for Construction to
    begin critical and long-overdue renovations to a 30-year-old building
    that houses 2 major programs and one-third of the NTID workforce. The
    original building design provided office space for approximately 98
    access service staff members. Today, there are 200 staff housed in the
    building. The academic program in Information and Computing Studies has
    been unable to keep their teaching laboratories, originally designed in
    1981, up to date in terms of functionality and accessibility (including
    ADA compliance). Failure to renovate this building will materially
    impact students' educational opportunities as well as the ability to
    provide them with quality access services. NTID is focused only on
    renovations that are absolutely necessary to maintain educational
    quality. For the past 2 fiscal years, most or all of NTID's
    Construction request has been diverted to Operations.
    Summary
        It is extremely important that our fiscal year 2013 funding request
    be granted in order that we might continue our mission to prepare deaf
    and hard-of-hearing people to enter the workplace and society. Our
    alumni have demonstrated that they can achieve independence, contribute
    to society, and find sustainable employment as a result of NTID.
        We are hopeful that the members of the subcommittee will agree that
    NTID, with its long history of successful stewardship of Federal funds
    and outstanding educational record of service with people who are deaf
    and hard-of-hearing, remains deserving of your support and confidence.
    Likewise, we will continue to demonstrate to the Congress and the
    American people that NTID is a proven economic investment in the future
    of young deaf and hard-of-hearing citizens. Quite simply, NTID is a
    Federal program that works.
                                     ______

    Prepared Statement of the Population Association of America/Association
                             of Population Centers
    Introduction
        Thank you, Chairman Harkin, Ranking Member Shelby, and other
    distinguished members of the Subcommittee, for this opportunity to
    express support for the National Institutes of Health (NIH), the
    National Center for Health Statistics (NCHS), and Bureau of Labor
    Statistics (BLS).
    Background on the PAA/APC and Demographic Research
        The Population Association of America (PAA)
    (www.populationassociation.org) is a scientific organization comprised
    of more than 3,000 population research professionals, including
    demographers, sociologists, statisticians, and economists. The
    Association of Population Centers (APC) (www.popcenters.org) is a
    similar organization comprised of more than 40 universities and
    research groups that foster collaborative demographic research and data
    sharing, translate basic population research for policymakers, 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 biomedical, social, and behavioral
    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 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. The 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,
    health and well being characteristics of the older population. The NIA
    Division of Behavioral and Social Research (BSR) is the primary source
    of Federal support for basic research on these topics.
        In addition to supporting an impressive research portfolio, that
    includes the prestigious Centers of Demography of Aging, the Roybal
    Centers for Translational Research on Aging, and the Research Centers
    for Minority Aging, the NIA BSR program also supports several large,
    accessible data surveys. These surveys include a new study, the
    National Health and Aging Trends Study (NHATS) will soon start
    providing detailed and nationally representative information on older
    people (and their informal caregivers) with disabilities. Another
    survey, 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 to study immediately the impact of important policy changes
    such as Medicare Part D and the opportunity to gain insight into
    emerging health-related policy issues, such as HRS data indicating an
    increase in pre-retirees self-reported rates of disability. It is so
    respected that the study is being replicated in 30 other countries,
    providing important data on how the United States compares with other
    countries whose populations are aging more rapidly. In March 2012, HRS
    took an important step forward by announcing that genetic data from
    approximately 13,000 individuals were posted to dbGAP, the NIH's online
    genetics database. The data are comprised of approximately 2.5 million
    genetic markers from each person and are now available for analysis by
    qualified researchers. These data will enhance the ability of
    researchers to track the onset and progression of diseases and
    conditions affecting the elderly.
        Despite its ability to support important research projects and
    programs, the NIA faces unique funding challenges. While the current
    dollars appropriated to NIA seem to have risen significantly since
    fiscal year 2003, when adjusted for inflation, they have decreased
    almost 18 percent in the last 9 years. Further, according to the NIH
    Almanac, out of each dollar appropriated to NIH, only 3.6 cents goes
    toward supporting the work of the NIA-compared to 16.5 cents to the
    National Cancer Institute, 14.6 cents to the National Institute of
    Allergy and Infectious Diseases, 10 cents to the National Heart, Lung,
    and Blood Institute, and 6.3 cents to the National Institute of
    Diabetes and Digestive and Kidney Diseases. Finally, despite enacting
    cost cutting measures, such as differing paylines for projects costing
    above and below $500,000 and a decrease in non-competing commitments,
    NIA's success rates remained below the NIH average in 2011.
        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 2013, 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. PAA and APC support providing a funding level
    recommended by the Friends of the National Institute on Aging and the
    Leadership Conference on Aging coalitions to provide NIA with a $300
    million increase in fiscal year 2013, bringing NIA to $1.4 billion.
    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). DBSB supports
    research in three broad areas: demography, HIV/AIDs, other sexually
    transmitted diseases, and other reproductive health; and population
    health, with focus on early life influences and policy.
        DBSB is the major supporter of the national studies that track the
    health and well-being of children and their families from childhood
    through adulthood. These studies include Fragile Families and Child
    Well Being, the first scientific study to track the health and
    development of children born to unmarried parents; the National
    Longitudinal Study of Youth, a multigenerational of health and
    development; and the National Longitudinal Study of Adolescent Health
    (Add Health), tracing the effects of childhood and adolescent exposures
    on later health. DBSB supports the prompt and widespread release of
    demographic data collected with NIH and other Federal Government
    funding through the Demographic Data Sharing and Archiving project.
        One of the most important programs the NICHD DBSB supports is the
    Research Infrastructure for Demographic and Behavioral Population
    Science (DBPop). This program promotes innovation, supports
    interdisciplinary research, translates scientific findings into
    practice, and develops the next generation of population scientists,
    while at the same time providing incentives to reduce the costs and
    increase the efficiency of research by streamlining and consolidating
    research infrastructure within and across research institutions. DBPop
    supports research at 24 private and public research institutions
    nationwide, the focal points for the demographic research field for
    innovative research and training and the development and dissemination
    of widely used large-scale databases.
        NIH-funded demographic research provides critical scientific
    knowledge on issues of greatest consequence for American families:
    marriage and childbearing, childcare, work-family conflicts, and family
    and household behavior. Demographic research is having a large impact
    in public health, particularly on issues such as infant and child
    health and development, and adolescent and young adult health, and
    health disparities. Research supported by DBSB has revealed the
    critical role of marriage and stable families in ensuring that children
    grow up healthy, achieving developmental and educational milestones.
    DBSB supported projects provides policymakers and communities with
    evidence-based knowledge on the critical intervention points and
    effective interventions to promote health. An example is a new finding
    from DBSB supported research on low birth weight, a condition
    associated with higher risk of a number of serious medical
    complications and learning disabilities for children. Based on an
    analysis of more than 5 million medical records, researchers found that
    pregnant women assaulted by an intimate partner are at increased risk
    of giving birth to infants at lower birth weights. This finding was
    adopted by the American College of Obstetricians and Gynecologists to
    develop physician training materials for screening patients for
    intimate partner violence.
        With additional support in fiscal year 2013, 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 is one
    of the lowest of the NIH Institutes and Centers. 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 DBPop.
    For these reasons, PAA and APC endorse the funding level recommended by
    the Friends of the NICHD to fund the Institute at $1.37 billion in
    fiscal year 2013.
    National Children's Study
        The PAA and APC are concerned about language included in the
    President's fiscal year 2013 proposed budget regarding the National
    Children's Study (NCS). Specifically, our organizations are troubled
    that in its budget, NIH suggested abandoning its previous commitment to
    a national probability sample because the study's recruitment goals
    have fallen short and because cost containment remains a priority. Our
    organizations have written to the NIH, urging them to work with experts
    in probability sampling and to conduct research to evaluate the
    feasibility and scientific value of any new sampling strategy--
    particularly as it potentially affects the inclusion of vulnerable,
    hard-to-reach populations, such as the children of legal and illegal
    immigrants. We also encourage the agency to contract with an
    independent scientific agency, such as the National Academy of
    Sciences, to assess any new proposed study designs. Given the magnitude
    of the study's scope, cost, and potential value to the scientific
    research community in particular, PAA and APC believe the agency should
    proceed cautiously before dramatic changes are made to this
    consequential, national study.
    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 policymakers,
    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, the Congress and the new administration worked together to
    give NCHS adequate resources and avert implementation of these
    draconian measures. Also, funding from the Prevention and Public Health
    Fund has been an invaluable source of support for the agency in fiscal
    year 2011 and fiscal year 2012, providing much needed funding to, for
    example, add components to NHANES and the National Hospital Ambulatory
    Medical Care Survey to assess physical activity in children and gather
    information on patients with heart disease and stroke, respectively.
    Despite the recent infusion of vital funding, the agency's long-term
    fiscal stability remains unstable.
        PAA and APC, as members of The Friends of NCHS, support the
    administration's request for fiscal year 2013, $162 million, a $23
    million (17 percent) increase over the agency's fiscal year 2012
    appropriation. This funding increase will fully support NCHS's ongoing
    seminal surveys, enable the purchase of vital statistics data for 12
    months within the calendar year, and allow the agency to proceed with
    the goal of fully implementing electronic death records in all States
    for more timely and accurate vital statistics collection.
    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 support the administration's request for BLS, which would
    provide the agency with a total of $647 million in fiscal year 2013. We
    are, however, opposed to the administration's proposed $6 million cut
    to the National Longitudinal Surveys (NLS) program within BLS in fiscal
    year 2013. A cut of this magnitude would force triennial fielding,
    which will create serious respondent recall problems and degrade data
    quality.
        NLS data are essential to understanding how labor market
    experiences evolve over the life-cycle, and how labor market outcomes
    differ for Hispanics and non-Hispanics. The NLS data have been
    collected for 47 years and are essential to understanding how labor
    market experiences and outcomes evolve and differ. The proposed BLS
    budget cuts will be devastating to the social science research
    community and to policymakers who rely on the survey's findings. We are
    pleased that the BLS restored funding to the NLS that it had initially
    proposed to cut in fiscal year 2012. We hope that the Congress will
    reject this proposed cut in fiscal year 2013.
    Summary of fiscal year 2013 Recommendations
        In sum, the PAA and APC asks the Subcommittee to consider our
    requests for fiscal year 2013:
      --provide the NIH with $32 billion;
      --provide the NIA with $1.4 billion;
      --provide the NICHD with $1.37 billion;
      --support the administration's request for the NCHS, $162 million;
            and
      --reject the administration's proposed $6 million cut to the National
            Longitudinal Studies program at the Bureau of Labor Statistics.
        Thank you for considering our requests and for supporting Federal
    programs that benefit the population sciences.
                                     ______

      Prepared Statement of the Physician Assistant Education Association
        On behalf of its membership, 164 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 2013 appropriations for PA education and other health
    professionals programs that are authorized through Title VII and VIII
    of the Public Health Service Act and administered through the Health
    Resources and Services Administration (HRSA).
        PAEA is a member of the Health Professions and Nursing Education
    Coalition (HPNEC) and we support the HPNEC recommendation for funding
    of at least $520 million in fiscal year 2013 for the health professions
    education programs authorized under Title VII and VIII. HPNEC is an
    informal alliance of more than 60 national organizations representing
    schools, programs, health professionals and students dedicated to
    ensuring that the healthcare workforce is trained to meet the needs of
    the country's growing, aging and increasingly diverse population.
    The Need for Increased Federal Funding for Physician Assistants
        PAs are licensed healthcare professionals who practice medicine as
    members of a team in concert with a supervising physician. PAs are
    medical professionals trained at the graduate level who have the
    advanced training to autonomously diagnose, treat, and prescribe
    medication for patients in a cost-effective manner. PAs typically
    complete their education and training within 27 months, and can enter
    the workforce much more quickly than other post-graduate health
    professions. PAs can only help meet the challenges facing America's
    healthcare system if appropriate resources are available to meet the
    demand for PA education. Title VII funding is the sole source of
    Federal dollars available for PA education.
        The way that PAs are trained in the United States--the caliber of
    the institutions and the expertise of the educators--is the gold-
    standard throughout the world. However, clinical site availability is
    one of the profession's critical unmet needs, as schools are struggling
    to train the growing classes of PAs. In order to support the growth of
    the profession and enable PAs to enter the workforce, additional
    Federal funding is needed to build infrastructure and improve the
    quality of clinical sites used to train PAs. Incentives for appropriate
    locations to offer their space can make a significant difference in
    helping PAs complete their education in a timely manner and begin
    treating patients. Similarly, a lack of preceptors is impeding the PA
    educational system's ability to train adequate numbers of PAs. Choosing
    a teaching career must be a practical and financially desirable option
    for practicing and returning PAs in order for the profession to grow
    and meet the demand for care. Financial incentives can help create such
    an environment, ensuring the United States can increase the supply of
    primary care clinicians and provide comprehensive clinical experiences
    for students.
    Physician Assistant Practice
        The PA practice model is, by design, a team-based approach to
    patient care and fits well into the patient-centered, medical home and
    accountable care organization models expected to transform our reformed
    healthcare system. The profession is projected to continue to grow as a
    result of the projected shortage of physicians, the demand for services
    from an aging population, and the continuously strong PA applicant
    pool.
        The base of applicants for PA programs has grown by more than 10
    percent each year since 2000, and 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-training, the PA profession is well-
    positioned to help fill projected shortages of available healthcare
    professionals.
        The need for generalist medical training, workforce diversity and
    health providers willing to practice in underserved areas are key
    priorities identified by HRSA. Studies have found that health
    professionals from underserved areas are three to five times more
    likely to return to underserved areas to provide care. To provide the
    highest quality care, it is increasingly important that the health
    workforce better represent America's changing demographics, as well as
    addresses issues of disparities in healthcare. PA programs have been
    successful in attracting students from underrepresented minority groups
    and disadvantaged backgrounds. Title VII grants are also weighted
    toward programs with a high success rate of placing PAs in underserved
    communities and are helping the profession make even greater strides
    toward these goals.
    Title VII Funding
        Title VII funding is the only potential source of Federal funding
    for PA programs. These Federal dollars play a crucial role in
    developing and supporting PA education programs, and are helping to
    facilitate the growth of a profession that meets many of the 21st
    century health system demands for improvements in quality, access and
    cost of care.
        Title VII funding fills a specific need for both curriculum and
    faculty development. These grants enhance primary care clinical
    training and education, assist PA programs with recruiting applicants
    from minority and disadvantaged backgrounds, and fund innovative
    programs that focus on educating a culturally competent workforce.
    Title VII funding also increases the likelihood that PA students will
    practice in medically underserved communities with health professional
    shortages.
        PA programs have already used Title VII funds to creatively expand
    care to underserved areas and populations, as well as develop a diverse
    PA workforce.
      --A Texas program has used its PA training grant to support a distant
            site in an underserved area. This grant provides assistance to
            the program to recruit, educate and train 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 relationships with three service-
            learning partners, develop new partnerships with 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
            current health behavior educational curriculum and HIV/STD
            training. It was 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 diagnosis
            and management.
      --A South Carolina program has developed a model program that offers
            a 2-year academic fellowship for recent PA graduates with at
            least 1 year of clinical experience. To further enhance an
            evidence-based approach to education and practice, two specific
            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.
        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 allocation in the
    appropriations process for PA programs at the primary care medicine
    line. This funding will enhance capabilities to train a growing PA
    workforce and is likely to increase the pool of faculty positions as PA
    programs will now be eligible for faculty loan repayment. As is true of
    many post-graduate programs, loan burdens are barriers to physician
    assistant entry into academia.
        In fiscal year 2013, a new priority for PA training grants will
    focus on training 1,400 additional physician assistants over a 5 year
    period, by providing funding to ``develop the infrastructure necessary
    to expand and improve teaching quality at clinical sites for Physician
    Assistant students.'' (Department of Health and Human Services, Fiscal
    Year 2013, HRSA Justification for Estimates for Appropriations
    Committee, Executive Summary). The future of the profession and its
    ability to meet patients' demands for care rests in large part on the
    ability to train the next generation of PAs. Title VII provides the
    support needed to ensure both the quantity and quality of teaching
    staff in the United States will continue to reflect the highest
    educational standards in the world.
    The History of Physician Assistant Education
        The first physician assistant class of 1965 was comprised of Navy
    corpsmen who served during the Vietnam war and applied their direct
    medical experience in the military to practicing primary care. Since
    those first three PAs graduated from Duke University, the profession
    has grown dramatically. Today, there are 164 accredited PA programs
    which graduate more than 6,000 new PAs each year, and more than 60 new
    programs are in the pipeline.
        The growth rate in the applicant pool is remarkable. Tracked via
    the Centralized Application Service (CASPA), in March 2006 there were a
    total of 7,608 applicants to PA education programs; as of March 2011,
    there were 16,112--a 112 percent increase over the past 5 years.
        One reason for the appeal of the PA profession is that the average
    PA education program is 27 months in length, significantly shorter than
    other post-graduate programs. Typically, 1 year is devoted to classroom
    study and approximately 15 months are devoted to clinical rotations.
    The curriculum generally includes 400 hours of basic sciences and
    nearly 600 hours of clinical medicine. Within the healthcare workforce,
    only physicians receive more clinical education than PAs.
        Federal support has been critical to the development of the
    profession at several key points, including the creation of the PAEA
    Faculty Development Institute, which provides training for new and
    experienced faculty to improve teaching quality and encourage sharing
    of curricular resources. To allow the profession to meet the obvious
    and growing demands of students and their future patients, continued
    funding is critical.
    Honoring the Roots of the PA Profession
        As the first class of PAs demonstrated, veterans with medical
    backgrounds are excellent potential candidates for PA programs due to
    their leadership and professional skills. Special incentives for both
    PA schools and students with a military background can help expedite
    the process of matriculation into the educational system. PAEA and
    other interested stakeholders are currently working with HRSA to
    identify best practices in ``bridge programs'' and career counseling
    services provided to service members and veterans interested in a
    health career. Additionally, there is a new priority included in the
    fiscal year 2013 PA training grant to identify best practices for:
      --Expedited curricula;
      --Enhanced veteran recruiting;
      --Enhanced retention; and
      --Enhanced mentoring services for veterans.
        This program ensures that our Nation's service members with medical
    skill and specialties are able to transition into a career in the
    civilian workforce when they leave the military. They, too, can
    contribute to a solution to the primary healthcare workforce shortage
    if given the right opportunities.
    Summary of fiscal year 2013 Funding Recommendations
        The Physician Assistant Education Association requests that the
    Appropriations Committee support funding for Title VII and VIII health
    professions programs at a minimum of $520 million for fiscal year 2013.
    This level of funding is needed to adequately support the Nation's
    demand for primary care practitioners, particularly those who will
    practice in medically underserved areas and serve vulnerable
    populations. The Physician Assistant Education Association also
    respectfully asks for support for the $12 million allocation in the
    President's fiscal year 2013 budget request for PA education programs.
        We thank the members of the subcommittee for their continued
    support of the health professions and look forward to working with you
    to solve the Nation's health workforce shortage and meet the need for
    high quality, affordable healthcare accessible to all. We appreciate
    the opportunity to present the Physician Assistant Education
    Association's fiscal year 2013 funding recommendation.
                                     ______

                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 2013 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 2013 to
    help promote eye health and prevent eye disease and vision loss:
      --Provide at least $1 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 at least $645 million in fiscal year 2013 to sustain
            programs under the Maternal and Child Health (MCH) Block Grant.
      --Provide $730 million to the National Eye Institute (NEI) in order
            to bolster efforts to identify the underlying causes of eye
            disease and vision loss, improve early detection and diagnosis,
            and advance prevention and treatment efforts.
    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 2013 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.
        Prevent Blindness America requests at least $1 million in fiscal
    year 2013 to maintain vision and eye health efforts of the CDC.
    Adequate fiscal year 2013 resources will allow the CDC to continue to
    address the growing public health threat of preventable chronic eye
    disease and vision loss among at-risk and underserved populations
    through increased coordination and integration of vision and eye health
    at State and local health departments, and through community health
    centers and rural services.
    Integrating Vision Health into Broader Disease Prevention and Health
            Promotion Efforts
        A cornerstone activity 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 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.
        For example, State-based programs to prevent and reduce diabetes
    should include efforts to educate patients and healthcare providers on
    the relationship between diabetes and certain eye problems, such as
    diabetic retinopathy, glaucoma, and cataracts. Similarly, State
    initiatives to reduce the incidence of falls among older Americans
    should include vision screening, as studies have found that one of the
    leading causes of falls and injuries among older adults is unaddressed
    vision problems.
        To advance State-based vision health integration, funding to the
    CDC has supported two joint efforts, one in New York and the other in
    Texas, focused on integrating vision-related services at the State and
    local level. Working together, the State health departments of these
    States and the State-based affiliates of Prevent Blindness America
    promoted vision loss prevention strategies among community groups and
    vision partners, and established State vision preservation plans. The
    goal of these integration efforts was 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
    were used more efficiently, eye health problems and vision loss were
    reduced, and the overall health and well-being of individuals and
    communities were improved.
    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.\3\
    ---------------------------------------------------------------------------
        \3\ ``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 MCHB established the National Center for Children's
    Vision and Eye Health (the Center), a national vision health
    collaborative effort aimed at developing the public health
    infrastructure necessary to promote eye health and ensure access to a
    continuum of eye care for young children.
        The Center has established a National Expert Panel comprised of
    experts in ophthalmology, optometry, pediatrics, public health,
    childcare, academia, family advocacy, and others who have a stake in
    the field of children's vision. Members of the National Expert Panel
    provide recommendations toward national guidelines for quality
    improvement strategies, vision screening and developing a continuum of
    children's vision and eye health. In addition, they serve as advisors
    to the Center as it pursues its goals and objectives.
        With this support the Center, will continue to:
      --Provide national leadership in dissemination of best practices,
            infrastructure development, professional education, and
            national vision screening guidelines that ensure a continuum of
            vision and eye healthcare for children;
      --Advance State-based performance improvement systems, screening
            guidelines, and a mechanism for uniform data collection and
            reporting; and
      --Provide technical assistance to States in the implementation of
            strategies for vision screening, establishing quality
            improvement measures, and improving mechanisms for
            surveillance.
        Prevent Blindness America also requests at least $645 million in
    fiscal year 2013 to sustain programs under the MCH Block Grant. The MCH
    Block Grant enables States to expand critical healthcare services to
    millions of pregnant women, infants and children, including those with
    special healthcare needs. In addition to direct services, the MCH Block
    Grant supports vital programs, preventive and systems building services
    needed to promote optimal health.
    Advance and Expand Vision Research Opportunities
        Prevent Blindness America calls upon the Subcommittee to provide
    $730 million 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.
        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 the 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 2013 funding for the CDC's vision and eye health efforts,
    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 the Pulmonary Hypertension Association
    Pulmonary Hypertension Association Fiscal Year 2013 LHHS Appropriations
            Recommendations
        $7 billion for HRSA, an increase of $500 million over fiscal year
    2012, including proportional increases for the Healthcare Systems
    Bureau and Organ Donation and Transplantation activities to promote PH
    education amongst healthcare providers and improve health outcomes for
    PH transplant patients.
        $7.8 billion for CDC, an increase of $1.7 billion over fiscal year
    2012, including a proportional increase for the National Center for
    Chronic Disease Prevention and Health Promotion (NCCDPHP) to facilitate
    critical PH education and awareness activities.
        $32 billion for NIH, an increase of $1.3 billion over fiscal year
    2012, including proportional increases for the National Heart, Lung,
    and Blood Institute (NHLBI); National Center for Advancing
    Translational Sciences (NCATS); Office of the Director (OD); and other
    NIH Institutes and Centers to facilitate adequate growth in the
    pulmonary hypertension (PH) research portfolio.
        Chairman Harkin, Ranking Member Shelby, and distinguished members
    of the Subcommittee, thank you for the opportunity to submit testimony
    on behalf of PHA. It is my honor to represent the hundreds of thousands
    of Americans who are affected by this devastating disease.
        I'd like to open with a personal story. Several years ago, I had
    the opportunity to visit the Pulmonary Hypertension Association of
    China and the Taiwan Foundation for Rare Disorders. On my return
    flight, I began to speak with the passenger in the seat next to mine, a
    resident of Taipei. He told me that he had once lived in Bethesda. I
    asked him what brought him back to Taiwan. He said, ``I'm a research
    scientist, an oncologist. I used to work at NIH. The research money
    dried up in the United States. It's flowing in Asia.'' To me, those
    four short sentences sum up the dangers of allowing a carefully built
    infrastructure to decline. Loss of leadership in science today will
    mean loss of quality healthcare and business markets tomorrow.
        PHA has served the PH community for more than 20 years. In 1990,
    three PH patients found each other with the help of the National
    Organization for Rare Disorders and shortly thereafter founded PHA. At
    that time, the condition was largely unknown amongst the general public
    and within the medical community; there were fewer than 200 diagnosed
    cases of the disease. Since then, PHA has grown into a nationwide
    network of more than 20,000 members and supporters, including more than
    230 support groups across the country.
        PHA is dedicated to improving treatment options and finding cures
    for PH, and supporting affected individuals through coordinated
    research, education, and advocacy activities. Since 1996, nine
    medications for the treatment of PH have been approved by the Food and
    Drug Administration (FDA), eight of those since 2001. These innovative
    treatment options represent important steps forward in the medical
    understanding of PH and the care of PH patients, but more needs to be
    done to end the suffering caused by this disease.
        PH is a debilitating 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. Symptoms of PH include shortness of
    breath, fatigue, chest pain, dizziness and fainting.
        I would like to extend my sincere gratitude to the Subcommittee for
    your historic support of PH programs at HRSA, CDC, and NIH. Thanks to
    your leadership, the PH research portfolio at NIH has advanced and
    improved our understanding of the disease, and awareness of PH by the
    general public has led to earlier diagnosis and improved health
    outcomes for patients. Please continue to support PH activities moving
    forward.
    Health Resources and Services Administration
        PHA joins the other voluntary patient and medical organizations
    comprising the public health community in requesting that you support
    HRSA by providing the agency with an appropriation of $7 billion in
    fiscal year 2013. Such a funding increase would allow the agency to
    implement a PH education and awareness campaign focused on healthcare
    providers, and take on activities that would improve health outcomes
    for PH patients who rely on heart or lung transplantation.
        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 2013, PHA recommends an appropriation of $26 million for
    this important program. Furthermore, we ask for your support in
    encouraging HRSA, specifically the United Network for Organ Sharing, to
    engage in active and meaningful dialogue with medical experts at the
    REVEAL Registry. Such a dialogue has the potential to improve the
    methodology used to determine lung transplantation eligibility for PH
    patients and to improve survivability and health outcomes following a
    transplantation procedure.
    Centers for Disease Control and Prevention
        PHA joins the other voluntary patient and medical organizations
    comprising the public health community in requesting that you support
    CDC by providing the agency with an appropriation of $7.8 billion in
    fiscal year 2013. Such a funding increase would allow CDC to undertake
    critical PH education and awareness activities, which would promote
    early detection and appropriate intervention for PH patients.
        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
    and citizens in rural areas remote from medical centers with PH
    expertise. 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 2013, we ask the Subcommittee to encourage CDC to
    partner with us once again to collaborate on and support PH education
    and awareness activities. This would make a tremendous difference in
    the fight against this devastating disease.
    National Institutes of Health
        PHA joins the other voluntary patient and medical organizations
    comprising the public health community in requesting that you support
    NIH by providing the agency with an appropriation of $32 billion in
    fiscal year 2013. This modest 4 percent funding increase would ensure
    that biomedical research inflation does not result in a loss of
    purchasing power at NIH, critical new initiatives like the Cures
    Acceleration Network (CAN) are adequately supported, and the PH
    research portfolio can continue to progress.
        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. Sustained investment in basic, translational,
    and clinical research can ensure that we capitalize on recent
    advancement and emerging opportunities to speed the discovery of
    improved treatment option and cures.
        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 connections 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 ask that
    you provide NHLBI with sufficient resources and encouragement to move
    forward with the establishment of a PH network in fiscal year 2013.
        We applaud the recent establishment of the National Center for
    Advancing Translational Sciences (NCATS) at NIH. Housing translational
    research activities at a single Center at NIH will allow these programs
    to achieve new levels of success. Initiatives like CAN are critical to
    overhauling the translational research process and overcoming the
    research ``valley of death'' that currently plagues treatment
    development. In addition, new efforts like taking the lead on drug
    repurposement hold the potential to speed new treatment to patients,
    particularly patients who struggle with rare or neglected diseases. We
    ask that you support NCATS and provide adequate resources for the
    Center in fiscal year 2013.
    Social Security Administration
        We would like to thank the Subcommittee for its commitment to
    addressing the longstanding backlog of disability claims at the Social
    Security Administration (SSA). We greatly appreciate this investment as
    a growing number of our patients are applying for disability coverage.
    Recently, SSA convened an Institute of Medicine (IOM) 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 last year. As we continue to work with
    SSA on this important effort, we encourage the Congress to continue to
    support this process moving forward.
        On a related note, we continue to applaud SSA for their leadership
    of the Compassionate Allowances Initiative (CAL), which seeks to speed
    the process of accessing disability benefits for patients diagnosed
    with serious conditions that undoubtedly leave them disabled. Last
    year, CAL concluded its initial roll out by reviewing conditions and
    designating a list of 113 as ``compassionate allowances.'' While we
    understand CAL will continue to designate conditions as compassionate
    allowances moving forward, it is unclear what this process will be now
    that the initial program roll out has concluded. We encourage you to
    work with CAL and stakeholder organizations to lay out the process for
    expansion of this important initiative moving forward.
        Thank you for your time and your consideration of our requests.
    Please contact me if you have any questions or if you require any
    additional information.
                                     ______

                     Prepared Statement of Research!America
        Thank you, Chairman Harkin and Ranking Member Shelby, for the
    opportunity to submit testimony regarding fiscal year 2013
    appropriations under the jurisdiction of the Subcommittee on Labor,
    Health and Human Services, Education, and Related Agencies. Our
    testimony will highlight the strength of public support for increased
    funding of several agencies within the Department of Health and Human
    Services (DHHS): the National Institutes of Health (NIH), the Centers
    for Disease Control and Prevention (CDC), and the Agency for Healthcare
    Research and Quality (AHRQ)--agencies that play an essential role in
    advancing health, fueling business development and job growth, and
    combating spiraling healthcare costs.
        Research!America appreciates the subcommittee's past support for
    research conducted and supported by NIH, CDC and AHRQ. We appreciate
    that NIH received a budget increase in fiscal year 2012. Unfortunately,
    CDC and AHRQ received budget cuts, muting the capacity of these
    agencies to contribute to our Nation's research enterprise and fulfill
    other facets of their crucial missions.
        It is counterproductive to discontinue our Nation's long-standing
    commitment to strong and sustained investments in research for health.
    Studies have shown that health research is a tool with the unique, dual
    capability of growing the economy and reducing Federal healthcare
    costs. And for research to be effective, it must be sustained. Progress
    is an iterative process that requires consistent support. We urge the
    subcommittee to provide funding increases for NIH, CDC and AHRQ,
    preventing further erosion in their capabilities and enabling them to
    continue to contribute meaningfully to the health and economic well-
    being of Americans.
        In January 2013, the sequester is scheduled to be triggered, which
    would have a disastrous impact on these agencies, the health of
    Americans and our economy. NIH alone would stand to lose billions in
    funding, most of which is used to support extramural grants at
    institutions in every State. Such dramatic cuts would greatly hamper
    medical innovation, depriving patients of new potential cures and
    treatments. New investigators are already facing unprecedented
    challenges in receiving funding--a situation that would become even
    more dire in the face of a sequester. Virtually stagnant funding for
    health research has already diminished our Nation's global
    competiveness, and the sequester may result in the United States
    forfeiting its role as the world leader in research for health.
        Each agency plays a unique role in promoting the best interests of
    our Nation:
      --Research funded by the National Institutes of Health at
            universities, academic medical centers, independent research
            institutions and small businesses across the country lays the
            foundation for new products development by the private sector.
            Since much of the research NIH supports is at the non-
            commercial stages of the research pipeline, NIH funding does
            not compete with, but rather sets the stage for, critical
            private sector investment and development. Recent studies have
            demonstrated that the NIH is an immense driver of job creation
            and economic development in every State. One study found that
            the NIH supported 432,000 jobs in 2011 alone.\1\ Overall,
            Federal and private investments are complementary funding
            streams that lead to business development, job growth and
            beneficial medical advances. Taxpayer-funded research through
            the NIH has allowed us to convert HIV/AIDS from a death
            sentence to a treatable chronic disease; has reduced the costly
            toll of premature heart disease death and disability and made
            childhood cancers treatable diagnoses; the secrets of diabetes,
            Alzheimer's, Parkinson's and host of cancers and many other
            diseases can and will be unlocked by science--the question is
            not if but when we will achieve our goals in these arenas.
            Whether viewed through the lens of advancing the health, well-
            being and longevity of Americans or of gaining control over
            health spending that is driving up the Federal budget,
            overcoming these health threats must remain a top priority.
    ---------------------------------------------------------------------------
        \1\ United for Medical Research. NIH's Role in Sustaining the U.S.
    Economy A 2011 Update. http://www.unitedformedicalresearch.com/wp-
    content/uploads/2012/03/NIHs-Role-in-Sustaining-the-US-Economy-
    2011.pdf.
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      --The Centers of Disease Control and Prevention engage in research
            that stems deadly and costly pandemics, bolsters our Nation's
            defenses against bioterrorism, and helps prevent the onset of
            debilitating and expensive diseases. The CDC is the Nation's
            first responder to lethal viruses and infections, including
            life-threatening and costly drug-resistant infections that pose
            a particular threat to children and young adults, as well as
            investigating tragic phenomena like cancer clusters. Due to
            cuts in recent years, the CDC is functioning with one hand tied
            behind its back, even as health challenges like the obesity
            epidemic, autism and infectious disease outbreaks capture
            headlines and ruin lives.
      --Research supported by the Agency for Healthcare Research and
            Quality identifies inefficiencies in healthcare delivery that
            inflate the cost of public and private insurance. AHRQ-
            supported research also improves the quality of care to help
            reduce the length and intensity of disability and disease, and
            helps patients and physicians make informed treatment
            decisions, improving outcomes and reducing costly ``false
            starts'' in the provision of healthcare services. Given the
            enormity of the challenge of inefficiency in healthcare
            delivery, AHRQ is severely under-powered.
        As national polling commissioned by Research!America in October
    2011 demonstrates, the American public strongly supports robust
    investment in research to improve health. The poll, which surveyed a
    nationwide mix of self-described conservatives (36.8 percent), liberals
    (27.9 percent) and moderates (35.3 percent), found that:
      --86 percent of Americans say that investing in health research is
            important to job creation and economic recovery;
      --77 percent of Americans think the United States is losing its
            global competitive edge in science, technology and innovation;
      --50 percent of Americans would be willing to pay higher taxes if
            they were certain that all of the money would be spent on
            additional medical research;
      --78 percent of Americans say the United States is not spending
            enough of our healthcare dollars on research;
      --58 percent of Americans believe we are not making enough progress
            in medical research in the United States;
      --79 percent of Americans agree with the following statement: ``Even
            if it brings no immediate benefits, basic scientific research
            that advances the frontiers of knowledge is necessary and
            should be supported by the Federal Government'';
      --92 percent of Americans say it is important that our Nation
            supports research that focuses on how well the healthcare
            system is functioning;
      --82 percent of Americans say that the Government should play a role
            in prevention research; and
      --54 percent of Americans say research to improve health is part of
            the solution to rising healthcare costs.
        These findings bear out some important points:
      --Americans not only value medical research that leads directly to
            advances in healthcare, they appreciate the importance of basic
            research that lays the groundwork for these discoveries, as
            well as health research, which focuses on such goals as
            improving healthcare delivery and identifying effective
            prevention strategies.
      --Americans recognize that our Nation's hold on global leadership in
            the R&D arena is precarious. Our leadership position will
            evaporate if policymakers shortchange Government investment in
            the basic research and development that fuels private sector
            innovation. As it stands, China, Brazil and India are rapidly
            increasing investments in R&D, while the United States invests
            less than 3 percent of its GDP.
      --Americans know that our Nation's best weapon against spiraling
            healthcare costs is research. Ignoring growing healthcare costs
            is a ticket to disaster. Alzheimer's disease alone is projected
            to cost the Federal Government trillions of dollars over the
            next 20 years. Ultimately, we must prevent and cure disease in
            order to tackle the costs associated with it.
        Beyond research focused on domestic health issues, Americans
    strongly support global health research. Some 78 percent of Americans
    say that it is important that the United States work to improve health
    globally through research and innovation. Compassion and common sense
    converge in the global health R&D arena. Tuberculosis alone represents
    a major humanitarian crisis, taking 1.8 million lives a year and
    leaving countless orphans and widows.
        In addition to the ethical imperative driving global health R&D,
    such research benefits our troops abroad and is 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.\2\ In an interconnected world, U.S. global health
    research saves lives at home and abroad. And like domestically focused
    research, global health research conducted in the United States drives
    new businesses and new jobs. Further, major global health threats
    individually and collectively represent one of the most significant
    destabilizing forces in the developing world. Diseases like HIV/AIDS,
    tuberculosis and malaria take the lives of tens of millions working-
    aged adults in developing countries, leaving poverty and social and
    political instability in their wake. Ultimately, global health is a
    global security, global development and global humanitarian assistance
    issue. Reducing the burden of disease in developing countries is a
    stabilization strategy that can save millions of precious lives and
    hundreds of billions of dollars going forward.
    ---------------------------------------------------------------------------
        \2\ 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.
    ---------------------------------------------------------------------------
        There are few Federal investments that confer as many benefits as
    research to improve health--new cures, new businesses, new jobs, new
    answers to spiraling healthcare costs, new tools to promote
    humanitarian and national security goals, and new fuel to drive U.S.
    leadership in a global economy increasingly shaped by the ability of
    competitor countries to continuously innovate.
        Research!America appreciates the difficult task facing the
    subcommittee as it seeks to simultaneously confront the budget deficit,
    strengthen the United States and promote the well-being of Americans.
    We firmly believe that investing in NIH, CDC, and AHRQ is a means of
    advancing all three of these fundamental goals.
        Thank you, Mr. Chairman, Ranking Member Shelby, and members of the
    subcommittee.
                                     ______

     Prepared Statement of the Research Working Group of the Federal AIDS
                               Policy Partnership
        Chairman Harkin, Ranking Member Shelby and members of the
    subcommittee, thank you for the opportunity to provide testimony on the
    National Institutes of Health (NIH) budget overall and for AIDS
    research in fiscal year 2013. Tomorrow's scientific and medical
    breakthroughs depend on your vision, leadership and commitment towards
    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 2013 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 promising vaccine candidates
    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 more than 1 million HIV-infected people in the United
    States, the highest number in the epidemic's 31-year history;
    additionally more than 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. Globally,
    around 34 million people are living with HIV; 3.4 million of them are
    children.\1\ 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 this summer, 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 global epidemic.
    ---------------------------------------------------------------------------
        \1\ http://www.avert.org/worlstatinfo.htm.
    ---------------------------------------------------------------------------
        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 HIV 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. The
    ultimate goal of a cure for HIV infection increasingly seems within
    reach based on scientific advances facilitated by NIH funding. Several
    major new NIH-supported projects are underway and they have helped spur
    international efforts to secure additional non-NIH financing and create
    a global strategy for HIV cure-related research.
        Increased funding for NIH in fiscal year 2013 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. NIH Director
    Francis Collins has stated that for every dollar invested in NIH
    research generates more than $2 for that local community within the
    same year.\2\ Strong, sustained NIH funding is a critical national
    priority that will foster better health and economic revitalization.
    ---------------------------------------------------------------------------
        \2\ NIH Fiscal Year 2012 Congressional Budget Justification. http:/
    /officeofbudget.od.nih.gov/pdfs/FY12/Volume%201%20-%20Overview.pdf.
    ---------------------------------------------------------------------------
        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 at home and around the world. 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 the Congress to sustain what has
    been a 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 2013. 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 the Ryan White Medical Providers Coalition
    Introduction
        I am Dr. Jim Raper, an HIV medical provider and Director of the
    1917 Clinic, a comprehensive HIV clinic funded in part by Part C of the
    Ryan White Program 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 Providers Coalition, the HIV
    Medicine Association, the CAEAR Coalition, and the American Academy of
    HIV Medicine estimate that approximately $461 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 $285.8 million for Ryan White
    Part C programs in fiscal year 2013, the authorized amount that the
    Congress legislated 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 who deliver 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, and we advocate for a full range
    of primary care services for patients living with HIV.
        Adequate funding for Part C of the Ryan White Program is essential
    to providing both effective and efficient care for individuals living
    with HIV/AIDS, and we thank the Subcommittee for its support of the
    Ryan White Part C Program in fiscal year 2012. And while we also are
    grateful for the $15 million in additional funding that the
    administration invested in Part C programs in honor of World AIDS Day
    2011 and its request to invest additional funding in fiscal year 2013,
    the economic pressures that Part C clinics face in order to serve all
    patients requesting HIV care and treatment remain significant.
    HIV Treatment is HIV Prevention: Part C Programs Save Both Lives and
            Money
        Investing in Part C services improves lives and saves money. 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. Part C
    providers serve more than 255,000 patients with HIV/AIDS per year, or
    over half of the individuals in regular care and treatment.
        The Ryan White Program has supported the development of expert HIV
    care and treatment programs that provide medical homes for patients
    with this serious, chronic condition. In 2011, a ground-breaking
    clinical trial (HPTN 052)--named the scientific breakthrough of the
    year by Science magazine--found that HIV treatment not only saves
    patient lives, but also reduces HIV transmission by more than 96
    percent--proving that HIV treatment is also HIV prevention.
        Now is the time to support the comprehensive medical care provided
    by Ryan White Part C clinics to save lives and better address the HIV
    epidemic in the United States. 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.
        Additionally, in the face of the potentially significant expansion
    of healthcare coverage for low income Americans through the Affordable
    Care Act, maintaining the infrastructure and expertise of Ryan White
    Part C programs is particularly important because these centers of
    excellence will help keep patients engaged in essential HIV care and
    treatment while the system around them is transforming.
    Patient Loads Are Increasing at an Unsustainable Rate
        Patient loads have been increasing at Part C clinics nationwide.
    This continued 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/.
    ---------------------------------------------------------------------------
        Last year in New York, when St. Vincent's Hospital in New York City
    closed, a Part C clinic at St. Luke's-Roosevelt Hospital had to absorb
    almost the entire St. Vincent's HIV/AIDS clinic, approximately 1,000
    patients, over the course of just a few days. Additional clinics have
    closed, such as one in Sonoma County, California, and others having
    longer wait times for new patient appointments (8 weeks long in some
    places). Other programs, such as one Part C clinic in Arizona, are
    deciding whether to close their doors to new patients entirely because
    of an inability to treat additional patients within existing financial
    and HIV workforce resources.
        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, economic pressures are
    creating a crisis. 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 the thousands of patients in HIV/AIDS care and
    treatment and the Part C programs nationwide that are struggling to
    serve them with extremely limited resources.
    The Triangle of Misery: Part C Caseload Increases Outpace Funding
            Increases 7 to 1

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Conclusion
        These are challenging economic times, and we recognize the severe
    fiscal constraints the 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 the request for $285.8 million
    in fiscal year 2013 funding for Ryan White Part C programs. This
    funding would help to support medical providers nationwide in
    delivering life-saving, effective HIV/AIDS care and treatment to their
    patients.
        Thank you for your time and consideration of our request. If you
    have any questions, please do not hesitate to contact the Ryan White
    Medical Providers Coalition Convener, Jenny Collier, at
    jennycollierjd@yahoo.com.
                                     ______

               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 2013 funding for the National
    Spina Bifida Program and other related Spina Bifida initiatives. SBA is
    a national patient advocacy organization, 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. A total of 19 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 in fiscal
    year 2013 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 2013, 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 the 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 2013 allocation for the
    National Spina Bifida Program, SBA urges the Subcommittee to provide
    $2.8 million for the CDC's national folic acid education and promotion
    efforts to support the prevention of Spina Bifida and other NTD; $22.3
    million to strengthen the CDC's National Birth Defects Prevention
    Network; and $137.2 million to fund the National Center on Birth
    Defects and Developmental Disabilities.
    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 2013. 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 2013 LHHS
    appropriations measure:

        ``The Committee encourages NIDDK, NICHD, and NINDS to study the
    causes and care of the neurogenic bladder in order to improve the
    quality of life of children and adults with Spina Bifida; to support
    research to address issues related to the treatment and management of
    Spina Bifida and associated secondary conditions, such as
    hydrocephalus; and to invest in understanding the myriad co-morbid
    conditions experienced by children with Spina Bifida, including those
    associated with both paralysis and developmental delay.''
    Conclusion
        Please know that SBA 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 2013 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 Scleroderma Foundation
        The members of the Scleroderma Foundation (SF) are pleased to
    submit this statement for the record recommending $32 billion in fiscal
    year 2013 for the National Institutes of Health (NIH), and an increase
    for the National Institute of Arthritis and Musculoskeletal and Skin
    Diseases (NIAMS) concurrent with the overall increase to NIH. The
    Scleroderma Foundation also recommends encouraging the Centers for
    Disease Control and Prevention to partner with the scleroderma
    community in promoting increased awareness of scleroderma among the
    general public and healthcare providers.
          statement of cynthia cervantes, huntington park, california
        Mr. Chairman, I am Cynthia Cervantes, and I am 17 years old. 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. Just
    this year I was in the hospital for 4 weeks with intense pain, nausea,
    and dizziness. The doctors believe I had an unknown virus but could not
    control my symptoms. It was a very frightening time for my family and
    I.
        About 7 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 months 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 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. More than $1 million in peer-reviewed research grants are
    awarded annually to institutes and universities to stimulate progress
    in the search for a cause and cure for scleroderma.
                             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
        Scleroderma research at the NIH was funded at a level of $25
    million in fiscal year 2012. This is of great concern to scleroderma
    patients and families who view biomedical research as their best hope
    for an enhanced 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
        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 1 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.
                                     ______

           Prepared Statement of the Society of Gynecologic Oncology
        The Society of Gynecologic Oncology (SGO) thanks the Subcommittee
    for the opportunity to submit comments for the record regarding SGO's
    fiscal year 2013 funding recommendations for the National Institutes of
    Health and the National Cancer Institute. We believe these
    recommendations are critical to ensure that advances can be made to
    help reduce and prevent suffering from gynecologic cancer.
        The SGO is a national medical specialty organization of physicians
    who are trained in the comprehensive management of women with
    malignancies of the reproductive tract. Our purpose is to improve the
    care of women with gynecologic cancer by encouraging research,
    disseminating knowledge which will raise the standards of practice in
    the prevention and treatment of gynecologic malignancies and
    cooperating with other organizations interested in women's healthcare,
    oncology and related fields. The Society's membership, totaling more
    than 1,600, is comprised of gynecologic oncologists, as well as other
    related women's cancer healthcare specialists including medical
    oncologists, radiation oncologists, nurses, social workers and
    pathologists. SGO members provide multidisciplinary cancer treatment
    including surgery, chemotherapy, radiation therapy, and supportive
    care. More information on the SGO can be found at www.sgo.org.
        Each day in the United States, one woman will be diagnosed with a
    gynecologic cancer every 7 minutes. That's more than 200 women today
    and close to 80,000 this year. One-third of these women will die
    unnecessarily. If detected early, the vast majority of these cancers
    are curable. The SGO believes that the Congress can take action to save
    the lives of thousands of our mothers, sisters, and daughters who die
    each year from gynecologic cancer, starting with this Subcommittee
    making a commitment to increase the funding in fiscal year 2013 for
    Federal research programs focused on education, prevention, screening
    and treatment of gynecologic cancers.
        Now is not the time to cut research funding for these devastating
    diseases. We must do better for the women of our great Nation.
    Therefore, the SGO joins with the broader public health and research
    community urging the Congress to provide $32.7 billion for the National
    Institutes of Health (NIH) in fiscal year 2013. This is the minimal
    level of funding that will allow the NIH to maintain current
    initiatives and investments.
        SGO is aware of the fiscal challenges facing the Subcommittee in
    fiscal year 2013; however, more than 10 million cancer survivors can
    attest to the fact that when investments are made in cancer research-
    related programs thousands of lives are saved. Therefore, the SGO
    recommends that this Subcommittee provide the NCI with $5.36 billion
    for fiscal year 2013.
    Pathways to Progress in Gynecologic Cancer Research
        In 2010, the leadership of the SGO organized a Research Summit on
    the Pathways to Progress in Women's Cancers. The Summit brought
    together gynecologic oncologists, medical oncologists, radiation
    oncologists; basic science researchers, epidemiologists, and educators
    to assess the landscape of gynecologic cancer research and recommend
    strategic goals for the next 10 years.
        The strongest priority emerging from the Research Summit was the
    need to identify a mechanism to maintain infrastructure for clinical
    trials in gynecologic oncology. Two out of three NCI clinical alerts
    (``Addition of Cisplatin to Radiation Therapy in Cervical Cancer'', and
    ``Prolonged Survival in Ovarian Cancer with Intraperitoneal
    Chemotherapy'') have been issued as a direct result of the clinical
    trials structure in gynecologic oncology. However, it was recognized
    that the current clinical trials mechanism must adapt to include novel
    agents and new imaging endpoints. The women of America deserve to have
    more breakthroughs advanced by well-designed clinical trials research
    dedicated to gynecologic cancers.
        Prior investment into the infrastructure of tissue banking has
    positioned gynecologic oncology research to both contribute to and
    benefit from national cancer resources, such as The Cancer Genome Atlas
    (TCGA). The Gynecologic Oncology Group (GOG) tissue bank was able to
    provide high quality ovarian cancer specimens as one of the first
    tissues in the TCGA, followed by endometrial cancers. By leveraging the
    TCGA and other resources, sophisticated research questions can begin to
    be addressed. These resources may be deployed to answer questions that
    cross biologic cancer sites, such as the mechanism of cancer cell
    invasion or the molecular markers of cancer initiating cells.
        Scientific innovation has provided the promise of personalized
    cancer therapies. Certainly, novel agents targeting specific tumor
    pathways are one part of personalized medicine. However, that concept
    does not encompass the spectrum of both treatment and survivorship,
    which is the ultimate goal. For instance, surgical intervention in
    endometrial cancer can be curative. But, the side effect of lymphedema
    may significantly affect the quality of a woman's life as well as her
    economic and social productivity. Women with gynecologic malignancies,
    as well as all cancer patients and survivors, deserve personal,
    specialized care to identify the essential interventions required at
    diagnosis and/or recurrence to maximize quantity and quality of life.
    In addition, personalized medicine must utilize multidisciplinary
    interventions to modify the overall trajectory of disease and evaluate
    their economic impact.
        In the past decade, cervical cancer became the first gynecologic
    cancer to be successfully prevented by a vaccine, which will continue
    to be refined and studied in different populations in for modifiers of
    efficacy. Prevention of cancer is also possible in endometrial cancer,
    where epidemiologic data supports the role of obesity in the
    development of endometrial cancer. Certainly education of the public
    about the connection between obesity and endometrial cancer as well as
    study of the cancer preventative effects of obesity reduction
    strategies, such as bariatric surgery are warranted at this time.
        Finally, sustaining a cadre of researchers in gynecologic
    malignancies will require resources targeted for women's cancer. While
    we anticipate that established national funding mechanisms will fund
    our most exciting research, public-private partnerships will become
    increasingly important. Previously, a successful partnership between
    the Gynecologic Cancer Foundation (GCF, now known as the Foundation for
    Women's Cancer) and the NCI provided training in basic science research
    for budding gynecologic oncologists. Creation of a similar cross-
    disciplinary gynecologic malignancies training grant would enhance the
    depth and breadth of researchers in women's cancers. For researchers
    already committed to research in women's cancers, private cancer
    advocacy groups and professional societies might be able to partner
    with the NCI to create a Women's Cancer Bridge Program to sustain such
    investigators during a funding shortfall.
        Fifteen years ago, the roadmap defined by the ``New Directions in
    Ovarian Cancer Research'' conference spurred progress in ovarian cancer
    research that has directly affected patient care and saved lives. It is
    our hope and confidence that this new ``Pathways to Progress'' research
    agenda will prompt similar acceleration in research in all gynecologic
    malignancies. The women of America deserve nothing less. To read the
    entire `Pathways to Progress in Women's Cancer,'' A Research Agenda
    Proposed by the Society of Gynecologic Oncology, please visit the SGO's
    website at www.sgo.org.

                                TABLE E-1.--GYNECOLOGIC MALIGNANCIES RESEARCH PRIORITIES
    ----------------------------------------------------------------------------------------------------------------
                                       Short (0-3 years)       Intermediate (4-6 years)        Long (7-10 years)
    ----------------------------------------------------------------------------------------------------------------
    Low Risk....................  4A1) Maintain               1E1, 1B3, 1B6) Develop new  4F2) Establish
                                   infrastructure for          trial endpoints and         collaborative teams of
                                   clinical trials in          biomarkers through          investigators to utilize
                                   gynecologic oncology.       imaging and circulating     banked specimens for
                                  2E4) Prevalence/QOL trial    analytes.                   gynecologic malignancies
                                   of lymphedema in EC.                                    research.
                                  5A1) Identify the
                                   essential interventions
                                   all cancer survivors
                                   require at diagnosis and/
                                   or recurrence to maximize
                                   quantity and QOL.
    Intermediate Risk...........  3D5) Cervical cancer        2E2) Quality outcomes of    2A3) Outcomes research on
                                   health disparities.         first surgery by            bariatric surgery/EC
                                  3D4) Cervical cancer         gynecologic oncologist.     risk.
                                   genetic and epigenetic
                                   susceptibility genes
                                   (TCGA).
    High Risk...................  2A6) CDC educational        1A1, 1A3, 1A5, 1B2) Define  5G1) Utilize
                                   campaign EC and obesity.    the ovarian cancer          multidisciplinary
                                  3E1) Progression of CIN3-    initiating stem-like cell.  interventions to modify
                                   SCC (biology of invasion). 4G2) Promote legislation     the overall trajectory of
                                                               and regulation at State     disease and evaluate
                                                               and Federal level for       their economic impact.
                                                               insurance cost coverage    6I1) Develop a bridge
                                                               of clinical trials costs.   program to sustain
                                                              6H2) Develop and implement   investigators who have
                                                               a training grant specific   lost extramural funding.
                                                               to Gynecologic Oncology.
    ----------------------------------------------------------------------------------------------------------------
    CDC Centers for Disease Control; CIN3 Cervical Intraepithelial Neoplasia 3; EC Endometrial Cancer; QOL Quality
      of Life; SCC Squamous Cell Carcinoma; TCGA The Cancer Genome Atlas.

        The SGO appreciates the opportunity to submit these comments and
    again urges this Subcommittee to increase Federal funding to $32.7
    billion for the National Institutes of Health (NIH) in fiscal year 2013
    and to provide from that at least $5.36 billion for the NCI for fiscal
    year 2013.
        This will allow for discoveries and research breakthroughs, while
    also investing in research infrastructure and training for the next
    generations of scientists. It will provide the resources needed for the
    implementation of the research agenda for the next decade in
    gynecologic cancers. The SGO thanks you for your leadership and the
    leadership of the Subcommittee on this issue.
                                     ______

               Prepared Statement of the Society for Neuroscience
    Introduction
        Mr. Chairman and Members of the Subcommittee, my name is Moses
    Chao, PhD. I am a professor of Cell Biology, Physiology and
    Neuroscience, and Psychiatry at the New York University School of
    Medicine, and President of the Society for Neuroscience. My major
    research efforts have been focused on growth factors (also called
    neurotrophins). These proteins are crucial for everything from neuron
    differentiation, growth, and survival during development to learning
    and memory in children and adults. Deficits in neurotrophins are
    involved in neurodegenerative disorders such as Alzheimer's,
    Parkinson's and Huntington's diseases, and Amyotrophic Lateral
    Sclerosis (ALS) as well as limiting recovery after stroke or brain
    injury.
        Founded in 1969, SfN has grown from a membership of 500 to more
    than 42,000, representing researchers working in more than 80
    countries. This rapid growth reflects the tremendous progress made in
    understanding brain cell biology, physiology, and chemistry, and the
    tremendous potential and importance of this field. Today, the field
    sits on the cusp of revolutionary advances, and NIH-funded research has
    played an essential role by enabling advances in brain development,
    imaging, genomics, circuit function, computational neuroscience, neural
    engineering and many other disciplines.
        To continue this important work SfN stands with partners in the
    medical and scientific community to request at least $32 billion for
    NIH in fiscal year 2013. In this testimony, I will highlight how these
    advances have benefited taxpayers, and some of the challenges that need
    to be addressed to prevent lapsing further behind other nations
    throughout the world both scientifically and economically.
    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, and support active and continuing discussions on ethical
    issues relating to the conduct and outcomes of neuroscience research;
    and 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 across
    disciplines--from biology and computer science to physics and
    chemistry--to examine molecules, nerve cells, networks, brain system,
    and behavior. Through research, neuroscientists work to understand
    normal functions of the brain and determine how the nervous system
    develops, matures, and maintains itself through life. This research is
    the foundation for preventing, treating or curing more than 1,000
    neurological and psychiatric disorders that result in more
    hospitalizations in the United States than any other disease group,
    including heart disease and cancer. In 2007, the World Health
    Organization estimated that neurological disorders affect up to 1
    billion people worldwide. In fact, neurological diseases make up 11
    percent of the world's disease burden, not including mental health and
    addiction disorders.
        Neuroscience includes basic, clinical and translational research.
    Basic science unlocks the mysteries of the human body by exploring the
    structure and function of molecules, genes, cells, systems, and complex
    behaviors, and basic science funding at NIH continues to be a
    springboard for discoveries that spur medical progress for future
    generations.
        The following are just three of many emerging stories of important
    progress in neuroscience research, and these are based in large part on
    strong historic investment in NIH and other research agencies:
        Neurotrophic Factors.--Maintaining brain health throughout life is
    an important public health goal. Extensive research has demonstrated
    that cognitive function can be enhanced with increased levels of Brain-
    Derived Neurotrophic Factor (BDNF) and other growth factors. These
    proteins are released in the brain with exercise, neuronal activity and
    behavioral stimulation, resulting in increased resistance to brain
    injury, the birth of new neurons and improved learning and mental
    performance. BDNF increases and strengthens the number of connections
    in the brain and promotes plasticity, by generating positive signals in
    neurons. Depression and anxiety are also influenced by neurotrophic
    factors. Future research will define new ways to use the knowledge from
    neurotrophic factors to protect the nervous system from damage and
    maintain brain function and plasticity during aging.
        Epigenetics Research.--Is it ``nature'' or ``nurture'' that
    influences behavior and health outcomes? Researchers now know these
    factors are not independent: experience and environment (``nurture'')
    modify genes (``nature'')--a phenomenon known as epigenetics. Some of
    these modifications can be passed to the next generation, suggesting it
    may be possible for our life experiences to affect our children and
    grandchildren. Recent research finds epigenetics affects normal brain
    processes--such as development or memory--and abnormal brain processes
    like depression and disease. Emerging studies in people suggest
    epigenetics may affect human behavior and be a factor in neurological
    and psychiatric disease. One example is Rett syndrome, a genetic
    disorder that almost exclusively affects young girls and currently has
    no cure, as well as schizophrenia, autism, and Alzheimer's disease.
    Also, unlike most genetic mutations, epigenetic marks can be reversed.
    In fact, the U.S. Food and Drug Administration have approved several
    drugs that work to improve health outcomes by modifying these marks.
    Many of these drugs were originally identified by cancer researchers,
    and brain scientists are now working to develop safer, more effective
    drugs to improve cognitive function and behavior in people--
    highlighting the importance of collaboration across scientific
    institutes and disciplines and the powerful potential to apply basic
    and applied research well beyond its original intent.
        Fear and Post-Traumatic Stress Disorder.--In a given year, about
    3.5 percent of Americans suffer from post-traumatic stress disorder
    (PTSD), a punishing disorder marked by intense fear, anxiety, and
    flashbacks that follow a traumatic experience. For U.S. military
    personnel returning from Iraq and Afghanistan, the prevalence of PTSD
    may be as high as one in five. Until now, there have been few treatment
    options for PTSD. However, new basic science and clinical research on
    the biological basis of fear suggests promising new therapeutic
    avenues. Rat studies determined that those with lesions in a brain
    region called the amygdala failed to associate a neutral stimulus, like
    a tone, with a fearful event, like a mild shock. Furthermore, people
    who had surgery to remove the portion of the temporal lobe that
    contains the amygdala, a treatment for some forms of epilepsy, had
    difficulty learning to associate a flash of light with an unpleasant
    noise. These findings suggest that fear is a special type of learning
    and memory.
        Rewriting fearful memories or forgetting them altogether might
    therefore help conquer fears. But as researchers learn how fear
    memories are encoded in the brain, and as animal research helps to
    identify new treatments, there may be new therapeutic options. One new
    treatment is the antibiotic D-cycloserine. This drug activates
    receptors in the amygdala that are important in extinction.
    Additionally, drugs called beta blockers are used to treat people with
    high blood pressure--they stabilize the body's response to a stressor,
    preventing the fight-or-flight response. A recent human study showed
    that, when given during recollection of a frightening memory, the beta
    blocker propranolol reduced fear but did not affect knowledge of an
    event. Researchers are currently evaluating propranolol's ability to
    prevent PTSD in trauma patients. These promising results of repurposing
    existing drugs would not have been possible without basic scientific
    research, funded largely by the NIH, National Science Foundation, and
    Department of Defense.
    Economic Impact
        These and thousands of other studies are advancing our
    understanding of the brain and nervous system, and are translating into
    potential treatments for patients in the future. Federal investments in
    scientific research fuel the Nation's pharmaceutical, biotechnology and
    medical device industries. The private sector utilizes basic scientific
    discoveries funded through NIH to improve health and foster a
    sustainable trajectory for American's Research and Development (R&D)
    enterprise. Basic science generates the knowledge needed to uncover the
    mysteries behind human diseases, which eventually leads to private
    sector development of new treatments and therapeutics. This important
    first step is not ordinarily funded by industry given the long-term
    path of basic science and the pressures for shorter-term return on
    investments by industry.
        Also, these investments 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, and
    many others. For example, in fiscal year 2010, NIH investments led to
    the creation of 487,900 jobs, and produced more than $68 billion in new
    economic activity--helping 16 States to experience job growth of 10,000
    jobs or more at a time when unemployment was otherwise rising.
    Conclusion
        With its rapid growth in countries worldwide, the SfN membership is
    a metaphor for the extraordinary opportunity and future of
    neuroscience. Like SfN, the study of neuroscience is growing rapidly,
    with young people flocking to the field. Tools to study the living
    brain and to connect brain structure and function to physiology,
    disease, and behavior give unmatched opportunities for scientists to
    understand how the brain works. The growth of neuroscience also
    reflects increased societal recognition of the field's importance.
    Understanding the brain is vitally important and urgent if humankind is
    to address successfully major challenges facing our society and our
    world, such as drug addiction, obesity and depression. As populations
    grow and age, understanding how to enhance human development and
    performance, and preserve function during aging, are critical to social
    and economic prosperity.
        I also submit that it is vital for this subcommittee to continue to
    recognize and sustain U.S. leadership in the global scientific arena.
    Neuroscience, like all fields of science, is an increasingly global
    enterprise, creating opportunities for both collaboration and
    competition. Fundamentally, neuroscientists worldwide are motivated to
    answer the question ``I wonder why?''--often, they seek to pursue those
    answers collaboratively, working across borders to tackle large
    problems with sophisticated technologies and coordinated sub-
    specialties. To that end, many countries other than the United States
    demonstrate established and growing scientific excellence in the field,
    and this is a healthy and very positive trend.
        At the same time, for the United States there is growing
    competition for leadership in science worldwide, as many nations
    recognize it will be the foundation for economic prosperity in the
    coming decades. Over the last century, the United States has served as
    the global pace-setter on investment in science, and leveraged research
    as a primary engine for economic growth and prosperity, but this
    leadership is at risk. The United States has an opportunity to retain
    its strong and unassailable leadership in global neuroscience by
    continuing to invest strongly in biomedical research. An investment in
    basic research is an essential component for reducing healthcare
    spending and improving healthcare delivery. We now stand at the
    precipice of an economic disaster because the costs of treating many
    diseases, such as Alzheimer's, will be astronomical in the next 50
    years. Additional scientific research is necessary to develop new
    treatments and cures, which will produce longer, healthier and more
    productive lives for Americans and create greater economic growth for
    our Nation.
        In conclusion, NIH investments have made it possible for the field
    of neuroscience research to make tremendous progress to understand
    basic biological principles and to advance the knowledge and treatments
    for hundreds of neurological and psychiatric illnesses. However,
    continued progress can only be accomplished by consistent and reliable
    support. This year's investment is a building block for success 10, 15,
    even 20 years or more from now.
        The administration's budget request for NIH is $30.7 billion, the
    same amount that was funded last year. This is a welcome start but it
    is insufficient to maintain the scientific progress and leadership
    required of the United States in the 21st century. This subcommittee
    knows that a flat budget is a cut, given the rate of inflation. The
    Society for Neuroscience does not believe that reducing our commitment
    to research is medically or economically justified. An fiscal year 2013
    NIH appropriation of at least $32 billion and sustained reliable growth
    in the future is essential to take the research to the next level in
    order to improve the health of Americans and to maintain American
    leadership in science worldwide. Thank you for this opportunity to
    testify.
                                     ______

         Prepared Statement of the Society for Public Health Education
        The Society for Public Health Education (SOPHE) is a 501(c)(3)
    professional organization founded in 1950 to provide global leadership
    to the profession of health education and health promotion. SOPHE
    contributes to the health of all people and the elimination of health
    disparities through advances in health education theory and research;
    excellence in professional preparation and practice; and advocacy for
    public policies conducive to health. SOPHE is the only independent
    professional organization devoted exclusively to health education and
    health promotion. Members include behavioral scientists, faculty,
    practitioners, and students engaged in disease prevention and health
    promotion in both the public and private sectors. Collectively, SOPHE's
    4,000 national and chapter members work in universities, medical/
    healthcare settings, businesses, voluntary health agencies,
    international organizations, and all branches of Federal/State/local
    government. There are currently 19 SOPHE chapters covering more than 30
    States and regions across the country.
        SOPHE's vision of a healthy world through health education compels
    us to advocate for increased resources targeted at the most pressing
    public health issues and disparate populations. For the fiscal year
    2013 funding cycle, SOPHE encourages the Labor, Health and Human
    Services, Education and Related Agencies (Labor-HHS) Subcommittee to
    increase funding for public health programs that focus on preventing
    chronic disease and other illnesses in adults as well as youth, and
    eliminating health disparities. In particular, SOPHE requests the
    following fiscal year 2013 funding levels for Labor-HHS programs:
      --$7.8 billion for the Centers for Disease Control and Prevention
            (CDC);
      --$1 billion for the Prevention and Public Health Fund;
      --$226 million for the Community Transformation Grants (CTG) Program;
      --$100 million for the CDC Preventive Health and Health Services
            Block Grant; and
      --$378 million for the CDC Coordinated Chronic Disease Prevention and
            Health Promotion Program.
        The discipline of health education and health promotion, which is
    some 100 years old, uses sound science to plan, implement, and evaluate
    interventions that enable individuals, groups, and communities to
    achieve personal, environmental and population health. There is a
    robust, scientific evidence-base documenting not only that various
    health education interventions work but that they are also cost
    effective. These principles serve as the basis for our support for the
    programs outlined below and can help ensure our Nation's resources are
    targeted for the best return on investment.
                           preventing chronic disease
        The data are clear: chronic diseases are the Nation's leading
    causes of morbidity and mortality and account for 75 percent of every
    dollar spent on healthcare in the United States. Collectively, they
    account for 70 percent of all deaths nationwide. Thus, it is highly
    likely that 3 of 4 persons living in the districts of the Labor-HHS
    Subcommittee members will develop a chronic condition requiring long-
    term and costly medical intervention in their lifetimes. Health
    expenditures increased from $1.4 trillion in 2000 to $2.6 trillion in
    2010, and from 14 percent of the Gross Domestic Product to 18 percent.
    Yet evidence shows that investing just $1 in preventing disease will
    yield a $5 return on investment.
        SOPHE is requesting a fiscal year 2013 funding level $7.8 billion
    for CDC in order to prevent chronic diseases and other illnesses,
    promote health, prevent injury and disability, and ensure preparedness
    against health threats. CDC is at the forefront of U.S. efforts to
    monitor health, detect and investigate health problems, conduct
    research to enhance prevention, develop sound public health strategies,
    and foster safe and healthful environments. More than 80 percent of all
    CDC funds are returned to States to address State and local health
    issues. The President's fiscal year 2013 budget proposal would reduce
    CDC's budget authority by $664 million, for a total reduction of $1.4
    billion since fiscal year 2010. Studies show that spending as little as
    $10 per person on proven preventive interventions could save the
    country more than $16 billion in just 5 years. The public
    overwhelmingly supports increased funding for disease prevention and
    health promotion programs. Investing now in community-led, innovative
    programs will help to increase our Nation's productivity and
    performance in the global market; help ensure military readiness;
    decrease rates of infant mortality, deaths due to cancer,
    cardiovascular disease, diabetes, and HIV/AIDS, and; increase
    immunization rates.
        SOPHE is requesting a fiscal year 2013 funding level of $1 billion
    for the Prevention and Public Health Fund to sustain essential core
    public health infrastructure, the workforce, and our capacity to
    improve health in our communities. The Prevention Fund helps States
    tackle the leading causes of death and root causes of costly,
    preventable chronic disease; detect and respond rapidly to health
    security threats; and prevent accidents and injuries. With this
    investment, the Fund helps States and the Nation as a whole focus on
    fighting disease and illness before they happen. A July 2011 study
    published in the journal Health Affairs found that increased spending
    by local public health departments can save lives currently lost to
    preventable illnesses; a 2011 Urban Institute study concluded that it
    is in the Nation's best interest from both a health and economic
    standpoint to maintain funding for evidence-based, public health
    programs that save lives and bring down costs; and finally, a 2011
    study in Health Affairs showed a combination of three strategies (i.e.
    delivering better preventive and chronic care, expanding health
    insurance coverage, and focusing on protection) is more effective at
    saving lives and money than implementing any one of these strategies
    alone.
        Although the enactment of the Middle Class Tax Relief and Job
    Creation Act of 2012 will reduce the Prevention and Public Health Fund
    by more than $5 billion over the next 10 years, SOPHE strongly
    discourages further reductions in the Fund so that we can continue to
    strengthen core public health infrastructure, the workforce, and our
    capacity to improve health in our communities.
        SOPHE is requesting a fiscal year 2013 funding level of $226
    million for the CTG program to empower communities to transform places
    where people live, work, learn, and play to promote prevention and
    improve health by lowering rates of chronic disease. The CTG program
    supports States and communities tackle the root causes of poor health
    so Americans can lead healthier, more productive lives. All grantees
    work to address the following priority areas: (1) tobacco-free living;
    (2) active living and healthy eating; and (3) quality clinical and
    other preventive services. Two-thirds of current CTG grantees address
    one or more other population groups experiencing disparities, including
    but not limited to the homeless and those living in underserved
    geographic areas.
        The CTG program is especially needed to address the health of our
    Nation's youth. In the last 20 years, the percentage of overweight
    youth has more than doubled, and for the first time in two centuries,
    children may have a shorter life expectancy than their parents. Fifteen
    percent of children and adolescents are overweight and more than half
    of these children have at least one cardiovascular disease risk factor,
    such as elevated cholesterol or high blood pressure. At the same time
    that obesity is becoming an epidemic, the CDC School Health Programs
    and Policy Study found that the majority of schools are teaching
    nutrition with health education teachers who do not meet even minimal
    certification standards.
        As part of the CTG initiative, SOPHE strongly supports CDC's Racial
    and Ethnic Approaches to Community Health Across the U.S. (REACH U.S.)
    program, which addresses health risk behaviors in both children and
    adults. Chronic diseases account for the largest health gap among
    populations and increase health disparities among racial and ethnic
    minority groups. As the U.S. population becomes increasingly diverse,
    the Nation's health expenditures will be heavily influenced by the
    morbidity of racial and ethnic minority communities. With CTG funding,
    the National REACH Coalition will address strategies in the areas of
    tobacco-free living, active living and healthy eating, clinical and
    other preventive services, social and emotional wellness, and healthy
    and safe physical environments--with a primary focus on African-
    American/Black, Hispanic/Latino, Asian, Native Hawaiian/Pacific
    Islander, and American Indian/Alaskan Native populations.
        SOPHE is requesting a fiscal year 2013 funding level of $100
    million for the CDC's Preventive Health and Health Services Block Grant
    to allow each State/territory to target resources to its unique public
    health challenges, while requiring timely reporting and accountability.
    The Block Grant was eliminated in the President's fiscal year 2013
    budget proposal. As a critical public health resource, the Block Grant
    gives States the autonomy and flexibility to tailor prevention and
    health promotion programs to their particular public health needs.
    Grantees use funds to support to areas where no Federal resources
    exist, or where categorical States funds are grossly insufficient for
    leading causes of illness, disability and death in their States/
    territories. With the uncertainty of State and local budgets, the
    proposed elimination of the Block Grant will limit the ability of
    public health departments to carry out essential services for chronic
    disease prevention, HIV/AIDs, food and water safety, bioterrorism and
    emergency preparedness, and other areas.
        SOPHE applauds the request of $378 million for the Coordinated
    Chronic Disease Prevention and Health Promotion Program, an increase of
    $128 million above the fiscal year 2012 level. The approach will enable
    CDC to create a coordinated, national response to school health and
    chronic disease, maximizing program effectiveness, reducing
    interrelated risk factors, and accelerating health improvements. Almost
    80 percent of young people do not eat the recommended 5 servings of
    fruits and vegetables each day. Daily participation in high school
    physical education classes dropped from 42 percent in 1991 to 32
    percent in 2001. Among 38 States that participated in CDC's latest
    School Health Policies and Programs Study, the percentage of schools
    that required a health education course decreased between 1996 and
    2000, as did the percentage of schools that taught about dietary
    behaviors and nutrition. Patterns of poor nutrition, lack of physical
    activity, and other behaviors such as alcohol and tobacco use
    established during youth often continue into adulthood and contribute
    markedly to costly, chronic conditions.
        CDC's Coordinated School Health Programs have been shown to be cost
    effective in improving children's health, their behavior, and their
    academic success. This funding builds bridges between State education
    and public health departments to coordinate health education,
    nutritious meals, physical education, mental health counseling, health
    services, healthy school environments, health promotion of faculty, and
    parent and community involvement. Gallup polls show strong parental,
    teacher, and public support for school health education.
        Thank you for this opportunity to present our views to the
    Subcommittee. SOPHE gratefully acknowledges the strong support that the
    Senate Subcommittee on Labor, Health and Human Services, Education and
    Related Agencies has given to public health and prevention initiatives.
    We look forward to working with you to prevent chronic illness, improve
    the quality of lives, and save billions of dollars in healthcare
    spending.
                                     ______

                Prepared Statement of the Sleep Research Society
        The members of the Sleep Research Society (SRS) are pleased to
    submit this statement for the record recommending $32 billion in fiscal
    year 2013 for the National Institutes of Health (NIH). The Scleroderma
    Foundation also recommends maintaining the Sleep Program at the Centers
    for Disease Control and Prevention (CDC). Established in 1961, the
    Sleep Research Society (SRS) is a member organization of scientists
    that exists to foster scientific investigation on all aspects of sleep
    and its disorders, to promote training and education in sleep research,
    and to provide forums for the exchange of knowledge pertaining to
    sleep.
        Sleep and circadian disturbances and disorders affect millions of
    Americans across all demographic groups. An estimated 25-30 percent of
    the general adult population, and a comparable percentage of children
    and adolescents, is affected by decrements in sleep health that are
    proven contributors to disability, morbidity, and mortality. As a
    result, sleep and circadian disturbances and disorders have been
    recognized by the Congress and the Department of Health and Human
    Services as high priority targets for basic and clinical scientific
    investigation.
        In November 2011 a new NIH Sleep Research Plan was released. It
    identifies new opportunities for continued advances in understanding
    the function of sleep to inform lifestyle choices and improve the
    opportunity of individuals to achieve their optimal health outcome. The
    plan was developed through an open process with the Sleep Disorders
    Research Advisory Board and with input from the public, academia and
    healthcare professionals. The plan provides the following insights
    regarding sleep loss's effects on society:
        Chronic sleep deficiency and circadian disruption is an emerging
    characteristic of modern urban lifestyles and is associated with
    increase disease risk through multiple complex pathways in all age
    groups. Developing a mechanistic understanding of the threat posed by
    sleep deficiency and circadian disturbance to health, healthy equity,
    and health disparities is an urgent challenge for biomedical research
    in many domains. Population-based data on the prevalence of circadian
    disruption and its relationship to disease risk is relatively limited.
    However, recent findings from large multi-site cohort studies and
    nationally representative surveillance data from the Centers for
    Disease Control indicate that sleep deficiency among Americans is
    pervasive, and much higher than inferred from clinical data. For
    example:
      --Nearly 70 percent of high school adolescents sleep less than the
            recommended 8-9 hours of sleep on school nights despite a
            physiological need. Short sleep in this age group is associated
            with suicide risk, obesity, depression and mood problems, low
            grades, and delinquent behavior.
      --Nationwide, 70 percent of adults report that they obtain
            insufficient sleep or rest at least once each month, and 11
            percent report insufficient sleep or rest every day of the
            month.
      --Frequent sleep problems are reported by 65 percent of Americans
            including difficulty falling asleep, waking during the night,
            and waking feeling unrefreshed at least a few times each week,
            with nearly half (44 percent) of those saying they experience
            that sleep problem almost every night.
      --Short and long sleep duration is associated with up to a two-fold
            increased risk of obesity, diabetes, hypertension, incident
            cardiovascular disease, stroke, depression, substance abuse,
            and all-cause mortality in multiple studies.
      --Drowsy driving may be a factor in 20 percent of all serious motor
            vehicle crash injuries. A large naturalistic study of 100
            drivers and nearly 2 million miles of driving identified
            sleepiness as a factor in 22 percent of crashes, and 16 percent
            of near-crashes. A third of Americans report falling asleep
            while driving 1 to 2 times per month and 26 percent drive
            drowsy during the workday.
        Although knowledge of basic sleep and circadian mechanisms and the
    pathophysiology of sleep and circadian disorders and disturbances has
    advanced considerably since the 1996 NIH Sleep Disorders Research Plan
    was developed, important questions remain. For instance, studies are
    needed to stratify risks to health and identify vulnerable populations.
    Mechanistic studies are needed to define the genomic, physiological,
    neurobiological, and developmental impact of sleep and circadian
    disturbances. Recent findings indicate that sleep and circadian rhythms
    are coupled to chromatin remodeling and regulate as much as 20 percent
    of gene expression in peripheral tissues including the heart, liver,
    pancreatic islets, adipose, and immune system. Genome-wide association
    studies have implicated pancreatic melatonin receptor polymorphism in
    both blood glucose regulation and diabetes risk. Research is also
    needed to enhance the translation of sleep and circadian scientific
    advances to clinical practice, researchers in cross-cutting domains,
    and communities.
        Advances in basic sleep and circadian knowledge are poised to
    provide an improved foundation for understanding how sleep and
    circadian rhythms contribute to health, and why a wide range of health,
    performance and safety problems emerge when sleep and circadian rhythms
    are disrupted. Strengthening and preserving our Nation's biomedical
    research enterprise through investment in NIH fosters economic growth
    and is vital to the innovations that enhance the health and well-being
    of the American people.
                                     ______

                 Prepared Statement of the Safe States Alliance
        On behalf of the Safe States Alliance, a national membership
    association representing public health injury and violence prevention
    professionals engaged in building a safer, healthier America, we thank
    you for the opportunity to provide our testimony in support of the
    Centers for Disease Control and Prevention (CDC) and the National
    Center for Injury Prevention and Control (NCIPC). Safe States is
    committed to raising the visibility of the critical need for continued
    funding in State and local public health department injury and violence
    prevention programs.
        The Safe States Alliance supports restoration of the Preventive
    Health and Health Services Block Grant to its fiscal year 2011 funding
    level of $100 million and restoration of the CDC Injury Center to its
    fiscal year 2011 funding level of $147.8 million. Preventable injuries
    exact a heavy burden on Americans through premature deaths and
    disabilities, pain and suffering, medical and rehabilitation costs,
    disruption of quality of life for families, and disruption of
    productivity for employers. Strengthening investments in public health
    injury and violence prevention programs is a critical step to keep
    Americans safe and productive for the 21st century.
        The CDC Injury Center is the only Federal agency that exclusively
    focuses on injury and violence prevention in home, recreational, and
    other non-occupational settings. It leads a coordinated public health
    approach to addressing critical health and safety issues. Despite the
    enormous toll of injury and violence and the existence of cost-
    effective interventions, there is no dedicated and ongoing Federal,
    State, or local funding to adequately respond to these problems. The
    CDC Injury Center only receives 2 percent of the CDC/Agency for Toxic
    Substances and Disease Registry (ATSDR) budget to address the
    significant burden of injuries and violence nationwide. In fiscal year
    2012, the total Injury Center budget was only $137.7 million, down from
    $147 million in fiscal year 2011.
        Injuries are the leading cause of death among persons 1-44 years of
    age, and are a major cause of death, disability, and hospitalization
    for all age groups. Every 3 minutes, a person dies from a preventable
    injury. Every 45 minutes, one of those preventable deaths is a child.
    In fact, more than 500 people die each day and 180,000 die each year
    from injuries in the United States. More than 29 million individuals
    survive non-fatal injuries, only to cope with painful recoveries and
    rehabilitation. Among the survivors are the nearly 9.2 million children
    under age 19 that are seen in emergency departments for injuries.
        Every year, injuries and violence will cost the United States $406
    billion: more than $80 billion in medical costs (6 percent of total
    health spending) and $326 billion in lost productivity. Long term
    disabilities from brain and spinal cord injuries, burns, and fall-
    related hip fractures frequently result in high-cost, extended care.
    Injuries, especially fractures, for persons age 65 and older make up a
    substantial proportion of Medicare expenditures. As the U.S. population
    continues to age, this problem will be an even more significant burden
    on the Medicare system.
        However, injuries and violence can be prevented, and their
    consequences can be reduced. For example: seat belts have saved an
    estimated 255,000 lives between 1975 and 2008; school-based programs to
    prevent violence have reduced violent behavior among high school
    students by 29 percent; and Tai chi and other exercise programs for
    older adults have been shown to reduce falls by as much as half among
    participants.
        Injuries, including falls among older adults, have significant
    costs for our mandatory spending programs. Currently, 35 million
    Americans are 65 years of age or older; by 2020 this number is expected
    to reach 77 million.
      --The annual costs for fall-related injuries are expected to reach
            $54.9 billion by 2020 \1\.
    ---------------------------------------------------------------------------
        \1\ Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of
    slip and fall injuries. Journal of Forensic Science 1996;41(5):733-
    46.trial. The Gerontologist 1994;34(1):16-23.
    ---------------------------------------------------------------------------
      --Falls account for 10 percent of visits to an emergency department
            and 6 percent of hospitalizations among Medicare beneficiaries
            \2\.
    ---------------------------------------------------------------------------
        \2\ Carroll NV, Slattum PW, Cox FM. The cost of falls among the
    community-dwelling elderly. Journal of Managed Care Pharmacy.
    2005;11(4):307-16.
    ---------------------------------------------------------------------------
      --In 2002, about 22 percent of community-dwelling seniors reported
            falling in the previous year. Medicare costs per fall averaged
            between $9,113 and $13,507 \3\.
    ---------------------------------------------------------------------------
        \3\ Shumway-Cook A, Ciol MA, Hoffman J, Dudgeon BJ, Yorston K, Chan
    L. Falls in the Medicare population: incidence, associated factors, and
    impact on health care. Physical Therapy 2009.89(4):1-9.
    ---------------------------------------------------------------------------
      --Among community-dwelling seniors treated for fall injuries, 65
            percent of direct medical costs were for inpatient
            hospitalizations; 10 percent each for medical office visits and
            home health care, 8 percent for hospital outpatient visits, 7
            percent for emergency room visits, and 1 percent each for
            prescription drugs and dental visits. About 78 percent of these
            costs were reimbursed by Medicare \4\.
    ---------------------------------------------------------------------------
        \4\ Carroll NV, Slattum PW, Cox FM. The cost of falls among the
    community-dwelling elderly. Journal of Managed Care Pharmacy.
    2005;11(4):307-16.
    ---------------------------------------------------------------------------
        CDC's research has also identified other cost impacts of injuries
    on CMS populations including costs related to prescription drug over
    doses. In Washington State, for example, from 2004 to 2007, 1,668
    people died of prescription opioid-related overdoses. Of those, 45.4
    percent were Medicaid enrolled, and this population had a 5.7 fold
    increased risk of prescription opioid-related overdose death \5\.
    Adoption of lock-in programs can produce significant cost benefits as
    in Florida, where its Medicaid lock-in program saved the State Medicaid
    program $12 million in less than 3 years \6\. Washington State has
    informally reported savings of $1.5 million per month with their
    program. Missouri, Hawaii, and Oklahoma have also reported some
    success. Medicaid programs spend well over $1 billion annually on
    opioid painkillers, and a 2009 GAO report found that these
    reimbursements are rife with fraud. A survey of five States identified
    65,000 beneficiaries visiting six or more doctors to acquire
    prescriptions for the same controlled substances. These beneficiaries
    cost the programs $63 million in reimbursements for those drugs, and
    this number does not account for other related costs \7\.
    ---------------------------------------------------------------------------
        \5\ CDC. Overdose deaths involving prescription opioids among
    Medicaid enrollees-Washington, 2004-2007. MMWR. 2010;59;705-9.
        \6\ Florida Medicaid. Medicaid Prescribed Drug Spending Control
    Program Initiatives: Quarterly Report January 1-March 31, 2005.
    Available at URL: http://www.fdhc.state.fl.us/medicaid/prescribed_drug/
    pdf%5Cquarterly_report_03_31_05.pdf.
        \7\ GAO. Fraud and abuse related to controlled substances
    identified in selected States. Sept. 2009. Available at URL: http://
    www.gao.gov/new.items/d09957.pdf.
    ---------------------------------------------------------------------------
        Safe States Alliance believes that all State and territorial health
    departments (SHDs) in the United States must have a comprehensive
    injury and violence surveillance and prevention programs, similar to
    other public health programs for chronic disease and infectious disease
    prevention. These programs must be adequately staffed and funded
    commensurate with the magnitude of the burden of injury and violence in
    each State with programs and expertise to address the leading causes of
    unintentional and violent injuries, and have disaster and terrorism
    epidemiology and injury mitigation programs. SHDs bring significant
    leadership to reduce injuries and injury-related healthcare costs by
    informing the development of public policies through data and
    evaluation; designing, implementing, and evaluating injury and violence
    prevention programs in cooperation with other agencies and
    organizations; collaborating with partners in healthcare and throughout
    the community; collecting and analyzing a variety of injury and
    violence data to identify high-risk groups; disseminating effective
    practices, and providing technical support and training to injury
    prevention partners and local-level public health professionals. The
    following are examples of how SHDs have prevented injuries and
    protected the lives of Americans throughout the United States:
      --An estimated 3,143 lives potentially have been saved since 1998 as
            a result of CDC-funded smoke alarm installation and fire safety
            education programs in high-risk communities. In funded States,
            more than 487,800 smoke alarms have been installed in
            approximately 250,000 homes. High-risk homes that were targeted
            by the program included children age 5 and younger and adults
            age 65 and older.
      --The Bureau of Injury Prevention at the New York State Department of
            Health conducted a study which was published in the 2010
            September issue of Pediatrics that found that the injury rate
            for motor vehicle crashes decreased by 18 percent for children
            4 to 6 years of age after the State law requiring booster seats
            was implemented in 2005.
      --Oregon's Prescription Drug Monitoring Program (PDMP) was launched
            by the State Injury and Violence Prevention Section in 2011 as
            s a tool to help patients better manage their prescriptions 24
            hours a day, 7 days a week. Within months, 76 percent of
            pharmacists were submitting to the PDMP system, more than
            699,000 prescriptions had been submitted to the system, and
            8,999 queries had been made by healthcare providers. The
            aggregate data that will be available will provide a vast new
            source of information for understanding the overdose epidemic
            in Oregon.
      --Following passage of Complete Streets legislation in Hawaii, the
            Injury Prevention and Control Program (IPCP) was selected to
            participate on a statewide taskforce which was responsible for
            providing guidance to the State and individual counties on road
            design that can safely accommodate all road users.
      --In 2010, with support from the CDC's Core State Injury program, the
            Colorado State Health Department Injury Program provided the
            science and data on child passenger safety to State advocates.
            Changes to strengthen Colorado's Child Passenger Safety Law
            were passed in August 2010. Colorado is now conducting a
            community education campaign about the change of law to support
            its law enforcement partners.
      --In 2007, Massachusetts Department of Public Health's Traumatic
            Brain Injury (TBI) Task Force report identified sports
            concussions as a leading and growing cause of TBI in the State.
            In January 2009, the Massachusetts injury prevention planning
            group (MassPINN)--which is coordinated by the Department of
            Public Health using CDC Core State Injury Program funds--forged
            a partnership with the Sports Legacy Institute and other
            partners to form the Massachusetts Youth Sports Concussion
            Prevention Team to raise awareness of the dangers of sports-
            related concussions and other head injuries among youth. Over a
            14-month period, more than 1,500 CDC ``Heads Up'' kits were
            distributed and more than 2,000 parents, coaches, and athletes
            were educated about the dangers of youth sports concussions.
      --The South Carolina Department of Health and Environmental Control
            (DHEC) used surveillance data collected and analyzed by staff
            supported through CDC's Core State Injury program, to
            thoroughly understand the burden of older adult falls in their
            State and to inform partners on how this issue impacts quality
            of life for seniors. This data was used by a State workgroup
            and resulted in the funding and implementation of an evidence-
            based fear of fall prevention program in select communities.
            DHEC provides personnel time for instruction and funds to
            purchase training materials.
        When evidence-based injury prevention strategies are implemented,
    the estimated return on investment is substantial. For instance, home
    visitation programs have been demonstrated to be particularly effective
    in reducing child abuse and injury, and provide a cost savings of
    nearly $3 to $6 for every $1 spent. Other proven cost-effective injury
    prevention strategies include booster seats, child bicycle helmets,
    motorcycle helmets, sobriety checkpoints, smoke alarms and fall
    prevention for the elderly with total costs ranging from $31 to $9,600
    each for cost-savings and total benefits to society \8\ between $570
    and $73,000 for each.
    ---------------------------------------------------------------------------
        \8\ The total benefit to society is defined as the amount injury
    prevention interventions saved by preventing injuries, including
    medical costs, other resource costs (police, fire services, property
    damages, etc.), work loss, and quality of life costs. These benefits
    are calculated in 2004 dollars.
    ---------------------------------------------------------------------------
        Currently, NCIPC provides up to $250,000 to 28 SHDs through the
    Core Violence and Injury Prevention Program (VIPP) to maintain and
    enhance effective delivery systems for dissemination, implementation
    and evaluation of best practice programs and policies. This includes
    support for the SHDs and their local partners, as well as strategy-
    specific support for the implementation of direct best practice
    interventions. In addition, Core VIPP supports SHDs in their efforts to
    work toward integration and strategically align their resources for
    meaningful change. According to Safe States Alliance's 2009 State of
    the States report, States received NCIPC Core funding were more likely
    to have a centralized program, a full-time director, and greater access
    to key injury data sets. They were more likely to provide support to
    local injury efforts, provide surveillance data and technical
    assistance. States with Core VIPP funding are also well-positioned to
    leverage additional resources, implement and evaluate interventions,
    and raise awareness of injury trends.
        CDC Injury Center's Core Violence and Injury Prevention Program is
    the only program of its kind in the Nation. No other Federal agency
    funds overall injury and violence prevention capacity development. An
    additional investment of just $10 million would allow the CDC Injury
    Center to fund all State and territorial public health departments
    through the Core VIPP. This funding would allow for expansion and
    stabilization of resources for State injury and violence prevention
    programs; strengthening the ability of States to improve the collection
    and analysis of injury data, build coalitions, and establish
    partnerships to promote evidence-based interventions; and dissemination
    of proven injury and violence prevention strategies, with a focus on
    persons at highest risk.
        In addition to the Core VIPP program, SHDs rely on the CDC
    Preventive Health and Health Services Block Grant which provides
    approximately $20 million for injury and violence prevention, including
    approximately $6 million set-aside specifically for sexual assault
    prevention. According to initial findings from the 2011 State of the
    States survey, 30 SHD injury and violence prevention programs reported
    receiving an average of $313,000 for injury and violence prevention
    efforts, much of which is used for local implementation of evidence-
    based practices. Safe States Alliance would like to thank the Committee
    for its consideration of this testimony.
                                     ______

         Prepared Statement of the Society for Women's Health Research
        The Society for Women's Health Research (SWHR) is pleased to have
    the opportunity to submit the following testimony in support of ongoing
    Federal funding for biomedical research and specifically into
    biological 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 believes 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 worldwide leader in medical research, education,
    and development.
        In his State of the Union address, President Obama stated that
    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.
    Additionally, SWHR believes that targeted research into biological sex
    differences will help determine targeted treatments that will propel
    the United States into the realm of personalized medicine and usher in
    a 21st century approach to patient care.
                         national institutes of health
        SWHR realizes that the Federal Government's focus is on austerity;
    however, 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 and jeopardized America place as the gold
    standard in biomedical research. 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.
        From 2003- 2012, NIH has faced a 20.8 percent decrease in buying
    power as a direct result of budget cuts. 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. 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, impacting a scientist's
    likelihood of continuing research. New and less established researchers
    are forced to consider other careers, or take positions outside the
    United States, resulting in the loss of the skilled bench scientists
    and researchers 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 the Congress set, at a minimum, a budget of $32 billion
    for NIH for fiscal year 2013.
    Study of Sex Differences
        Scientists have just 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, be mandated to
    report sex/gender differences in all research findings, including those
    studying a single sex but with explanation and justification. 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
    mandating sufficient female subjects only 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
    including female subjects in earlier phases of clinical research
    studies, the NIH will 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.
        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, more
    than 400 scholars have been trained in 41 centers, and 80 percent of
    those scholars have been female. The BIRCWH centers have produced more
    than 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 has resulted in more than 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 NIH institute and center (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, the Congress must direct that NIH
    continue its support of ORWH and provide it with a $1 million budget
    increase, bringing its fiscal year 2013 total to $43.3 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 (FDA), Centers for Disease Control and
    Prevention (CDC), Agency for Healthcare Quality and Research (AHRQ),
    Indian Health Service (INS), Substance Abuse and Mental Health Services
    Administration (SAMHSA), Health Resources and Services Administration
    (HRSA), and Centers for Medicare and Medicaid Services (CMS). It is
    imperative that all 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. This is
    especially true for HRSA, which promotes an integrated approach to
    women's health across the lifespan and helps low income women access
    necessary health services. SAMHSA has taken a lead role promoting
    improvement in women's mental health services and best-practices. The
    agency also devotes significant resources to assist the VA and DOD with
    mental health services and support for members of the armed services,
    their families and veterans. It is only through consistent funding that
    these offices, as well as the OWH are able to achieve their goals.
        We ask that the Committee report reflect the Congress' 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. These
    offices do important work, both individually and in collaboration with
    other offices and Federal agencies--to ensure that women receive the
    appropriate care and treatments in a variety of different areas. The
    budgets for these 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 the
    Congress to provide an increase of $1 million for the HHS OWH, a total
    $34.7 million requested for fiscal year 2013.
                   centers for disease control and prevention
        The CDC's Office of Women's Health (OWH) works to promote and
    protect the health, safety, and quality of life of women at every stage
    of life. SWHR supports the domestic and international work of the
    office. 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. Now
    even fewer options for information through the many educational
    outreach programs of the CDC.
        The OWH within CDC plays a fundamental role in the agency; leading
    the CDC in the collaboration with other offices in CDC, HHS, and the
    State Department in the early development of the Global Health
    Initiative. In 2012, CDC OWH functioned with a budget of just $473,291
    and routinely collaborates with other agencies to advance the knowledge
    and research into women's health issues. In a time of limited budgetary
    dollars, the Congress should invest in those offices that promote
    working in collaboration with other agencies, which shares much needed
    expertise while avoiding unnecessary duplication. SWHR recommends that
    the Congress provide the CDC OWH with a 1.06 percent increase for
    fiscal year 2013, 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, the
    agency has always lacked the funding to truly revolutionize healthcare
    in America. Funds from the American Recovery and Reinvestment Act moved
    AHRQ in the right direction; however, those funds were never added to
    AHRQ's base funding level. SWHR recommend the Congress fund AHRQ at the
    President's request for fiscal year 2013, with $334 million acting as
    AHRQ's base discretionary funds. 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 Trust for America's Health
        My name is Jeff Levi, and I am Executive Director of Trust for
    America's Health (TFAH), a nonprofit, nonpartisan organization
    dedicated to saving lives by protecting the health of every community
    and working to make disease prevention a national priority. I am
    grateful for the opportunity to submit testimony to the Subcommittee
    regarding funding for key public health programs. As you craft the
    fiscal year 2013 Labor, Health and Human Services, Education and
    Related Agencies (LHHS) appropriations bill, I urge you to include
    adequate funding for prevention and preparedness programs to promote
    America's health. Moreover, as you work with the Department of Health
    and Human Services (HHS) to allocate funding from the Prevention and
    Public Health Fund (Fund), I urge you to ensure that the Fund is
    invested in transformative programs that will modernize our public
    health system, lower health costs, and enable Americans to lead longer,
    healthier lives.
        Centers for Disease Control and Prevention (CDC).--TFAH is
    extremely concerned by the diminished funding proposed for the Centers
    for Disease Control and Prevention. The President's fiscal year 2013
    budget calls for a $664 million reduction in budget authority for CDC,
    which is an 11.7 percent cut from fiscal year 2012, and a $1.4 billion
    cut since fiscal year 2010. These cuts will force the Agency to choose
    between vaccinating children against deadly, preventable illnesses,
    detecting foodborne outbreaks, and preventing death and injury from the
    next disaster. We urge you to restore base funding to no less than last
    year's level, or at least protect CDC from further cuts and focus our
    investment on cost-effective public health and prevention programs.
        The Prevention and Public Health Fund.--The Prevention and Public
    Health Fund is the only dedicated funding for prevention and public
    health in U.S. history. Despite the cut contained in the Middle Class
    Tax Relief and Job Creation Act, the Fund will still provide an
    additional $12.5 billion over the next 10 years (fiscal year 2013 to
    fiscal year 2022) to enable communities in every State to invest in
    effective, proven prevention efforts. To date, the Fund has invested
    $2.25 billion since fiscal year 2010 to support State and local public
    health efforts to transform and revitalize communities, build
    epidemiology and laboratory capacity to track and respond to disease
    outbreaks, train the Nation's public health and health workforce,
    prevent the spread of HIV/AIDS, expand access to vaccines, reduce
    tobacco use, and help control the obesity epidemic.
        The Fund was intended to supplement, not supplant, existing
    investments with the first-ever, reliable national funding stream for
    public health, while creating jobs, bending the healthcare cost curve,
    and prioritizing disease prevention. In the long-run, expenditures from
    the Fund should be guided by the National Prevention Strategy (NPS).
    The Fund gives the Congress the authority to direct the investment,
    while at the same time guaranteeing an ongoing commitment to prevention
    unprecedented in today's ``sick care'' system. Eliminating the Fund, or
    using a substantial portion of it to supplant existing discretionary
    dollars, would be an enormous step backwards in our progress on cost
    containment, public health modernization, and wellness promotion. We
    urge the Committee to protect the Fund and ensure it is used to reduce
    healthcare costs and help create a long-term path to a healthier and
    economically sound America.
        Community Transformation Grants.--Chronic diseases are responsible
    for 75 percent of healthcare costs in the United States, and the causes
    are often environmental, social, or economic and not addressed by the
    clinical care system. The Community Transformation Grants (CTG)
    program, administered by the CDC, implements and evaluates evidence-
    based community preventive health activities to reduce chronic disease
    and address health disparities. The program focuses on innovative,
    cross-cutting approaches to reducing health risks. The program aligns
    with the NPS by funding multi-sector coalitions to make healthy living
    easier and more affordable where people work, live, learn, play, and
    exercise. We recommend the Committee allocate $250 million for the CTG
    program in fiscal year 2013, which will permit CDC to continue funding
    the current grantees and fund additional communities to broaden the
    scope and success of the program to reach millions more Americans.
    Grants will be used for both community prevention capacity building and
    investing in targeted interventions to reduce the prevalence of the
    leading causes of death, associated risk factors, and health
    disparities.
        National Center for Chronic Disease Prevention and Health
    Promotion.--Starting in 2011, CDC awarded coordinated chronic disease
    State grants to all 50 States to begin to build a core capacity to
    address common risk factors and implement comprehensive strategies for
    promoting health. CDC recently concluded its first round of meetings
    with regional grantees and many States are already reporting
    considerable progress in their efforts to reorganize and achieve
    progress toward this new approach. TFAH recommends a funding level of
    $42 million for the Coordinated Chronic Disease State Grants for fiscal
    year 2013, which will permit CDC to continue to support all States in
    their efforts to coordinate and integrate chronic disease funding and
    activities. The President's proposal to consolidate budget lines for
    the Center is another approach that could further aid coordination of
    national and State chronic disease activities.
        Racial and Ethnic Approaches to Community Health (REACH) programs
    work in communities across the country to eliminate racial and ethnic
    disparities in health and reduce the burden of chronic disease among
    at-risk populations. REACH partners employ innovative, culturally
    competent, community-based, and participatory approaches to develop and
    implement evidence-based practices, empower communities, and reduce
    health disparities. TFAH recommends maintaining the REACH program at
    the fiscal year 2012 funding level of $53.94 million. Eliminating REACH
    would have a devastating impact on the underserved communities
    benefiting from REACH, and would prevent dissemination of best
    practices from REACH communities that can reduce health disparities
    throughout the Nation.
        National Center for Environmental Health (NCEH).--Since fiscal year
    2009, NCEH funding has been cut approximately 25 percent. NCEH cannot
    afford to sustain additional funding cuts without critically damaging
    our Nation's core environmental health infrastructure. The cuts
    implemented to the Healthy Homes and Lead Poisoning Prevention program
    for fiscal year 2012 alone will jeopardize the health of families and
    nearly 450,000 children living in homes nationwide where exposure to
    lead, rodent infestation, and other risk factors is likely. We support
    funding for NCEH at $181.66 million for fiscal year 2013.
        Since 2002, the mission of the National Environmental Public Health
    Tracking Network has been to provide information that communities can
    use to improve their health; the information will come from a
    nationwide network that brings together health and environmental data.
    The program currently operates in 23 States and one city. TFAH
    recommends $43 million for the Tracking Network to expand the program
    to link environmental and health data to identify problems and
    effective solutions that will reduce the burden of chronic disease.
    This level of funding would enable CDC to fund at least five additional
    grantees. An additional $5 million over the fiscal year 2012 level
    would enable the program to add at least three States to the existing
    network. However, the current level of funding is not sufficient to
    fill the health and environmental data gap that is preventing our full
    understanding of how our health is affected by the environment.
        For over 30 years, the Environmental Health Laboratory of NCEH has
    been performing biomonitoring measurements--direct measurements of
    people's exposure to toxic substances in the environment. TFAH
    recommends a funding increase of $2 million from fiscal year 2012
    levels to enable the Division of Laboratory Sciences to work with the
    clinical laboratory community to create a standardized measurement
    process for several cardiovascular disease biomarkers. A reference
    method for these specific biomarkers would improve diagnosis of disease
    and create a tremendous return on investment for Federal and State
    healthcare programs.
        Public Health Emergency Preparedness.--The State & Local
    Preparedness & Response Capability program at the Centers for Disease
    Control and Prevention is the only Federal program that supports the
    work of health departments to prepare for and respond to all types of
    disasters, including bioterror attacks, natural disasters, and
    infectious disease outbreaks. The centerpiece of the program is the
    Public Health Emergency Preparedness (PHEP) Cooperative Agreements.
    PHEP grants support all 50 States, as well as major cities and
    territories, to develop 15 core public health capabilities identified
    by CDC, including in the areas of biosurveillance, community
    resilience, countermeasures, mitigation, incident management,
    information management, and surge management. TFAH recommends providing
    $761.1 million for State and Local Preparedness and Response
    Capability, equivalent to the fiscal year 2010 allocation. Recent and
    proposed cuts mean that our Nation may be less prepared than it was
    just a few years ago, including the potential loss of as many as 1,500
    highly trained frontline public health preparedness workers, reducing
    the number of high-level laboratories, defunding academic and research
    centers, and eroding training, exercise, planning, epidemiology, and
    surveillance capacity. Preparedness is dependent on maintaining a well-
    trained public health workforce, and inconsistent funding results in
    serious gaps in our ability to respond to new health threats.
        In the event of a major disease outbreak or bioterror attack, the
    public health and healthcare systems would be severely overstretched.
    TFAH recommends $426 million for fiscal year 2013 for Hospital
    Preparedness Program (HPP), equivalent to the fiscal year 2010
    allocation. The HPP, administered by the Assistant Secretary for
    Preparedness and Response (ASPR), provides funding and technical
    assistance to prepare the health system to respond to and recover from
    a disaster. The program, which began in response to 9/11, has evolved
    from one focused on equipment and supplies held by individual hospitals
    to respond to a terrorist event to a system-wide, all-hazards approach.
    Funding for HPP must be maintained to retain and build on the progress
    made in hospitals' ability to respond to a disaster.
        Pandemic Influenza and Medical Countermeasures Enterprise.--The
    2011 H1N1 flu outbreak demonstrated how rapidly a new strain of flu can
    emerge and spread around the world. In 2011, CDC confirmed reports from
    several States of the first human-to-human transmission of a novel
    H3N2v influenza virus, illustrating how quickly the virus can mutate
    and spread. Funding for research, prevention, and response cannot
    simply be provided after a pandemic emerges. TFAH recommends $160
    million for CDC's seasonal and pandemic influenza program, equivalent
    to the fiscal year 2012 allocation, to ensure preparedness for this
    deadly infectious disease. In fiscal year 2013, CDC will use the
    funding to continue to protect the public against seasonal flu, track
    the H3N2 variant, monitor changes in the deadly H5N1 virus, work to
    reduce ongoing racial and ethnic disparities in adult vaccine demand,
    and plan for deploying new advances in vaccine formulations and
    diagnostics.
        The Biomedical Advanced Research and Development Authority (BARDA),
    within the office of the Assistant Secretary for Preparedness and
    Response was established in 2006 to jumpstart a new cycle of innovation
    in vaccines, diagnostics, and therapeutics, which would not be
    developed in the private market, in order to combat emerging health
    threats. BARDA provides incentives and guidance for research and
    development of products to counter bioterrorism and pandemic flu and
    manages Project BioShield, which includes the procurement and advanced
    development of medical countermeasures for chemical, biological,
    radiological, and nuclear agents. TFAH recommends $547 million for
    BARDA for fiscal year 2013 to continue development and acquisition of
    medical products key to America's biodefense strategy.
        The President's fiscal year 2013 request also includes funding for
    a new medical countermeasure strategic investment (MCMSI) firm, as
    proposed in the 2011 review. TFAH recommends $50 million to launch the
    MCM Strategic Investor to provide business and financial resources to
    biotech firms working to bring medical countermeasures into production.
        Global Disease Detection.--Through integrated disease surveillance,
    prevention and control activities, CDC's Global Disease Detection (GDD)
    program aims to recognize infectious disease outbreaks faster, improve
    the ability to control and prevent outbreaks, and to detect emerging
    microbial threats, in support of the International Health Regulations.
    In collaboration with host countries and the World Health Organization,
    CDC has established seven GDD Regional Centers, which strengthen our
    capacity to detect and respond to infectious disease outbreaks before
    they reach American shores, such as respiratory syndromes, diarrheal
    diseases, food-borne illnesses, and zoonotic diseases. TFAH recommends
    a $6 million increase for the GDD Program in fiscal year 2013, which
    would add at least two new Regional Centers, and enhance capacity at
    two existing Regional Centers. This increase would broaden our
    geographic coverage by establishing new developing Centers in West
    Africa or South America. According to CDC, additional cuts to the
    program could result in the closure of existing Regional Centers and
    diminished capacity at other Regional Centers. Establishing a Center
    requires years of negotiation, training, and nurturing of partnerships
    between CDC and local health and governmental officials. Closing a
    Center could result in that nation or region remaining closed to CDC
    for years to come.
    Conclusion
        Investing in disease prevention is the most effective, common-sense
    way to improve health. Hundreds of billions of dollars are spent each
    year via Medicare, Medicaid, and other Federal healthcare programs to
    pay for healthcare services once patients develop an acute illness,
    injury, or chronic disease and present for treatment in our healthcare
    system. A sustained and sufficient level of investment in public health
    and prevention is essential to reduce high rates of disease and improve
    health in the United States. Mr. Chairman, thank you again for the
    opportunity to submit testimony on the urgent need to enhance Federal
    funding for public health programs which can save countless lives and
    protect our communities and our Nation.
                                     ______

                    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
    2013 Labor, Health and Human Services, Education and Related Agencies
    appropriation measure. We thank you for your support over the years,
    and hope you will adequately fund them in the future in order to
    provide for and protect the health of many Americans.
        HIV/AIDS remains one of the world's worst health pandemics.
    According to the Centers for Disease Control (CDC), more than 620,000
    people have died of AIDS and there are 50,000 new infections each year
    in the United States. An all-time high of approximately 1.2 million
    people in the United States are living with HIV/AIDS. Persons of
    minority races and ethnicities are disproportionately affected, as well
    as low income people, with nearly 90 percent of those infected relying
    on publicly funded healthcare.
        The vast majority of the discretionary programs supporting domestic
    HIV/AIDS efforts are funded through your Subcommittee. We are keenly
    aware of current budget constraints and competing interests for limited
    dollars, but programs that prevent and treat HIV are inherently in the
    Federal interest as they protect the public health. The AIDS Institute,
    working in coalition with others, has developed funding request numbers
    for each of these programs. We ask that you do your best to adequately
    fund them at the requested level.
    National HIV/AIDS Strategy
        The Obama administration is implementing a comprehensive National
    HIV/AIDS Strategy (NHAS) that seeks to reduce new HIV infections,
    increase access to care and improve health outcomes for people living
    with HIV, as well as reduce HIV-related health disparities. The
    Strategy sets ambitious goals and seeks a more coordinated national
    response with a focus on communities where HIV is most prevalent and on
    programs that work. In order to attain the goals, additional investment
    in key areas will be needed and health reform must be implemented.
    Centers for Disease Control and Prevention-HIV Prevention and Research
    Fiscal year 2012: $786.2 million
    Fiscal year 2013 community request: $1,311.2 million
        The United States allocates only 3 percent of its domestic HIV/AIDS
    spending on prevention. Investing in prevention today will save money
    tomorrow. Preventing one infection will save approximately $355,000 in
    future lifetime medical costs. Preventing all the new 50,000 cases in
    just 1 year would translate into an astounding $18 billion in lifetime
    medical costs.
        The CDC is focused on carrying out several goals of the NHAS.
    Specifically, (1) lowering the annual number of new infections by 25
    percent; (2) reducing the transmission rate by 30 percent; and (3)
    increasing from 79 to 90 the percentage of people living with HIV who
    know their serostatus. In order to address the needs of affected
    populations and the increased number of people living with HIV, CDC
    needs additional funding. While an increase of more than $500 million
    would be needed to achieve the goals of the NHAS, The AIDS Institute
    supports an increase of at least $40.2 million over fiscal year 2012,
    as proposed by the President.
        With this funding, the CDC will be able to implement its new, high-
    impact approach to HIV prevention, based on the combination of
    scientifically proven, cost-effective, and scalable interventions
    directed to the right populations in the right areas. Funds will also
    expand HIV testing.
        Included in the President's CDC HIV budget proposal is $10 million
    to restore a 25 percent cut to HIV Division of Adolescent and School
    Health (DASH) programs. The CDC reports that young people aged 13-29
    accounted for 39 percent of all new HIV infections in 2009. The AIDS
    Institute strongly supports the restoration of these funds.
    Ryan White HIV/AIDS Programs
    Fiscal year 2012: $2,392.2 million
    Fiscal year 2013 community request: $2,875.0 million
        The centerpiece of the Government's response to caring for and
    treating low-income people with HIV/AIDS is the Ryan White HIV/AIDS
    Program. It now serves 577,000 low-income, uninsured, and underinsured
    people. In fiscal year 2012, all but one part of the Program
    experienced cuts in appropriated dollars. This is occurring at a time
    of increased need and demand. Consider the following:
      --Caseloads are increasing. People with HIV are living longer due to
            lifesaving medications, and each year there are 50,000 new
            infections with increased testing programs identifying
            thousands of new people infected with HIV. As unemployment
            rates climb, people are losing their employer-sponsored health
            coverage.
      --Recent research has proven that HIV treatment also serves as HIV
            prevention. In 2011, a landmark study found that successful
            anti-retroviral treatment of HIV reduced the risk of
            transmitting the virus to others by up to 96 percent.
      --There are significant numbers of people with HIV in the United
            States who are not in care and receiving life-saving AIDS
            medications. Recent CDC analysis reveals that only 41 percent
            of the 1.2 million people living with HIV in the United States
            are retained in HIV care and only 28 percent have a suppressed
            viral load.
        Specifically, The AIDS Institute requests the following:
        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 $118.2 million, for a total of $789.5
    million.
        Part B Base provides essential services including diagnostic, viral
    load testing and viral resistance monitoring, and HIV care to all 50
    States, DC, Puerto Rico, and the territories. We are requesting an
    $80.7 million increase, for a total of $502.9 million.
        The AIDS Drug Assistance Program (ADAP) provides life-saving HIV
    drug treatment to more than 209,000 people, or about 46 percent of the
    HIV positive people in care in the United States. The majority of whom
    are people of color (65 percent) and very poor (75 percent are at or
    below 200 percent of the Federal poverty level). ADAPs are experiencing
    unprecedented growth. Over the course of fiscal year 2011, HRSA reports
    that nearly 15,000 new people were added to the program.
        At the same time, State budgets have been stretched and the Federal
    contribution to the program as a percentage has dropped resulting in a
    crisis situation. According to NASTAD, State funding for ADAPs
    increased 11.5 percent between fiscal year 2010 and fiscal year 2011,
    and drug company rebates grew 18.43 percent to $618.9 million.
        Because of a lack of funding, there are currently 3,097 people in
    10 States on waiting lists, thousands more have been removed from the
    program due to lowered eligibility requirements, and drug formularies
    have been reduced. The AIDS Institute is very appreciative of the $15
    million increase to ADAP in fiscal year 2012, but it is far from what
    is currently required to meet the growing demand.
        Recognizing the current ADAP crisis, on World AIDS Day, December 1,
    2011, President Obama announced a transfer of $35 million from existing
    health programs to ADAP. The President proposes to continue that
    funding into fiscal year 2013 as part of his budget as well as an
    increase of $66.7 million for a total of $1 billion. While this is
    short of the actual need of $1,123.3 million, The AIDS Institute
    strongly supports this increase.
        Part C provides early medical intervention and other supportive
    services to 255,000 people at 345 directly funded clinics. Recognizing
    the shortage of resources for providing healthcare, on World AIDS Day
    2011, President Obama redirected $15 million to Part C Programs. The
    President is requesting to continue this funding in his fiscal year
    2013 budget and increase it by $15 million. While still short of the
    actual total need of $286 million, The AIDS Institute supports this
    request.
        Part D provides care to more than 90,000 women, children, youth,
    and families living with and affected by HIV/AIDS at 700 sites. This
    family centered care promotes better health, prevents mother-to-child
    transmission, and brings hard-to-reach youth into care. We are
    disappointed that the President has proposed cutting Part D programs by
    $7.6 million and ask that you reject this request. Rather, The AIDS
    Institute supports a $10.1 million increase, for a total of $87.3
    million.
        Part F includes the AIDS Education and Training Centers (AETCs)
    program and the Dental Reimbursement program. We are requesting a $7.7
    million increase for the AETC program, for a total of $42.2 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 2012: $3.07 billion
    Fiscal year 2013 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. This research has already helped in the development of
    many highly effective new drug treatments, however as neither a cure
    nor a vaccine exists, and patients continue to build resistance to
    medications, additional research must be carried out. 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 how one can prevent
    transmission is critical. It is for this reason The AIDS Institute
    supports the funding of the Teen Pregnancy Prevention Initiative for a
    total of $130 million. Additionally, we oppose funding of abstinence
    only education programs, which have proven to be ineffective.
    Minority AIDS Initiative
        The AIDS Institute supports increased funding for the Minority AIDS
    Initiative (MAI), which funds services nationwide that address the
    disproportionate impact that HIV has on communities of color. For
    fiscal year 2013, 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. This includes
    implementation of the Affordable Care Act. We urge you not to prevent
    the implementation of programs, such as syringe exchange programs,
    which are scientifically proven to prevent HIV and Hepatitis. The AIDS
    Institute was disappointed the Federal funding ban was reinstated in
    fiscal year 2012, and appreciates that this language was not included
    in the President's budget.
    Viral Hepatitis
        There are more than 5.3 million people in the United States
    infected with viral hepatitis, but hepatitis prevention at the CDC is
    funded at only $29.8 million. This is insufficient to provide basic
    health services or to implement the HHS Viral Hepatitis Action Plan.
    While the President's fiscal year 2013 budget flat funds overall CDC
    Hepatitis programs at $29.7 million, it does include $10 million
    allocated from the Prevention and Public Health Fund in fiscal year
    2012 to continue as appropriated dollars in fiscal year 2013. For
    fiscal year 2013, we request an increase of $30.1 million for a total
    of $59.8 million.
        The AIDS Institute asks that you give great weight to our testimony
    as you develop the fiscal year 2013 appropriation bill. Should you have
    any questions or comments, feel free to contact Carl Schmid, Deputy
    Executive Director, The AIDS Institute, cschmid@theaidsinstitute.org.
        Thank you very much.
                                     ______

                  Prepared Statement of The Endocrine Society
        The Endocrine Society is pleased to submit the following testimony
    regarding fiscal year 2013 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 15,000 members worldwide. Our organization is
    dedicated to promoting excellence in research, education, and clinical
    practice in the field of endocrinology. The Society's membership
    includes thousands of researchers who depend on Federal support for
    their careers and their scientific advances.
        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 States' global preeminence in
    research and fostered the development of a biomedical research
    enterprise that was at one time unrivaled throughout the world.
    However, the dominance of the U.S. research enterprise is being sorely
    tested with the consistently low funding increases allotted to the NIH
    since 2003. Just one small example of this is the dramatic increase in
    the percentage of manuscripts from investigators in Europe and Asia
    that are published in our own journals.
        While funding for basic research in the United States appears to be
    slowing down, other countries are ramping up funding. China, for
    instance, plans to increase investment in basic research by 26 percent
    per year, and European countries will increase funding for basic
    research over the next 7 years by 40 percent.\1\ The countries of
    China, Ireland, Israel, Singapore, South Korea and Taiwan collectively
    increased their research and development (R&D) investments by 214
    percent between 1995 and 2004. The United States increased its total
    R&D investments by 43 percent during the same period.\2\
    ---------------------------------------------------------------------------
        \1\ Dr. Francis Collin's Testimony to House Appropriations
    Subcommittee. March 20, 2012
        \2\ The Task Force on the Future of American Innovation. Measuring
    the Moment: Innovation, National Security, and Economic
    Competitiveness.
    ---------------------------------------------------------------------------
        Although some would argue that the investment of other countries in
    R&D will benefit the United States through the subsequent discoveries,
    innovation is one of the keys to the economic growth and stability of
    our country. As President Obama stated, ``The key to our success--as it
    has always been--will be to compete by developing new products, by
    generating new industries, by maintaining our role as the world's
    engine of scientific discovery and technological innovation. It's
    absolutely essential to our future.'' Unfortunately, the President's
    fiscal year 2013 budget request for the NIH does not reflect this
    commitment.
        The relative lack of support for funding the biomedical research
    enterprise has consequences for our economy. Funding from the NIH
    supported more than 432,000 jobs and generated more than $62.1 billion
    in economic activity last year. More than 80 percent of its budget
    directly funds ``extramural'' research performed by 325,000 scientists
    at more than 3,000 institutions in all 50 States and the District of
    Columbia.\3\ While the number of jobs supported is impressive, it is
    unfortunately a decline from 2010, when the money spent by NIH
    extramurally supported 487,900 jobs, approximately 55,000 more jobs
    than in 2011. This is a direct illustration of the impact that lack of
    sustained investment in the agency is beginning to have.
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        \3\ United for Medical Research. NIH's Role in Sustaining the U.S.
    Economy; A 2011 Update. March 20, 2012.
    ---------------------------------------------------------------------------
        In addition to creating jobs, funds from NIH grants put money back
    into the local and State economies through salaries and purchase of
    equipment, laboratory supplies, and vendor services. On average, for
    each dollar of taxpayer investment, NIH grants generate $2.21 in
    economic activity. As an example, UCLA generates almost $15 in economic
    activity for each dollar, resulting in a $9.3 billion impact on the
    region. The estimated economic impact of Baylor on the surrounding
    community is more than $358 million, generating more than 3,300
    jobs.\4\
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        \4\ Federation of American Societies for Experimental Biology. NIH
    Advocacy Slides: California, Texas.
    ---------------------------------------------------------------------------
        Although the NIH has a significant impact on our local, State, and
    national economies, its primary purpose is to improve the health of the
    American people. Each year, the NIH funds thousands of research grants,
    facilitating the discovery of methods of prevention, treatment, and
    cure for debilitating diseases that negatively impact the health of the
    Nation's citizens and fuel rising healthcare costs. Nearly half of all
    Americans have a chronic medical condition, and these diseases now
    cause more than half of all deaths worldwide. Deaths attributed to
    chronic conditions could reach 36 million by 2015 if the trend
    continues unabated. In order to prevent and treat these diseases, and
    save the country billions in healthcare costs, significant investment
    in biomedical research will be needed.
        During a time of economic instability, 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 the local community.
        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 increased Federal
    funding for biomedical research in order to provide the additional
    resources needed to enable American scientists to address the
    burgeoning scientific opportunities and maintain the country's status
    of the preeminent research enterprise. The Endocrine Society recommends
    that NIH receive at least $32 billion in fiscal year 2013. This funding
    recommendation represents the minimum investment necessary to avoid
    further loss of promising research and global preeminence, while
    allowing the NIH's budget to keep pace with biomedical inflation.
                                     ______

         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
    more than 11 million supporters nationwide, we appreciate the
    opportunity to provide testimony on our top NIH funding priorities for
    the Labor, Health and Human Services, Education and Related Agencies
    Appropriations Subcommittee in fiscal year 2013.
                      breeding of chimpanzees for research
        The HSUS requests that no Federal funding be appropriated for the
    breeding of chimpanzees for research purposes. The National Institutes
    of Health has had a moratorium on the breeding of federally owned and
    federally supported chimpanzees in place since 1995, but evidence shows
    that Government supported breeding still continues. However, given the
    lack of necessity for chimpanzees as models for human disease, the
    exorbitant costs of maintaining chimpanzees in laboratories, and the
    ethical issues surrounding the use of chimpanzees, there is no
    justification for the breeding of additional chimpanzees, who have a
    lifespan of up to 60 years, for research; therefore, Federal funds
    should not be used for this purpose.
        Further basis of our request can be found below.
    Background Information and Costs
        In 1995, the National Institutes of Health implemented a moratorium
    on the breeding of federally owned and supported chimpanzees, due to a
    ``surplus'' of chimpanzees and the excessive costs of lifetime care of
    chimpanzees in laboratory settings.\1\ The cost of maintaining
    chimpanzees in laboratories is exorbitant, up to $66 per day per
    chimpanzee; more than $1 million 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.
    ---------------------------------------------------------------------------
        \1\ NRC (National Research Council) (1997) Chimpanzees in research:
    strategies for their ethical care, management and use. National
    Academies Press: Washington, DC.
    ---------------------------------------------------------------------------
        The breeding moratorium was extended indefinitely in 2007. As a
    result, none of the federally owned chimpanzees should have given birth
    or sired infants since 1995. However, there is evidence that at least
    one laboratory has used millions of Federal dollars in recent years to
    support breeding of Government owned chimpanzees. According to records
    provided by the New Iberia Research Center (NIRC) and the National
    Institutes of Health, at least 132 infants were born to a federally
    owned mother and/or federally owned father at NIRC between January 2000
    and November 2011.
        Some of the infants born at NIRC to federally owned parents were
    used to fulfill a multi-year, multi-million dollar contract that the
    laboratory has with an institute within NIH to provide NIH researchers
    with ``4 to 12 disease free infants per year.'' This contract is
    scheduled to end in fiscal year 2012 and this language will ensure that
    it is not renewed.
        In 2010, the Senate Committee on Appropriations included report
    language asking NIH to look into allegations that 123 infants had been
    born to at least one federally owned parent between 2000 and 2009 at
    NIRC. NIH responded that they had could not find evidence that it was
    happening to the extent that had been alleged and they believed NIRC
    was compliant with the moratorium. However, in an article in the
    journal Nature in November 2011, the director of NIRC admitted that he
    did not dispute the allegations and is, in fact, breeding federally
    owned chimpanzees.\2\
    ---------------------------------------------------------------------------
        \2\ Wadman, Meredith. (2011). Lab bred chimps despite ban. Nature,
    Vol 479, Pages 453-454.
    ---------------------------------------------------------------------------
    Chimpanzees Are Not Necessary for Most Current Research
        In December 2011, the Institute of Medicine (IOM) and National
    Research Council released a report entitled ``Chimpanzees in Biomedical
    and Behavioral Research: Assessing the Necessity''. The report found
    that chimpanzees are ``largely unnecessary'' for research and, further,
    could not identify any current area of research for which chimpanzees
    are essential. The report also called for a sharp reduction in the use
    of chimpanzees in biomedical and behavioral research and noted that the
    ``current trajectory indicates a decreasing scientific need for
    chimpanzee studies due to the emergence of non-chimpanzee models and
    technologies.'' \3\
    ---------------------------------------------------------------------------
        \3\ Institute of Medicine and National Research Council. (2011).
    Chimpanzees in Biomedical and Behavioral Research: Assessing the
    Necessity. National Academies Press: Washington, DC.
    ---------------------------------------------------------------------------
        It is also important to note that even in the decade prior to IOM's
    findings, the vast majority of chimpanzees were not being used in any
    studies but, rather, were being warehoused at taxpayer expense. A main
    reason for implementing the breeding moratorium in the first place was
    due to a ``surplus'' of chimpanzees after it turned out that
    chimpanzees were not ideal models for HIV/AIDs.\1\
        Given the obvious downward trend of chimpanzee research, it makes
    little sense to invest limited research resources into any further
    breeding.
    Concerns Regarding Chimpanzee Care in Laboratories
        A 9 month undercover investigation by The HSUS at University of
    Louisiana at Lafayette New Iberia Research Center (NIRC)--the largest
    chimpanzee laboratory in the world--revealed some chimpanzees living in
    barren, isolated conditions and documented more than 100 alleged
    violations of the Animal Welfare Act at the facility 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.
    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 grant agreements or contracts with facilities defined in 7
    U.S.C. Sec. 2132(e) if those agreements or contracts allow or encourage
    the breeding of chimpanzees.''

        We appreciate the opportunity to share our views for the Labor,
    Health and Human Services, Education and Related Agencies
    Appropriations Act for Fiscal Year 2013. 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.
      alternatives to the use of chimpanzees in prophylactic hepatitis c
                           vaccine efficacy research
        In their December 2011 report entitled ``Chimpanzees in Biomedical
    and Behavioral Research: Assessing the Necessity'', the Institute of
    Medicine found that chimpanzees are ``largely unnecessary'' for current
    research and pointed to several available alternatives to the use of
    chimpanzees. The efficacy testing of a prophylactic hepatitis C
    vaccine, once developed, is the only area for which the committee
    wasn't able to reach consensus as to whether chimpanzees are necessary
    for this purpose. However, the committee pointed to several
    alternatives which are currently in development that could eliminate
    any need for chimpanzees in this type of research. Given the financial
    and ethical costs of maintaining chimpanzees in laboratories, coupled
    the serious doubts about the necessity of chimpanzees for such
    research, The Humane Society of the United States believes development
    of alternatives for this purpose should be an urgent priority for the
    National Institutes of Health. Not only would this ensure better use of
    limited research funds, but will also serve to move scientific
    innovation forward.
        We respectfully request the following committee report language.

        ``The Committee supports the immediate implementation and
    prioritization of the development of non-chimpanzee alternatives for
    hepatitis C prophylactic vaccine efficacy studies--as supported by the
    recent IOM report entitled ``Chimpanzees in Biomedical and Behavioral
    Research: Assessing the Necessity.''
     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, The Procter & Gamble Company, and
    the American Chemistry Council.
    ``NIH Director
        ``The Committee supports NIH's leadership role in the creation of a
    new paradigm for chemical risk assessment based on the incorporation of
    advanced molecular biological and computational methods in lieu of
    animal toxicity tests. NIH has indicated that development of this
    science is critical to several of its priorities, from personalized
    medicine to tackling specific diseases such as cancer and diabetes. The
    Committee encourages NIH to continue to expand its extramural support
    for the use of human biology-based experimental and computational
    approaches in health research to further define toxicity and disease
    pathways and develop tools for their integration into evaluation
    strategies. Extramural and intramural funding should be made available
    for the evaluation of the relevance and reliability of Tox21 methods
    and prediction tools to assure readiness and utility for regulatory
    purposes, including pilot studies of pathway-based risk assessments.
    The Committee requests NIH provide a report on associated funding in
    fiscal year 2013 for such activity and a progress report of Tox21
    activities in the congressional justification request, featuring a 5-
    year plan for projected budgets for the development of Tox21 methods,
    including prediction models, and activities specifically focused on
    establishing scientific confidence in them for regulatory. The
    Committee also requests NIH prioritize an additional (1-3 percent) of
    its research budget within existing funds for such activity.''
                                     ______

               Prepared Statement of the Tri-Council for Nursing
        The Tri-Council for Nursing, comprising the American Association of
    Colleges of Nursing, the American Nurses Association, the American
    Organization of Nurse Executives, and the National League for Nursing,
    respectfully requests $251 million 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 2013.
        The Tri-Council is a long-standing nursing alliance focused on
    leadership and excellence in the nursing profession. 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 (BLS) projects a
    growth of 26 percent by 2020.
        Notwithstanding the economic challenges facing our Nation today,
    the BLS projects there will be 712,000 new nursing jobs created between
    2010 and 2020. This workforce growth is expected to continue as the
    demand for nursing care in traditional acute care settings and the
    expansion of non-hospital settings such as home care and long-term care
    accelerates. The BLS projections further explain the need for 495,500
    replacements in the nursing workforce, bringing the total number of job
    openings for nurses due to growth and replacements to 1.2 million by
    2020.
        As our Nation regains its economic foothold, the Tri-Council urges
    the Subcommittee to focus on the larger context of building the nursing
    capacity needed to meet the increasing healthcare demands of our
    Nation's population. Starting on January 1, 2011, baby boomers began
    turning 65 at the rate of 10,000 a day. With them comes the increased
    demand for healthcare and services of an aging population, which will
    swell the pressure on the healthcare system, especially when coupled
    with near epidemic growth in childhood obesity, diabetes, and other
    chronic diseases experienced among our country's populations.
        Moreover, the acute nurse faculty shortage is a primary reason why
    schools of nursing across the country turn away thousands of qualified
    applications each year. The demand for nurses and the faculty who
    educate them is a serious impediment to improving the health of
    America. Nurses continue to be the largest group of healthcare
    providers whose services are directly linked to quality and cost-
    effectiveness. The Tri-Council is grateful to the Subcommittee for its
    past commitment to Title VIII funding and respectfully asks for a
    continued long-term investment that will build the nursing workforce
    necessary to deliver the quality, affordable care envisioned in health
    reform.
           a proven solution: 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.), have
    helped build the supply and distribution of qualified nurses to meet
    our Nation's healthcare needs since 1964. Over the last 48 years, the
    original programs as well as newly added and expanded programs have
    addressed all aspects of supporting the workforce--education, practice,
    retention, and recruitment. They have bolstered 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. A description of the Title
    VIII programs and their impact are included below.
      --Advanced Nursing Education (ANE) Grants (Sec. 811) support the
            preparation of registered nurses (RNs) in master's and doctoral
            nursing programs. The ANE grants help prepare our Nation's
            nurse practitioners, clinical nurse specialists, nurse
            midwives, nurse anesthetists, nurse educators, nurse
            administrators, nurses in executive practice, public health
            nurses, and other nursing specialists requiring advanced
            nursing education. In fiscal year 2010, these grants supported
            the education of 7,863 students.
      --Advanced Education Nursing Traineeships (AENT) assist graduate
            nursing students by providing full or partial reimbursement for
            the costs of tuition, books, program fees, and reasonable
            living expenses. Funding for the AENTs supports the education
            of future nurse practitioners, clinical nurse specialists,
            nurse midwives, nurse anesthetists, nurse educators, nurse
            administrators, public health nurses, and other nurse
            specialists requiring advanced education.
      --Nurse Anesthetist Traineeships (NAT) supports the education of
            students in nurse anesthetist programs. In some States,
            certified registered nurse anesthetists are the sole anesthesia
            providers in almost 100 percent of rural hospitals. Much like
            the AEN Traineeships, the NAT provides full or partial support
            for the costs of tuition, books, program fees, and reasonable
            living expenses.
      --In fiscal year 2010, the AEN Traineeship and the NAT supported
            12,325 nursing students.
      --Nursing Workforce Diversity Grants (Sec. 821) prepare students from
            disadvantaged backgrounds to become nurses. This program awards
            grants and contract opportunities to schools of nursing for a
            variety of clinical training facilities to address nursing
            educational needs for not only disadvantaged students but also
            racial and ethnic minorities underrepresented in the nursing
            profession. In fiscal year 2010, the program supported 10,361
            students.
      --Nurse Education, Practice, Quality and Retention Grants (Sec. 831
            and Sec. 831A) help schools of nursing, academic health
            centers, nurse-managed health centers, State and local
            governments to strengthen nursing education programs. In fiscal
            year 2010, this program supported 4,860 undergraduate nursing
            students.
      --Nurse Loan Repayment and Scholarship Program (Sec. 846, Title VIII,
            PHSA) provides grants to students that pay up to 85 percent of
            a student's loan in return for at least 3 years of service in a
            designated health shortage area or in an accredited school of
            nursing. In fiscal year 2010, the Nurse Loan Repayment and
            Scholarship Programs supported 1,304 nurses and nursing
            students.
      --Nurse Faculty Loan Program (Sec. 846A, Title VIII, PHSA) provides
            up to 85 percent of loan cancellation if the student agrees to
            a 4-year teaching commitment in a school of nursing. In fiscal
            year 2010, these grants supported the education of 1,551 future
            nurse educators.
      --Comprehensive Geriatric Grants (Sec. 855, Title VIII, PHSA provide
            support to nursing students specializing in care for the
            elderly. These grants may be used to educate RNs who will
            provide direct care to older Americans, develop and disseminate
            geriatric curriculum, prepare faculty members, and provide
            continuing education.
        Our Nation is faced with a growing healthcare crisis that must be
    addressed on many fronts. Nurses are an important part of the solution
    to the crisis of cost, burden of disease, and access to quality care.
    To meet this challenge, funding of proven Federal programs such as
    Title VIII will help ease the demand for RNs. The Tricouncil
    respectfully requests your support of $251 million for the Title VIII
    Nursing Workforce Development Programs in fiscal year 2013.
                                     ______

       Prepared Statement of The Society for Healthcare Epidemiology of
    America and the Association for Professionals in Infection Control and
                                  Epidemiology
        The Society for Healthcare Epidemiology of America (SHEA) and the
    Association for Professionals in Infection Control and Epidemiology
    (APIC) thank you for this opportunity to submit testimony on Federal
    efforts to eliminate preventable healthcare-associated infections
    (HAIs). 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 annually according to the CDC's most recent
    official estimates. In addition to the substantial human suffering,
    HAIs contribute $28 to $33 billion in excess healthcare costs each
    year.
        The good news is that some HAIs are on the decline as a result of
    recent advances in the understanding of how to prevent certain
    infections. 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. Over the past decade, the Agency for Healthcare Research
    and Quality (AHRQ) has funded numerous projects targeting HAI
    prevention that have led to the successful reduction of central line-
    associated blood stream infections (CLABSIs) in hospital intensive care
    units (ICUs). Healthcare professionals have reduced these infections in
    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 toward the goal of HAI elimination.
        To build and then sustain these winnable battles against HAIs, we
    urge you, in fiscal year 2013, to support the CDC Coalition's request
    for $7.8 billion for the CDC's ``core programs.'' We are concerned
    about the President's fiscal year 2013 budget proposal that would
    reduce the CDC's budget authority by $664 million, for a total
    reduction of $1.4 billion since fiscal year 2010. At the same time, the
    administration and the Congress increasingly rely on the Prevention and
    Public Health Fund and funding transfers from other agencies to
    backfill the cuts to CDC's budget authority. We believe that the
    Congress should prioritize funding for the activities and programs
    supported by CDC that are essential to protect the health of the
    American people.
        We especially want to highlight our support for the $27.5 million
    in the President's budget for the CDC's National Healthcare Safety
    Network (NHSN). These funds are critically needed to ensure high-
    quality monitoring of HAI prevalence as well as antibiotic usage in the
    U.S. Collection of accurate, timely, and complete data is necessary to
    measure the true extent of the problem, develop evidence-based HAI
    prevention strategies and monitor their effectiveness. In addition,
    consistent, high quality, scientifically sound and validated data are
    necessary to be reported at the State and Federal level to ensure that
    accurate data are available to evaluate the HHS National Action Plan to
    Prevent HAIs progress as well as to support transparency to the public,
    allowing for fair comparisons between facilities. Such data are
    critical to understanding patterns of HAI prevalence, which help public
    health and healthcare practitioners better coordinate prevention
    efforts and measure reduction in HAIs. Since NHSN is the only system
    with this capability, the majority of States have adopted it for
    legislatively mandated public reporting and most inpatient facilities
    reimbursed by Medicare are required to report specified HAIs via NHSN.
    Data from other care settings and additional infection types are being
    phased in. Thus, the number of facilities, types of facilities and
    number of infection indicators are growing exponentially.
        Despite the system's importance in our Nation's efforts to monitor
    and prevent HAIs, funding for NHSN has been flat since fiscal year
    2010. Without additional funding, increasing the number of facilities
    reporting into NHSN from 3,000 in 2010 to an expected 16,500 in 2013
    will exceed the capacity of the system. The requested funding for NHSN
    will allow CDC to modernize the NHSN information technology platform to
    enhance electronic data collection, reduce the burden of data
    collection and allow facilities, States and Federal agencies to focus
    on infection prevention and control. The NHSN serves as the foundation
    for prevention and the development of innovative, evidence-based HAI
    prevention strategies. Federal resources are required to ensure
    accurate, timely, and complete data are reported to NHSN and become
    available to the public. We urge you to support the requested funding
    level for NHSN to allow the CDC, States and other Federal agencies to
    use this tool to carry out their mission to ensure the public's health,
    assure and improve the quality of care and enhance patient safety.
        CDC's Antimicrobial Resistance activities are included within the
    Emerging and Zoonotic Infectious Disease programs' proposed budget.
    SHEA and APIC commend the CDC for creating an expert advisory group on
    antimicrobial resistance. Continued support for the Emerging Infections
    Program (EIP) is also critical as the HAI component engages a network
    of State health departments and their academic medical center partners
    to help answer important questions about emerging HAI threats, advanced
    infection tracking methods and antibiotic resistance in the United
    States. Ensuring the effectiveness of antibiotics well into the future
    is vital for the Nation's public health, particularly at this time when
    our current therapeutic options are dwindling and research and
    development of new antibiotics is lagging. As bacteria and other micro-
    organisms are becoming more resistant to antimicrobials, it is
    essential that the CDC maintains the ability to monitor organism
    resistance in healthcare as it is one of the most pressing problems and
    greatest challenges that healthcare providers will confront during the
    coming decade.
        It is critical that antimicrobial stewardship programs are adopted
    in all settings where antimicrobials are used. SHEA and APIC applaud
    the CDC for its Get Smart for Healthcare campaign, which aims to
    optimize antibiotic use by encouraging adherence to appropriate
    prescribing guidelines in hospitals and long-term care facilities and
    we encourage its continued support. We also strongly support the NHSN's
    Antibiotic Use Module. Launched in May 2011, it is the first effort in
    the United States to define national data on antibiotic use in
    healthcare institutions. Because single payer systems have the
    advantage of making it easier to track antimicrobial resistance, the
    United States stands at a disadvantage to European countries in this
    regard.
        SHEA and APIC are strongly supportive of the CDC Prevention
    Epicenters Program, a collaboration of CDC's Division of Healthcare
    Quality Promotion (DHQP) and five academic medical centers that conduct
    innovative infection control and prevention research to address
    important scientific questions regarding the prevention of HAIs,
    antibiotic resistance and other adverse healthcare events. The
    Epicenters Program is funded through the NHSN and has provided a unique
    forum in which academic leaders in healthcare epidemiology can partner
    directly with each other and with CDC subject matter experts. The
    resultant emphasis on multicenter collaborative research projects,
    through which investigators work together as a group, allows for
    research that in many cases, would not have been possible for a single
    academic center. The knowledge gained through the Epicenters Program
    has been highly valuable to the field, and has resulted in more than
    150 publications in peer-reviewed journals on a wide range of HAI
    prevention topics.
        Existing HAI prevention strategies are limited by the current state
    of science, and as a result cannot prevent all HAIs even when fully
    implemented. As we strive to eliminate all preventable HAIs, we need to
    identify the gaps in our understanding of what is actually preventable.
    This distinction is critical to help guide subsequent research
    priorities and to help set realistic expectations. SHEA and APIC
    believe in the importance of conducting basic, epidemiological and
    translational studies to fill basic and clinical science gaps. While
    health services research (i.e., successful implementation of strategies
    already known or suspected to be beneficial) may provide some immediate
    short-term benefit, to achieve further success, a substantial
    investment in basic science, translational medicine, and epidemiology
    is needed to permit effective and precise, interventions that prevent
    HAIs. Moreover, experts in the field (Epidemiologists and Infection
    Preventionists), in collaboration with CDC and AHRQ, should be engaged
    in order to further define and prioritize the research agenda.
        SHEA and APIC strongly support the proposed investment of $34
    million by AHRQ in fiscal year 2013 to reduce and prevent healthcare-
    associated infections (HAIs). This total includes $11.6 million in HAI
    research grants to improve the prevention and management of HAIs and
    $22.4 million in HAI contracts including nationwide implementation of
    Comprehensive Unit-based Safety Program (CUSP). AHRQ-funded projects
    related to HAI prevention involve the implementation of CUSP, which is
    based on an Intensive Care Unit Safety Reporting System developed by
    the Johns Hopkins University Quality and Safety Research Group,
    Baltimore, Maryland. SHEA and APIC are very pleased that AHRQ is
    expanding the CUSP program to all 50 States, extending its reach to
    other settings in addition to ICUs, and broadening the focus to address
    other types of infections, such as catheter-associated urinary tract
    infections (CAUTIs). Our organizations are participating in the CUSP-
    CAUTI initiative through identification of expert members to serve on a
    national network of clinical faculty working to improve patient safety
    through dissemination of educational modules across the Nation.
        Despite the fact that HAIs are among the top 10 annual causes of
    death in the United States, support for basic, translational and
    epidemiological HAI research has not been a priority of the National
    Institutes of Health (NIH). The reality is that scientists studying
    these infections receive relatively less funding than colleagues in
    many other disciplines. The limited availability of Federal funding to
    study HAIs has the effect of steering young investigators interested in
    pursuing research in this area toward other, better-funded fields. This
    severely hampers the HAI clinical research enterprise at a time when it
    should be expanding. 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 and move our discipline to the next level of evidence-based
    patient safety. SHEA and APIC urge your support of increased NIH
    funding for basic, translational and implementation research
    proportionate to the clinical significance of HAIs.
        Although we are pleased that HHS' Office of the Assistant Secretary
    for Health (OASH) has expressed support for the implementation of HAI-
    related reforms through the overall OASH budget, we believe having
    dedicated funding of $5 million for the HAI Action Plan is the best way
    to ensure that this critical initiative is adequately resourced. SHEA
    and APIC members have been actively 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. 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 to prevent infections.
    Additionally, we believe strongly that the CDC is the agency with the
    necessary expertise to define appropriate metrics through which the HAI
    Action Plan can best measure its efforts.
        SHEA and APIC also request that the Subcommittee approve $16.1
    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. This funding will allow the CMS
    to continue the enhanced survey process--developed jointly with the
    CDC--to target infection control deficiencies in ASCs every 4 years. We
    believe this enhanced survey process is a good way of ensuring that
    basic infection prevention practices are followed, thus avoiding
    potential outbreaks due to unsafe practices.
        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.
        About SHEA.--SHEA has helped define best practices in healthcare
    epidemiology worldwide since its founding in 1980. 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 of 2,200
    in all branches of medicine, public health, and healthcare
    epidemiology. SHEA members are committed to implementing evidence-based
    strategies to prevent HAIs and improve patient safety, and have
    scientific expertise in evaluating potential strategies to accomplish
    this goal.
        About APIC.--APIC's mission is to create a safer world through
    prevention of infection. The association's more than 14,000 members
    direct infection prevention programs that save lives and improve the
    bottom line for hospitals and other healthcare facilities. APIC
    advances its mission through patient safety, implementation science,
    competencies and certification, advocacy, and data standardization.
                                     ______

     Prepared Statement of the University of North Dakota and North Dakota
                                State University
        On behalf of the University of North Dakota and North Dakota State
    University, thank you for the opportunity to submit our written
    testimony regarding the fiscal year 2013 funding for the National
    Institutes of Health (NIH) Institutional Development Award (IDeA)
    program. We respectfully request your support of no less than $310
    million for this critically important program. We further request that
    the Subcommittee gives serious consideration to legislative language
    which would direct that future NIH budgets include funding for the IDeA
    program that reaches no less than 1 percent of the total NIH budget.
    IDeA was authorized by the 1993 NIH Revitalization Act (Public Law 103-
    43) and funds only merit-based, peer reviewed research that meets NIH
    research objectives in the 23 IDeA States and Puerto Rico.
        The States eligible for IDeA funding are defined as ``all States/
    commonwealths with a success rate for obtaining NIH grant awards of
    less than 20 percent over the period of 2001-2005 or received less than
    an average of $120 million per year during that time period.''
    Currently this includes 23 States and Puerto Rico--nearly half of the
    States. Funding from this critical capacity-building program has been a
    key part of the growth in research capacity and impact at the two North
    Dakota research universities in recent years.
        Funding for the IDeA program in fiscal year 2012 was $276.48
    million. The total budget for NIH in fiscal year 2012 was $30.86
    billion; thus in fiscal year 2012, the IDeA program--funding
    competitively awarded biomedical research in nearly half the Nation--
    comprised only 0.89 percent of the entire NIH budget. The IDeA program
    exists because the 23 eligible States overall receive less than 20
    percent of NIH's extramural funding. The proposed reduction in the
    President's fiscal year 2013 budget request of $51 million represents a
    staggering 18 percent cut to the budget of the IDeA program, but
    represents only 0.16 percent of the entire proposed NIH budget. Making
    such a serious, disproportionate cut to a program designed to aid
    small, rural States is manifestly unfair. This program is small in the
    overall scheme of things at NIH, but huge for the States that compete
    for these funds. Our requested funding level of $310 million represents
    only 1 percent of the President's total fiscal year 2013 budget request
    for NIH.
        Our State, North Dakota, has benefited immensely from the
    competitive funding available through the IDeA program in the form of
    COBRE (Center for Biomedical Research Excellence) and INBRE (IDeA
    Networks of Biomedical Research Excellence) grants, and we anticipate
    submitting a joint proposal in September of this year for an IDeA
    Program Infrastructure for Clinical and Translational Research (IDeA
    CTR) grant.
        At the University of North Dakota, we have been awarded funding for
    two phases of a COBRE grant supporting research on neurodegenerative
    diseases. We have been notified informally that we can expect funding
    for Phase III, the final phase of a COBRE project, during fiscal year
    2012. North Dakota has one of the largest populations of the extremely
    old in the Nation (second only to Florida in the percentage of its
    citizens over 85 years of age), and high rates of neurodegenerative
    diseases such as Alzheimer's, Parkinson's, and multiple sclerosis. As
    an example of the impact of this funding and the research capacity it
    has built, externally funded research at the University of North
    Dakota's School of Medicine and Health Sciences has grown
    substantially. Prior to COBRE funding, in fiscal year 2002, the SMHS
    received about $12 million in external funding; by fiscal year 2011,
    this had increased to $20.5 million, an increase of 71 percent. In
    2010, when UND developed a new strategic plan for research,
    neuroscience was identified as an existing strength on which to build
    further.
        Thus, the neurobiology COBRE grant is achieving its intended
    purpose of expanding our research capacity and our ability to compete
    for Federal funding. That research is directed at problems of direct
    interest to our citizenry, but also to the rest of the United States.
        The University of North Dakota has submitted a proposal for an
    additional COBRE grant on the topic of epigenetics. Epigenetics is the
    study of how environmental factors influence the expression of our
    genes; in many cases these changes in gene expression can then be
    inherited by the next generation. Although possible funding for this
    COBRE grant application has not yet been determined, we believe that
    the submitted grant is a highly competitive one that addresses a
    burgeoning area of research interest and importance.
        North Dakota State University has received COBRE grants to fund
    research at its Center for Protease Research and the Center for Visual
    and Cognitive Neuroscience. COBRE funding supported important chemical
    and biological research at the Center for Protease Research relating to
    the roles played by enzymes that break down proteins in cancer and
    asthma.
        COBRE funding at NDSU's Center for Visual and Cognitive
    Neuroscience facilitated research illuminating and ameliorating
    conditions such as disordered perception, cognition, emotion, attention
    and executive function which are hallmarks of debilitating and costly
    disease syndromes (e.g. ADHD, ARMD, agnosia, amblyopia, autism,
    depression, dementia, dyslexia, hemi neglect, multiple sclerosis,
    Parkinson's disease, PTSD, and schizophrenia).
        COBRE funding has contributed to the success that both NDSU's
    Centers have achieved in obtaining competitive grants from privates
    sources and a variety of Federal agencies. Additionally, the COBRE
    grants led to the publication of NDSU's research findings in
    international, refereed publications and have aided in the recruitment
    of new faculty and increased enrollments in related graduate and
    undergraduate programs.
        Another critically important IDeA program is INBRE, which provides
    funding to build the biomedical workforce through activities ranging
    from outreach to elementary school children to creating opportunities
    for undergraduates to engage in research. This program has provided
    support for undergraduate students at 2- and 4-year colleges in North
    Dakota to participate in research during the summer at their home
    institutions. This program includes two tribal colleges and serves
    between 70 and 100 students each year. Another program at the
    University of North Dakota serves about 60 undergraduates per year and
    applications routinely exceed the number of slots that are available.
    These programs are critical for keeping students in the pipeline for
    the STEM (science, technology, engineering, and math) workforce.
    Studies have repeatedly shown that engaging undergraduates in original
    research is a powerful tool for retaining students in college so that
    they graduate in a timely way.
        A major emphasis has been on outreach programs to Native American
    students, the minority group that is most under-represented in the
    fields of science, engineering, and math. Between 25 and 35 Native
    American students in grades 7-12 participate each year in a program
    that uses traditional Native American tools to teach science. As many
    as 40 students from tribal colleges are funded each year to visit UND
    and learn about opportunities to transfer to the university and
    complete their 4-year degrees. INBRE provides support for transfer
    students from tribal colleges through the Pathway program, a 6-week
    summer program that prepares participants for advanced coursework in
    science. Pathway students can also receive tuition waivers from the
    university. INBRE funding is also provided to support the American
    Indian Health Research Forum on the UND campus each year; this forum
    attracts attendees from across the Nation.
        We expect to submit a joint proposal from the two North Dakota
    research universities this fall to help us develop a joint center for
    clinical and translational research. The basic science departments in
    our School of Medicine and Health Sciences have grown as a result of
    COBRE and INBRE programs. Like other States, we need to move the
    results of that research to patients' bedsides. If we are successful in
    competing for a CTR grant, we will be able to build the necessary
    infrastructure that we need to do so.
        North Dakota, with a population of 672,591 according to the 2010
    Census, is the smallest of all the IDeA States. Yet, our School of
    Medicine and Health Sciences graduates a disproportionately large
    number of primary care physicians who practice in rural areas, and 20
    percent of all Native American physicians in the United States are
    graduates of the University of North Dakota. This medical school is
    clearly making important contributions to healthcare for underserved
    populations. Like all medical schools, it must have a healthy research
    program underpinning its training of physicians, and funding from the
    IDeA program is critical to the health of that program and to building
    research capacity for the future.
        The IDeA States produce STEM graduates at the same per capita rate
    as States with larger populations and larger research portfolios. The
    students from IDeA States need and deserve the same exposure to
    research as students in larger States. If the proposed reductions in
    the President's fiscal year 2013 budget request for the IDeA program
    are not rejected, North Dakota and other small, mostly rural States,
    will receive a major setback in their efforts to increase their
    capacity to undertake biomedical research and to train the next
    generation of scientists who are critical for the health of our Nation
    and our economy.
        The IDeA program is absolutely critical not only for the University
    of North Dakota and North Dakota State University, but also for the
    biomedical research capacity and capability of research institutions
    nationwide. We sincerely appreciate the Subcommittee's ongoing support
    of the IDeA program and request that you give full consideration to our
    recommendations and fiscal year 2013 request of no less than $310
    million for the National Institutes of Health IDeA program. We further
    request that the Subcommittee considers legislative language directing
    that future NIH budgets include funding for the IDeA program that
    reaches no less than 1 percent of the total NIH budget.
    Contact Information
        Phyllis E. Johnson, Ph.D. Vice President for Research and Economic
    Development, University of North Dakota. 264 Centennial Drive, Stop
    8367, Grand Forks, North Dakota 58201.
        Joshua Wynne, M.D., M.B.A., M.P.H. Vice President for Health
    Affairs and Dean of the School of Medicine and Health Sciences,
    University of North Dakota. 501 N. Columbia Road, Stop 9037, Grand
    Forks, ND 58202.
        Philip Boudjouk, Ph.D. Vice President for Research, Creative
    Activities, and Tech Transfer, North Dakota State University. Research
    1, Dept. 4000, PO Box 6050, Fargo, ND 58108-6050.
                                     ______

         Prepared Statement of the US Hereditary Angioedema Association
        Thank you for the opportunity to present the views of the US
    Hereditary Angioedema Association (US HAEA) regarding the importance of
    Hereditary Angioedema (HAE) public awareness activities and research.
        The US HAEA is a nonprofit patient advocacy organization founded in
    1999 to help those suffering with HAE and their families to live
    healthy lives. The Association's goals were, and remain, to provide
    patient support, advance HAE research and find a cure. The US HAEA
    provides patient services that include referrals to HAE knowledgeable
    healthcare providers, disease information and peer-to-peer support. US
    HAEA also provides research funding to scientific investigators to
    increase the HAE knowledge base and maintains an HAE patient registry
    to support ground-breaking research efforts. Additionally, US HAEA
    provides disease information materials and hosts forums to educate
    patients and their families, healthcare providers, and the general
    public on HAE.
        HAE is a rare and potentially life-threatening inherited disease
    with symptoms of severe, recurring, debilitating attacks of edema
    (swelling). HAE patients have a defect in the gene that controls a
    blood protein called C1-inhibitor, so it is also more specifically
    referred to as C1-inhibitor deficiency. This genetic defect results in
    production of either inadequate or nonfunctioning C1-inhibitor protein.
    Because the defective C1-inhibitor does not adequately perform its
    regulatory function, a biochemical imbalance can occur and produce an
    unwanted peptide--called bradykinin--that induces the capillaries to
    release fluids into surrounding tissues, thereby causing swelling.
        People with HAE experience attacks of severe swelling that affect
    various body parts including the hands, feet, face, airway (throat) and
    intestinal wall. Swelling of the throat is the most life-threatening
    aspect of HAE, because the airway can close and cause death by
    suffocation. Studies reveal that more than 50 percent of patients will
    experience at least one throat attack in their lifetime.
        HAE swelling is disfiguring, extremely painful and debilitating.
    Attacks of abdominal swelling involve severe and excruciating pain,
    vomiting, and diarrhea. Because abdominal attacks mimic a surgical
    emergency, approximately one-third of patients with undiagnosed HAE
    undergo unnecessary surgery. Untreated, an average HAE attack lasts
    between 24 and 72 hours, but some attacks may last longer and be
    accompanied by prolonged fatigue.
        The majority of HAE patients experience their first attack during
    childhood or adolescence. Most attacks occur spontaneously with no
    apparent reason, but anxiety, stress, minor trauma, medical, surgical,
    and dental procedures, and illnesses such as colds and flu have been
    cited as common triggers. ACE Inhibitors (a blood pressure control
    medication) and estrogen-derived medications (birth control pills and
    hormone replacement drugs) have also been shown to exacerbate HAE
    attacks.
        HAE's genetic defect can be passed on in families. A child has a 50
    percent chance of inheriting the disease from a parent with HAE.
    However, the absence of family history does not rule out the HAE
    diagnosis; scientists report that as many as 25 percent of HAE cases
    today result from patients who had a spontaneous mutation of the C1-
    inhibitor gene at conception. These patients can also pass the
    defective gene to their offspring. Worldwide, it is estimated that this
    condition affects between 1 in 10,000 and 1 in 30,000 people.
    Public Awareness at the Centers for Disease Control and Prevention
        HAE patients often suffer for many years and may be subject to
    unnecessary medical procedures and surgery prior to receiving an
    accurate diagnosis. Raising awareness about HAE among healthcare
    providers and the general public will help reduce delays in diagnosis
    and limit the amount of time that patients must spend without treatment
    for a condition that could, at any moment, end their lives.
        Once diagnosed, many individuals are able to piece together a
    family history of mysterious deaths and episodes of swelling that
    previously had no name. In some families, over many years, this
    condition has come to be accepted as something that must simply be
    endured. Increased public awareness is crucial so that these patients
    understand that HAE often requires emergency treatment and disabling
    attacks no longer need to be passively accepted. While HAE cannot yet
    be cured, intelligent use of available treatments can help patients
    lead a productive life.
        In order to prevent deaths, eliminate unnecessary surgeries, and
    improve patients' quality of life, it is critical that CDC pursue
    programs to educate the public and medical professionals about HAE in
    fiscal year 2013.
    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 HAE-
    specific research since 2009, and there is no longer any Federal
    research as it relates to HAE.
        As it may provide greater opportunities for HAE research, we
    applaud the recent establishment of the National Center for Advancing
    Translational Sciences (NCATS) at NIH. Housing translational research
    activities at a single Center at NIH will allow these programs to
    achieve new levels of success. Initiatives like the Cures Acceleration
    Network are critical to overhauling the translational research process
    and overcoming the challenges that plague treatment development. In
    addition, new efforts like taking the lead on drug repurposing have the
    potential to speed access to new treatments, particularly to patients
    who struggle with rare or neglected diseases. As a rare disease
    community, HAE patients may also benefit from the Therapeutics for Rare
    and Neglected Diseases (TRND) program, housed at NCATS, as well
    coordination with the Office of Rare Diseases Research (ORDR). We ask
    that you support NCATS and provide adequate resources for the Center in
    fiscal year 2013.
        In order to reinvigorate HAE research at NIH, it is vital that NIH
    receive increased support in fiscal year 2013. US HAEA recommends an
    overall funding level of $32 billion for NIH in fiscal year 2013 and
    the inclusion of recommendations emphasizing the importance of HAE
    research to learn more about this rare disease and new pathways for
    appropriate treatment.
        Thank you for the opportunity to present the views of the HAE
    community.
                                     ______

                Prepared Statement of the U.S. Soccer Foundation
        Thank you Chairman Harkin, Ranking Member Shelby, and Members of
    the subcommittee, for the opportunity to submit this testimony. I am Ed
    Foster-Simeon, the president and chief executive officer of the U.S.
    Soccer Foundation (USSF). As the Congress works on priorities for
    fiscal year 2013 Federal appropriations, I would like to respectfully
    urge that the subcommittee prioritize the Social Innovation Fund, an
    account in the Federal Corporation for National and Community Service,
    which is under the subcommittee's jurisdiction.
        The U.S. Soccer Foundation, the major charitable arm of soccer in
    the United States, was established in 1994. Thanks to support from
    donors, our corporate partners, and countless youth development
    organizations, the Foundation has provided more than $55 million in
    grants, financial support, and loans to help fund programs and projects
    in all 50 States. Thousands of individuals have benefited from the
    Foundation's support, and the need continues to grow.
        The U.S. Soccer Foundation seeks to improve the health and well-
    being of children in urban economically disadvantaged areas using
    soccer as a vehicle for youth development and social change.
    Specifically, our goal is ensure that children in underserved
    communities have easy and affordable access to high-quality out-of-
    school programs that improve health and social outcomes among this
    vulnerable population. We accomplish this through our innovative
    program: Soccer for Success, a free afterschool sports-based youth
    development program designed to address such national priorities as
    childhood obesity and juvenile delinquency. I will discuss this program
    further in my testimony, after detailing the urgent needs we are
    working to address and the Federal resource that provides tremendous
    support to these efforts.
        There is a great need for the expansion of multi-faceted youth
    development programs across the United States. First, childhood obesity
    rates have increased sharply in the United States over the past 30
    years. Today, nearly one-third of children and adolescents are
    overweight or obese (White House Task Force on Childhood Obesity). The
    rate of childhood obesity is even more alarming among children growing
    up in economically disadvantaged communities. We can reverse this
    pattern by providing children with more opportunities to be physically
    active and by educating them on the importance of developing and
    maintaining active, healthy lifestyles. In many urban communities,
    however, there is a lack of suitable recreation facilities and
    organized programming. Our urban soccer programs provide inner-city
    children with safe havens to play, stay active, and engage with
    positive adult role models and mentors who help them develop important
    life skills.
        Second, additional resources must be dedicated to address the needs
    of America's at-risk youth. The statistics are alarming. According to
    the U.S. Census Bureau's 2012 statistical abstract, more than 1.5
    million juveniles were arrested in 2009, including more than 69,000 for
    a violent crime. As reported in the National Youth Gang Survey, more
    than 28,000 gangs were active in larger cities (55.6 percent), suburban
    counties (23.3 percent), smaller cities (18.3 percent), and rural
    counties (2.7 percent) among U.S. jurisdictions in 2009. According to
    the U.S. Department of Health and Human Services (HHS), at-risk youth
    across low-income urban communities not only have a higher chance of
    being obese, but are more likely than youth from middle- or upper-class
    families to join a gang, get in a fight or steal something worth more
    than $50.
        Further, MENTOR/National Mentoring Partnership estimates that 18
    million young people--nearly one-half of the population between the
    ages of 10 and 18--live in situations which put them at-risk of ``not
    living up to their potential.'' They also identified a total of 3
    million youth currently benefiting from a formal mentoring
    relationship. This leaves as many as 15 million American youth in want
    or need of mentors which comprise what MENTOR calls the ``mentoring
    gap''. To meet this need and overcome one of the biggest barriers in
    the mentoring field, which is difficulty in mentor recruitment and
    retention, alternatives to the classic ``one-to-one'' mentoring model
    must be considered, utilized, and leveraged.
        By leveraging Social Innovation Fund dollars, the U.S. Soccer
    Foundation is expanding its Soccer for Success program to address these
    national issues and reduce mentoring wait lists by utilizing a group
    mentoring model.
        According to the Corporation for National and Community Service,
    the Social Innovation Fund leverages a modest investment of public
    funds to significantly expand the most promising, evidence-based
    nonprofit programs serving low-income communities. Each Social
    Innovation Fund dollar must be matched by at least three private and
    non-Federal funders. The proposed $50 million investment will bring an
    additional $150 million to promising, locally driven programs with
    evidence of compelling results--including the Foundation's programs.
        The Social Innovation Fund program clearly has wide-ranging impact.
    Currently, there are more than 200 organizations benefiting from the
    Social Innovation Fund, operating in more than 100 cities in 31 States
    and our Nation's capital. This national footprint will expand after all
    of the 2011 sub-grants have been awarded. Under consistent and
    effective program evaluation, the Social Innovation Fund is an
    excellent example of the Federal dollar being used to propagate best
    practices and ensure greatest impact.
        The U.S. Soccer Foundation is a 2011 recipient of a $2 million, 2-
    year Social Innovation Fund award that is enabling us to reach 12,000
    children, 3 days a week, 24 weeks a year, through Soccer for Success--
    our sports-based after school youth development program. Soccer for
    Success is an evidence based program that promotes healthy lifestyles
    and works to reduce childhood obesity and juvenile delinquency rates
    among at-risk youth in underserved urban communities by providing
    exercise, nutritional education, and mentoring by positive adult role
    models in a safe environment.
        the U.S. Soccer Foundation is matching the $2 million Social
    Innovation Fund award dollar for dollar. Each sub-grantee is matching
    their award dollar for dollar with private, non-Federal dollars. The
    result is that each Federal taxpayer dollar awarded is being leveraged
    3-to-1.
        The following is a list of the 13 community-based organizations
    selected as Social Innovation Fund sub-grantees who will implement
    Soccer for Success in the upcoming school year. This list includes the
    number of children anticipated to be served:

    ----------------------------------------------------------------------------------------------------------------
                                                                                                            No. of
        SIF Soccer for Success Organizations                     City/State                  Grant (2-     children
                                                                                            year award)     served
    ----------------------------------------------------------------------------------------------------------------
    Brotherhood Crusade........................  Los Angeles, California..................     $600,000        1,600
    Boys & Girls Club of Camden County.........  Camden, New Jersey.......................      200,000          840
    Boys & Girls Club of Metro Atlanta.........  Atlanta, Georgia.........................      200,000          670
    Colorado Fusion Soccer Club................  Denver, Colorado.........................      300,000        1,125
    DC Scores..................................  Washington, DC...........................      220,000          650
    El Monte CBI...............................  El Monte, California.....................      270,000        1,080
    Independent Health Foundation..............  Buffalo, New York........................      320,000          700
    Think Detroit PAL..........................  Detroit, Michigan........................      300,000          950
    Widener University.........................  Chester, Pennsylvania....................      230,000        1,000
    Boys & Girls Club of Trenton...............  Trenton, New Jersey......................      200,000        1,000
    YMCA of Greater Dayton.....................  Dayton, Ohio.............................      320,000        1,000
    Houston Parks & Recreation Department......  Houston, Texas...........................      240,000        1,000
    Washington Youth Soccer Association........  Seattle, Washington......................      200,000          800
                                                --------------------------------------------------------------------
          Total................................  .........................................    3,600,000       12,415
    ----------------------------------------------------------------------------------------------------------------

        These 13 organizations demonstrated through a rigorous selection
    process the strong organizational capacity needed to manage the grant
    and implement the program. They serve the desired population--children
    growing up in economically disadvantaged urban communities--have the
    ability to match the funds awarded dollar for dollar, have an effective
    cost model for program implementation, and have strong partnerships and
    funding prospects for long-term sustainability.
        Before I end, let me share with you a story about the impact youth
    development programs like Soccer for Success can have in addressing
    national priorities. Celeste Amaya, a 10-year old girl in our Los
    Angeles program, weighed 145 when she began our program. Soccer for
    Success' physical activity and nutritional lessons component has helped
    her drop nearly 16 lbs. ``I eat the same food, but it was the amount of
    food'', she says, about cutting back on portion size. ``A lot of the
    clothes [that I had outgrown] fit me now,'' she shared. Celeste
    recently weighed in at 129 lbs. Soccer for Success has not only made a
    difference in Celeste's life, but also has helped the entire family
    become more active. Celeste's mother says that when her daughter's
    doctor warned her that her overweight child could develop diabetes, the
    whole family became determined to get in shape. ``We do everything
    together'', says Mrs. Amaya. While her mom gets exercise by walking
    around the soccer field with some of the other parents, as part of
    Soccer for Success Los Angeles' parent engagement component, Celeste's
    father helps the Soccer for Success mentors coach Celeste and the other
    children. Celeste's little sister also participates in Soccer for
    Success. Due to the funding we received from the Social Innovation
    Fund, we will be able to leverage each Federal dollar and continue
    making this type of impact, while changing the lives of more than
    12,000 youth like Celeste.
        In conclusion, we respectfully ask you to support $70 million in
    funding for the Social Innovation Fund which is the level at which it
    is authorized in the Serve America Act. At a time when the Federal
    Government seeks to leverage every taxpayer dollar to greatest effect,
    the Social Innovation Fund provides a critical mechanism for
    identifying innovative, cost-effective, evidence-based programs like
    Soccer for Success--programs that make a real difference in lives of
    the Nation's most vulnerable children. Every child should have a chance
    to play, to be a teammate, to build self-confidence and to live a
    healthy and active life. Funding from the Social Innovation Fund helps
    to further this vision.
        Thank you once again for the opportunity to provide testimony to
    your subcommittee in support of this important program. Your attention
    and assistance are greatly appreciated.
                                     ______

           Prepared Statement of the United Tribes Technical College
        For 43 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 one-half of our operating budget
    and provide for our core instructional programs. The requests of the
    United Tribes Technical College Board for fiscal year 2013 is for
    Department of Education programs as follows:
      --$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 over the fiscal year 2012 level and
            the President's request. These funds are awarded competitively
            and are distributed via formula;
      --$30 million as requested by the administration and the American
            Indian Higher Education Consortium for title III-A (section
            316) of the Higher Education Act (Strengthening Institutions
            program). This is $5 million over fiscal year 2012 enacted;
      --Maintain Pell Grants at the $5,635 maximum award level; and
      --Support the proposed Community College to Career Fund.
                                 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 the 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, and necessary life skills.
      --Renewed unrestricted accreditation from the North Central
            Association of Colleges and Schools for the period July 2011
            through July 2021, including authority to offer all of our full
            programs online.
      --Services including a Child Development Center, family literacy
            program, wellness center, area transportation, K-8 elementary
            school, tutoring, counseling and housing.
      --A semester completion rate of 82 percent.
      --A graduate placement rate of 83 percent (placement into jobs and
            higher education).
      --A projected return on Federal investment of 20-1 (2005 study).
      --more than 30 percent of our graduates move on to 4 year or advanced
            degree institutions.
      --A current student body from 63 tribes who come mostly from high-
            poverty, high-unemployment tribal nations in the Great Plains;
            many students have dependents.
      --76 percent of undergraduate students receive Pell Grants.
      --21 2 year degree programs, 12 certificates, and 3 bachelor degree
            programs (elementary education; business administration; and
            criminal justice).
      --An expanding curricula to meet job-training needs for growing
            fields including law enforcement and health information
            technology. We have new short-term training programs for
            welding technology (in particular demand in North Dakota
            because of the oil boom), electrical, energy auditing, and
            Geographic Information System technology.
      --A dual enrollment program targeting junior and senior high school
            students, providing them an introduction to college life and
            offering high school and college credits.
      --A critical role in the regional economy. Our presence brings at
            least $34 million annually to the economy of the Bismarck
            region.
      --A workforce of 360 people.
      --An award-winning annual powwow which last year had participants
            from 60+ tribes and international indigenous dance groups,
            drawing more than 10,000 spectators.
                                funding requests
        Section 117 Perkins Base Funding.--Funds requested under section
    117 of the Perkins Act above the fiscal year 2012 level are needed to:
    maintain 100-year-old education buildings and 50-year-old housing stock
    for students; upgrade technology capabilities; provide adequate
    salaries for faculty and staff (who have not received a cost of living
    increase for the past year and who are in the bottom quartile of salary
    for comparable positions elsewhere); and fund program and curriculum
    improvements.
        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.--Among the
    Title III-A statutorily allowable uses is facility construction and
    maintenance. We are constantly in need of additional student housing,
    including family housing. We would like to educate more students but
    lack of housing has at times limited the admission of new students.
    With the completion this year of a new Science, Math and Technology
    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.
        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 housing that was donated 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.
        Pell Grants.--We support maintaining the Pell Grant maximum amount
    to at least a level of $5,635. As mentioned above, 76 percent of our
    students are Pell Grant-eligible. This program makes all the difference
    in the world of whether these students can attend college.
        Community College to Career Fund.--We support the proposed
    Community College Career Fund, and understand that tribally controlled
    colleges will be eligible applicants. UTTC is ready with training--
    campus-based and online--to help meet the needs of high-demand
    businesses.
                    government accountability office report
        As you know, the Government Accountability Office in March 2011
    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. Even these combined sources do not provide the resources
    necessary to operate and maintain the college and thus we actively seek
    alternative funding to assist with academic programming, deferred
    maintenance of our physical plant and scholarship assistance, among
    other things.
        We reiterate that 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 2012 Federal operational funds ($8 million from Perkins; $7
    million from the BIE). That is a modest amount for two campus-based
    institutions which offer a broad (and expanding) array of programs
    geared toward the educational, job-training, and cultural needs of
    their students.
        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. 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, we make this investment through
    other sources of funding to help ensure that our students succeed at
    the postsecondary level.
        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 highly competitive, often one-time supplemental funds.
        Thank you for your consideration of our requests.
                                     ______

                Prepared Statement of the University of Virginia
        This testimony is submitted for the record on behalf of the
    University of Virginia, a nonprofit public institution of higher
    education located in Charlottesville, Virginia. The University sustains
    the ideal of developing, through education, leaders who are well-
    prepared to help shape the future of the nation. In fiscal year 2011
    the University received research awards totaling more than $338 million
    from all sources (Federal and State agencies, industry and private
    foundations). Of this amount, $241 million, or 71 percent, came from
    Federal grants and contracts.
        As Vice President for Research and on behalf of UVa, I urge the
    Committee to support $32 billion for the National Institutes of Health
    (NIH) in fiscal year 2013. We are aware of the difficult budgetary
    decisions facing the Congress and the administration in the coming
    years, yet Federal investments in scientific and engineering research
    remain critical to spurring innovation, driving the economy, and
    developing the knowledge and technologies to tackle current and future
    health challenges. According to the Science Coalition, more than half
    of our economic growth in the United States since World War II can be
    traced to science-driven technological innovation. The platform for
    this innovation has been scientific and engineering research conducted
    at universities and supported by the Federal Government through
    agencies such as NIH.
        Ground-breaking discoveries to better diagnose and treat
    debilitating human diseases and improve the health and quality of life
    of our citizens would not be possible without the foundational work of
    basic research. Universities conduct most of the basic research in this
    country and NIH is the critical funder of basic biomedical research.
    NIH continues to be the largest source of Federal research funding at
    UVa, providing more than $144 million in competitive grants to
    researchers at UVa in fiscal year 2011 alone. Funding from NIH has
    allowed faculty and students at UVa to conduct ground-breaking research
    to transform our understanding of and develop new treatments for
    diabetes, asthma, cardiovascular disease, and Alzheimer's disease,
    among many other conditions, while also furthering our fundamental
    knowledge of biology, health, and development from childhood to old
    age.
        Considering the tight budget conditions that the country faces, it
    is imperative to make strategic investments in critical areas of
    science and biomedical research that will produce technological
    innovation and societal benefit. For example, continued support for the
    National Institute of Biomedical Imaging and Bioengineering (NIBIB) is
    critical to advancing the next generation of technologies that can be
    used to address a myriad of health challenges. Researchers at UVa are
    already making substantial advances on a wide array of new technologies
    for applications such as molecular imaging and tissue engineering.
        NIH is also at the forefront of efforts to ensure that basic
    research is transformed into products and knowledge that improve
    everyday life and power our innovation economy. UVa appreciates NIH's
    commitment to funding programs that support commercialization such as
    the new National Center for Advancing Translational Sciences (NCATS).
    UVa also urges support for a newly created pilot program to fund proof-
    of-concept research that will enable universities to more effectively
    commercialize new technologies and propel the creation of successful
    small businesses. Modeled after the Coulter Process and authorized in
    the Small Business Innovation Research (SBIR) and the Small Business
    Technical Transfer (STTR) Reauthorization Act of 2011, the program will
    allow NIH to award competitive grants of up to $1 million to
    universities and other research institutions, which then would award
    grants to investigators for activities such as prototype development,
    market research, or developing an intellectual property strategy and/or
    business development plan. We look forward to seeing how NIH will
    implement this new program and urge the Congress to encourage NIH to
    support proof-of-concept funds to advance commercialization.
        At UVa we are devoting significant institutional resources to the
    process of bringing discoveries to the marketplace and have experienced
    considerable success. For instance, UVa and the Coulter Foundation have
    recently teamed to create the UVa Coulter Translational Research
    Partnership to foster collaborations between clinicians and biomedical
    engineers at UVa in order to advance translational research which will
    result in new technologies to improve patient care and human health. An
    independent audit has shown that our proof-of-concept funds have led to
    a 7:1 return on investment after 5 years and a 42:1 return on
    investment for the top 10 percent of portfolio projects. We attribute
    UVa's success in proof-of-concept research to the now nationally well-
    known Coulter process, involving a very diverse review board, in-person
    final review sessions, milestone-driven projects, quarterly reporting
    that is simple yet effective in re-directing projects, the ``will to
    kill'' projects or re-direct funds if insurmountable obstacles occur,
    and excellent networking to the venture capital and private sector. The
    key differentiators of this process as we employ it at UVa versus most
    prior proof-of-concept funding mechanisms is the in-person diligence on
    the involved people and ideas, dedicated project manager, the diverse
    composition of the board, the urgency of quarterly reviews, and will to
    re-direct funds as results emerge.
    Conclusion
        I would like to thank the Committee for your support of biomedical
    research in these tough budgetary times. While we understand that
    funding is greatly constrained, I hope that you will choose to support
    a strategic increase for the National Institutes of Health to spur
    innovation, strengthen our technology and economic base, train the next
    generation of scientists and engineers, and improve our health. Further
    investment in discovery science and commercialization will help create
    the new discoveries and technologies needed for long-term economic
    growth.
        I thank you for your consideration of these important issues.
                                     ______

      Prepared Statement of the Department of Mines, Minerals and Energy,
                            Commonwealth of Virginia
        We are writing in opposition to the fiscal year 2013 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 reject MSHA's proposed reduction of $5 million 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.
        Over the past several years, MSHA's budget request for State's
    Grants was approximately $9 million, which approached the statutorily
    authorized level of $10 million, but still did not consider
    inflationary and programmatic increases being experienced by the
    States. This drastic change in funding the State's Grants programs will
    certainly have negative impacts on the availability and quality of mine
    safety training. Without full funding of the State's Grants programs,
    the Federal required safety training for miners will suffer. This
    situation will be further exacerbated by the new statutory, regulatory
    and policy requirements that grow out of the various reports and
    recommendations pending the Upper Big Branch mine disaster
    investigation. We therefore urge the subcommittee to restore funding to
    the statutorily authorized level of $10 million for State's grants so
    that States can meet the training needs of miners and fully and
    effectively carry out State responsibilities under Section 203(a) of
    the Act.
        While we can appreciate MSHA's desire to realign its resources to
    focus on inspection and enforcement activities, one of the most
    effective ways to ensure miner health and safety in the first place is
    through comprehensive and high quality training. MSHA Assistant
    Secretary Main specifically spoke of this in a recent letter to State's
    Grant recipients wherein he stated: ``As in the past, we are reaching
    out to grantees, recognizing the positive impact you have in delivering
    training to miners. I am asking that you incorporate, as appropriate
    training on these types of fatal accidents as well as measures needed
    to prevent them. Increased training and awareness is necessary if we
    are to prevent these types of deaths''.
        Certainly, we can all agree that high quality; effective training
    plays a critical role in preventing miner deaths, injuries and illness
    across the Nation. Comprehensive, up-to-date training is the most
    effective means for preparing miners to recognize and correct unsafe
    acts and unsafe conditions in the workplace. Unsafe acts and unsafe
    conditions have been proven to contribute significantly to accidents
    and injuries. Training enhances the capability of miners to recognize
    potential hazards in the workplace and to follow safe work procedures.
        The Virginia State's Grants training program has contributed
    significantly to training approximately 5,400 miners, annually, for the
    past 5 years. Our training program also develops miner training
    programs, mine safety videos, mine and equipment examination record
    books, among other useful resources. These programs and materials are
    distributed to industry, independent and college trainers and mine
    officials to enhance their capability to provide on-target, up-to-date,
    effective training for miners.
        The DMME has been in the forefront of providing this training in
    Virginia for over 40 years and is best positioned to continue that work
    into the future. The Federal Government's relatively modest investment
    of money in supporting the States to coordinate this training has
    certainly paid huge dividends in protecting lives and preventing
    injuries/illnesses for our miners. The VA-DMME State's Grants programs
    play a particularly critical role in providing quality mine safety
    training and providing special assistance to small mine operators. Our
    State's grant program provides these services at a cost well below what
    it would cost the Federal Government to do so.
        Without the training programs that are funded/provided by the VA-
    DMME State's grants program, pursuant to the funding that we receive
    from MSHA, mine safety training responsibilities and costs will shift
    to mine operators. Mine operators will be compelled to comply with
    MSHA-required miner training by obtaining training services from any
    available resource. Quality, effective training for our most valuable
    resource--the miner--will be diminished, especially for miners employed
    at small mines (50 or less employees). In addition, some training
    services now funded/provided by the VA-DMME State's grants program will
    be significantly reduced or eliminated.
        In conclusion, the everyday miner in the workplace will be the
    greatest loser if this proposed funding reduction is imposed upon the
    VA-DMME State's Grant training program.
    .................................................................

           LIST OF WITNESSES, COMMUNICATIONS, AND PREPARED STATEMENTS

                                  ----------
                                                                       Page

    AcademyHealth, Prepared Statement of.............................   312
    Ad Hoc Group for Medical Research, Prepared Statement of the.....   340
    Adult Congenital Heart Association, Prepared Statement of the....   314
    Alexander, Senator Lamar, U.S. Senator From Tennessee, Questions
      Submitted by.............................................68, 144, 265
    Alliance of Information and Referral Systems, Prepared Statement
      of the.........................................................   344
    Alzheimer's:
        Association, Prepared Statement of the.......................   281
        Foundation of America, Prepared Statement of the.............   333
    American:
        Academy of:
            Family Physicians, Prepared Statement of the.............   296
            Ophthalmology, Prepared Statement of the.................   308
            Pediatrics, Prepared Statement of the....................   310
        Association:
            For:
                Cancer Research, Prepared Statement of the...........   292
                Dental Research, Prepared Statement of the...........   294
            Of:
                Colleges of:
                    Nursing, Prepared Statement of the...............   286
                    Osteopathic Medicine, Prepared Statement of the..   288
                    Pharmacy, Prepared Statement of the..............   290
                Immunologists, Prepared Statement of the.............   298
                Museums, Prepared Statement of the...................   301
                Nurse Anesthetists, Prepared Statement of the........   306
        College of Physicians, Prepared Statement of the.............   319
        Congress of Obstetricians and Gynecologists, Prepared
          Statement of the...........................................   317
        Dental:
            Education Association, Prepared Statement of the.........   325
            Hygienists' Association, Prepared Statement of the.......   328
        Diabetes Association, Prepared Statement of the..............   322
        Foundation for Suicide Prevention, Prepared Statement of the.   334
        Heart Association, Prepared Statement of the.................   337
        Indian Higher Education Consortium, Prepared Statement of the   342
        Lung Association, Prepared Statement of the..................   345
        National Red Cross and United Nations Foundation, Prepared
          Statement of the...........................................   353
        Nurses Association, Prepared Statement of the................   351
        Psychological Association, Prepared Statement of the.........   358
        Public:
            Health Association, Prepared Statement of the............   360
            Power Association, Prepared Statement of the.............   363
        Society:
            For:
                Microbiology, Prepared Statement of the..............   374
                Nutrition, Prepared Statement of the.................   377
                Pharmacology & Experimental Therapeutics, Prepared
                  Statement of the...................................   382
            Of:
                Hematology, Prepared Statement of the................   372
                Nephrology, Prepared Statement of the................   379
                Plant Biologists, Prepared Statement of the..........   380
                Tropical Medicine and Hygiene, Prepared Statement of
                  the................................................   384
        Thoracic Society, Prepared Statement of the..................   387
        Urogynecologic Society, Prepared Statement of the............   390
    Americans for Nursing Shortage Relief, Prepared Statement of.....   355
    Animal Welfare Institute, Prepared Statement of the..............   393
    Arthritis Foundation, Prepared Statement of the..................   331
    Association:
        For:
            Clinical Research Training, Prepared Statement of the....   321
            Patient-Oriented Research, Prepared Statement of the.....   321
            Professionals in Infection Control and Epidemiology,
              Prepared Statement of the..............................   596
            Research in Vision and Ophthalmology, Prepared Statement
              of the.................................................   369
        Of:
            American:
                Cancer Institutes, Prepared Statement of the.........   283
                Medical Colleges, Prepared Statement of the..........   304
            Maternal and Child Health Programs, Prepared Statement of
              the....................................................   347
            Minority Health Professions Schools, Prepared Statement
              of the.................................................   349
            Public Television Stations and the Public Broadcasting
              Service, Prepared Statement of the.....................   363
            Rehabilitation Nurses, Prepared Statement of the.........   367
    Autism Speaks, Prepared Statement of.............................   371

    Battey, Jr., James F., 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..........................................   175
    Birnbaum, Linda S., Ph.D., D.A.B.T., A.T.S., Director, National
      Institute of Environmental Health Sciences, National Institutes
      of Health, Department of Health and Human Services, Prepared
      Statement of...................................................   177
    Brain Injury Association of America, Prepared Statement of the...   394
    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...................................................   178
    Brown, Senator Sherrod, U.S. Senator From Ohio, Statement of.....   215

    Centers for Disease Control and Prevention Coalition, Prepared
      Statement of the...............................................   401
    Charles R. Drew University of Medicine and Science, Prepared
      Statement of the...............................................   423
    Children's Environmental Health Network, Prepared Statement of
      the............................................................   405
    Christopher & Dana Reeve Foundation, Prepared Statement of the...   404
    Clinical Research Forum, Prepared Statement of the...............   321
    Coalition:
        For Health Funding, Prepared Statement of the................   414
        Of:..........................................................
            EPSCor/IDeA States and the Mississippi Research
              Consortium, Prepared Statement of the..................   407
            Northeastern Governors, Prepared Statement of the........   415
    Cochran, Senator Thad, U.S. Senator From Mississippi, Questions
      Submitted by..................................................67, 144
    College:
        Of Veterinary Medicine, Nursing & Allied Health, Tuskegee
          University, Prepared Statement of the......................   427
        On Problems of Drug Dependence, Prepared Statement of the....   421
    Collins, Francis S., M.D., Ph.D., Director, National Institutes
      of Health, Department of Health and Human Services.............   151
        Prepared Statement of........................................   160
        Summary Statement of.........................................   156
    Commissioned Officers Association of the U.S. Public Health
      Service, Prepared Statement of the.............................   416
    Communities Advocating Emergency AIDS Relief Coalition, Prepared
      Statement of the...............................................   395
    COPD Foundation, Prepared Statement of the.......................   419
    Council:
        For Opportunity in Education, Prepared Statement of the......   417
        Of Academic Family Medicine, Prepared Statement of the.......   398
        On Social Work Education, Prepared Statement of the..........   425
    Cystic Fibrosis Foundation, Prepared Statement of the............   411

    Department of Mines, Minerals and Energy, Commonwealth of
      Virginia, Prepared Statement of the............................   608
    Dickman, Martin J., Inspector General, Office of Inspector
      General, Prepared Statement of.................................   275
    Durbin, Senator Richard J., U.S. Senator From Illinois, Questions
      Submitted by..................................................54, 254
    Dystonia Medical Research Foundation, Prepared Statement of the..   429

    Elder Justice Coalition, Prepared Statement of the...............   430
    Eldercare Workforce Alliance, Prepared Statement of the..........   430

    Fauci, Anthony S., M.D., Director, National Institute of Allergy
      and Infectious Diseases, National Institutes of Health,
      Department of Health and Human Services........................   151
        Prepared Statement of........................................   165
    Federation of American Societies for Experimental Biology,
      Prepared Statement of the......................................   433
    Friends of the:
        Health Resources and Services Administration, Prepared
          Statement of...............................................   434
        National Institute:
            Of Child Health and Human Development, Prepared Statement
              of the.................................................   438
            On:
                Aging, Prepared Statement of the.....................   436
                Drug Abuse, Prepared Statement of the................   441
    FSH Society, Inc., Prepared Statement of the.....................   442

    Glass, Roger I., M.D., Ph.D., Director, Fogarty International
      Center, National Institutes of Health, Department of Health and
      Human Services, Prepared Statement of..........................   180
    Global Health Technologies Coalition, Prepared Statement of the..   447
    Goodwill Industries International, Prepared Statement of.........   450
    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............   182
    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............   183
    Greenberg, Judith H., Ph.D., Acting Director, National Institute
      of General Medical Sciences, National Institutes of Health,
      Department of Health and Human Services, Prepared Statement of.   185
    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................................   187

    Harkin, Senator Tom, U.S. Senator From Iowa:
        Opening Statements of....................................1, 81, 151
        Questions Submitted by.................................40, 111, 240
    Harm Reduction Coalition, Prepared Statement of the..............   455
    Harrison, Patricia, President and CEO, Corporation for Public
      Broadcasting, Prepared Statement of............................   277
    Health Professions and Nursing Education Coalition, Prepared
      Statement of the...............................................   452
    Hodes, Richard J., M.D., Director, National Institute on Aging,
      National Institutes of Health, Department of Health and Human
      Services.......................................................   151
        Prepared Statement of........................................   171

    Infectious Diseases Society of America, Prepared Statement of the   458
    Inouye, Senator Daniel K., U.S. Senator From Hawaii:
        Prepared Statements of...................................3, 83, 156
        Questions Submitted by.................................41, 123, 246
    Insel, Thomas R., M.D., Director, National Institute of Mental
      Health, Acting Director, National Center for Advancing
      Translational Sciences, National Institutes of Health,
      Department of Health and Human Services........................   151
        Prepared Statement of........................................   173
    International Foundation for Functional Gastrointestinal
      Disorders, Prepared Statement of the...........................   460
    Interstate Mining Compact Commission, Prepared Statement of the..   463
    Interstitial Cystitis Association, Prepared Statement of the.....   456

    Johnson, Senator Ron, U.S. Senator From Wisconsin, Questions
      Submitted by...................................................    75

    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..........................................   189
    Kirk, Senator Mark, U.S. Senator From Illinois, Questions
      Submitted by...................................................   146
    Kohl, Senator Herb, U.S. Senator From Wisconsin, Questions
      Submitted by..................................................46, 248

    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...................................................   190
    Landrieu, Senator Mary L., U.S. Senator From Louisiana, Questions
      Submitted by.............................................50, 132, 249
    Lindberg, Donald A.B., M.D., Director, National Library of
      Medicine, National Institutes of Health, Department of Health
      and Human Services, Prepared Statement of......................   192
    Lummi Indian Business Council, Prepared Statement of the.........   464

    March of Dimes Foundation, Prepared Statement of the.............   468
    Medical Library Association, Prepared Statement of the...........   471
    Meharry Medical College, Prepared Statement of...................   475
    Mesothelioma Applied Research Foundation, Prepared Statement of
      the............................................................   466
    Mikulski, Senator Barbara A., U.S. Senator From Maryland:
        Questions Submitted by.....................................137, 261
        Statement of.................................................    14
    Moran, Senator Jerry, U.S. Senator From Kansas, Questions
      Submitted by.............................................79, 147, 268
    Morehouse School of Medicine, Prepared Statement of the..........   477
    Murray, Senator Patty, U.S. Senator From Washington, Questions
      Submitted by..................................................48, 124

    National:
        AHEC Organization, Prepared Statement of the.................   489
        Alliance:
            For Eye and Vision Research, Prepared Statement of the...   486
            Of State and Territorial AIDS Directors, Prepared
              Statement of the.......................................   493
        Assembly on School Based Health Care, Prepared Statement of
          the........................................................   491
        Association of:
            Clinical Nurse Specialists, Prepared Statement of the....   484
            Community Health Centers, Prepared Statement of the......   482
            County and City Health Officials, Prepared Statement of
              the....................................................   480
            Nutrition and Aging Services Programs, Prepared Statement
              of the.................................................   489
            State Comprehensive Health Insurance Plans, Prepared
              Statement of the.......................................   492
        Congress of American Indians, Prepared Statement of the......   498
        Consumer Law Center, Prepared Statement of the...............   504
        Council:
            For Diversity in the Health Professions, Prepared
              Statement of the.......................................   503
            Of Social Security Management Associations, Prepared
              Statement of the.......................................   507
        Energy Assistance Directors' Association, Prepared Statement
          of the.....................................................   509
        Head Start Association, Prepared Statement of the............   518
        Hispanic Council on Aging, Prepared Statement of the.........   516
        Kidney Foundation, Prepared Statement of the.................   521
        League for Nursing, Prepared Statement of the................   523
        Marfan Foundation, Prepared Statement of the.................   528
        Minority Consortia, Prepared Statement of the................   526
        Multiple Sclerosis Society, Prepared Statement of the........   531
        Nursing Centers Consortium, Prepared Statement of the........   535
        Postdoctoral Association, Prepared Statement of the..........   537
        Primate Research Centers, Prepared Statement of the..........   541
        Public Radio, Prepared Statement of..........................   539
        Respite Coalition, Prepared Statement of the.................   543
        Technical Institute for the Deaf, Prepared Statement of the..   547
    Nemours, Prepared Statement of...................................   513
    Nephcure Foundation, Prepared Statement of the...................   515
    Neurofibromatosis Network, Prepared Statement of the.............   533
    North Dakota State University, Prepared Statement of.............   599
    Nursing Community, Prepared Statement of the.....................   496

    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...................................................   194
    Physician Assistant Education Association, Prepared Statement of
      the............................................................   553
    Population Association of America/Association of Population
      Centers, Prepared Statement of the.............................   549
    Prevent Blindness America, Prepared Statement of.................   555
    Pryor, Senator Mark, U.S. Senator From Arkansas, Questions
      Submitted by..................................................60, 260
    Pulmonary Hypertension Association, Prepared Statement of the....   558

    Reed, Senator Jack, U.S. Senator From Rhode Island, Questions
      Submitted by.............................................57, 135, 257
    Research Working Group of the Federal AIDS Policy Partnership,
      Prepared Statement of the......................................   563
    Research!America, Prepared Statement of..........................   560
    Rochester Institute of Technology, Prepared Statement of the.....   547
    Rodgers, Griffin P., M.D., M.A.C.P., Director, National Institute
      of Diabetes and Digestive and Kidney Diseases, National
      Institutes of Health, Department of Health and Human Services..   151
        Prepared Statement of........................................   167
    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.   196
    Ryan White Medical Providers Coalition, Prepared Statement of the   564

    Safe States Alliance, Prepared Statement of the..................   579
    Schwartz, Michael S., Chairman of the Board, Railroad Retirement
      Board, Prepared Statement of...................................   273
    Scleroderma Foundation, Prepared Statement of the................   569
    Sebelius, Hon. Kathleen, Secretary, Office of the Secretary,
      Department of Health and Human Services........................     1
        Prepared Statement of........................................     7
        Summary Statement of.........................................     6
    Shelby, Senator Richard C., U.S. Senator From Alabama:
        Prepared Statements of...................................4, 82, 154
        Questions Submitted by.................................61, 138, 262
        Statements of................................................3, 153
    Shurin, Susan B., M.D., Acting Director, National Heart, Lung,
      and Blood Institute, National Institutes of Health, Department
      of Health and Human Services, Prepared Statement of............   198
    Sieving, Paul A., M.D., Ph.D., Director, National Eye Institute,
      National Institutes of Health, Department of Health and Human
      Services, Prepared Statement of................................   200
    Sleep Research Society, Prepared Statement of the................   578
    Society:
        For:
            Clinical and Translational Science, Prepared Statement of
              the....................................................   321
            Neuroscience, Prepared Statement of the..................   573
            Public Health Education, Prepared Statement of the.......   575
            Women's Health Research, Prepared Statement of the.......   582
        Of Gynecologic Oncology, Prepared Statement of the...........   570
    Solis, Hon. Hilda L., Secretary, Office of the Secretary,
      Department of Labor............................................    81
        Prepared Statement of........................................    86
        Summary Statement of.........................................    83
    Somerman, Martha J., D.D.S., Ph.D., Director, National Institute
      of Dental and Craniofacial Research, National Institutes of
      Health, Department of Health and Human Services, Prepared
      Statement of...................................................   201
    Spina Bifida Association, Prepared Statement of the..............   566

    Tabak, Lawrence A., D.D.S., Ph.D., Principal Deputy Director,
      National Institutes of Health, Department of Health and Human
      Services, Prepared Statement of................................   203
    The AIDS Institute, Prepared Statement of........................   588
    The Association of Academic Health Sciences Libraries, Prepared
      Statement of...................................................   471
    The Endocrine Society, Prepared Statement of.....................   591
    The Humane Society of the United States, Prepared Statement of...   592
    The Society for Healthcare Epidemiology of America, Prepared
      Statement of...................................................   596
    Tri-Council for Nursing, Prepared Statement of the...............   595
    Trust for America's Health, Prepared Statement of the............   585

    U.S. Soccer Foundation, Prepared Statement of the................   603
    US Hereditary Angioedema Association, Prepared Statement of the..   601
    United Tribes Technical College, Prepared Statement of the.......   605
    University of:
        North Dakota, Prepared Statement of the......................   599
        Virginia, Prepared Statement of the..........................   607

    Varmus, Harold, M.D., Director, National Cancer Institute,
      National Institutes of Health, Department of Health and Human
      Services.......................................................   151
        Prepared Statement of........................................   169
    Volkow, Nora D., M.D., Director, National Institute on Drug
      Abuse, National Institutes of Health, Department of Health and
      Human Services, Prepared Statement of..........................   205

    Warren, Kenneth R., Ph.D., Acting Director, National Institute on
      Alcohol Abuse and Alcoholism, National Institutes of Health,
      Department of Health and Human Services, Prepared Statement of.   207
    Whitescarver, Jack, Ph.D., Director, Office of AIDS Research,
      National Institutes of Health, Department of Health and Human
      Services, Prepared Statement of................................   209

                                 SUBJECT INDEX

                                  ----------

                       CORPORATION OF PUBLIC BROADCASTING

                                                                       Page

    Corporation of Public Broadcasting...............................   277
    Corporation of Public Broadcasting's Request for Appropriations..   278

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                         National Institutes of Health

    A Future of Sustainable Commitment...............................   198
    A Patient Story..................................................   165
    A Technological Revolution.......................................   205
    Accelerating:
        Discovery....................................................   191
        Early Diagnosis at the Point-of-Care.........................   196
        The Pace of Discovery........................................   186
    Additional Committee Questions...................................   240
    Advancing:
        Research on Natural Products.................................   179
        The Quality of Life: Symptom Management......................   182
        Translational Sciences.....................................181, 190
    All Systems Go...................................................   185
    Alzheimer's Research.............................................   233
    Angiogenic Levels................................................   262
    Antimicrobial Resistance.........................................   255
    Basic and Science................................................   169
    Benefits of AIDS Research to Other Diseases......................   211
    Biology of Aging.................................................   238
    Building:
        And Disseminating Rigorous Evidence..........................   179
        Momentum in the Fight Against Alzheimer's Disease............   171
        New Opportunities: Basic Research Discoveries................   168
    Cancer Genome Atlas..............................................   261
    Catalyzing Innovation in:
        Clinical Research............................................   174
        Therapeutics.................................................   174
    Chronic:
        Disease Risk Reduction.......................................   198
        Inflammation.................................................   202
        Pain.........................................................   202
    Clinical:
        And Translational Science Awards.............................   265
        Research: National Center for Advancing Translational
          Sciences...................................................   163
        Translational Research.......................................   200
    Congenital Heart Disease.........................................   254
    Craniofacial Development.........................................   203
    Diabetes.........................................................   267
        Prevention Program...........................................   255
    Diagnosis and Treatment..........................................   170
    Disaster Information Management..................................   194
    Discovery Science and Technologies To Empower Patients...........   194
    Division of Program Coordination, Planning, and Strategic
      Initiatives....................................................   204
    Down Syndrome....................................................   224
    Drug Rescue and Repurposing......................................   264
    Early Experience Shapes Salt Preference..........................   175
    Economic Returns and Global Competitiveness......................   164
    Empowering the Next Generation of Aging Researchers..............   173
    End of Life and Palliative Care..................................   183
    Engaging Communities.............................................   197
    Ensuring a Strong Foundation.....................................   184
    Evidence-Based Care..............................................   203
    Extending the Reach of Basic Research............................   187
    Extraordinary Opportunities for Fiscal Year 2013.................   210
    Federal Employees: Recruitment and Retention.....................   236
    50 Years of Contributions to Health..............................   187
    Food Allergies...................................................   244
    Fulfilling Our Mission...........................................   173
    Gene and Cellular Therapies......................................   199
    Genetics.........................................................   201
    Gestational Diabetes.............................................   250
    Global Impact of National Institutes of Health AIDS Research.....   211
    H5N1 Research....................................................   222
    HIV-Exposed Children at High Risk of Language Delay..............   176
    Health:
        Data Standards and Electronic Health Records.................   193
        Disparities..................................................   246
        Economics....................................................   265
        Promotion and Disease Prevention.............................   182
    Hemovigilance....................................................   200
    Identification of Major Proteins Involved in Hearing.............   176
    Immunotherapy Advancements.......................................   232
    Impact of Sequestration..........................................   211
    Improving:
        Public Healthcare: Delivery and Performance..................   206
        The Health and Well-Being of Older Americans.................   172
    Infectious Diseases Research.....................................   166
    Information Services for the Public..............................   193
    Innovation in Research...........................................   197
    Institutional Development:
        Award Program................................................   246
            Funding..................................................   221
        Awards Eligibility...........................................   214
    Integrating Science-Based Information Into Practice..............   169
    Interagency Collaborations and Cystic Fibrosis...................   225
    Interpreting the Human Genome in Health and Disease..............   198
    Intersection of National Cancer Institute and National Center for
      Advancing Translational Science................................   268
    Intramural Loan Repayment and Scholarship Programs...............   205
    Investing in:
        Basic:
            Research.................................................   190
            Science, Applying Knowledge to Therapies.................   161
        Innovation...................................................   183
        Nurse Scientists.............................................   182
        People.......................................................   175
        The Future of Discovery......................................   186
    Keep Noise Down on the Farm......................................   176
    Long-Term Goals..................................................   260
    Looking Ahead: Scientific Visioning..............................   188
    Minority Health and Health Disparities...........................   267
    Model Systems Illuminate Human Health............................   185
    National:
        Cancer Institute:
            Budget Restraints........................................   212
            Drug Resistance..........................................   251
            Funding Level............................................   251
        Center for Advancing Translational Sciences Role and
          Responsibility.............................................   217
        Children's Study.......................215, 241, 248, 252, 257, 262
        Institute of:
            Diabetes and Digestive and Kidney Diseases Funding Levels   249
            Environmental Health Sciences Strategic Planning.........   177
        Institutes of:
            Health:
                Funding..............................................   238
                Institutional Development Award Program..............   249
                Investigator-Initiated Research......................   253
                Meritocracy Model....................................   233
                Priorities...........................................   226
            Health's Mission.........................................   160
    Neuroscience.....................................................   201
    New:
        Advances Continue the Momentum...............................   187
        Investigators................................................   230
            New Ideas..............................................181, 196
        Therapies for Heart, Lung, and Blood Disorders...............   199
    Number of New Grants.............................................   240
    Obesity Epidemic.................................................   213
    Office of:
        AIDS Research................................................   204
        Behavioral and Social Sciences Research......................   204
        Disease Prevention...........................................   205
        Research:
            Infrastructure Programs..................................   204
            On Women's Health........................................   204
        Strategic Coordination and the Common Fund...................   205
    Oral Cancer......................................................   202
    Pain Research....................................................   242
    Pancreatic Cancer................................................   219
        Research.....................................................   260
    Pediatric Cancer Research........................................   259
    Personalized Medicine............................................   266
    Post-Traumatic Stress Disorder...................................   231
    Preparing for Genomic Medicine...................................   185
    Preventing and Treating Disease--In Clinics and Communities......   168
    Prioritizing Cancer Funding......................................   220
    Provocative Questions............................................   171
    Rare Diseases....................................................   199
    Recent Accomplishments...........................................   178
    Recruitment of Scientists........................................   231
    Reducing Pain and Improving Symptom Management...................   179
    Replicating Results..............................................   235
    Research.........................................................   207
        Information Resources........................................   193
        On Immunology and Immune-Mediated Disorders..................   167
    Saliva Is Effective in Screening for Cytomegalovirus Infection in
      Newborns.......................................................   176
    Scope of the Problem.............................................   207
    Screening and Prevention.........................................   170
    Staying Ahead of the Curve.......................................   207
    Strategic Scientific Plan........................................   262
    Strengthening Sustainable Research Capacity......................   180
    Support for Rare and Neglected Diseases..........................   175
    Supporting an Innovative, Multidisciplinary Workforce............   169
    Technologies To Accelerate Therapeutics Development..............   195
    The AIDS Pandemic................................................   209
    Therapeutics Development.........................................   206
    30 Years of Extraordinary National Institutes of Health AIDS
      Research Accomplishments.......................................   209
    Toward Diversity in the Workforce................................   197
    Translating:
        Discovery to Health..........................................   191
        The Potential................................................   184
    Trends in Complementary and Integrative Healthcare...............   178
    Tuberculosis: Prevention, Detection, and Treatment...............   216
    Understanding Aging at the Most Basic Level......................   172
    Update on National Cancer Institute Initiatives..................   269
    Using Science To Inform Healthcare Decisions.....................   189
    Value of Cancer Centers..........................................   269

                            Office of the Secretary

    Additional Committee Questions...................................    40
    Advance Scientific Knowledge and Innovation......................    11
    Affordable Care Act Waivers......................................    27
    Aligning Hawaii's Prepaid Health Care Act and the Affordable Care
      Act............................................................    42
    Antideficiency Act Violations....................................    17
    Centers:
        For:
            Disease Control and Preventions Chronic Disease Program
              Consolidation..........................................    53
            Medicare & Medicaid Services:
                Demos/Center for Medicare and Medicaid Innovation....    62
                Exchange.............................................    63
        Of Excellence in Early Childhood.............................    70
    Child:
        Care Quality Initiatives.....................................    15
        Welfare and Adoption Assistance..............................    36
    Children's Hospitals Graduate Medical Education..............46, 56, 63
    Chronic Disease Coordination.....................................    73
    Community Transformation Grants..................................    37
    Compact of Free Association......................................    42
    Congenital Heart Disease.........................................    54
    Consumer Oriented and Operated Plans.............................    71
    Contraception....................................................    49
    Critical Access Hospitals........................................    32
    Duplication and Overlap..........................................    65
    Elimination of Preventive Health Block Grant.....................    67
    Environmental Health/Lead........................................    73
    Exchange Grants..................................................    72
    Exchanges........................................................    50
    Health:
        Centers......................................................    51
        Insurance Exchanges..........................................    17
        Professions..................................................    32
    Healthcare:
        Cost Estimates...............................................    24
        Exchanges....................................................    30
        Fraud, Waste, and Abuse...................................... 7, 19
        Premiums.....................................................    65
        Reform....................................................... 6, 35
    Healthy Home and Community Environments..........................    58
    HIV/AIDS Prevention Funding......................................    44
    Impact of Sequestration..........................................    18
    Improving Healthcare Quality.....................................    14
    Increase Efficiency, Transparency, and Accountability of the
      Department of Health and Human Services Programs...............    12
    Lead Poisoning Prevention........................................    57
    Lobbying Restrictions............................................    64
    Low-Income Home Energy Assistance Program........................    52
    Medicaid.........................................................    19
        Funding......................................................    29
    Medicare:
        Fraud........................................................    31
        Part D Preferred Network Pharmacy Plans......................    79
        Solvency.....................................................    30
    National:
        Health Service Corps and Title X.............................    40
        Institute for Occupational Safety and Health's Spokane
          Research Laboratory........................................    49
        Institutes of Health:
            Funding..............................................16, 34, 39
            Institutional Development Award Program..................    51
    Native Hawaiian Healthcare.......................................    41
    Obesity Funding..................................................    61
    Patient Protection and Affordable Care Act:
        Accounting...................................................    69
        Regulations..................................................    68
    Physician Payments...............................................    27
    Prevention Fund..................................................    72
    Primary Care Workforce...........................................    22
    School-Based Health Centers......................................    52
    Section 317......................................................    74
        Immunization Program.........................................    56
        Immunizations................................................    57
    State Cancer Registries..........................................    59
    Strengthen:
        Healthcare...................................................     7
        The Nation's Health and Human Service Infrastructure and Work

          Force......................................................    12
    Support American Families........................................     9
    Teen Pregnancy Prevention........................................    67
    Title:
        VII Health Professions.......................................    58
        X Family Planning Program....................................    48
    Tuberculosis in High-Risk Areas..................................    46
    Viral Hepatitis Screening........................................    45

                              DEPARTMENT OF LABOR

                            Office of the Secretary

    Additional Committee Questions...................................   111
    Addressing the Shortage of Medical Laboratory Technicians........   147
    Administrative Procedure Act.....................................    99
    Aligning Hawaii's Prepaid Health Care Act and the Affordable Care
      Act............................................................   124
    Child Labor in Agriculture.......................................    98
    Community College Career Fund....................................   130
    Compact of Free Association......................................   123
    Companionship Rule...............................................   103
    Consolidation of Workforce Investment Act Program Evaluations....   127
    Continuing Women in Apprenticeship and Nontraditional Occupations
      Act Mission....................................................   130
    Duplication and Overlap..........................................   140
    Employment Opportunities for Disabled Individuals................   102
    Farm Labor.......................................................   143
    Federal Regulation Waivers.......................................   120
    Fiscal Year 2013:
        President's Budget...........................................    81
        Request Summary..............................................    86
    Focusing Enforcement on a Broader Range of Hazards...............   116
    Getting the Most Deterrence From Penalties.......................   116
    Government Accountability Office Principles for Successful
      Collaboration Between Employers and Employees..................   124
    Governor's Set Aside.............................................   138
    Guidance for H-2A Program Users..................................   130
    Gulfport:
        Job Corps Center.............................................   144
        Mississippi Job Corps Center.................................   107
    H-2B:
        Program Rules................................................   137
        Rule 2.......................................................   132
        Visa Program.................................................   105
    Improving the Whistleblower Protection Program...................   117
    Increased Publicity and Direct Outreach..........................   117
    Investing in a Competitive Workforce.............................84, 88
    Job Corps......................................................136, 148
        Center Closures........................................82, 121, 125
        Contracts....................................................   126
        Defining Chronically Low-Performing Centers..................    92
    Leveraging Enforcement Actions To Maximize Hazard Elimination....   116
    Libraries and the Workforce Investment System....................   135
    Mandatory Proposals..............................................   139
    Measuring Voluntary Protection Program Performance...............   134
    Mine Safety and Health Administration Mine Inspections...........    86
    National Apprenticeship Act......................................   121
    Occupational Safety and Health Administration:
        Enforcement..................................................   115
        State Programs...............................................   117
    One-Stop Career:
        Center System Review.........................................   119
        Centers......................................................    85
    Operating the Voluntary Protection Program With Reduced Resources   134
    Pension Benefit Guarantee Corporation............................   142
    Planned Use of Additional Funds and Personnel....................   118
    Programmatic Impacts of a 7.8-Percent Cut........................    92
    Proposed:
        Child Agricultural Safety Rule...............................   145
        Community College Career Fund................................   146
        Companionship Exemption Rule.................................   144
        H-2B Rules...................................................   108
    Protecting American Workers......................................    89
    Re-employment Services for Unemployment Insurance Claimants.....85, 122
    Rebranding:
        And Strengthening One-Stop Career Centers....................   129
        Of Workforce Career Centers..................................   122
    Reducing Employer Burden in Meeting Occupational Safety and
      Health Administration Standards................................   118
    Regional Office Consolidation..................................114, 126
    Securing Americans' Incomes and Benefits.........................    89
    Sequestration:
        Impact.......................................................   111
        Under the Budget Control Act of 2011.........................    91
    State Involvement in Occupational Safety and Health
      Administration Policy..........................................   119
    Steps To Improve Effectiveness of Whistleblower Program..........   118
    Targeted Investments Through Difficult Choices...................    87
    Targeting:
        Teen Unemployment Under the Workforce Innovation Fund........   129
        The Most Hazardous Worksites for Inspection..................   116
    Universal Dislocated Worker Program..............................   120
    Updates to H-2B Rules............................................    94
    Upper Big Branch.................................................   141
    Veterans' Jobs Programs..........................................   146
    Veterans--Transition Assistance Program..........................   139
    Voluntary Protection Program...................................119, 143
    Wage Equality for Individuals With Disabilities..................   114
    Work Sharing.....................................................   135
    Worker:
        Protection Programs..........................................    85
        Training Programs and the Sectors Act........................    95
    Workforce:
        Innovation Fund..............................................   138
            Funding Awards...........................................   129
        Investment Act:
            ``Pay For Success'' Projects.............................   128
            Program Performance......................................   124
            Research Programs........................................   128
    Wyoming Job Corps Center.........................................   143
    Youth Unemployment and Job Training..............................    97

                           RAILROAD RETIREMENT BOARD

    Agency Operations................................................   274
    Budget Request...................................................   275
    Financial:
        Management Integrated System.................................   274
        Status of the Trust Funds....................................   274
    Office of:
        Audit........................................................   275
        Investigations...............................................   276
    Operational Components...........................................   275
    Other Requested Funding..........................................   274
    Proposed Funding for Agency Administration.......................   273