[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 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\
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    \1\ http://www.benchtobassinet.org/.
    \2\ http://www.pediatricheartnetwork.com/.
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    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.
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    \3\ http://public.nhlbi.nih.gov/newsroom/home/
GetPressRelease.aspx?id=2689.
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    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.
---------------------------------------------------------------------------
    \1\ http://www.hhs.gov/secretary/about/priorities/
youth_futures.html.
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    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.
---------------------------------------------------------------------------
    \1\ http://www.jsonline.com/business/nonprofit-health-insurer-
lands-Federal-loan-rm49ho7-139863553.html.
---------------------------------------------------------------------------
    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\
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    \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.
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    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.
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    \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.
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    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\
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    \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.
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    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\
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    \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.
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    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/.
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    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.
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    \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).
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    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.
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    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.
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    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.
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    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.
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    \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.
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    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.
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    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.
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    \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).
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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.
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    \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.
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    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.
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    \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.
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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.
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    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.
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    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.
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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 
[email protected]. 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 [email protected].
                                 ______
                                 
   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, [email protected] or Maria 
Spencer, Director, Federal Affairs for NIH/CDC [email protected].
                                 ______
                                 
      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 [email protected] 
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 
[email protected], or Ulyana Desiderio, PhD, ASH Senior Manager 
for Scientific Affairs, at [email protected], 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 
[email protected].
                                 ______
                                 
        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 [email protected].
                               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\
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    \1\ Holtgrave DR, Briddell K, Little E, Bendixen AV, Hooper M, 
Kidder DP, et al. Cost and threshold analysis of housing as an HIV 
prevention intervention. AIDS & Behavior.(2007)11(Suppl 2), S162-S166.
    \2\ Montaner J, Lima VD, Barrios R, et al. Association of highly 
active antiretroviral therapy coverage, population viral load, and 
yearly new HIV diagnoses in British Columbia, Canada: a population-
based study. The Lancet (2010) 376(9740): 532-539.
    \3\ Martin EG, Paltiel AD, Walensky, RP, Schackman BR, Expanded HIV 
Screening in the United States: What Will It Cost Government 
Discretionary and Entitlement Programs? A Budget Impact Analysis. Value 
in Health (2010) 13: 893--902.
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    Community-based providers are stretched to provide high-quality 
care with the scarce resources available. CAEAR Coalition is concerned 
that many HIV expert medical staff are scheduled to retire and the 
persistent financial pressures may accelerate the loss of trained 
professionals in the field. This additional pressure on an already 
overburdened system will leave many of the more than 200,000 HIV-
infected individuals who do not know their HIV status without access to 
the care they need.
    State budget cuts have created a continuing and growing ADAP 
funding crisis as a record number of people are in need of ADAP 
services due to the economic downturn. As of 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.

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    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 [email protected] and Amber Ebarb, NCAI Legislative 
Associate, at [email protected].
                                 ______
                                 
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.
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    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\
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    \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.
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    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\
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    \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.
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    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.
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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 
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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.
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    \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.
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    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.
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    \1\ http://www.avert.org/worlstatinfo.htm.
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    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.
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    \2\ NIH Fiscal Year 2012 Congressional Budget Justification. http:/
/officeofbudget.od.nih.gov/pdfs/FY12/Volume%201%20-%20Overview.pdf.
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    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\
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    \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/.
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    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 
[email protected].
                                 ______
                                 
           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.
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  --Falls account for 10 percent of visits to an emergency department 
        and 6 percent of hospitalizations among Medicare beneficiaries 
        \2\.
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    \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.
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  --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\.
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    \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.
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  --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\.
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    \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.
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    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\.
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    \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.
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    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.
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    \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.
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    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, [email protected].
    Thank you very much.
                                 ______
                                 
              Prepared Statement of The Endocrine Society
    The Endocrine Society is pleased to submit the following testimony 
regarding fiscal year 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\
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    \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.
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    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.
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    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.
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    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.
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    \1\ NRC (National Research Council) (1997) Chimpanzees in research: 
strategies for their ethical care, management and use. National 
Academies Press: Washington, DC.
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    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.
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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