[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]


                                                                      ?

                 DEPARTMENTS OF LABOR, HEALTH AND HUMAN

               SERVICES, EDUCATION, AND RELATED AGENCIES

                        APPROPRIATIONS FOR 2014

_______________________________________________________________________

                                HEARINGS

                                BEFORE A

                           SUBCOMMITTEE OF THE

                       COMMITTEE ON APPROPRIATIONS

                         HOUSE OF REPRESENTATIVES

                     ONE HUNDRED THIRTEENTH CONGRESS
                              FIRST SESSION
                                ________
  SUBCOMMITTEE ON THE DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, 
                    EDUCATION, AND RELATED AGENCIES
                    JACK KINGSTON, Georgia, Chairman
 RODNEY ALEXANDER, Louisiana        ROSA L. DeLAURO, Connecticut
 MICHAEL K. SIMPSON, Idaho          LUCILLE ROYBAL-ALLARD, California
 STEVE WOMACK, Arkansas             BARBARA LEE, California
 CHARLES J. FLEISCHMANN, Tennessee  MICHAEL M. HONDA, California      
 DAVID P. JOYCE, Ohio               
 ANDY HARRIS, Maryland              
                                    

 NOTE: Under Committee Rules, Mr. Rogers, as Chairman of the Full 
Committee, and Mrs. Lowey, as Ranking Minority Member of the Full 
Committee, are authorized to sit as Members of all Subcommittees.
                Susan Ross, John Bartrum, Allison Deters,
                      Jennifer Cama, and Lori Bias,
                           Subcommittee Staff
                                ________

                                 PART 6
                                                                   Page
 Health and Human Services Public Health and Research 
Organizations.....................................................    1
 Addressing Social Security Administration's Management Challenges 
in a Fiscally Constrained Environment.............................  269
 Children's Mental Health.........................................  335
 Budget Hearing--Department of Health and Human Services..........  413

                                   S

                                ________
         Printed for the use of the Committee on Appropriations
?


                                 Part 6









      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION,

              AND RELATED AGENCIES APPROPRIATIONS FOR 2014
                                                                      ?
?

                 DEPARTMENTS OF LABOR, HEALTH AND HUMAN

               SERVICES, EDUCATION, AND RELATED AGENCIES

                        APPROPRIATIONS FOR 2014

_______________________________________________________________________

                                HEARINGS

                                BEFORE A

                           SUBCOMMITTEE OF THE

                       COMMITTEE ON APPROPRIATIONS

                         HOUSE OF REPRESENTATIVES

                     ONE HUNDRED THIRTEENTH CONGRESS
                              FIRST SESSION
                                ________
  SUBCOMMITTEE ON THE DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, 
                    EDUCATION, AND RELATED AGENCIES
                    JACK KINGSTON, Georgia, Chairman
 RODNEY ALEXANDER, Louisiana        ROSA L. DeLAURO, Connecticut
 MICHAEL K. SIMPSON, Idaho          LUCILLE ROYBAL-ALLARD, California
 STEVE WOMACK, Arkansas             BARBARA LEE, California
 CHARLES J. FLEISCHMANN, Tennessee  MICHAEL M. HONDA, California      
 DAVID P. JOYCE, Ohio               
 ANDY HARRIS, Maryland              
                                    

 NOTE: Under Committee Rules, Mr. Rogers, as Chairman of the Full 
Committee, and Mrs. Lowey, as Ranking Minority Member of the Full 
Committee, are authorized to sit as Members of all Subcommittees.
                Susan Ross, John Bartrum, Allison Deters,
                      Jennifer Cama, and Lori Bias,
                           Subcommittee Staff
                                ________

                                 PART 6
                                                                   Page
 Health and Human Services Public Health and Research 
Organizations.....................................................    1
 Addressing Social Security Administration's Management Challenges 
in a Fiscally Constrained Environment.............................  269
 Children's Mental Health.........................................  335
 Budget Hearing--Department of Health and Human Services..........  413

                                   S

                                ________
         Printed for the use of the Committee on Appropriations
                                ________
                     U.S. GOVERNMENT PRINTING OFFICE
 86-214                     WASHINGTON : 2014

                                  COMMITTEE ON APPROPRIATIONS

                    HAROLD ROGERS, Kentucky, Chairman

 C. W. BILL YOUNG, Florida \1\      NITA M. LOWEY, New York
 FRANK R. WOLF, Virginia            MARCY KAPTUR, Ohio
 JACK KINGSTON, Georgia             PETER J. VISCLOSKY, Indiana
 RODNEY P. FRELINGHUYSEN, New JerseyJOSE E. SERRANO, New York
 TOM LATHAM, Iowa                   ROSA L. DeLAURO, Connecticut
 ROBERT B. ADERHOLT, Alabama        JAMES P. MORAN, Virginia
 KAY GRANGER, Texas                 ED PASTOR, Arizona
 MICHAEL K. SIMPSON, Idaho          DAVID E. PRICE, North Carolina
 JOHN ABNEY CULBERSON, Texas        LUCILLE ROYBAL-ALLARD, California
 ANDER CRENSHAW, Florida            SAM FARR, California
 JOHN R. CARTER, Texas              CHAKA FATTAH, Pennsylvania
 RODNEY ALEXANDER, Louisiana        SANFORD D. BISHOP, Jr., Georgia
 KEN CALVERT, California            BARBARA LEE, California
 JO BONNER, Alabama                 ADAM B. SCHIFF, California
 TOM COLE, Oklahoma                 MICHAEL M. HONDA, California
 MARIO DIAZ-BALART, Florida         BETTY McCOLLUM, Minnesota
 CHARLES W. DENT, Pennsylvania      TIM RYAN, Ohio
 TOM GRAVES, Georgia                DEBBIE WASSERMAN SCHULTZ, Florida
 KEVIN YODER, Kansas                HENRY CUELLAR, Texas
 STEVE WOMACK, Arkansas             CHELLIE PINGREE, Maine
 ALAN NUNNELEE, Mississippi         MIKE QUIGLEY, Illinois
 JEFF FORTENBERRY, Nebraska         WILLIAM L. OWENS, New York        
 THOMAS J. ROONEY, Florida          
 CHARLES J. FLEISCHMANN, Tennessee  
 JAIME HERRERA BEUTLER, Washington  
 DAVID P. JOYCE, Ohio               
 DAVID G. VALADAO, California       
 ANDY HARRIS, Maryland              
   
 ----------
 1}}Chairman Emeritus    
                                    
                                    

               William E. Smith, Clerk and Staff Director

                                  (ii)

 
DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED 
                    AGENCIES APPROPRIATIONS FOR 2014

                              ----------                              

                                            Tuesday, March 5, 2013.

   HEALTH AND HUMAN SERVICES PUBLIC HEALTH AND RESEARCH ORGANIZATIONS

                               WITNESSES

PATRICK CONWAY, M.D., DIRECTOR, CENTER FOR CLINICAL STANDARDS AND 
    QUALITY, REPRESENTING MEDICARE AND MEDICAID INNOVATION
FRANCIS S. COLLINS, M.D., PH.D., DIRECTOR, NATIONAL INSTITUTES OF 
    HEALTH
TOM FRIEDEN, M.D., M.P.H., DIRECTOR, CENTERS FOR DISEASE CONTROL AND 
    PREVENTION
CAROLYN M. CLANCY, M.D., DIRECTOR, AGENCY FOR HEALTHCARE RESEARCH AND 
    QUALITY
MARY WAKEFIELD, PH.D., R.N., ADMINISTRATOR, HEALTH RESOURCES AND 
    SERVICES ADMINISTRATION
    Mr. Kingston. Good morning. I welcome everyone to the first 
hearing for the year for Labor, Health and Human Services, 
Education, and Related Agencies. We look forward to a good and 
vigorous hearing schedule. We will actually, you know, finish 
up, we think, in April. So we will go at a pretty fast clip. We 
will have a second hearing this week.
    We are starting this hearing without the White House 
budget. The House budget, of course, has not been passed 
either, but we are going to go ahead and get to work on it.
    We want to have good and nonpartisan hearings. We want to 
learn all about the agencies, and we want to have a good 
relationship with the agencies not necessarily always agreeing, 
but always communicating and there will be a lot of back and 
forth. And we know that you answer to lots and lots of 
constituencies, as do we. And so as we are hearing the outside 
noise and getting all kinds of advice, we will just work 
together in the best way we can.
    I had mentioned to the panelists earlier that we are 
concerned about reprogramming, making sure that in this tight 
environment now that there is flexibility but also that we are 
not over-abusing reprogramming. And we want all the agencies to 
review programs and propose eliminations in terms of 
duplications and erring and straying from the normal mission 
statements, and we will talk more about that during the 
hearing.
    At today's hearing, we will have the panelists from five of 
the key HHS organizations and those witnesses are Dr. Patrick 
Conway, Director of the Center for Clinical Standards and 
Quality and CMS Chief Medical Officer, who is here to represent 
and discuss the mission of CMS Innovation Fund activity; Dr. 
Francis Collins, Director of the National Institutes of Health; 
Dr. Tom Frieden, Director of the Centers for Disease Control 
and Prevention; Dr. Carolyn Clancy, Director of the agency for 
Healthcare Research and Quality, who has recently announced she 
is going to be stepping down in the coming months. I do not 
know what you will be doing with your time, but I know you will 
find lots of it after that job. Dr. Mary Wakefield, who is the 
Administrator of Health Resources and Services Administration.
    So this is the first time that we will receive an overview 
from the full group of you at once. So we are excited about 
that. And I am looking forward to this.
    We will ask you to have your opening statements in 3 
minutes. If you have to go a little bit longer, we will go 
maybe 3 and a half, but that will be about it. And then we will 
jump into Q&A.
    With that, I yield to my good friend and ranking member, 
Ms. DeLauro.
    Ms. DeLauro. Thank you very much, Mr. Chairman. And I am 
proud to join you here today and obviously welcoming our 
speakers and waiting for their testimony today.
    Just a very, very quick word, and I am going to apologize 
to the audience for this, but a week ago we had a wonderful 
gathering with staff and members to get acquainted with what 
the chairman proposed. And at that time, I was not able to 
bring any Italian pastry from New Haven, Connecticut, but I 
have got to say for staff and for the witnesses, there is 
Italian pastries from the Libby's Bakery on Olive Street in New 
Haven, Connecticut. To the audience, my apologies. [Laughter.]
    Ms. DeLauro. Today we will review the mission and the 
programs of several of the major health agencies under the 
purview of the subcommittee. It is my hope that the discussion 
will serve to demonstrate the irrationality of the budget 
policies currently being pursued by the House majority. The 
agencies here today accomplish work that is critical to the 
health of all of us. This includes the basic medical research 
by the NIH, the CDC's efforts to detect and control dangerous 
diseases, HRSA's programs to expand access health care, the 
Agency for Health Research Quality, AHRQ's, work to improve the 
quality of health care. It includes the research and the 
demonstration work at CMS that tries to develop ways of 
delivering better and more effective health care at the same or 
lower cost.
    Much of the work is vital to the health of the economy. For 
example, independent of all of the many health benefits, NIH 
research is vital to maintaining our Nation's leadership in 
emerging fields like biotechnology. That means good jobs and 
economic growth. According to one estimate, every dollar 
invested in the NIH generates well over $2 in economic 
activity.
    Many of the things these agencies do also help to reduce 
health-related costs while improving health. For example, AHRQ 
studies how to deliver health care more effectively, and both 
AHRQ and NIH sponsor research into which treatments work best 
for which patients. CDC supports screening for diseases like 
cancer and HIV, education and outreach to help people better 
manage chronic conditions like diabetes and asthma, and efforts 
to expand immunizations that can prevent serious infectious 
diseases. HRSA works to expand the availability of primary care 
in underserved rural and urban communities, care designed to 
find and treat problems before they become crises. HRSA also 
works to expand the number of health professionals delivering 
that primary care in the places that they are most needed.
    And despite the importance of these and other missions, the 
budgets for many of these programs have seriously eroded over 
the last decade. In many cases, funding has failed to keep up 
with the costs, and for some programs, funding has been cut in 
actual dollar terms.
    For NIH, the purchasing power of its appropriation has 
dropped about 16 percent since 2003 after adjustment for rising 
costs of biomedical research. The number of NIH research 
project grants has fallen from a peak of just over 37,000 in 
2004 to about 34,000 last year. NIH's work alleviates pain and 
saves lives, which is why we worked together in a bipartisan 
way to provide the funding that made it the gold standard for 
biomedical research not only in the United States but in the 
world. But we are now in jeopardy of ceding that leadership to 
other countries.
    At HRSA, basic health professions training programs have 
been cut by $37,000,000 since 2010. That is in actual dollars 
before any adjustments for costs or need. Discretionary 
appropriations for health centers are down $623,000,000, 28 
percent since 2010. Thankfully that cut has been offset with 
funds made available through the Affordable Care Act, but the 
intended purpose of those funds was to expand sources of 
primary care, not to backfill for cuts in appropriation for 
ongoing operations. Adjusted for inflation and population 
growth, the overall HRSA appropriation has lost $2,000,000,000 
in purchasing power since 2002.
    CDC. Discretionary funding is down by more than 
$700,000,000 since 2010, including the cuts of $149,000,000 to 
chronic disease prevention programs, and $104,000,000 to 
programs that improve the capacity of State and local health 
departments to respond to emergencies.
    Under the 10-year caps on discretionary spending that are 
already in law, it will be extremely difficult to turn this 
situation around. In fact, before the decade is out, the cuts 
we have made will take non-defense discretionary spending to 
the lowest level as a share of GDP on record, and records go 
back 50 years.
    Yet, some people are demanding further reductions in caps 
which would mean the shortfalls just get worse. And because a 
majority refused to act last week, we now have sequestration, 
an indiscriminate 5 percent cut to everything on top of all 
these cuts that have already been made. The sequester will take 
another $1,500,000,000 from the NIH, $325,000,000 from CDC, and 
so on. All of this will be bad for the health and the well-
being of American families.
    I hope our witnesses today will convey to us what their 
agencies do, why it is important, and how their efforts will be 
impacted by all of the cuts that are on the table. I thank you 
and I look forward to your testimony.
    Thank you, Mr. Chairman.
    Mr. Kingston. Thank you very much.
    Mr. Simpson, Ms. Roybal-Allard, do you have any statements?
    With that, Dr. Conway.
    Dr. Conway. Chairman Kingston, Ranking Member DeLauro and 
members of the subcommittee, thank you for this opportunity to 
highlight the efforts of the Centers for Medicare and Medicaid 
Services to strengthen public health. As Chief Medical Officer 
of CMS and practicing physician and a health services 
researcher, I am excited to discuss public health and research.
    CMS has been focused on improving the quality of health 
care, keeping beneficiaries healthy, and ensuring payments 
reward value and excellent care.
    While CMS primarily deals with the clinical health care 
delivery system, a 2010 Institute of Medicine report noted the 
importance of integrating the clinical delivery system with the 
public health system. CMS has multiple programs to support this 
integration. Today I will specifically discuss three areas: new 
payment initiatives aimed at improving quality while lowering 
cost; quality measurement and improvement; and data to support 
research into public health.
    Through the Innovation Center, CMS has launched numerous 
innovative care delivery models designed to improve 
beneficiaries' health outcomes and reduce costs. The 30-day 
all-cause readmission rate has dropped from approximately 19 
percent or more for many years to 17.8 percent in the last 
quarter of 2012. This decrease is an early sign that our 
payment delivery system improvements are having an impact.
    In 2012, we launched Medicare Accountable Care 
Organizations, groups of providers working together to redesign 
care processes for high quality and efficient care delivery. To 
date, there are more than 250 Medicare ACO's in operation 
serving about 4,000,000 beneficiaries in almost every State.
    Our Innovation Center is selecting and testing the most 
promising innovative payment and service delivery models and 
can expand those that are successful. Some of the models being 
tested are intended to reduce unnecessary hospital admissions 
among residents of nursing homes, improve care coordination for 
beneficiaries with end-stage renal disease, decrease premature 
births, and incentivize primary care providers to offer high 
quality coordinated care.
    The Innovation Center has also partnered with the CDC to 
launch the Million Hearts Initiative, which is focused on 
preventing a million heart attacks and strokes over 5 years. 
Million Hearts has engaged partners across the Nation. It 
includes both clinical and community health goals. It has the 
potential to help Americans live longer and healthier lives.
    Next I will discuss quality measurement and improvement. 
CMS funds numerous initiatives in all 50 States focused on 
improving the quality and the health of all Americans. Quality 
improvement organizations are working with physician practices 
to help these practices improve the health of their patients. 
Through large-scale learning networks, QIO's accelerate the 
pace of change and rapidly spread best practices. Some of the 
QIO current initiatives include contributing to reductions in 
hospital-acquired conditions, working with nursing homes to 
reduce pressure ulcers, and boosting population health by 
improving the use of EHR's to increase preventive services.
    Consistent with the national quality strategy, CMS is 
implementing quality measures related to population health and 
prevention across its programs. Examples include influenza and 
pneumonia vaccination and smoking cessation.
    CMS has also launched health care-acquired infection 
measures in numerous quality reporting and payment programs. 
AHRQ, under Dr. Carolyn Clancy's leadership, has played a 
leading role in developing the evidence base and funding 
quality improvement science on how to decrease HAI's that we 
have collaboratively scaled nationally. We have benefitted from 
Tom Frieden and CDC's collaboration on reliable measurement of 
HAI's, supporting public reporting and links to State and local 
public health departments. Nationally this work, in 
collaboration with hospitals and other stakeholders, has led to 
a greater than 40 percent reduction in central line blood 
stream infections, meaning thousands of lives saved.
    Finally, I will discuss data support research and public 
health. CMS is providing data to support health services 
research and the improvement of public health. CMS has launched 
a new office to provide data to health services researchers, as 
well as public use files for easy download. CMS has implemented 
an initiative requiring the provision of claims data to 
qualified entities across the country for the evaluation of 
performance and to support transparency efforts.
    In conclusion, CMS is taking major steps to help transform 
the delivery system to achieve the best possible health 
outcomes for all Americans. While CMS is an agency that 
primarily deals with the clinical delivery system, we 
understand that the integration of the clinical delivery system 
and the public health infrastructure will allow our overall 
health system to be more effective and efficient and, most 
importantly, to improve the health of all Americans.
    Thank you.

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    Mr. Kingston. Thank you, Dr. Conway.
    Dr. Collins.
    Dr. Collins. Good morning, Chairman Kingston, Ranking 
Member DeLauro, and members of the subcommittee. This 
subcommittee has long supported NIH's mission and we are happy 
to be here with you with our distinguished colleagues this 
morning.
    Our mission is to seek fundamental knowledge and apply it 
in ways that enhance human health, lengthen life, and reduce 
suffering.
    NIH is the world's leading supporter of biomedical research 
in the world, investing more than $30,000,000,000 annually in 
medical research for the American public. In fiscal year 2012, 
about 84 percent of NIH's appropriation supported scientists in 
all 50 States. NIH-funded advances in basic and translational 
science have fueled a revolution in the diagnosis, treatment, 
and prevention of disease. Let me share just three of our many 
stories of success.
    First, the mortality rate due to stroke is less than a 
third of what it was in 1950. Less than a third, and it is 
still continuing to decline.
    Second, since the mid-1990's, U.S. cancer death rates have 
fallen about 1 percent each year. Each percentage drop saves 
our Nation an estimated $500,000,000.
    Third, a diagnosis of HIV/AIDS is no longer a death 
sentence but is now compatible with an almost normal lifespan. 
In fact, you may have recently seen in press reports (about a 
very special two-and-a-half-year-old in Mississippi) that HIV/
AIDS may even in some instances be curable. With effective 
prevention and treatment strategies, an AIDS-free generation 
may truly be within our grasp.
    Innovation in medical research not only saves lives, it 
sparks economic growth, strengthening our global 
competitiveness. In fiscal year 2011, NIH research supported an 
estimated 432,000 jobs across the country, and directly spawned 
more than $62,000,000,000 in new economic activity.
    What is more, discoveries arising from NIH research serve 
as the foundation for our Nation's biotech and pharmaceutical 
industries which employ another 7,500,000 U.S. citizens.
    But NIH does much more than stimulate our economy. 
Groundbreaking innovations are now happening at an accelerating 
and breathtaking pace. Time is short, so I will just mention 
one.
    We just passed through our annual health challenge called 
influenza. In an average year, the flu claims about 24,000 
American lives and costs the U.S. economy about 
$87,000,000,000. But it does not have to be that way. The 
outside of the flu virus, if you look at it under an electron 
microscope, is studded with these tiny nail-shaped proteins. 
Current vaccines target the head of the nail which is 
constantly mutating. So to keep up, a new vaccine has to be 
produced each year, requiring people to get an annual flu shot. 
And despite best efforts, the vaccine is not always ideal, and 
each year many Americans go unvaccinated.
    In collaboration with our CDC colleagues, NIH is working on 
a universal flu vaccine that would protect people against 
virtually all strains of the flu for extended periods of time. 
The goal is to teach the immune system to ignore the head and 
target the stem of that viral protein because that part of the 
virus remains relatively unchanged from strain to strain. This 
would protect us from multiple flu strains and eliminate the 
need for an annual flu shot. It could also help protect against 
a future global influenza pandemic. This universal flu vaccine 
is not science fiction. Early clinical trials are already under 
way.
    In closing, I just want to thank you for holding this 
hearing, and I welcome any questions the subcommittee members 
may have.

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    Mr. Kingston. Thank you very much.
    Dr. Frieden.
    Dr. Frieden. Mr. Chairman, Ranking Member DeLauro, members 
of the subcommittee, thank you so much for this opportunity to 
discuss CDC's unique role working 24/7 to protect Americans 
from health threats. I am honored to be Director of the CDC at 
a time of both particular vulnerability and the crucial window 
of opportunity for health progress.
    CDC is at the forefront of finding and stopping the spread 
of threats to health, whether they are things like Ebola or 
antivirus or emerging problems in this country. We respond to 
emergencies, including by deploying resources within hours, as 
we did for Superstorm Sandy.
    CDC also provides childhood vaccines, many of them 
developed through NIH's research. This program has been a 
stunning success saving millions of lives and billions of 
dollars. Each year we estimate that the childhood vaccines we 
give prevent 42,000 deaths, save more than $13,000,000,000 in 
health care costs, and return nearly $70,000,000,000 to the 
economy.
    Because we have worked to find these disease outbreaks 
where they emerge and stop them before they spread, we invest 
heavily in supporting State and local entities. And in fact, 
most of our budget goes to support work in your communities. We 
have staff in all 50 States and funding to all 50 States.
    To give you two examples of this, during the deadly 
listeria outbreak in 2011, it was CDC's supportive work at the 
Colorado Health Department that identified the listeria in 
cantaloupe, which had never been found before, within days, got 
the product off the shelves. And we know that even a slight 
delay could have doubled what was already one of the most 
deadly outbreaks that we have seen.
    Similarly, last year, we had a fungal meningitis outbreak 
which has now affected more than 700 people and killed 48. That 
infection was identified first by a CDC-trained epidemiologist 
in Tennessee working with her CDC-funded staff to identify the 
problem. It was then identified in the laboratory in Virginia 
by a staff person who had been trained by CDC. We at CDC had 
our laboratorians, who are state-of-the-art scientists, work 
around the clock to develop a PCR test for this rare infection. 
We have done about 1,000 of them. We also worked with health 
departments in 23 States to inform 14,000 patients that they 
had been exposed, and we convened daily conference calls to 
give doctors the best advice that they could have to take the 
best possible care of their patients. The result was fewer 
serious infections, fewer deaths, lower health care costs, and 
a lot of suffering avoided.
    Microbes evolve in minutes, and we at CDC work to keep pace 
with them using scientific breakthroughs such as analyzing the 
microbial genome to find outbreaks sooner and stop them 
earlier. Most U.S. health care costs are spent treating 
preventable conditions. CDC promotes evidence-based prevention 
initiative as the most effective, common sense way to improve 
health and reduce health care costs.
    Most of the information you see about the health status of 
the U.S. comes from CDC. We have a unique role in definitive 
health monitoring used by doctors, businesses, insurers and 
others.
    We also prevent health threats that begin overseas from 
reaching our borders. The movie ``Contagion'' was fiction, but 
in real life, our scientists and disease detectives have 
investigated more than 1,000 outbreaks and identified at least 
five new organisms in recent year. These outbreaks include 
organisms that are resistant to just about all antibiotics such 
as extensively drug-resistant tuberculosis and organisms that 
kill most of the people they infect like hemorrhagic fevers.
    CDC is unique. No other organization in the world has our 
capacity to detect and respond to outbreaks. No other 
organization in the world leads an interconnected global 
network at the cutting edge of health security with disease 
detectives in labs to keep people safe from food-borne illness, 
bio-security threats, and other health threats.
    In sum, CDC puts science into action to saves lives today, 
prevent illness tomorrow, and increase our productivity. I am 
honored to work at CDC.
    I am happy to answer your questions.

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    Mr. Kingston. Thank you, Dr. Frieden.
    Dr. Clancy.
    Dr. Clancy. Good morning, Chairman Kingston and Ranking 
Member DeLauro, and members of the subcommittee. I am very 
pleased to be here to discuss the role that AHRQ plays in 
creating a health care system in which the care provided is 
consistently safe, high quality, and affordable.
    AHRQ is the only Federal agency whose sole mission is 
improving health care. AHRQ supports research that builds a 
solid evidence base on how to make care safer and of high 
quality. We work with our partners, which include providers, 
patients, hospitals, States, and other Federal agencies like my 
distinguished colleagues, to get these lessons implemented into 
practice.
    For example, today we are releasing a report identifying 
the top 10 patient safety strategies ready for immediate use. 
This report provides a clear road map for high priority areas 
where the health care system is failing, and these 10 
strategies, if widely implemented, have the potential to vastly 
improve patient safety and save lives.
    Today I would like to highlight our efforts related to 
health care-associated infections. AHRQ supports practical 
studies to help eliminate infections in the real world. We 
translate this research into practical solutions that have 
saved lives and lowered health care costs. For example, an 
AHRQ-funded project had very gratifying results, and Dr. Conway 
mentioned a moment ago how that had been scaled up, courtesy of 
the Innovation Center. But in our project the over 1,100 
intensive care units nationwide that implemented this program 
achieved a 41 percent reduction in the rate of these deadly 
infections, saving over 500 lives and avoiding more than 
$36,000,000 in excess costs. Neonatal ICU's saw a 58 percent 
reduction in these infections, avoiding 41 infant deaths and 
more than $2,000,000 in health care costs.
    So our research helps the health system where the rubber 
meets the road by outlining how to spread and implement proven 
methods of infection prevention and on the impact prevention 
efforts.
    Two other unique areas for us in patient safety include 
work to support the development and use of health care teams. 
Health care professionals often speak of teams metaphorically. 
In fact, they have had no training in how to do that. And this 
training has now literally been part of every military health 
care facility worldwide and a vast number of civilian hospitals 
in this country. The other area is in the use of simulation to 
make care safer. Everyone should be able to have a surgical or 
other procedure without having to think about am I the first 
person here, confident that their clinician has been well 
trained and practiced in a laboratory.
    Armed with critical information from the Centers for 
Disease Control about these infection rates and AHRQ's 
practical evidence-based solutions to reducing these 
infections, CMS has used payment incentives to help establish a 
new normal for hospitals and other settings. My colleague, 
Jonathan Blum from CMS was here speaking to the Senate last 
week about the tangible results that Medicare patients have 
seen right now.
    Ensuring that patients are not harmed when they receive 
health care services is a shared goal among AHRQ and its sister 
agencies, and we each play specific but interrelated roles in 
making sure that happens. Each piece of the puzzle needs to be 
completed and connected for health care to improve.
    Mr. Chairman, thank you again for inviting me to discuss 
AHRQ's efforts to make health care safer. I appreciate this 
opportunity and look forward to answering any questions.

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    Mr. Kingston. Dr. Wakefield.
    Ms. Wakefield. Thank you, Mr. Chairman and Ranking Member, 
for the opportunity to highlight the important work of the 
Health Resources and Services Administration.
    While some may not be familiar with HRSA, they nevertheless 
often know about the organizations that we support in their 
local communities and States. They know, for example, their 
local community health center, their colleges' health care 
workforce training programs. They might know about the poison 
control centers that are called in emergencies, among other 
programs that we support.
    Across the Nation in every State and in almost every 
congressional district, more than 3,100 local nonprofits, 
faith- and community-based organizations receive HRSA grants 
that enable them to provide health care to millions of people 
to train the next generation of health care providers and to 
maintain and even strengthen the health care safety net.
    HRSA's investments in communities and States are important, 
both for the people who are served and for local economies. For 
example, our funding to community health centers enables 8,900 
primary health care clinics to provide care to more than 
20,000,000 people. And health centers are also important local 
economic engines, employing more than 138,000 people from 
doctors and dentists to medical assistants and receptionists.
    On another front, the number of National Health Service 
Corps clinicians has increased to an all-time high, providing 
health care in some of our most underserved urban and rural 
areas. Today, nearly 10,000 corps providers are impacting the 
health of over 10,000,000 patients and in the process impacting 
the economic health of the communities where they work.
    Many of HRSA's programs are a lifeline for some of 
America's most vulnerable people. Funding through the Ryan 
White Program means that more than half a million people with 
HIV/AIDS have access to lifesaving services.
    We support the Nation's Organ Procurement and Transplant 
Network, and Congress has given HRSA the extraordinary 
challenge to help meet growing demands for this gift of life.
    And HRSA's support of maternal and child health programs 
has helped reduce infant mortality in the United States.
    HRSA's investments also seed local innovations that can 
grow to improve health across the Nation. For example, in terms 
of training, Texas A&M's nursing school is using funds to help 
veterans build on their military training and move more swiftly 
into health careers, and we are working to expand those 
training initiatives. And rural communities are using HRSA's 
outreach grants to support approaches like mobile dental 
clinics to reach more people who do not have access to oral 
health care.
    Finally, across all of HRSA's programs, we are working to 
implement new ways to improve the quality of our agency's work, 
from developing new tools for fiscal monitoring and oversight 
to using the latest technologies to educate both our staff and 
grantees on fraud and waste.
    Thank you again, Mr. Chairman, for the opportunity to speak 
about our programs and I welcome questions.

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                           POLIO ERADICATION

    Mr. Kingston. Thank you very much, and I thank all of you 
for being prompt and quick.
    The only thing I am very disappointed about is my friend, 
Tom Frieden, did not brag about the polio success, and if you 
know those stats off the top of your head or if you have 
somebody who can get them out, I think it would be good to 
share with the folks real quick. I think it is something that 
really is a modern miracle that we are taking for granted, and 
it is the work of CDC and Rotary International and so many 
other people.
    Dr. Frieden. In 1988, CDC and three other partners led an 
effort endorsed by the World Health Organization to eradicate 
polio forever. At that time, there were about 350,000 cases per 
year. That is about 1,000 a day. Polio eradication activities 
have benefitted from the support from Rotary International 
which has generated more than $1,000,000,000 in support, as 
well as supporting the programs around the world. UNICEF and 
WHO have been critical partners, and CDC has spearheaded this 
for the U.S.
    What we have seen is that last year there were just a 
little over 200 cases, the fewest there have ever been in the 
fewest districts of those countries. And a couple of years ago, 
India got over the finish line through an enormous effort and 
has not had a case in more than 2 years. So we are closer than 
ever to polio eradication. Cases only remain spread in Nigeria, 
Pakistan, and Afghanistan.
    Mr. Kingston. A great success story.

                            END OF LIFE CARE

    Dr. Conway, I wanted to ask about--and I am not sure that 
this comes directly into your sphere of control and study, but 
on end of life, what percentage of the Medicare budget is spent 
in the last 3 months or 2 months of a patient's life? Do you 
know? I have heard it is very high.
    Dr. Conway. So I will have to get back to you with an exact 
number. The percentage on end-of-life care is significant in 
the last 12 months of life. I believe around 20 to 25 percent. 
We will get back to you on an exact number on that. And other 
colleagues may jump in.
    I think at CMS I would highlight that we are committed to 
high quality care. We are committed to engaging patients and 
families in decision-making. In our quality programs, we 
increasingly have quality measures around patient and family 
care just to make sure we meet the goals of patients and 
families.
    Mr. Kingston. And I think what my question would be when 
you get back to me is the living will. What is the correlation 
between having a living will and not spending as much and 
spending a lot not having a living will and what are the 
impacts of it? So if that comes under your silo, that would be 
very helpful.
    Dr. Conway. Yes, sir. We will have to get back to you with 
the specifics on that.
    [The information follows:]

    Dr. Conway: Yes, sir. In CY 2011, spending in the last six 
months of life represented about 17% of total spending in 
Medicare Parts A and B. CMS does not track utilization of 
living wills by beneficiaries.

    Mr. Kingston. Okay.

                        HEALTH SERVICES RESEARCH

    And then I have a general question for all of you. In terms 
of the health services research, NIH has that under its 
jurisdiction and has had about a 58 percent increase in budget 
authority since 2008 on it. And yet, AHRQ spends $400,000,000 
on it, and CMS Innovation Fund and CDC all have components of 
health services research in it. So there is overlap, and how 
much of it is duplicative? How well do you coordinate, and how 
committed are you in terms of, okay, if you are doing that, we 
will do this? We both can join in the middle. But for the time 
being, we do not all have to be on a parallel track spending 
dollars doing the same thing.
    Dr. Collins. Thank you for the question. I will start and 
others, no doubt, will want to pitch in.
    I do think you raise a very important question. Obviously 
we are critically interested in discovering which kinds of 
interventions are actually going to produce the best outcomes 
in real-world situations. NIH's role in this generally is to 
conduct large-scale, randomized clinical trials to assess what 
works and to be able to get that information in front of 
caregivers and the public.
    So take, for instance, the question about atrial 
fibrillation, a common form of a cardiac arrhythmia where there 
have been serious questions about exactly what is the right 
approach. Is this something where you should try to convert 
this using some sort of electrical shock? Should you just 
basically treat with anticoagulants in order to reduce the risk 
of stroke? NIH is in the position to then conduct a randomized 
trial where individuals are assigned to one of those outcomes 
by their full informed consent and try to see on the large 
scale what the outcomes look like. But those are very carefully 
controlled situations. Patients need to be free of other kinds 
of complicated features, otherwise we are not sure we are 
getting a clear answer.
    On the other hand, AHRQ--and Carolyn Clancy no doubt will 
want to talk about this--will conduct broad-scale analysis of 
all of the many studies that have been done in this space to 
try to see if you put those all together, many of those 
observational, not necessarily interventional, can you draw 
conclusions in that regard.
    CDC has a critical role working with the States and the 
public health agencies to try to then implement whatever seems 
to be best practices.
    We have been working closely with CMS in the last year and 
a half, meeting every quarter with their senior staff, to look 
at ways that the Innovation Center can also step in here.
    So I think we are actually working pretty closely together. 
It is a very complicated landscape in terms of this kind of 
research.
    Mr. Kingston. Dr. Clancy, unfortunately, we are running out 
of time. So we will get back to you on it.
    Dr. Clancy. If I could just make one point on our budget, 
if anyone is spending a nickel that we might have spent, we 
make sure that we find out about it.
    Mr. Kingston. Good.
    Ms. DeLauro.
    Ms. DeLauro. Thank you very much, Mr. Chairman.
    And I would just say to all of you, you just continue to--
and I listened to your testimony--reinforce what my view was 
all along, that the agencies that you head up and what you are 
charged with, quite frankly, is giving the gift of life. And 
for that, we are so grateful for the work that you do.

                             SEQUESTRATION

    As you know, the President implemented the sequestration 
order. He was required to do that by the Budget Control Act. 
What I would like to do is to ask the directors of NIH, CDC, 
and HRSA what actions will you be required to take as a result 
of the across-the-board budget cuts. What effect will there be 
on your ability to carry out your agency's missions? Dr. 
Collins, if you could begin.
    Dr. Collins. Certainly. So the sequestration order results 
in a 5 percent cut to our fiscal year 2013 budget already now 
well into the fiscal year, total dollars, $1,545,000,000 that 
are now not going to be available for support of research. And 
of course, we are concerned about that for this year. We are 
particularly concerned about that in the sense that there is a 
potential that this could go on for as long as a decade, and 
then you could compound the consequences of this.
    There are many consequences, but if I could just mention 
the one that worries me the most. It is the impact on young 
scientists who are looking at this circumstance and wondering 
whether there is a career path for them. In a situation where 
your ability to get funded by the NIH, which is the main source 
of medical research in this country, has been already getting 
deteriorated over the course of the last 10 years so that now 
an applicant has only one chance in six of getting funded, that 
will drop further as a result of the sequester. And if you are 
a person in high school or college and you are looking at 
medical research as a career and you are seeing those 
statistics, how many of those folks will be able to stick it 
out? And how many of the ones that are already in training 
careers are going to get exhausted by the frustration and 
decide to do something else? That is our seed corn. It has been 
the strength of America. It is the biomedical research 
community, their creativity, their innovative instincts, and we 
are putting that at serious risk as we see this kind of 
downturn in the support for research.
    Ms. DeLauro. Dr. Frieden.
    Dr. Frieden. The threats to our health are not decreasing 
by 5 percent. So the cut of 5 percent in CDC's budget means 
that we will have roughly $300,000,000 less. About two-thirds 
of our dollars go out to State and local entities. They are 
already, as one health commissioner describes it, at the 
breaking point which through State and local reductions, there 
are 45,000 fewer staff working at that level. That means our 
support will be able to provide assistance to State and local 
entities to hire perhaps as many 2,000 fewer disease control 
experts, disease detectives. We will have less money for flu, 
less money for HIV, less money to protect our children through 
things like fluoridation, autism research, asthma prevention, 
and decreased ability to detect and respond to outbreaks. This 
will cut our outbreak control staff by more than $12,000,000, 
and also a decreased ability to keep us safe from global 
threats because we will have to cut back on our work in other 
countries to find threats before they come to our borders.
    Ms. DeLauro. Dr. Wakefield.
    Ms. Wakefield. So the overwhelming amount of money that 
HRSA receives is then used to support grants that go directly 
out to local communities and the States. We have 80-plus 
programs and that 5 percent cut will be taken across each of 
those programs, policies, and activities. That is the 
requirement. So each one will have a 5 percent cut.
    You can look at the impact in any one program, but I will 
just give you one example. Our ADAP program, AIDS Drug 
Assistance Program, as part of our Ryan White Program, will see 
a cut to that program as a result of the rescission of about 
$45,000,000. That will mean that the ADAP program can serve 
about 7,400 fewer patients.
    We could not tell you right now, because we are still 
working on the numbers, what States would be impacted or where 
this might then drive up waiting lists. But what I can tell you 
is that since 2011, the fall of 2011, that was sort of our high 
water mark. The waiting list to get on the ADAP program across 
States had really peaked to about 9,300. And do you know just 
within the last couple of months, we have gotten that waiting 
list down to 63 people. That is it in two States. And so now 
what is going to happen is likely we will see that waiting list 
start to expand, go that direction again. What will happen then 
in local States? Well, States are going to have to scramble. 
Case managers will have to scramble to try and find patient 
assistance programs that will be able to accommodate those 
patients. And that means that those costs then will be shifted 
to manufacturing, drug manufacturing companies, et cetera to 
try and provide those resources, pharmaceutical resources, for 
those patients.
    That is just one example. But cuts proportionate to each 
one of our programs.
    Ms. DeLauro. Thank you very much for the time.
    Mr. Kingston. Mr. Simpson.
    Mr. Simpson. Thank you, Mr. Chairman.
    And I thank all of you for being here today. This is the 
first time I have ever seen where we have five doctors. It is 
kind of intimidating for all of us to have all these doctors on 
the panel.
    But I have several questions that, as you might expect, 
deal with dentistry to some degree but I am not going to ask 
most of those because they deal with the budget that is not out 
yet, so we do not have a chance to do that. I have been to most 
of these places, but I will tell you for any of the Members of 
Congress that want to see what Government does and does right, 
they need to get out to some of these agencies and see what 
goes on. I have been out to NIH several times. It has been a 
couple years since I have been there. I need to get back out 
there because it is just awe-inspiring what goes on in these 
programs.
    And I would be remiss if I did not thank Dr. Frieden for 
maintaining the oral health division as we have talked about 
over the last couple years. It has been one of your smallest 
divisions, but they obviously play an important role in 
dentistry.

                          PHS EVALUATION FUNDS

    Now, let me turn to a question with several statements to 
start with. The HHS Secretary is authorized to tax or as HHS 
refers to it, ``tap'' PHS Act-authorized programs up to 1 
percent of their appropriation in order to conduct program 
evaluations. The administration has requested language to 
increase the tap over time.
    The fiscal year 2013 budget we can talk about because it 
was last year--the budget request attempted to take tap to 3.2 
percent, or $1,300,000,000 of the resources. The House bill 
reduced tap to the authorized level of 1 percent last year.
    The public perception is that NIH received $30,600,000,000 
in fiscal year 2012 and that NIH is using $30,600,000,000 for 
biomedical research. But because NIH is subjected to the tap, 
over $700,000,000 was shifted to other activities within HHS 
outside of NIH, in essence allowing HHS to count the funds 
twice. In fact, the fiscal year 2013 President's budget 
request, once adjusted for tap increases, actually proposes to 
cut NIH by about $250,000,000. So NIH would have only about 
$29,600,000,000 last year to spend on biomedical research under 
the President's proposal.
    In addition, HHS recently began to expand its definition of 
what programs are subject to tap to include mandatory programs 
which effectively results in the conversion of mandatory funds 
to discretionary funds. The intent of this authority is to 
provide the support for program evaluations.
    I know in fiscal year 2012, CDC received over $370,000,000 
of tap funding while AHRQ received $400,000,000 in tap funds.
    Can you explain to me how much of these funds are actually 
going to program evaluation and how much of them are going to 
expanded programs? And why does it need to be 3.2 percent, as 
requested by the administration, as opposed to the 1 percent 
which decreases the amount we are actually spending on 
research?
    Dr. Clancy. So it is my understanding, Mr. Simpson, that 
the actual tap is something that was a decision made by the 
Congress, which is why AHRQ is funded out of that tap. I am 
less familiar with----
    Mr. Simpson. At 1 percent.
    Dr. Clancy. And AHRQ has had a significant proportion of 
its budget funded by that 1 percent tap since 2003 and even 
before 2003, since the agency was created in 1989, and since 
2003, it has been all of the evaluation tap.
    Frankly, this has not been our decision. Our commitment has 
been to make sure that American taxpayers get the best value 
and return on that investment.
    Mr. Simpson. Could you tell me how much of those funds are 
actually in program evaluation?
    Dr. Clancy. Well, what I can tell you is that almost every 
study that we invest in--about 80 percent of the money goes out 
the door to universities, to research firms, and so forth--is 
actually evaluating various aspects of how health care is 
delivered and how we could make it better. So I think to some 
extent that depends on the definition of program evaluation.
    Dr. Frieden. The resources that are used from the 
evaluation funds at CDC include the National Institute for 
Occupational Safety and Health, the National Center for Health 
Statistics, and some of the basic surveys that all of HHS 
benefits from. So, for example, our National Health and 
Nutrition Examination Survey receives funds from many other 
parts of the Federal Government and coordinates that work so 
that we do not have to do it in multiple places but can get 
definitive information that the entire Government can use to 
evaluate programs.
    Mr. Simpson. Is the 3.2 percent requested in the last 
budget request by the administration a necessary increase, or 
is the 1 percent sufficient? And will the sequestration affect 
the tap funds or not?
    Dr. Clancy. Yes, it will.
    Mr. Kingston. The gentleman's time has expired.
    We have now been joined by the ranking member, Ms. Lowey, 
and we would like to yield the floor to you.
    Mrs. Lowey. Well, thank you very much, Chairman Kingston 
and Ranking Member DeLauro. This is one of my most favorite 
places to be because of all the good work you do, and I have 
had the opportunity to interact with so many of you and I thank 
you. And I remember when we first were looking at the genome 
map and it was blank, and now it is just extraordinary. So 
thank you, thank you. I am in awe of your commitment and your 
hard work. Thank you.
    As we listen to the testimony, I hope that all of the 
members contemplate the impact to our communities. Extramural 
grants fund groundbreaking research, and as Dr. Collins will 
testify, every $1 of the NIH funding generates $2.21 in local 
economic growth. In 2011, the CDC obligated more than 
$473,000,000 in funds to public health initiatives throughout 
New York, nearly three-quarters of which was for vaccines for 
children and infectious disease programs. These are vital 
services that this subcommittee has responsibility to support.
    But one of the best ways for me to illustrate the 
importance of the work that is led by our witnesses is to 
examine HIV programs. This weekend doctors announced that 2-
year-old child born with HIV and treated with the 
antiretroviral drugs in the first days of life no longer has 
detectable levels of the virus, despite not taking HIV 
medication for 10 months. The two pediatric experts who led the 
research received funding from the NIH.
    Dr. Frieden and I have had numerous conversations about 
CDC's significant efforts on HIV both at home and abroad.
    HRSA is another leader through the Ryan White Program which 
provides medical care, pharmaceutical support services to more 
than 500,000 Americans living with HIV/AIDS.
    And while AHRQ strives to improve health care for all, 
CMS--I know we get tired of these acronyms, but it saves a 
couple of minutes----
    [Laughter.]
    Mrs. Lowey [continuing]. Provides coverage to tens of 
thousands of Americans with HIV/AIDS.
    Each agency plays an important but distinct role in our 
fight against this terrible disease, and these are services 
that need greater investments, not cuts.
    This is one of many reasons why I hope my colleagues and I 
will pass a balanced solution to prevent the full impact of 
sequestration.
    Thank you. Thank you to our witnesses. I am so 
appreciative. And I just want to say in closing--oh, I have got 
2 minutes. Okay. [Laughter.]
    Mrs. Lowey. I do want to say in closing I was in a meeting 
with several of our major hospitals in the New York 
metropolitan area, and they were talking to me about how 
critical are the hundreds of millions that they get in 
research. And I just want to emphasize again it is not just the 
research that is saving lives. Whether it is cancer, whether it 
is autism, whether it is Alzheimer's or heart disease--we can 
go on and on--these are jobs. And when you see what the 
sequester will do--it is estimated--and we cannot be fooled 
because it is a slope, not a cliff--that it will cost us 
750,000 jobs. This research, these investments is economic 
development in our future. So I just wanted to emphasize that.

                          BIOMEDICAL RESEARCH

    And perhaps it would be helpful if you share with us how 
we, the United States of America--and I always feel we are the 
beacon of hope to the world. How long have we been leaders and 
will we continue to be leaders? And what investments are other 
countries making in biomedical research? I apologize that I 
missed the statements. So I will go on to the next question if 
they answered that. Would you like to tell me about that in a 
minute, 20 seconds?
    Dr. Collins. I will tell you a quick story. I am honored to 
serve as the chairman of a group, a rather informal one, called 
the Heads of International Research Organizations. It is the 
major supporters of biomedical research around the world. We 
get together every 6 months. It is sort of group therapy, but 
it is also an opportunity to talk about our dreams and our 
hopes and what our various countries are doing. And when we go 
and sit around the table and I hear from South Korea, and I 
hear from China, and I hear from India, I hear from Germany, I 
hear from the United Kingdom, from Brazil about how they are 
ramping up their support of biomedical research because they 
have read our playbook and then it comes to me and I say, well, 
I hope maybe we could be flat this year, they are shaking their 
heads. They are wondering what happened. You are supposed to be 
the country that leads us forward. We are learning from you. 
Surely you must be able to do something to support this kind of 
economic growth as well as health.
    Mrs. Lowey. Thank you.
    Mr. Kingston. It is hard to stop you. We are just trying to 
stay on track.
    Ms. Roybal-Allard, you are next. And I want to make sure 
everyone knows I am trying to do this in the order of arrival.

                           NEWBORN SCREENING

    Ms. Roybal-Allard. Welcome to all of you.
    I would like to direct my first question to Dr. Wakefield. 
Congressman Simpson and I have worked together for many years 
to promote strong standards in newborn screening, and we are 
currently preparing to introduce a bill to reauthorize the 
Newborn Screening Saves Lives Act that was signed into law in 
2007.
    As you know, the Newborn Screening Act codified the 
Advisory Committee on Heritable Disorders in Newborns and 
Children to help address the vast discrepancy between the 
number and quality of State screening tests. The committee's 
recommended standards of newborn screening has led to 
lifesaving treatments and interventions for at least 12,500 
newborns diagnosed with genetic and endocrine conditions each 
year.
    Congressman Simpson and I are very concerned by HRSA's plan 
to disband the Secretary's advisory committee in April. Pompe's 
disease was scheduled to be evaluated by the advisory committee 
in May. Including a treatable disease on the panel's list for 
newborn screening could save approximately 100 babies who 
otherwise would die before their first birthday.
    Dr. Wakefield, I have a series of questions. I want to try 
and get them all in and see if you can respond to them.
    First, as a nurse, can you briefly highlight the value of 
this advisory committee?
    As Director of HRSA, can you tell us what will happen to 
the review of diseases such as Pompe's disease if the committee 
is disbanded in April?
    Does HRSA have an alternative plan to address future 
lifesaving screening tests if the committee no longer exists to 
make recommendations?
    And third, Congressman Simpson and I are working to pass a 
reauthorization bill this year, and in the meantime, will you 
use the authority of the Secretary of HHS under the Public 
Health Service Act to extend the committee charter?
    Ms. Wakefield. Sure. Thank you very much for that question.
    As you indicated, the Newborn Screening Act needs to be 
reauthorized at the end of April, and the Secretary's Advisory 
Committee on Heritable Disorders sunsets without that 
reauthorization. So what we are doing is going ahead and moving 
up more quickly a meeting that will occur before that sunset in 
April so that they can continue their work on Pompe's disease, 
as you had mentioned that specific illness.
    We highly value and hold in high regard the expertise of 
the national experts that come from across the United States to 
do that really important work of the Secretary's Advisory 
Committee on Heritable Disorders. So it is critically 
important.
    What we are doing right now is to look at the options that 
we have available should that law not be reauthorized and 
should that committee be sunsetted. We are looking at our 
internal options and working through them right now.
    Ms. Roybal-Allard. The question is as we are working to 
reauthorize the bill, will the Secretary use her authority 
under the Public Health Service Act to extend the committee at 
least until a decision has been made and we are able to pass 
that bill.
    Ms. Wakefield. We have had a lot of conversations about 
using that authority internally and we are absolutely looking 
at that option and looking at how that could be done. I could 
not give you specifics because we do not have them yet. But we 
are looking at that vehicle as a possibility to extend that 
committee. We absolutely are exploring that option right now, 
working with counsel and so on. I have been involved in those 
meetings myself.
    Ms. Roybal-Allard. I know you know this, and I understand 
that some of the decision is based on cost savings. But it 
would come at a cost of both human suffering, lives lost, and 
future costs that would be incurred in having to take care of 
those that are affected by these newborn diseases.
    Ms. Wakefield. To your point, we do not have another source 
of this type of information. It is a critically important 
source of experts to us.
    Ms. Roybal-Allard. What I will do is I will just yield the 
rest of my time and ask my questions in the second round. We 
will have second rounds, Mr. Chairman?
    Mr. Kingston. Yes.
    Ms. Roybal-Allard. Yes.
    Mr. Kingston. Thank you.
    Mr. Joyce.
    Mr. Joyce. Thank you, Mr. Chairman.
    I appreciate you all being here today.

                     BIOMEDICAL RESEARCH WORKFORCE

    Dr. Collins, I have heard you express your concern about 
the future of biomedical scientists going forward. I was 
wondering what NIH is doing to ensure that we have an adequate 
supply in the next generation of biomedical scientists and what 
we are doing to ensure that we have advanced the translational 
and clinical research that they are doing.
    Dr. Collins. Thanks. I appreciate the question.
    We recently conducted, over a period of about a year and a 
half, a fairly detailed analysis of the state of the biomedical 
research workforce and particularly the way in which young 
scientists are coming to join us. It is clear that there is 
great interest out there in young people who are seeing that 
science right now is at a remarkable time of discovery and are 
interested in participating in it. But it is also clear that 
these are not easy times for people coming to join us. People 
who are, in fact, trained through graduate school and through 
post-doctoral fellowships often do not have an easy time 
finding the kind of dream job they were looking for. Over the 
last 10 years, the support for biomedical research through NIH, 
which is the largest supporter of universities, having lost 
about 17 or 18 percent of its purchasing power, many 
universities have cut back in terms of their hiring of new 
faculty. So many of these highly trained individuals find 
themselves taking other kinds of positions. That, of course, is 
good. We want to populate other situations in industry, in 
teaching, in science policy, and so on.
    But clearly we are at a point where there is a bit of a 
crisis emerging as the ability to continue to support the 
number of individuals that I think would be good for our future 
is not quite clearly there anymore. If you are a young person 
looking at the situation, I think the consequence of that is 
increasing anxiety about whether this is a career path that is 
actually going to be one you want to choose.
    Young scientists oftentimes, because of this, end up 
spending many, many years in training. The average age at which 
somebody comes to NIH for their first independent grant and 
successfully gets it is age 42. That is not a good picture. We 
are basically keeping young talented scientists in less than 
independent positions for too long. We are working hard to try 
to do something about that. I started a new program that allows 
the most independent-minded scientists to go directly from 
their Ph.D.'s to an independent position instead of a long 
period of post-doctoral training.
    The other area that we are very intensely looking at is the 
lack of diversity in our workforce. Despite many programs over 
many years, we have not achieved a situation where the best and 
brightest from all groups are coming to join us. We have a bold 
new set of programs to try to make that more appealing for 
individuals who traditionally choose other pathways, who do not 
have role models from their own communities. And we are 
optimistic that is going to change that dynamic, but it is 
going to be a long path to make that come true.
    Mr. Joyce. Thank you very much. I yield back.
    Mr. Kingston. Ms. Lee.
    Ms. Lee. Thank you very much.
    First, let me just thank all of you so much on behalf of my 
constituents, on behalf of my family. On a personal level, my 
mother has COPD. My sister has multiple sclerosis. So I know 
your work very intimately and I just have to take this moment 
to thank you so much because all of you are doing life-
affirming work.
    And, Dr. Collins, I just have to say I remember your speech 
at the Prayer Breakfast in 2007. I think it was one of the most 
profound speeches that I have ever heard from a scientist.
    Let me ask you, Dr. Frieden. First, I also thank you for 
your work on domestic and global efforts to prevent diseases, 
including cancer, hepatitis B, HIV and AIDS which all 
disproportionally affect minorities. Your agency is a leader in 
many initiatives such as--and I want to call one to your 
attention. It is the Racial and Ethnic Approaches to Community 
Health. I think it is called the REACH program, which really 
aims to eliminate racial and ethnic disparities in health. How 
do you anticipate sequestration affecting these programs and 
the populations that they serve?
    And then secondly, let me just ask you about HIV 
criminalization laws. You know, we have 32 States and U.S. 
territories that have criminal statutes based on perceived 
exposure to HIV. These laws have been on the books since the 
1980's and most of them need to be modernized to reflect 
current scientific advances in AIDS research. And last year the 
UN body which I sit on--we issued a report against these laws, 
and the President's Advisory Committee on HIV--you know, they 
cited a direct impact that these laws have on public health and 
the fear that they instill in people who seek HIV testing and 
counseling. And so I know you have been working on a review of 
these laws and the implications for public health, and I would 
like to find out the status of that and can you give us an 
update?
    Dr. Frieden. Thank you very much.

                        REACH AND SEQUESTRATION

    In terms of the REACH program and sequestration, 
sequestration would affect virtually every program at CDC with 
a decrease of approximately 5 percent. So it would be that much 
less that we would be able to do to address communities, that 
particular need for health programs that would reduce health 
disparities. We focused on trying to reduce disparities. We 
released for the first time what is called a surveillance 
summary or monitoring report on inequalities and disparities in 
health status in the U.S. We identified some of the leading 
disparities and some of the specific things that can be done to 
reduce them.

                        HIV CRIMINALIZATION LAWS

    In terms of the HIV laws, we look at this very broadly. We 
found that many laws have been out of date, ranging from 
testing to monitoring to some of the criminal sanctions that 
are in existence. So what we have done working with other 
groups is to just survey what is the lay of the land out there. 
What are people doing? What are the laws that exist? And we 
believe that that should go through a peer review process and 
be published in the medical literature. So we can get back to 
you with the exact timeline of that, but I understand that the 
review is largely finished and we are now finalizing with the 
goal of ensuring that whatever laws are there at least address 
or are cognizant of the latest scientific information.
    Ms. Lee. Okay. Are you looking at the impact, though, on 
public health of these laws, I mean, what it means, for 
instance, in terms of stigmatization, in terms of people 
willing to come forward to get testing knowing that they could 
be put in jail?
    Dr. Frieden. I would have to get back to you on that in 
terms of how that would be looked at and what they have done in 
that area.
    Ms. Lee. Okay.

                        NIH WORKFORCE DIVERSITY

    And, Dr. Collins, let me just follow up on the issue that 
was discussed earlier with regard to the whole inclusion of 
minorities. Specifically in the RO1 grants, can you kind of 
elaborate on that and how this will impact--how these RO1 
grants and the whole effort to diversity will impact the health 
disparities issue?
    Dr. Collins. I appreciate the question.
    So a couple of years ago, there was a publication 
indicating that African American individuals who come to NIH 
seeking their first RO1 had a lower success rate than 
individuals from other groups, and you cannot account for that 
by the number of correlates that people would have assumed 
might have played some role in terms of previous training, 
publication record, and so on. We are continuing to look 
closely at that to try to understand it. It certainly sent a 
shock wave through our community.
    I have organized an effort, through my advisory committee 
to the director led by Reed Tuckson and John Ruffin and Larry 
Tabak, to look at our whole area of diversity in our workforce. 
And they concluded that we have a problem which is beyond 
simply looking at success rates of investigators who have 
already made it into the position of applying to NIH for a 
grant, but also why are there so few of those individuals.
    We have just begun and we will be spending substantial 
funds, even in very difficult budgetary times, on several new 
programs to try to assist us. One is to try to make it possible 
for individuals from under-represented groups to have a real 
research experience as undergraduates, together with some 
tuition rebates to make this more financial possible. Another 
is to set up a national research mentoring network because it 
is clear that one of the problems that we see is that under-
represented groups do not have that same network of support 
that the majority, folks do. We think that could be a very 
important part of it.
    There are several other parts. I see my time is up. I would 
love to talk to you more about that.
    Ms. Lee. Thank you very much.
    Mr. Kingston. Dr. Harris.
    Dr. Harris. Thank you very much.
    First, I want to echo the ranking member with her comments, 
you know, thanking you all for being around to protect and 
improve the life and health of not only Americans but really 
people throughout the world. And I have taken a leadership role 
in that.
    I do want to echo, though, the chairman because I do have 
some concerns about duplications that are occurring. You know, 
the GAO reports multiple duplications in the Federal 
Government. Our goal really in this time of contracting 
resources is to look for efficiency and effectiveness. So I am 
going to ask very specific questions. I just need a kind of a 
yes or no from Dr. Clancy, Dr. Collins, Dr. Conway.

                        PATIENT SAFETY RESEARCH

    Do each of your entities fund patient safety research?
    Dr. Clancy. Yes.
    Dr. Harris. Dr. Collins.
    Dr. Collins. A very small amount.
    Dr. Harris. Dr. Conway.
    Dr. Conway. Only if it relates to payment and delivery 
system----
    Dr. Harris. So it does. Okay.
    Dr. Frieden and Dr. Collins, do you fund obesity research?
    Dr. Frieden. We do surveillance on obesity and support 
communities in their work on that.
    Dr. Collins. Yes.
    Dr. Harris. Dr. Collins, Dr. Frieden, are there other areas 
of research in other disease processes, hypertension or 
whatever? So Dr. Frieden, do you also survey hypertension, 
other disease processes as well?
    Dr. Frieden. Surveillance, yes.
    Dr. Harris. So you do. Okay.
    And AHRQ and NIH fund telemedicine research?
    Dr. Clancy. Moderate, a little bit, yes.
    Dr. Harris. You do. So there is a little bit of 
duplication.
    Look, I have held grants from DOD health grants, worked on 
VA health grants. So I understand that there are multiple areas 
in the Government that actually look at very similar things, 
and that is some concern. So I just want to mention that again 
as we look toward effectiveness and efficiency.

                         VACCINES FOR CHILDREN

    Now, I want to ask in the last remaining minutes, Dr. 
Frieden, I have a great deal of concern about a document my 
office got from the White House that talked about the cuts that 
were going to occur due to Republicans and affecting children. 
And I am going to read their quote about vaccines for children. 
It says, in Maryland, about 2,050 fewer children will receive 
vaccines due to reduced funding for vaccinations of about 
$140,000. Did the CDC assist the White House in preparing that 
estimate?
    Dr. Frieden. I would have to get back to you on that.
    Dr. Harris. You as the Director do not know if you assisted 
the White House in preparing an estimate that was distributed 
to every Member of Congress?
    Dr. Frieden. On that specific number, I would have to give 
you----
    Dr. Harris. Okay. Let us forget the number. Let us forget 
the idea of how vaccines for children are going to be affected 
by the sequester. Is this the vaccine for children program?
    Dr. Frieden. No, it is not, sir.
    Dr. Harris. Which program is it? Is it 317?
    Dr. Frieden. Yes, it is.
    Dr. Harris. And what did the President's budget do to 317, 
the President's prospective budget for 2013?
    Dr. Frieden. The precise numbers I would have to get back--
--
    Dr. Harris. Well, does a $58,000,000 cut sound familiar?
    Dr. Frieden. Yes.
    Dr. Harris. And what was the sequester cut?
    Dr. Frieden. Again, the precise----
    Dr. Harris. Does $30,000,000 sound familiar? Do you think 
that is around the ball park, is it not?
    So actually the President cut the program twice as much in 
his budget. Can I assume that the President's proposed cut 
would have reduced the funding to 4,100 children in Maryland?
    Dr. Frieden. As per the justification that was published 
with that, we have looked at ways that we can run the program 
more efficiently by helping State and local health departments 
recoup dollars, for example, for----
    Dr. Harris. And you cannot do that under a sequester, but 
you can do it under the President's budget? Is that my 
understanding of your testimony today?
    Dr. Frieden. I would have to get back to you on that.
    Dr. Harris. So let me get it straight. Under the 
President's cut of $58,000,000 to the 317 program, you think 
you could get around that to avoid cutting vaccines to 
children, but under a sequester that the President blames on 
Republicans, you do not know if you can do that?
    Dr. Frieden. We are going to do everything we can to limit 
any damage that occurs because of the across-the-board cut, but 
it reduces our flexibility significantly.
    Dr. Harris. Is it your testimony that under the President's 
proposed cut of $58,000,000 in his budget to the 317 program, 
you could have avoided cuts to vaccines to children in 
Maryland?
    Dr. Frieden. We believe that we could have maintained 
vaccination levels, yes.
    Dr. Harris. Very interesting.
    I yield back the balance of my time for now.
    Mr. Kingston. Thank you.
    Mr. Womack.
    Mr. Womack. Thanks to all of the expert witnesses here 
today for your testimony and for your service to your country.

                              DUPLICATION

    I have really one fundamental question. In my 2-plus years 
of serving in this capacity, not on this subcommittee, but as 
an appropriator and as a Member of Congress, I notice that so 
much of our Government is duplicative in nature. There is a lot 
of turf protection that goes on in our business throughout the 
Federal bureaucracy, but there is also a whole lot of--in the 
military we called it ``mission creep.'' I will stop short of 
that and just say there are a lot of things that we do from one 
agency to another that can be looked at as duplicative in 
nature. And I am going to ask this long question and then I 
will just leave it to the panel. And then I will yield back my 
time.
    For example, all of your organizations fund activity or 
some do related to health care-associated infections, on 
prenatal care models, on issues involving biomedical research, 
tobacco cessation programs, and other similar related programs 
that come under a different title or a different theme from 
organization to organization.
    Are we being efficient? Is there proper collaboration, and 
in your professional opinions, what are we doing to ensure that 
the Federal outlays, in a constrained resource environment as 
we operate today, are actually accomplishing the short-term and 
long-term goals and not involving a waste of resources? So I 
will just kind of throw that out on the table and let each one 
of you have a stab at it. Thank you.
    Dr. Clancy. Well, I will start with health care-associated 
infections because I made a big focus on that in my opening 
statement.
    Our focus is on answering the question ``how do we do 
that.'' We have known about these infections for decades. My 
colleagues, Drs. Frieden and Collins, have done groundbreaking 
science and so forth, but meanwhile, it was accepted as 
disappointing but almost inevitable in health care settings 
that a very unacceptably high rate of these infections 
continued to occur. And we funded what turned out to be a 
groundbreaking study in the State of Michigan in 2003, and that 
led to dramatic improvements. And what was exciting about this 
was the focus on making it work in small rural access hospitals 
as well as ICU's and so forth. So that is our unique focus.
    We use every piece of information we can use from the CDC 
in doing this work. We do not reinvent definitions or anything 
like that. Anytime there is new biomedical science, we are 
there for it.
    We play a minuscule or other role in the other areas that 
you delineated, but I think it is fair to say that both through 
a very short list of high priority goals for HHS, as well as 
through multiple components of her leadership, the Secretary 
herself insists on a great deal of collaboration so that we are 
at all times making sure that we are getting the best value for 
every dollar that the taxpayers have invested in this work. And 
I will say that the return on investment for our investments in 
reducing HAI's has been quite wonderful. I will have to turn to 
my budget officer to get you the numbers, but we would be happy 
to do that.
    Dr. Frieden. Just health care-associated infections is a 
good example where research from AHRQ, policies from CMS, and 
monitoring support to States from CDC work really in close 
coordination. And we have had terrific partnerships in this and 
other areas.
    Another area to think about is HIV where research at the 
NIH developed the drugs. Funding through HRSA gives people 
access to them, and support from CDC helps programs monitor 
what is happening and prevent HIV. And of course, through the 
Medicaid program as well, there is a lot of access to HIV care.
    So there are many areas in which complex problems work. And 
I will say that we work very closely together.
    One additional example is CMMI has some new programs to try 
things, and when they are in areas where CDC has expertise, 
rather than hiring their own staff to monitor those programs, 
they are paying us to make sure that we can put our staff on 
the case and do that without duplication.
    Dr. Conway. Just HAI's I do think is an excellent example. 
We use the CDC measurement system and their expertise. We put 
it in payment and delivery system programs at CMS, and we have 
seen an over 40 percent reduction in central line infections. I 
personally as an intern took care of a family whose neonate 
passed away. So I think it is dramatic.
    Mr. Womack. Thank you. I will yield back the balance of my 
time.
    Mr. Kingston. Well, that was generous of you. [Laughter.]
    Mr. Fleischmann, you came late. Are you up to speed on what 
we have been talking about?
    Mr. Fleischmann. Well, yes, Mr. Chairman. Sorry. I was in 
another subcommittee hearing.
    Mr. Kingston. That is okay. You buy the coffee for 
everybody. No. You buy Tennessee Italian pastry. I think that 
is the penalty for coming late. [Laughter.]
    Mr. Fleischmann. We can call them Little Debbie's. 
[Laughter.]
    Mr. Kingston. They do not have pastry but they have another 
fine product they brew in the mountains. [Laughter.]
    Mr. Fleischmann. Having said that with our good medical 
personnel here, I am a teetotaler for the record.
    Thank you, Mr. Chairman.

                        INTERAGENCY COORDINATION

    I will address this to all witnesses. HHS has many 
interagency coordinating committees and working groups. Could 
you please tell us how many interagency coordinating committees 
and working groups are in existence, and how are 
recommendations from these advisory groups handled at HHS?
    Dr. Collins. So this is, I think, very much a follow-up to 
the question Mr. Womack was asking. You would want us to have a 
lot of these interagency working groups, I believe, because the 
ecosystem represented by the agencies at this table stretches 
from very basic science trying to make discoveries about causes 
of illness and the means to prevent and cure all the way 
through understanding how that works in an epidemiological way 
across the country in terms of health services and quality of 
care in terms of issues that Medicare and Medicaid has to deal 
with all the time. So we all are engaged in this.
    Take diabetes, for instance, an enormous threat to the 
health of our Nation. Each one of the agencies here has a 
particular role to play in that kind of a circumstance, but we 
need to be sure that we are together and we are not duplicating 
efforts, but we are actually being synergistic and 
complementary.
    I could not tell you how many interagency working groups 
there are, but I suspect if we tallied them all up, there would 
be dozens. And that is a good thing. And we populate those with 
people at a high level who have the ability to know what their 
agencies are up to and have worked together quite closely.
    And each of us at this table--we know each other really 
well. We talk to each other a lot. We have senior staff 
meetings shared between agencies in a bilateral sort of way. We 
get it. This is a time where budgets are extremely tight. We 
would not be happy about the idea of wasting a single dollar 
right now either.
    Mr. Fleischmann. All good? Okay, thank you.

                  DISSEMINATION OF HEALTH INFORMATION

    A follow-up. In the area of health information, could you 
each please take about 30 seconds to educate us on how your 
organization spends on dissemination of health information?
    Dr. Frieden. So CDC often is the lead for monitoring of the 
health status of Americans and that information is provided to 
individual researchers. It is provided through our website. It 
is provided through grantees who get information to the public 
in a wide variety of areas. We also coordinate across HHS on 
issues like vaccine safety where we want to make sure that all 
information is present so there is not a partial view.
    Dr. Clancy. So I am going to make a quick statement. You 
know, we all know, all of us, that it takes too long for 
scientific information to benefit patient care. The statistic 
is that it takes 17 years for 14 percent of funded research to 
benefit patients. 14 percent. I do not know if that is good or 
bad. Research can be risky business in terms of what is going 
to pay off. We all think 17 years is too long. So I think it is 
fair to say that each of us is trying to exploit and take 
advantage of all kinds of new opportunities.
    We have a particularly big role in getting health 
information out to the public, both by virtue of how our 
authorizing statute is written to get information out to the 
public and to health professionals and also through a new 
authority in the Affordable Care Act for getting information 
about patient-centered outcomes research out there. We think we 
are really cheap and efficient.
    And we rely a lot on partners because particularly for 
clinicians, many of them would much rather hear from the 
College of Cardiology than even wonderful AHRQ in the Federal 
Government, even NIH. They like hearing from their professional 
organizations. So we utilize those partnerships very 
effectively.
    Ms. Wakefield. And I could just add, just to give you an 
example, we would use from CDC their guidelines for screening 
and treatment around heart disease, take those guidelines and 
push them out to the community health centers across the United 
States, of which there are about 9,000 sites. So that is a good 
utilization of pulling it in very rapidly and pushing it out 
through the infrastructure that we support across the country 
in every State and territory.
    Dr. Collins. NIH sees a major part of our role is 
distributing information about the results of research, 
clinicaltrials.gov, a place where anybody who is interested in 
a clinical trial can find out what is going on anywhere in the 
country, both publicly and privately supported. The PubMed 
database, which is where people go to look at the public 
literature, downloaded 40,000,000 pages on an average day by 
people who are interested in that information, and MEDLINE, 
which is perhaps one of the most trusted resources for the 
public looking for medical information that is well-based on 
evidence.
    Dr. Conway. So we share our quality information, including 
the private sector companies that utilize that information, to 
build technology to support choice by Medicare beneficiaries 
and their families.
    Mr. Kingston. Okay. We are going to go to a second round, 
and we will try to limit it to 4 minutes each, if everybody is 
in agreement, and we will just keep going. We will try to talk 
fast.
    Dr. Frieden, we are probably looking at--I do not know--low 
side 675, high side maybe 900 in IQ at the collective table 
here at the moment. [Laughter.]
    Ms. Lee. Your table. [Laughter.]
    Mr. Kingston. I know I am not adding to the average.

                    COMMUNITY TRANSFORMATION GRANTS

    But, Dr. Frieden, I want to talk to you about it 
specifically. I am troubled and very unimpressed with community 
transformation grants. I would ask you as a really smart 
scientist who has earned his stripes, pseudo-science, public 
relations, real serious stuff, good politics?
    Dr. Frieden. The community transformation grants, which 
were authorized and directed by Congress----
    Mr. Kingston. That should tell you right there. [Laughter.]
    Dr. Frieden [continuing]. Are an opportunity to allow 
communities to work in specific areas with specific outcomes, 
healthier school food, better control of blood pressure, 
reduced exposure of children to tobacco and other cancer-
causing chemicals.
    Mr. Kingston. I am going to kind of move along on a clip 
here. It just strikes me that the only thing we are getting out 
of them is a bunch ``me too'' stuff of kind of, oh, yeah, the 
tobacco. Oh, well, that is an original thought. Sugary 
beverages. Oh, that is an original thought. I mean, I do not 
see much coming out of community transformation grants that 
show, hey, you know what, this is a really good investment.
    It disturbs me when tax dollars are used to fund government 
to single out food rather than educate people on what you 
should be doing for your exercise. It seems that there is a 
real slant towards let's tax certain food items and make it 
harder for people to get in as opposed to talking about the 
broader picture of obesity. I do hope to have a hearing on 
obesity.
    But I am very concerned that what we are seeing now--for 
example, CDC gets $825,000,000 in PPH funds, and $226,000,000 
are used in community transformation grants. If we are talking 
about not immunizing children so we can get a bunch of people 
in Los Angeles to say, oh, we should have less tobacco, I do 
not think that is a good investment of tax dollars.

                                LOBBYING

    I just need assurances from you that these grants are not 
going to be used to just continually lobby for more taxes, more 
bans, and more restrictions on particular food.
    Dr. Frieden. We take very seriously the restriction on 
lobbying by grantees. We have a rigorous process in place to 
monitor and oversee grantees and provide training, technical 
assistance and guidance on this topic. And if we identify a 
potential issue, we address it immediately.
    Mr. Kingston. I am going to look forward to working with 
you on that.

                                 SODIUM

    And I want to ask you about sodium because we get mixed 
signals on sodium. You have said in the past that--and there 
was a New York Post article that you said too much sodium 
raises blood pressure which is a major risk factor for heart 
disease and stroke. These diseases kill more than 800,000 
Americans each year and contribute to the estimated 
$273,000,000,000 in health care costs. But when pressed for 
specifics, Karen Hunter of the CDC says that the CDC does not 
have data on the number of heart attacks and strokes that are 
caused by excess sodium.
    So what specific data do you have on the number of deaths 
caused by sodium? And this is a computer-generated number or 
has it been peer-reviewed? Is it solid data or not? And does a 
low-sodium diet lead to health problems in certain populations? 
And I see you have 7 seconds. [Laughter.]
    So I tell you what if we have a third round, I will let you 
answer that. If not, let's do it for the record. Thank you.
    Ms. DeLauro.

                         VACCINES FOR CHILDREN

    Ms. DeLauro. Thank you. Just a quick comment on the 
$58,000,000 in the immunization effort. I too would be opposed 
to that cut. I think it is important to recognize as well, 
though, that the administration made a presumption that the 
Affordable Care Act would be implemented and that in fact would 
accommodate immunization.
    Let me move on and, Dr. Clancy, let me ask you a couple of 
questions if I can. I will just tick them off very, very 
quickly.

               AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

    Last year, the subcommittee would have eliminated AHRQ. 
What would we lose? And secondly, you began to mention one of 
the arguments for eliminating AHRQ was that it is duplicative 
of other agencies. You made a response. I do not know if you 
would want to add to that response about whether there is 
overlap with other agencies.
    And last, AHRQ and the Patient-Centered Outcomes Research 
Institute, which is set up by the Affordable Care Act. Some 
have suggested that we should stop providing an appropriation 
to AHRQ to do the patient-centered outcomes research because 
that research can now be supported by PCORI. Is PCORI in a 
position to take over the support of all of AHRQ's patient-
centered outcomes research?
    Dr. Clancy. So thank you very much for your question. I 
think that you probably got from my earlier statement my 
passion for this work, and given the opportunities for 
improving quality and safety and given what I think is sort of 
a new day among health professionals in terms of their 
excitement about improving health care, I think we would lose a 
lot if AHRQ were to go away.
    Quite specifically, the question I hear from health 
professionals all the time is ``I want to be part of this 
transformation. How do I do that? How do I get on board with a 
variety of policy initiatives? How do I know what is right for 
my practice? How do I do that?'' And we are the agency that 
actually gives them evidence-based tools to make it easy for 
them to do the right thing. And the excitement and enthusiasm 
among health professionals--you cannot buy it. The payment 
policies are really important, but the professional commitment 
to providing the best possible patient care. So it is HAI's. It 
is the work in team work. It is the work in communication. It 
is information for the public. Dr. Frieden mentioned being a 
disease detective. In our world, being a disease detective 
often involves trying to find out precisely what medications 
this patient is taking now and how can we make sure that we are 
helping them to avoid potentially deadly interactions. So that 
is the work in patient safety.
    The second question was about duplication. I think the 
unique area that we focus on is the ``How do I do that.'' Dr. 
Conway referred to it as ``improvement science,'' which is a 
slightly more glamorous sounding label. I do not care what you 
call it. What I see is that we have got a health care system 
that is not equipped to provide high quality, safe, affordable 
care, and we have developed and generated practical solutions 
for doctors, hospitals, nurses, pharmacists, and so forth to be 
able to do that. And I cannot tell you how excited they are, 
and we hear from them all the time. The words I hear are they 
are ``game-changing.'' This approach to HAI's--that is what 
really turned the corner for us, and we thought we were trying 
really hard before.
    In terms of patient-centered outcomes research, that is a 
program we are phasing out. You probably know we think and are 
very proud of the work we have done to date, particularly with 
the Recovery Act funding as a foundation for the Patient-
Centered Outcomes Research Institute. Dr. Collins and I are 
both on the board of that institute. So we have both, I am just 
going to say, been quite generous both with our own time and 
with sharing lessons learned. We have a unique and exciting 
opportunity because 16 percent of the allocation from the PCORI 
trust fund comes to AHRQ to support two vital areas. One is 
dissemination of the findings to the patients, to families, to 
health professionals, and so forth so that they have got good 
information when they need it to shorten that 17-year time 
frame. The other is building capacity, training future 
researchers, training people who can understand how to use this 
information.
    Sorry for going over.
    Ms. DeLauro. Thank you, Mr. Chairman.
    Mr. Kingston. Dr. Harris.
    Dr. Harris. Thank you very much.
    Again, I want to thank you for all you do for protecting 
and improving life and health.

                         VACCINES FOR CHILDREN

    Dr. Frieden, I do look forward to your answer about who was 
the source within the CDC for the information that I got 
concerning Maryland. So I look forward to your answer.
    [The information follows:]

    Dr. Frieden: CDC provided data that was used in developing 
the report.

    Let me just follow up one more thing for you. A concern I 
have is the ATSDR which apparently has issued reports on Dimock 
and one other place where hydraulic fracturing was alleged to 
have contaminated drinking water. And I read through the 
reports. It is actually good that the ATSDR actually pointed 
out that the EPA sampling was improper, you know, quality 
control samples. I mean, I like that idea. But I would urge you 
to keep it to science and leave the politics aside. That is the 
one good thing I think we should insist upon, medicine, medical 
research, public health research, is that we leave the politics 
aside. Let's concentrate on science.

                          NIH RESEARCH FUNDING

    Now, Dr. Collins, I have got to ask you a couple of things 
here, and I did not think I was going to except that it popped 
across one of my local, online--I guess you would call it a 
blog--yesterday--2 days ago. It says, NIH study claims link 
between the Tea Party and the tobacco industry. Are you aware 
of this? I mean, again this popped across one of my local--let 
me ask you. The only comment says--so it is a study. I guess it 
was--was it University of California? Are you aware of it?
    Dr. Collins. UC San Francisco.
    Dr. Harris. UC San Francisco. So they allege that somehow 
the Tea Party had its origin in the 1980's with tobacco 
funding, which is pretty incredible because, I mean, I am a Tea 
Party guy. I was there when it was established in 2009. I know 
the origins. I find it incredible that NIH funding is funding 
this because the one comment says, what may I ask does this 
article have to do with Chestertown, which is the local 
community. Of course, it has nothing to do with Chestertown and 
everything to do with a partisan political agenda. I could not 
agree more.
    Dr. Collins, what methods does the NIH have when this kind 
of research takes dollars from cancer research and other 
important, vital research--what does the NIH do to universities 
that waste Federal tax dollars this way?
    Dr. Collins. Dr. Harris, I appreciate your question, and I 
too am quite troubled about this particular circumstance. Dr. 
Stanton Glantz, who is the author of that article, has been a 
funded grantee of the National Institutes of Health, the Cancer 
Institute, for 14 years and has done some very important work 
in terms of tobacco control over those years and is considered 
by peers to be among the best in the field.
    Dr. Harris. If I might just interrupt, you do not consider 
this among his most important work in tobacco research. 
[Laughter.]
    Dr. Collins. No, I would not.
    Dr. Harris. Okay. Thank you.
    Dr. Collins. If you look carefully at the acknowledgements 
at the end of this particular paper, which came as a surprise 
to us as well----
    Dr. Harris. I am looking at them, but go on.
    Dr. Collins [continuing]. It does cite two different grants 
from the NCI. There is also wording there--and maybe you could 
read it off to us--which says that this particular work and 
this particular paper was not suggested or encouraged by the 
NIH. He did this on his own.
    Dr. Harris. Correct. And that drills down exactly to my 
question. This was the use of Federal dollars on a clearly 
partisan political agenda. I mean, look, we are going to come 
to agree--clearly partisan political agenda. What is the NIH 
going to do to make sure that we do not fund this research, we 
fund the real medical research as we go forward in a time of 
constrained resources?
    Dr. Collins. Of course, we thought we were funding a 
different kind of research when those grants were awarded.
    Dr. Harris. So what is within the NIH's abilities to, shall 
we say, make sure that this researcher of this institution does 
not play fast and loose with taxpayer money in this kind of 
research?
    Dr. Collins. So it is a very appropriate question and I am 
struggling with it, to be honest.
    Dr. Harris. Could you get back to me about what plans the 
NIH is going to have to be certain that this kind of research 
is not funded?
    Dr. Collins. The tension here is both to recognize that 
this is an unfortunate outcome but also not to put NIH in the 
position of basically playing a nanny over top of everything 
that our grantees do because a lot of what they do, which is 
more appropriate, ends up being quite innovative.
    Dr. Harris. Thank you very much.
    Thank you, Mr. Chairman.
    Mr. Kingston. This is a very good discussion, but we are 
out of time.
    Ms. Lowey.
    Mrs. Lowey. Thank you very much, Mr. Chairman.
    And I just want to say to Dr. Collins and my colleagues, 
since I got on this committee, which I love, many years ago I 
have always tried to figure out how you can legislate 
excellence consistently. And that is the challenge that we all 
have because we are so committed to the important work that you 
are all doing. So I thank you for your comments and maybe you 
can come back with some good advice.

                      DIABETES PREVENTION PROGRAM

    I would like to focus for a moment on the diabetes 
prevention program because we know that between 1980 and 2010, 
the number of Americans diagnosed with diabetes more than 
tripled. I understand that some of you are involved with an 
effort to alter that trend called the Diabetes Prevention 
Program which helps people at risk make the kinds of modest 
life changes that can substantially reduce their chances of 
developing diabetes. The program originated with a large study 
by the NIH that demonstrated the potential of modest lifestyle 
changes in reducing risk of type 2 diabetes, and CDC is now 
leading the implementation of these findings in partnership 
with organizations throughout the country using funding from 
the Prevention and Public Health Fund.
    Now, before I ask the question, I just want to associate 
myself with the chairman's comments before about sodium because 
there have been recent reports on the Mediterranean diet and 
another report, no salt, no sugar, no fat. And at some point 
maybe we can have a hearing or a discussion of all these diets 
because it is so important, Dr. Frieden, to your work and to 
everyone's work. I would be interested in that.
    But my question today to Dr. Collins and Dr. Frieden, can 
you tell us how the Diabetes Prevention Program works, about 
the respective role of your agencies in developing and carrying 
out this effort, and are we seeing some results?
    Dr. Frieden. So the Diabetes Prevention Program is a great 
example of partnerships where the NIH funded research that 
shows that for people with pre-diabetes, if they participate in 
this program, their risk of developing diabetes falls by 58 
percent. We then took that and worked with the YMCA, now called 
the Y, to come up with a lower cost way of doing that, and now 
we are working with providers throughout the country and 
insurers throughout the country to identify ways to get 
patients access to these programs. What we have done is to 
essentially verify that a provider is doing the program with 
fidelity to the model and require them to provide aggregate 
reporting periodically to us, and then United Health Care and 
other insurers are going to pay those providers because there 
is a great return on investment here. A single person with 
diabetes costs on average $6,600 more to care for per year than 
someone without diabetes. So if we can prevent a few of these 
cases, we can save a lot of money for the health care system.
    One of the areas that this is addressing is how do you get 
the health care system to pay for lower cost, high value 
preventative services. And that is something that I think all 
of us are learning and understanding more of.
    Dr. Collins. Yes. I think this is a great example of our 
agencies working together in terms of conducting the original 
study, which has now been extended out over 10 years, a follow-
up, showing that the benefits of this lifestyle change, which 
is diet and exercise, are sustained over long periods of time, 
especially for people over 60, which is also an interesting 
part of the discovery, and then CDC picking this up in terms of 
implementation in the real world to see how this works out.
    We have been talking now a lot with CMS about how we could 
see a path forward here for a proven, successful enterprise 
here to prevent diabetes to be more broadly available to people 
who have Medicare and Medicaid coverage.
    It was a challenge because a lot of the delivery of the 
health care depends upon non-traditional providers, coaches, 
lifestyle coaches who are successful in being able to maintain 
people's exercise and diet abilities.
    Mrs. Lowey. Well, thank you, Mr. Chairman. My time is up.
    I would like to add this discussion to the one that we are 
going to have because we have known a lot of this for a long 
time. Whether it is Weight Watchers or Over-Eaters Anonymous 
how do you really get people to change behavior with all the 
advertisement for sugar, starches, etc.? But this is a longer 
discussion. Thank you very much.
    Mr. Kingston. It is a great discussion, and I do hope to 
have some hearings on it.
    Ms. Roybal-Allard.

                       TB OUTBREAK IN LOS ANGELES

    Ms. Roybal-Allard. Dr. Frieden, before he went into 
politics, my father was a public health educator responsible 
primarily for educating the Latin communities in California 
about the spread and prevention of TB. So I grew up with a 
healthy respect for the dangers of that disease.
    I have been closely following the rising number of TB cases 
among L.A.'s skid row homeless population which has been called 
the largest TB outbreak in a decade. Equally concerning are 
other communicable disease outbreaks such as last year's TB 
outbreak in Florida and last year's whooping cough outbreak in 
the State of Washington.
    Given that CDC's budget has been significantly cut over the 
past several years and sequester is expected to take an 
additional $300,000,000 from CDC's budget, will the CDC have 
adequate funding and resources to control and prevent the 
spread of communicable diseases in all States? And if not, will 
some communities be hit harder than others? And what risks, if 
any, will this pose to the rest of the population at large?
    Dr. Frieden. We will do the best we can to mitigate the 
damage that sequestration cuts will do, but the reality is that 
about two-thirds of our budget goes out to State and local 
entities. Those entities have already absorbed about 45,000 
fewer staff because of State and local reductions in funding. 
And so this comes at a very difficult time for State and local 
governments, and there is always the risk that an outbreak will 
be undetected or detected more slowly or controlled more slowly 
with fewer resources.
    With respect to the Los Angeles tuberculosis outbreak, we 
have a team that arrived yesterday at the request of the State. 
We only go places where we are requested. They requested 
assistance and we have sent a team there. But some aspects of 
the investigation will be difficult to do in this budgetary 
climate.
    For example, we are increasingly using what is called whole 
genome sequencing of bacteria and viruses to understand the 
transmission, where they spread and how they spread. It is a 
costly and difficult study to do. They are getting cheaper, but 
the bioinformatics needs are great. And this is an area where 
we need to continue to grow our capacity.
    Just to give you an example a couple of years ago when 
cholera hit Haiti, we were able to do sequencing of the genome 
of that bacteria, but we were not able to interpret the results 
because we did not have the bioinformatics capacity. And I am 
ashamed to say we had to send the information to Canada for 
them to interpret it for us. I never want to have that happen 
again on my watch at CDC. So we will do everything we can to 
respond as effectively as we can to outbreaks that occur.
    On average, we start an investigation about every day. So 
which of those we may be able to address less well I cannot 
predict.
    Ms. Roybal-Allard. And if you are not able to address them, 
what communities do you think will be hit the hardest and how 
will that impact the population at large?
    Dr. Frieden. I think the spread of infectious diseases 
knows no boundaries around the world and also can spread in 
hospitals from food. There are populations at higher risk, 
people who chose not to get vaccinated, for example, or 
communities that have low vaccination rates. But ultimately 
because we are all connected by the air we breathe, the spread 
of communicable disease is a potential risk to everyone.
    Ms. Roybal-Allard. It will affect all of us. Thank you.

                VIOLATIONS OF ANIMAL WELFARE REGULATIONS

    Dr. Collins, in January I sent a letter asking about 
violations of Federal animal welfare regulations in NIH-funded 
research laboratories. Since I have not received a response to 
date, I want to follow up on that issue.
    It is my understanding that NIH requires federally funded 
animal research laboratories that violate animal welfare 
regulations to return the funds used for the noncompliant 
activities. There was a well publicized case several years that 
a noncompliant lab was ordered more than $65,000.
    My questions are, are the FDA and USDA notifying NIH about 
noncompliant projects funded by NIH, and what is NIH doing in 
response to these reports? For example, over the last 5 years, 
how many incidents requiring grant repayment have been reported 
to NIH? What actions have been taken, and how much in taxpayer 
money has been returned to the NIH?
    Mr. Kingston. And, Dr. Collins, you will have to answer on 
the record.
    Dr. Collins. Okay. I will be glad to answer on the record. 
I am sorry you did not get a response to your letter, and I 
will be sure you get one.
    [The information follows:]

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    [GRAPHIC] [TIFF OMITTED] T6214A.033
    
    Ms. Roybal-Allard. Okay. Thank you.
    Mr. Kingston. Ms. Lee.
    Ms. Lee. Thank you very much.

             DIABETES IN INDIVIDUALS WITH SICKLE CELL TRAIT

    Dr. Collins, let me ask you if you could give us--and you 
may not have it here--an update on an effort that actually was 
through this committee we mounted as it relates to the whole 
issue of diabetes with individuals who have the sickle cell 
trait and the A1C test. Several years ago, I just happened to 
stumble upon the fact that the A1C test is not valid if in fact 
one has the sickle cell trait, which primarily are in 
population of African American and Southeast Asian populations. 
We raised this with the National Institute of Diabetes and 
Digestive and Kidney Disease and also worked with NIH to 
develop a public awareness campaign.
    I want to know how that is going. Do physicians now and 
labs know that--because there were many, many people who were 
being treated for diabetes who did not have the disease because 
they had the sickle cell trait, and they were never tested for 
the sickle cell trait. And so it was a real problem throughout 
many communities. And so I am wondering if you could give us an 
update on that, if we know what has happened. Are labs and 
physicians fully aware now that they need to be very careful in 
administering that test?
    Dr. Collins. So, Congresswoman Lee, you were right to raise 
this. This is an important issue because it was leading to 
confusion and misdiagnosis. And there has been attention paid 
to this by the National Institute of Diabetes, Digestive, and 
Kidney Diseases with Dr. Griff Rodgers as the director of that 
effort. And there has been, although I do not have the details 
on the tip of my tongue, a recent workshop looking at this 
trying to figure out how best to distribute the information 
that you refer to.
    All of this I think is being assisted--and it is an 
important thing to bring up at this hearing--by a much closer 
relationship across the Department in terms of sickle cell 
disease and other things that need to be looked at more 
closely. The CDC is now engaged in a surveillance effort so 
that we have much better record availability in terms of sickle 
cell disease across many States, which has been something we 
have not previously had access to, and Tom and his team have 
taken that on.
    Susan Shurin, who is the former acting director and now 
deputy director of NHLBI, has made it a personal priority to 
bring together various parts of HHS in the sickle cell agenda.
    We have two new, very exciting approaches therapeutically 
to sickle cell disease, one of which has already gone into 
phase I trials at our clinical center, the sort of first really 
new ideas about drugs since hydroxyurea, which has been almost 
20 years.
    So there is an increased focus on this first molecular 
disease, this disease that very much deserves attention and 
advances all across the board, from basic science to clinical 
issues such as the one you raised. I could give you a more 
thorough report on that for the record.
    [The information follows:]

    [GRAPHIC] [TIFF OMITTED] T6214A.034
    
    Ms. Lee. I would appreciate that because I hope this 
committee realizes the importance of this and the seriousness 
of this because there are many people who are being treated and 
mistreated because they were not properly diagnosed. And I 
think it is a really important issue that I am going to stay on 
until no one is being mistreated.
    Dr. Collins. You have been very effective in drawing 
attention to that. Thank you.
    Ms. Lee. Thank you.

             IMPACT OF SEQUESTRATION ON MEDICARE & MEDICAID

    And finally, if I have a couple more minutes, you probably 
will not have to answer this on the record, Dr. Conway. The 
budget cuts, as it relates to the sequestration, the impact on 
administering Medicare and Medicaid services because of the 
fact that these payments are going to be cut to doctors and 
hospitals and health plans and providers who provide services 
to Medicaid and Medicare patients--what is going to happen to 
the patients and the doctors?
    Dr. Conway. So as the agency has said publicly, on April 
1st there will be a 2 percent cut to all doctors, hospitals, as 
well as health plans in terms of the sequestration cut. So as 
you alluded to, that is a major cut in terms of payments. 
Administratively we also will need to look at our operations 
and prioritize work to try to deal with the cuts as best as 
possible.
    Mr. Kingston. Mr. Honda.
    Mr. Honda. Thank you, Mr. Chair.

                           HEPATITIS B AND C

    My question will be around hep B and C. It is directed to 
Dr. Frieden. We have seen hep B and C rise to alarming levels 
to a point where the new prevalence rates for hep C now 
overshadow those of other major diseases. This is not a problem 
that is going to go away. And yet, we find that we continue to 
fund CDC's division on viral hepatitis at a very meager level. 
So in an ideal world, what is an appropriate funding level that 
the CDC should have, and then what kind of sacrifices have you 
had to make due to the insufficient funding put towards 
combating hepatitis B and C?
    Dr. Frieden. As you point out, Congressman, hepatitis B and 
C are a major problem. And we do have new treatments available 
through work that NIH and others have funded which are 
effective at achieving long-term viral suppression, essentially 
a cure.
    Last year, CDC published guidance on encouraging doctors to 
test everyone born in a certain cohort, I believe 1945 to 1965, 
at least once for hepatitis C and to get people into treatment 
because we know that many people who are infected are not aware 
that they are infected and therefore cannot get the treatment 
that they would benefit from. And we work closely with CMS, 
with AHRQ, with HRSA to increase access to testing.
    In terms of the exact funding level of the program, I would 
have to get back to you. But as with every program, it would 
face roughly a 5 percent budget cut. It is funded at a very low 
level currently relevant to other programs. Our major effort 
here, in addition to trying to come up with better ways to 
diagnosis the acuteness of hepatitis C infection, is to scale 
up the treatment throughout the country by supporting State and 
local governments and health providers to do that.
    Mr. Honda. In the area of public and private funding, that 
cooperation, what kinds of partnerships have you been able to 
leverage and what kind of leverage has been realized through 
this relationship?
    Dr. Frieden. We have had an excellent relationship with 
many of the professional societies and nongovernmental 
organizations that have been advocating for better prevention 
and treatment of people living with hepatitis B and hepatitis 
C. We have also worked closely with many of the providers in 
thinking about how to scale things up and with State and local 
governments in terms of how to affect the practice of care in 
their communities and identify parts of their community that 
may be at highest risk and ensure that they get the services 
they need.
    Mr. Honda. What kind of attention is being focused towards 
screening of hep B and C in the public? Is that a question for 
yourself?
    Dr. Frieden. We have released a public education campaign 
called No More Hepatitis, encouraging people to know more about 
their status. We have reached out to health care--
    Mr. Honda. Oh, know, k-n-o-w. Okay.
    Dr. Frieden. And also no. [Laughter.]
    Dr. Frieden. And so this is one of the efforts that we have 
had. We also find that working closely with health care 
providers, people are seeing a doctor. So through electronic 
health records, through CMS, HRSA, and others, we are looking 
at how to ensure that people get the test, and then if they are 
positive, follow up in care. And we are seeing many gaps in 
that cascade. We are working with different groups to try to 
close them.

                    FUTURE IMPACTS OF SEQUESTRATION

    Mr. Honda. Through the chair, if I may ask, the members 
here, the panelists, we are looking at sequestration. We are 
looking at cutbacks. You said 2 percent in your arena. If we 
look at the cutbacks and we get a funding level that has been 
cut, is there a way you could project what it is that we are 
going to suffer in the future? What are the future impacts on 
our society? What is the cost of that? If you can come up with 
something like that, I would like to be able to share that so 
that we can let people know how short-sighted some of our 
actions are right in this country. And so if that information 
can be shared, I would be very appreciative of it.
    Mr. Kingston. Mr. Alexander.
    Mr. Alexander. Mr. Chairman, if you will, just three short 
questions to read into the record, if you would allow me.

                           FOOD-BORNE ILLNESS

    The CDC has a key role in investigating food-borne illness 
and helping identify suspect foods. The outbreak of listeria in 
cantaloupes was the example. How can you assure us that we are 
able to detect such outbreaks quickly?

                  CDC FUNDING AT STATE AND LOCAL LEVEL

    And why is CDC's funding so focused on supporting public 
health agencies at the State and local level?

                           CDC'S UNIQUE ROLE

    And number three, in an era of reductions, we cannot afford 
to have agencies tripping over themselves. What makes CDC 
unique and deserving of our support?
    Thank you, sir.

                           FOOD-BORNE ILLNESS

    Dr. Frieden. Thank you very much. CDC's role in terms of 
food-borne infections is to identify outbreaks when they occur 
and then work with State and local governments to stop them.
    We coordinate very closely with both the Food and Drug 
Administration and the USDA. Our top scientists meet weekly. 
There are 30 to 40 clusters of infections that we are 
investigating at any one time, and with that interagency 
coordination, we are able to prioritize those and take rapid 
action.

                  CDC FUNDING AT STATE AND LOCAL LEVEL

    It is State and local governments that monitor whether 
infections are spreading. They track the laboratory results. We 
coordinate a network called PulseNet. PulseNet takes the 
infections that occur and subjects them to a DNA test to see if 
they are related. It is an old technology, and actually we need 
to replace it in the coming years with something that works 
even better based on whole genome sequencing. That is going to 
take a while, but that will allow us to find outbreaks sooner 
and stop them quicker.

                           CDC'S UNIQUE ROLE

    But CDC's role is fundamentally to identify and stop 
outbreaks. We handle the illness part of it. FDA and USDA 
handle the food part of it. And often it is our investigations 
that will identify a new way that food became contaminated so 
that the manufacturers can reduce the risk. And we emphasize 
the entire food chain from farm to table. At every step, there 
are responsibilities and things that can be done to make our 
food safer.
    Mr. Kingston. Thank you, Mr. Alexander.
    And that is the end of the second round, and what we are 
going to do is ask members to submit the rest of their 
questions for the record. There will be a lot of questions like 
that.
    Mr. Kingston. I do want to say this and I think Ms. DeLauro 
is just going to make a statement or two right now.

                                NIH LOGO

    About every other campaign, somebody comes to me and says 
you have to change your logo because you have had it the same. 
And I always say, you know, I understand there is always 
somebody new who wants to tell you why something that is tried 
and true does not work. And I have said, you know, if you guys 
want to change the logo, fine, but I am not paying for it 
because this logo was designed by my wife and good friend on my 
kitchen table.
    But I heard you guys are looking at a new logo. And so my 
question is to you for the record, you know, whose idea is 
that? Why is it necessary? Is this a good time for it? And how 
much are we talking about? And I see you are prepared to answer 
this question. [Laughter.]
    All new logos take a while to get used to.
    Dr. Collins. This is one old, ugly logo. So this is 
basically what we have had for the NIH logo for the last 34 
years.
    When I came to the NIH----
    Mr. Kingston. Well, let me do this in fairness and 
consistency. Could I get that for the record?
    Dr. Collins. Sure. If I could just say, the point of this 
was actually to save money. We have proliferation of way too 
many logos. We are going to focus on just one.
    [The information follows:]

    [GRAPHIC] [TIFF OMITTED] T6214A.035
    
    [GRAPHIC] [TIFF OMITTED] T6214A.036
    
    Mr. Kingston. Okay. And I do want you to know--well, let me 
yield to my friend, Ms. DeLauro, and then I will conclude.
    Ms. DeLauro. I do not have any closing statements, but I 
want to very quickly get three answers.

           NATIONAL CENTER FOR ADVANCING TRANSLATED SCIENCES

    Dr. Collins, we gave you money for NCATS. What has been 
accomplished? There was a question about duplication there. How 
are we preventing that?

                 MATERNAL AND CHILD HEALTH BLOCK GRANT

    Dr. Wakefield, return on child health block grant. It has 
been cut back in appropriations. What is its role? What kind of 
efforts does it deal with in terms of prenatal care and infant 
health?

                           FOOD-BORNE ILLNESS

    And Dr. Frieden, just to piggyback on Mr. Alexander's 
comment on food-borne illness, how do we modernize your 
capability to implement the Food and Safety Modernization Act? 
What is your concern about sequestration and food safety?
    Mr. Kingston. Those are for the record?
    Ms. DeLauro. No. Quick answers.

          NATIONAL CENTER FOR ADVANCING TRANSLATIONAL SCIENCES

    Dr. Collins. So NCATS, the National Center for Advancing 
Translational Sciences, has been I think in its course of its 
just 1 year and 3 months actually embraced by virtually all the 
sectors that are touched upon, academics, universities, and 
industry.
    I would like to maybe send for the record an editorial 
written by Bernie Munos who is sort of seen as a really 
authoritative view about the intersection between public and 
private who has ringingly endorsed the way in which NCATS has 
provided an opportunity to tackle bottlenecks in the pipeline 
that were otherwise not being attended to for the benefit of 
industry as well as academia. This is turning out to be a 
really wonderful enterprise.

                 MATERNAL AND CHILD HEALTH BLOCK GRANT

    Ms. Wakefield. So in terms of the Maternal and Child Health 
Block Grant, a couple of comments I think could be made. First 
of all, the money that we receive is distributed based on a 
formula using the number of children that are in poverty in a 
State compared to national poverty rates. It is a matching 
program, so it is really important in that respect too. So the 
States match. We match 4 Federal dollars for every $3 that are 
invested by the States. The resources of that program go to 
care for Nation quality improvement, State infrastructure, 
special attention to children with special needs, for example.
    In terms of infant mortality, it is an extremely important 
investment to help drive down rates of infant mortality, and we 
have actually been fairly successful on that front over the 
last few years. But we have very large disparities between 
African American infants and white children, and that is an 
area where we need to continue to do our work.

                           FOOD-BORNE ILLNESS

    Dr. Frieden. And we do need to modernize our laboratory 
testing so that we can go to methods that are quicker and more 
sensitive for detecting outbreaks.
    I would also like to mention that as we understand how our 
health departments work to collect money from insurers, we are 
realizing it is much harder than we had anticipated. And that 
is one of the things that we are dealing with with many of our 
programs, including the immunization program, and the reason 
why we are less optimistic now about the ability to modulate 
the impact of cuts than we were a year ago.
    Ms. DeLauro. Can you let me know just what sequestration 
would do to the food safety area?
    Dr. Frieden. It would reduce our funding by about 5 percent 
which would limit our ability to develop new tools as well as 
better use the existing tools that we have now to find and stop 
outbreaks.
    Ms. DeLauro. And PulseNet will not be able to be upgraded.
    Dr. Frieden. We will do everything we can to manage through 
it.
    Ms. DeLauro. Thank you.

                    COMMUNITY TRANSFORMATION GRANTS

    Mr. Kingston. You know, there is $226,000,000 in these 
pseudo-science community transformation grants that we could 
probably get you. I am just thinking that that is going to be a 
source of discussion.
    I want to say this, Dr. Collins. While you and I have 
talked about that Tea Party tobacco study privately, I did not 
know that other committee members were monitoring it as well. 
And I think that is where we can find some common ground as we 
grapple with this issues, is just the straight allocation of 
resources to what makes sense and what does not.
    And I do, Dr. Frieden, have a lot of questions on BARDA. We 
had a bill on the floor yesterday. It is very important to all 
of us in terms of stockpiling and chemical, biological attacks 
and everything else that are of national security. I am going 
to submit those to you for the record.
    Mr. Kingston. So there is so much here and I know that Rosa 
and I could probably sit here till 5 o'clock, but at some point 
we may need to vote and eat. [Laughter.]
    But with that, this hearing is adjourned. We meet again 
tomorrow at 10 o'clock.
    [The following questions were submitted for the record.]

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                                          Thursday, March 14, 2013.

ADDRESSING SOCIAL SECURITY ADMINISTRATION'S MANAGEMENT CHALLENGES IN A 
                    FISCALLY CONSTRAINED ENVIRONMENT

                                WITNESS

CAROLYN COLVIN, ACTING COMMISSIONER, SOCIAL SECURITY ADMINISTRATION
    Mr. Kingston. Well, welcome. This is actually the way Ms. 
DeLauro and I like it. [Laughter.]
    We get to ask all the questions.
    It is great to have you here. I welcome Commissioner Colvin 
here. I know you will be managing the Social Security 
Administration I guess until further notice, and we are 
delighted to be working with you.
    A couple things that we are concerned about is 2 years ago 
we directed the Social Security Administration in the fiscal 
year 2012 omnibus develop, with assistance of the National 
Academy of Public Administration, a strategic plan to direct 
how the agency's service delivery approach should evolve in 
response to a number of pressures. Like any other multi-billion 
dollar operation, a large service delivery organization needs 
to understand where it is headed and how it plans to tackle the 
well-known and unknown challenges ahead. It is, therefore, 
extremely difficult for me to understand why the Social 
Security Administration has refused to follow the direction of 
Congress and develop a truly long-range strategic plan in 
consultation with the well-respected NAPA.
    Social Security needs to long-term plan more than ever. A 
large number of employees are retiring. We actually had some 
incredible testimony yesterday from some of the folks involved 
in the aging advocacy forum, and something like--I cannot 
remember the number--10,000 people a day will start retiring 
and that by 2050, 19,000,000 of the population will be over 65 
years old. And it is just staggering when we look at the 
graying of America, although I know I think people prefer the 
word ``silvering'' of America. ``The silver tide,'' or what is 
the name for it?
    So I understand the needs and the pressures on funding, but 
what we really do not have as clearly as I think the committee 
would like is a vision in terms of where the agency is going 
and how it is going to deal with this. And we all know Social 
Security is extremely difficult to reform, otherwise we would 
have done it. It is enormously popular. It is a universal 
program, and making changes--there is always a constituency 
group that says too far, too fast, not me, not in that 
direction. But the reality is we do need to have a thoughtful 
focus on where Social Security is going to be in 10 years, 15, 
20, 30 years.
    So I am looking forward to this hearing.
    And with that, I will yield to Ms. DeLauro.
    Ms. DeLauro. Thanks very much, Mr. Chairman.
    I want to say thank you to our witness for joining us and 
thank you for everything that you are doing at the Social 
Security Administration.
    Social Security is the ultimate legislative expression of 
the shared values of this Nation. For over 75 years, it has 
tied generation to generation. It ensures that seniors have a 
secure retirement after decades of service to their community. 
And it provides a safety net for those who can no longer work 
due to an accident or to disability.
    As soon as the first Social Security check was issued, 
poverty amongst the elderly began to drop. There were 30 
percent of elderly Americans in the 1950's who were in poverty. 
Today it is about 10 percent. Two out of three seniors today 
rely on Social Security as the prime source of monthly income, 
including three-quarters of all elderly women. Women live 
longer than men. Sorry, Jack. That is a fact of life. We live 
longer.
    Mr. Kingston. If you would yield to me. If you want to live 
longer in a world without men, that is your business. That will 
be your loss. It will not be as fun or as confusing. 
[Laughter.]
    We have had this technical mike problem. It is because of 
sequestration, let the record show. [Laughter.]
    Ms. DeLauro. Without doubt.
    Speaking of sequestration, the decision to let that go 
through in my view puts the basic functions of Social Security 
at risk. These are cuts that come at a time when agencies have 
been dealing with funding that has not kept up with inflation 
or demand over the years. In the case of Social Security, 
funding over the past 2 fiscal years for routine operations has 
been essentially flat. In each of these years, the funding 
level provided was below the President's request by 
$924,000,000, or about 8 percent. The cuts have an impact on 
our ability to serve seniors, to ensure that they get the 
proper benefits they have earned. Efforts to prevent waste, 
fraud, and abuse to ensure that benefits only go to eligible 
individuals have not been fully funded. The Budget Control Act 
permits additional funding to be provided above the spending 
caps for continuing disability reviews and SSI 
redeterminations. If we had fully funded this in 2012, it would 
have provided an additional $140,000,000 for program integrity.
    The 2013 House subcommittee provided none of the funding, 
cut this work by about $483,000,000, and while the claims are 
that we want to save money by cutting out program waste and 
inefficiencies, rhetoric is not matched by action. Rather, it 
suggests that people would prefer to see Social Security falter 
in its basic responsibilities to America.
    We need to be clear. The only thing SSA uses its funding 
for is to get Social Security benefits to the seniors and 
others who deserve them in a timely fashion. We are talking 
about retirees that have worked their entire lives for 
retirement benefits, individuals with disabilities, and seniors 
who live in poverty. Right now, people are waiting desperately 
for resources they deserve, earned, or they need to get by. 
With these deep cuts, fewer applications will be processed, 
backlogs will grow, more erroneous payments will be made, and 
people will have to wait even longer in offices to have their 
phone calls answered. The Social Security Administration is 
already understaffed, and these cuts will only make things 
worse.
    Due to limited resources, the Social Security 
Administration has already taken measures such as curbing 
hiring and closing offices.
    Meanwhile, a record number of individuals filed retirement 
claims in 2012, and while the Social Security agency should be 
applauded for completing 820,000 disability appeals this last 
year, the backlog grew by 29,000. It still grew by 29,000. 
Despite the recent progress, the average wait for a disability 
appeals hearing is nearly 1 year.
    I also understand that the agency has taken advantage of 
technology to curb and cushion some of the effects of these 
deep cuts. We want to hear about those efforts. In fact, 
though, technology can only go so far since much of the work is 
lengthy, it is complicated, and it requires individual 
attention, the kind of work that demands a trained, 
knowledgeable employee, a real person, if you will, working 
with the beneficiary to assist him.
    So a combination of more work, fewer staff has really 
stretched the agency, and unfortunately, the future looks 
bleak. In less than 10 years, the cuts made through existing 
BCA caps will take non-defense discretionary spending to the 
lowest level on record as a share of GDP.
    Some people are demanding further reductions in caps, which 
would mean that the shortfalls will just get worse. My view is 
that we simply cannot do that and properly provide our seniors 
and others with the benefits they deserve.
    Let me just say a quick thank you to you for what you are 
working to do to make the SSA more modern, efficient, the use 
of technology to become more advanced to ensure that people get 
the benefits that they have earned. I welcome you today and 
hope that you can help the subcommittee to understand the 
impact of these budget policies on our seniors and families. 
Thank you so much for being here.
    Ms. Colvin. Chairman Kingston, Ranking Member DeLauro, I 
want to thank you for inviting me to discuss our service 
delivery challenges and what we must do to successfully manage 
them.
    I am Social Security's Acting Commissioner.
    At Social Security, we are responsible for administering 
some of the Nation's largest and most successful programs. We 
also administer programs providing an economic lifeline for the 
most vulnerable among us. Last year, we paid over 
$800,000,000,000 to almost 65,000,000 beneficiaries. We take 
great pride in helping the American people by providing some 
peace of mind during important transitions in their lives. 
These transitions may include retirement, surviving the loss of 
a family member, or coping with severe disabilities. While the 
faces and circumstances of our customers vary, our commitment 
to serve them never changes.
    Over the years, Congress has asked us to take on more 
responsibilities and challenges. Time and again, we have 
succeeded when given adequate, predictable funding. Most 
recently when Congress asked us to reduce the time it takes for 
an individual to get a hearing decision and gave us the funding 
to meet that objective, we delivered. In addition, when 
Congress gave us funding to ramp up program integrity, we 
dedicated those resources to tools that deliver an excellent 
rate of return for the American taxpayer. In fact, recent 
estimates suggest that continuing disability reviews save $9 
for every dollar invested, and Supplemental Security Income 
(SSI) redeterminations save about $6 for every dollar invested.
    But in this difficult fiscal climate, our ability to serve 
the public has suffered. Over the past 2 years, we have 
operated at funding levels nearly $1,000,000,000 below the 
President's budget. Sequestration further threatens our ability 
to serve the public. At this time, we cannot adequately invest 
in the information technology that would help us reach more of 
our customers. Further, we have lost many of our Federal and 
State employees through attrition.
    To get by, we have consolidated 41 field offices and closed 
490 contact stations. We have also abandoned plans to open new 
hearing offices and a new teleservice center. The result is 
deteriorating service nationwide. Wait times are going up in 
our field offices and hearing offices, and those who call our 
800 number have to wait longer.
    Predictably, the American people are frustrated. Longer 
waits can lead to dangerous behavior. More and more we receive 
reports of receive frustrated customers threatening and 
assaulting our employees and other members of the public. Just 
last month, in Representative Simpson's district, a visitor to 
the Boise office told one of our employees, ``If I get denied, 
I am pretty sure I am going to lose it and hurt people or even 
shoot someone.'' In Casa Grande, Arizona, someone even set off 
an explosive device in one of our offices.
    Still, we focus on what we have always focused on, 
conscientiously and compassionately serving our customers. They 
are, after all, to us people, not numbers. They are a 
grandmother seeking a replacement Medicare card, a worker of 30 
years applying for hard-earned retirement benefits, and a 
wounded warrior in need of disability benefits because of 
severe Posttraumatic Stress Disorder. We will never lose sight 
of our customers. We remain committed to serving them with 
care, diligence, and skill.
    However, without sufficient, predictable funding, we can 
only do so much. In this day and age, Americans increasingly 
want to do more business with us online, and doing more 
business online makes sense for the taxpayer. Our online 
services are the highest rated in the public and private 
sectors, but with limited funding, we cannot do much more than 
maintain the information technology that we have.
    Moreover, without sufficient, predictable funding, we 
cannot invest in our best asset, the employees of Social 
Security. If we do not have enough staff to keep up with the 
work, the public can expect to wait longer in our offices, on 
the phone, and for disability decisions. The quality of 
decisions will also suffer without resources to invest in 
training.
    Of course, we recognize that fiscal belt-tightening means 
making tough choices. We may need to further reduce office 
hours, close offices, defer workloads, and take other cost-
saving measures that will sadly delay services to the public 
even more. We will do what we can to manage these cuts fairly.
    However, if Congress makes a greater investment in our 
agency and the millions of people we serve, we will do what we 
have always done. We will deliver. We will invest in 
information technology and in our employees. We will continue 
to streamline our business processes and our rules. We will 
maintain Social Security as one of the most efficient and 
effective agencies in the Federal Government, one with an 
administrative overhead that is a mere 1.5 percent of all the 
payments that it makes.
    Thank you for the opportunity to appear before you today. I 
will be happy to answer any questions you have. 

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    Mr. Kingston. Thank you very much, Ms. Colvin.
    I wanted to get something clear in my mind. You have 
something like $100,000,000 to $200,000,000 in IT carryover 
funds that are accessible to you. Correct?
    Ms. Colvin. Yes, we do have carryover funds available.
    Mr. Kingston. But I think you just said--and I actually was 
having trouble finding--because I think your testimony was not 
quite tracking the complete written testimony. But I think you 
said something like without sufficient funds to implement some 
of the high-tech----
    Ms. Colvin. Yes.
    Mr. Kingston. But you have $100,000,000 to $200,000,000 
sitting there.
    Ms. Colvin. Well, that certainly is nowhere near the 
dollars that we need to be able to do both maintenance of our 
systems, as well as additional online services and improvements 
in applications.
    Mr. Kingston. How much will that take?
    Ms. Colvin. I would have to get back to you with a specific 
number. But right now at the sequestration level, we----
    Mr. Kingston. Well, let me interrupt you a minute. 
Shouldn't you know how much you need? And the reason why I 
asked is----
    Ms. Colvin. I have it. I do not have it right here.
    Mr. Kingston. But somebody here would know. Right?
    Ms. Colvin. I do not think so. It depends upon what we are 
going to do. When we get an allocation, we lay out what our 
plan for the year is going to be, what new applications we 
expect to do, what modernization, what our maintenance costs 
will be. So we always submit a budget that indicates the amount 
that we are going to--I mean, if we were to submit to you 
everything that we would like to do, the funding would be just 
not possible. So what we do is try to, each year, look at what 
we think is reasonable and make a request. So if you want to 
know what we submitted in our 2013 request, I can provide you 
with that figure.
    Mr. Kingston. That would be helpful to me.
    [The information follows:]

    The fiscal year (FY) 2013 President's Budget assumed $857 
million for our Information Technology Systems budget.

    Mr. Kingston. And it gets back to my opening statement on 
the centralized plan.
    Ms. Colvin. Let me speak to that, if you would like.
    Mr. Kingston. Please.
    Ms. Colvin. We were advised by our attorneys, when we 
received our appropriation, that we could not do a single 
source contract, that it would be in violation of the 
procurement law.
    So based on that, what we did was develop a service 
delivery plan with in-house staff. We consulted with the staff 
of this committee to get their input. We have used that input 
and the input of various other stakeholders--the advisory 
board, and advocacy groups, et cetera--and we have developed a 
draft plan. It is still in the works, but it will be posted on 
the Federal Register hopefully this week and it will ask for 
comments. We expect that the staff will probably offer further 
comments, and then we would expect to finalize it.
    Certainly strategic planning is something that we need to 
focus on more in the agency. That is certainly something that I 
am very much interested in as the Acting Commissioner. So this 
plan was developed under Commissioner Astrue. I expect, once 
that is submitted, that I will begin a further planning process 
in the agency during the interim that I am there.
    Mr. Kingston. And are you dealing with the National Academy 
of Public Administration?
    Ms. Colvin. No, we are not. As I indicated, our attorneys 
said we could not do sole source, that there were many other 
organizations out there that had the capacity to do this. And 
so unless I get a different legal opinion, I do not think that 
I would feel comfortable doing anything differently.
    Mr. Kingston. I need a clarification. Maybe staff can help 
me on it on your side of the table or mine.
    But if it was stipulated in the fiscal year 2012 law to 
work with them, why would that be a violation of the law?
    Ms. Colvin. I have been informed that the Competition and 
Contracting Act of 1984 requires us to obtain full and open 
competition through the use of competitive procedures when we 
contract for goods and services. And we do not believe that the 
language expressly authorized us to do that.
    Now, this is very technical. I would be very happy----
    Mr. Kingston. No, no.
    Ms. Colvin [continuing]. To provide you a more complete 
response for the record, if you would like.
    But I know we have had a lot of discussions with the 
committee staff, and I think the conclusion was that the 
language was not sufficient to allow us to do a sole source 
competition--I mean, non-competition contract.
    Mr. Kingston. All right.
    Ms. Colvin. Would you like something further?
    Mr. Kingston. Yes. I think that would be helpful.
    Ms. Colvin. All right. We will do that.
    [The information follows:] 

    [GRAPHIC] [TIFF OMITTED] T6214A.240
    
     [GRAPHIC] [TIFF OMITTED] T6214A.241
    
    Mr. Kingston. And I will yield to Ms. DeLauro.
    Ms. DeLauro. You have mentioned some of these facts, if you 
will, in your testimony.
    But Commissioner, let me ask you about the number of closed 
field offices. The closures, as I understand it, will respond 
to the pressure of dealing with flat funding you pointed out, 
which has been eroded by inflation. Again, now we see 
sequestration, new cuts, stagnant funding levels. Just in a 
couple of areas, tell us a little bit more about what you have 
already done in terms of office closures. Is closing additional 
offices something that the Social Security Administration is 
looking at to achieve the cuts required by sequestration? Let 
me start there.
    And I do not know. I think we ought to make a list 
available probably to all Members about the Social Security 
offices that have been closed in their communities and what is 
pending as it regards this effort. I think they ought to have 
that information.
    So tell me about the office closures. I want to also ask 
you about recent staffing trends, and will you have to 
terminate any employees or implement furloughs under 
sequestration? But let's start with the office closures.
    Ms. Colvin. Thank you, Ms. DeLauro.
    I would like to first say that we have had to make some 
really tough and undesirable decisions over the last 2 years. 
In 1989, we received the President's budget. For 2010 and 2011, 
we received $1,000,000,000 less. And so that meant we had to 
make some very difficult decisions.
    One of those was that because we had such high attrition, 
many of our offices were viable because we did not have 
sufficient staff to be able to staff them. And in those areas 
where we had offices that were nearby, we consolidated offices 
and moved those staffs together. And we did work with the 
community. We did notify individual members whose districts 
would be impacted. We have closed 41 since then. We closed 490 
contact stations.
    Ms. DeLauro. What is a contact station?
    Ms. Colvin. That is where we would have one individual who 
staffed that facility and would go there maybe 1 day a week or 
2 days a week or on a schedule so that people would know when 
someone would be there and they could, in fact, go there.
    With the use of videoconferencing and some of the Internet 
usage, we felt that we could no longer keep contact stations 
open. It did not make good business sense.
    We have closed 490. We probably have another 40 or so that 
we expect to close, and there will probably be a small number 
that will remain open. We can give you the specifics on that, 
if you would like.
    This was not something that we did lightly, but we have 
continued to try to serve our customers in those areas. We 
realize that everyone is not going to use the Internet. They 
are not going to have access to it. They are not going to feel 
comfortable using it. So we are going to always have to have 
field offices. But we have lost significant numbers of staff 
over the last 2 years both at the State and local level. So we 
just cannot do that.
    In the testimony, you should have pictures of long lines at 
some of our offices. People wait from 30 minutes to 2 hours. 
That is not the type of service that we are proud of, nor is it 
the type of service that someone who has paid for an earned 
benefit deserves. But we do not have the ability to do anything 
differently.
    Ms. DeLauro. Will you have to close additional offices, 
additional contact stations, if the sequester continues?
    Ms. Colvin. We may. That is an option. My absolute last 
alternative is to furlough staff because we have lost so many 
already. We have to have staff to do the work. We also expect 
another 3,000-plus persons who will attrit out of the system 
this year, and we had hoped to be able to fill some of those 
critical positions. But we are not certain yet what we will be 
able to do there. So, yes, there is a possibility that we may 
have to close offices.
    As you know, we have also reduced our office hours that we 
serve the public. We have reduced it by a full hour, Monday, 
Tuesday, Thursdays, and Fridays, and a half day on Wednesdays 
because we do not have overtime. And staff have to have time to 
adjudicate the cases. Even though we do work online, it still 
requires a human being to review the application, make sure it 
is accurate, and then to adjudicate the case. And we have other 
post-entitlement work.
    But more importantly, we have program integrity work that 
we have to do. If we do not do that, we keep people on the 
rolls who should not be there.
    Ms. DeLauro. My time has run out. But I am going to ask you 
later about some of the limitations of technology in terms of a 
personal commitment.
    Thank you, Mr. Chairman.
    Mr. Kingston. Mr. Joyce.
    Mr. Joyce. Good morning, Commissioner Colvin.
    Ms. Colvin. Good morning, sir.
    Mr. Joyce. Thank you for your testimony here today.
    I was wondering if a disability claim is denied, someone 
has a right to appeal, and the appellate process can take more 
than a year. What, if anything, has your agency been doing to 
try to speed that process up?
    Ms. Colvin. Thank you for that question.
    Congress was very generous in funding us to reduce the 
hearings backlog, and as I say, we deliver when you fund us. 
And as a result, we started with a processing time in the 
hearing offices of over 500 days. I think it was 555. We were 
down to about 350, 357. I will give you the exact numbers in 
writing.
    [The information follows:]

    At the height of the backing in August 2008 our hearing 
offices had an average processing time of 532 days. We reduced 
the average processing time down to 340 days by October 2011.

    Ms. Colvin. And our goal was 270. But as a result now of 
the cuts, that number is going back up. But we made tremendous 
progress in reducing that number. As I said, it was over 500 
when we received the funding from you, and now it is down to 
less than a year. That is still too long, but I mean, we did do 
what we said we would do based on the funding that you made 
available to us.
    Mr. Joyce. Thank you.
    I yield back.
    Mr. Kingston. Ms. Lee.
    Ms. Lee. Thank you very much.
    Good morning. Good to see you.
    Ms. Colvin. Good morning.
    Ms. Lee. Let me first say thank you for being here and 
thank you for doing a tremendous job under very dire 
circumstances really.
    My mother actually is a retired Social Security employee. 
She worked for Social Security 20 years. She is 88 years old 
now.
    Ms. Colvin. And we certainly thank her for her services. 
The strength of our organization is our employees.
    Ms. Lee. Yes, I tell you. And I come from Oakland, 
California, and we have some wonderful employees and it is just 
a great operation. And I just hate to see and to hear all of 
the, I say, assaults that you are under and attacks.
    First, you have had to downgrade the service in terms of 
staff hours. You just laid out the day's hours. Now you have 
got on top of that sequestration.
    Let me ask you. What demographic is this going to hit the 
worst?
    And secondly, what is the morale like with your employees 
at this point? I mean, this seems like a heavy-duty burden that 
you all are carrying. And it really concerns me because the 
Social Security offices are the offices of last resort for so 
many people just to be able to live their daily lives. And now 
with the kinds of cuts and trauma that the agency is facing, 
you know, I am really worried about what is taking place.
    Ms. Colvin. Thank you, Congresswoman Lee.
    We are very concerned. We are an agency under stress. And 
as I mentioned before, the employees are heroic in their 
performance. Caseloads have increased. We cannot give them 
overtime. We have not given them training. There is no travel. 
And yet, they still serve in a compassionate and caring way. We 
serve those people who are most at risk. Congress recognized 
the need for a safety net, and we have the Social Security 
program.
    But we also provide other services. In addition to our core 
services, we provide the Medicare cards. We process those. We 
process Medicare Part D and because so many of the local and 
State benefits require verification of benefits, many, many of 
our customers come to get verification of benefits. So we 
really are a basic safety net service in the community.
    I would say that there is no one demographic that is 
impacted. All of the seniors of this country are impacted, all 
of the disabled, survivors. People who come to us come when 
there is some transition in their life, normally not a good 
transition.
    And we have tried to stem the tide. We have had great 
efficiencies with our IT investments. We continue to improve 
those. And by the way, our Internet applications are rated the 
best in Government and best in the private sector. But you 
still need a human being. You have to be able to review these 
applications to make sure they are accurate, and you also have 
to go back and contact people, and you have to adjudicate. So 
there is a tremendous need for staff. We are way down below 
where we were 2 years ago, and yet we are at a time when the 
baby boomers are aging out and people are reaching their 
disability-prone years. And so our workloads are going up 
tremendously.
    So we have proven time and time again that when you give us 
adequate, sustained, and predictable resources, we deliver. I 
remember back when I was here in the 1990's, 1994 to 2001. 
Congress gave us 7 years, multiple years, of funding for the 
CDRs. We did every CDR and had no backlog. We knew what we had 
to do. We knew what our timeframe was. We knew what our funding 
was going to be, and we delivered. You asked us to reduce the 
disability backlog. You gave us the funding. We delivered.
    So we are an agency that when you invest in us, you get 
your money's worth plus more. When you invest $1 in a CDR, you 
get $9 back. When you invest $1 in a redetermination, you get 
$6 back. And I do not think there is any Federal agency or 
private agency that has an overhead of 1.5 percent of its 
expenditures.
    Ms. Lee. But even when we do not invest where we should, 
you still deliver under dire circumstances.
    Ms. Colvin. Yes, but we cannot anymore. We cannot anymore. 
We are a ``can do'' agency, and it hurts an employee to have to 
close the door and people have to come back a second day.
    Ms.  Lee. So what is their morale like?
    Ms. Colvin. It is very low. It is very low. Fortunately, 
because they are committed to public service, they still try to 
do what they can do, but you see higher stresses as a result of 
more illness. We have an older workforce. We have major 
challenges.
    Mr. Kingston. Thank you. The gentlewoman's time has 
expired.
    You know, I have to say, though, while I understand and I 
am hearing you, you have 17 employees who are full-time union 
representatives, paid by the taxpayers to do nothing but union 
activities--17. And then you have 1,463 who do part-time union 
activities, paid for by the taxpayers. It is $14,000,000. It is 
such a disturbing thing to taxpayers.
    I am hearing you say, well, we cannot pay claims. But I 
would suspect--I am not sure, but I would suspect if you asked 
those people standing in line, Democrat, Republican, liberal, 
conservative, do you know that 17 employees at Social Security 
are full-time union and that it costs about $14,000,000 a year 
that you are paying for, do you feel good about that, or would 
they say why don't they do that on their own time. And you 
know, I know there is a statute on that, but I do not ever hear 
administrators like you saying, you know, I want you to know 
this is a problem.
    Now, that is nothing--nothing--compared to what the GAO 
said the overpayments were on SSI, $3,300,000,000. Let me 
repeat that to my friends. $3,300,000,000 in overpayments. How 
much of that money has been recovered? And that is a GAO report 
which you have seen.
    Ms. Colvin. And it is an accurate report.
    Let me, first of all, say that we take, first of all, 
preventing overpayments and then collecting them very 
seriously. In fact, as the deputy during the time that I was a 
deputy and certainly now as Acting Commissioner, I have been 
personally involved in improper payments. Our accuracy rate for 
improper payments in our title II program, which is less 
complex--you have the age, you have the quarters, you get a 
benefit--is 99.8 percent. You cannot get better than that. In 
SSI, it is 92.7 percent.
    So we have been making tremendous strides in our accuracy 
rate. The problem is just one-tenth of a percent can result in 
$50,000,000. So we are taking major steps to increase the 
accuracy rate.
    Mr. Kingston. It sounds a little bit like, well, you know, 
the reductions, if you look at those as percentages, those 
would be small too, and yet we have spent a lot of time this 
morning talking about those. But $3,300,000,000 is big money, 
and that is only 1 year, by the way, as you know.
    Ms. Colvin. Absolutely.
    Mr. Kingston. Only 1 year. So if it is 8 percent and 8 
percent is a small amount, that is still huge money, 
$3,300,000,000 in a 1-year period of time.
    Ms. Colvin. The SSI program is very complex--very complex. 
Some of our biggest challenges are individuals reporting their 
changes in assets and wages. We have instituted a program 
called--well, it is Access to Financial Institutions--where now 
we are able to work with the banks and go out and identify any 
assets that individuals have not reported. And that has been 
very effective. As our budget allows, I will continue to reduce 
the threshold so that we can do more and more of that. And we 
are removing individuals because they have, in fact, not 
reported all of their resources.
    We also have instituted a telephone wage reporting system 
where individuals can report their wages so that we can learn 
early because, as you know, we do not get the wage reports but 
once a year, although there has been a proposal in the 
President's budget to get it quarterly because the earlier we 
get it, the quicker we can check. So the agency is very 
aggressive, in preventing overpayments.
    We have the CDI units, which are our Cooperative Disability 
Units, where we work with our Office of Inspector General to 
identify any potential fraudulent cases so that we can prevent 
anything from happening before it happens. We focus on 
aggressively going after any dollars that are overpaid.
    I will say we also focus on under payments. We have 
individuals who should have been paid more, but because of the 
complexity of the program, we have not been able to do that. 
But that is a high priority.
    Mr. Kingston. How much of the $3,300,000,000 in 1 year 
overpayment for SSI has been recovered?
    Ms. Colvin. I can provide you that for the record, but you 
will see that our numbers have increased each year.
    [The information follows:]

    Below is our SSI overpayment collections for the last five 
fiscal years:
     FY 2008--$1,059,600,000
     FY 2009--$1,102,600,000
     FY 2010--$1,168,900,000
     FY 2011--$1,171,400,000
     FY 2012--$1,202,200,000.

    Mr. Kingston. Thank you. My time has expired.
    Ms. DeLauro. It is not the question I was going to ask, but 
I cannot stay out of this discussion because I just find it 
very interesting.
    Mr. Kingston. I had a feeling.
    Ms. DeLauro. Oh, yes. I just find it so, so interesting 
that my majority counterpart has--we are always eager to bring 
up waste, fraud, and abuse. Quite frankly, we are not 
interested when it comes to other areas of the budget like crop 
insurance or any other way, but that is a fact of life.
    However, when we come to funding the efforts that would 
allow for this redetermination or for the continuing disability 
reviews, the subcommittee has a very dismal record.
    Example. 2012, Budget Control Act explicitly provided an 
exemption in the caps for program integrity at SSA at 
$623,000,000. The enacted level was $140,000,000 less than was 
permitted.
    The 2013 House bill that barely made it to the 
subcommittee, provided no additional BCA-permitted funding. 
Zero. Zero for program integrity. $751,000,000 less than was 
permitted.
    According to the chief actuary at the SSA, the lack of 
funding in the House subcommittee bill would have cost 
approximately $5,000,000,000 to $6,000,000,000 over the long 
run. Each dollar spent, as the Commissioner has pointed out, 
for the program integrity saves between $6 and $9 on average.
    I would encourage my colleagues to provide the funding for 
program integrity so that in fact we can see what those 
redeterminations cough up or the reviews cough up so that we 
can save money and cut out whether it is an overpayment, 
whether it is an underpayment, or whatever it is. You cannot 
have it both ways. You cannot make a determination that you do 
not want to provide the money and then say, my God, you are 
losing money. And that has been the case over and over and over 
again. And if this subcommittee wants to do its job, it would 
provide this agency with that money for program integrity--it 
is what it is all about--instead of complaining about program 
waste.
    I just will mention this. I will bring it up in another 
context. And that is I hope my colleagues on the other side of 
the aisle will help us to uncover the 26 people who get at 
least $1,000,000 in a premium subsidy from crop insurance, and 
in fact, they have no asset test, no threshold levels in income 
or anything else. We cannot even find out who they are. Nobody 
will make it public. So I am going to enlist my colleagues when 
we are talking about this issue and trying to find those folks 
who are getting this money which we cannot account for.
    You do not have to comment on that. I have got about a 
minute or so left here.
    Mr. Kingston. Let the record show your microphone is 
working fine now. [Laughter.]
    Ms. DeLauro. Yes, indeedy. Yes, indeedy.
    I just want to ask you this question, and then I am going 
to have to dash to the Ag Committee, but I will come back.
    In terms of what you talked about, a skilled labor force at 
Social Security over the long term, how long does it take to 
train an employee? What are the limitations of the technology 
in terms of the complex nature of some of the cases that we are 
talking about here?
    Ms. Colvin. We have determined that it takes well over a 
year for a new claims examiner to be qualified to adjudicate a 
case. And we provide very intensive training. In addition, they 
are assigned to a mentor. These are very, very complex cases. 
The cases that are less complex have been automated. SSI is 
certainly our most difficult program to administer, and we do 
have a long-range plan to try to automate that also, but that 
is very complex. But you are talking about looking at all of 
the information that has been provided and then other medical 
information in adjudicating a case.
    As you know, the disability process starts at the State 
level with the disability examiners, and we are very concerned 
because we have not hired anyone in those positions over the 
last 2 years. And so as we are losing the more seasoned 
examiners. We know that even if we hire today, it is going to 
take us about a year to have a proficient staff person there.
    Mr. Kingston. Mr. Joyce.
    Mr. Joyce. Thank you, Chairman Kingston.
    Commissioner, I would like to follow up on something the 
chairman brought up with you, and maybe I missed it in your 
answer. But what is the threshold amount at which you start to 
look for overpayments?
    Ms. Colvin. What is the threshold amount?
    Mr. Joyce. Yes. You said there was a threshold, but I did 
not hear a number.
    Ms. Colvin. No, I do not recall saying there is a 
threshold. We go after any overpayment. We do not have a 
minimum number that we would look for. What we do is review a 
case to see if the information that we received is accurate, 
and then if it is not, it means that we have overpaid that 
individual. It could be a month's over-payment, 2 months 
overpayment. We would pursue that.
    Now, I do not know if you are referencing the fact that 
there could be a waiver under extenuating circumstances, but we 
generally pursue all overpayments.
    Mr. Joyce. Well, I am sorry. I just heard you say the word 
``threshold,'' but I did not hear the amount.
    Ms. Colvin. Are you talking about overpayments 
specifically?
    Mr. Joyce. Yes. That is what you are looking for is people 
that you have overpaid.
    Ms. Colvin. Yes. Well, we would pursue all of those.
    Mr. Joyce. And I also wanted to follow up. In an NPR 
testimony, former Commissioner Astrue mentioned that the 
program needs to adapt to the times. Do you agree?
    Ms. Colvin. I am not certain what his reference was when he 
said ``adapt to the times.'' Do you know what he was 
referencing?
    Mr. Joyce. Well, that the program is maybe running a 1980's 
program when we are in 2013. That is the way I took the 
comment. I was wondering if you had any ideas about that.
    Ms. Colvin. Well, if he was speaking of the disability 
program, we are always looking at medical advancements. We are 
looking at policy changes that need to occur. We are in the 
midst right now of updating our medical listings. In some 
instances, those medical listings had not been updated for 
many, many years. We now have updated, I believe, 10 of the 14, 
and we are on a cycle where we will update those every 3 years 
so that as medical advances occur, the listings would reflect 
those medical advances. I think you certainly have to 
constantly be attentive to the changes both in technology and 
in the medical community. And I know that is happening on an 
ongoing basis.
    I would suggest that the program is not the same as when it 
was originally implemented. Even Congress has made many changes 
over the years to try to keep up with the changes that they 
believed were necessary.
    Mr. Joyce. So you agree that something needs to be done 
then to continue working forward and make it this----
    Ms. Colvin. We have research that is going on internally 
and externally. So we are always looking for ways to improve 
the program to make it more appropriate and relevant to today's 
needs. I would say that is something that is ongoing. Yes.
    Mr. Joyce. And efficient?
    Ms. Colvin. I think it is efficient. I think that clearly 
there are always pros and cons. Sometimes Congress agrees and 
sometimes it does not. But you know, you all make the laws and 
we try to implement them at Social Security.
    Mr. Joyce. Thank you.
    I yield back my time.
    Mr. Kingston. Thank you, Mr. Joyce.
    Ms. Lee.
    Ms. Lee. Thank you.
    I wanted to go back to this whole issue of online activity. 
The digital divide is still very real in many parts of the 
country in many of our communities, and while we have to move 
toward technology--I understand that and you all are doing a 
really great job--I wanted to find out if you have certain 
online requirements. For instance, oftentimes employers will 
not accept a resume unless that resume is submitted online. 
Well, a lot of people in my district cannot submit resumes 
because they do not have a computer. They go to the library. 
There is a long wait. Then they have to leave and do other 
things. Do you have any requirements for online-specific 
response?
    And then the other issue is how are you addressing--given 
your cutbacks and given the stresses that your employees are 
dealing with now, how are you calibrating that so that people 
who do not have access to computers are still able to receive 
the services that they deserve?
    Ms. Colvin. Thank you, Ms. Lee.
    We recognize that we are going to always have customers who 
will not choose to work with us online. We are almost at 50 
percent of our claimants using online services. So that is 
about 50 percent who are not. And so we expect that some people 
will always want to call in by phone or walk into the office to 
have face-to-face services. We do not expect that we will ever 
have a system where we will not have that.
    What online services allow us to do is two things. One, it 
allows us to meet customer expectations because some customers 
really want to be served in the privacy of their home, and they 
do not want to come to the office. Two, because we get certain 
efficiencies with online services, it allows us to be more 
efficient, to be able to process cases faster, and to keep up 
with the increasing workloads. So there is always going to be a 
balance.
    But we do not require anyone to use online services. We 
make them aware of it. We encourage them to use it. And 
certainly as the populations get younger and younger, they 
will, in fact, want to use online services.
    Ms. Lee. Okay. Thank you very much. So there is no 
requirement for any service to be accessed online.
    Ms. Colvin. You are thinking of direct deposit, which is a 
Treasury requirement. We do not require that you do online 
services.
    Ms. Lee. Are you still mailing checks?
    Ms. Colvin. The Treasury Department requires that you have 
the direct deposit. There are a number of individuals who still 
have not signed up for direct deposit. Treasury has assured us 
that they will still get their paper check, but they are out of 
compliance. So they will still encourage them to move to direct 
deposit. They do have a waiver for individuals who do not want 
to do direct deposit, particularly those who are older, 90 and 
older.
    Ms. Lee. I know a lot of people who do not want direct 
deposit.
    Ms. Colvin. Right. But Treasury at this point has said that 
they will still get their paper checks. I do not know how long.
    Ms. Lee. They will get their----
    Ms. Colvin. Yes. Treasury has said that they will.
    Ms. Lee. Once Treasury says that is it, direct deposit, 
then we have to go to Treasury----
    Ms. Colvin. Yes.
    Ms. Lee. Because that is a big issue. That is a big issue.
    Ms. Colvin. It is. And we are working with Treasury. We are 
letting them know the issues that develop from our perspective. 
But it is a statute, and it is a Treasury requirement.
    Ms. Lee. Thank you.
    Mr. Kingston. Mr. Womack.
    Mr. Womack. Thank you, Mr. Chairman. Sorry I am late. I had 
a previous hearing that I was attending.
    If I go back over some material that has already been 
covered, I certainly apologize up front.
    I am going to confine my line of questions toward 
automation because this is an agency that I think has 
benefitted from and can continue to benefit from our capacity 
to utilize the automated technology that is out there and maybe 
that we have yet to see. So I am kind of asking at a 30,000-
foot level. Are we continuing to do the things necessary to 
ensure that we are maximizing our technological capability 
without sacrificing privacy and matters of privacy that can be 
compromised? And then I will follow up on that.
    Ms. Colvin. Thank you, Mr. Womack.
    We believe that technology is the one thing that has 
allowed us to consistently see a 4 percent production increase 
each year for the last 5 years. Certainly with the loss of 
staff that we have had and the increasing workloads, we would 
not have been able to keep up without automation.
    About 50 percent of our applications now for disability and 
retirement are filed online, and that number continues to go 
up. It is probably about 48 percent, but it continues to go up. 
And we are constantly bringing on new applications. People can 
file for retirement and disability online. With My Social 
Security now they can get their earnings statement online. They 
can do a change of address, direct deposit, and other things of 
that nature. And we are constantly developing additional 
applications.
    A great part of our workload is individuals coming into the 
offices for benefit verification because they need that to get 
local and State benefits, and we work with those local and 
State entities. We now have the ability to provide the benefit 
verification online. We have just started that. So now we need 
to make sure that the providers and local governments will, in 
fact, go online rather than send their individuals into the 
office.
    We have an IT plan relative to how we would roll out 
increased online services, but right now, we are operating 
within the agency, at what we call, it's ``lights on,'' minimum 
that is necessary to keep us running. We do not have an 
allocation in this existing budget to do new applications. I 
think the number that--we have about $850,000,000 in the IT 
budget now. We would need money above and beyond that amount to 
do additional applications.
    My desire is to try to at least keep the things that we 
have in place going. For instance, we are bringing up a major 
system, Disability Case Processing System, where instead of 
having 54 separate State Disability Determination Services 
(DDS) systems, we will have one system that is Federal. That 
will speed things up. It will make it consistent. That is going 
to cost money.
    Now, we have budgeted that each year. We would certainly 
expect that would be there each year because we developed a 
long-term plan. And that is what we do when we are looking at 
systems that we can bring up.
    But again, unless we have sustained and predictable 
funding, it is very difficult to plan because, you know, IT is 
not something you can do overnight. And so you have got to have 
some sense of what your budget is going to be from year to 
year. So it is difficult, but we certainly are trying to do the 
very thing that you have asked are we doing.
    Mr. Womack. This year my wife received a--and I am not real 
sure how she got this, whether it was the paper statement that 
came in the mail, the calculation that shows your Social 
Security. I cannot remember what you call that. We used to get 
those. But this year, all of a sudden, another name showed up--
I guess it was called an alias that she might have gone by--
showed up with a different income stream, and it was a very 
complicated thing. But it just appeared out of nowhere. And I 
am not asking for any help in deconflicting that because we 
have already taken steps to do that. There is a basis for my 
question.
    Now, there were some coincidental things about it. The name 
was the same. General location, geographic location of the 
State was the same, where they were from, and both of their 
parents--two different people--by the same name had a father 
that had an initial H and D. And so all of a sudden, boom, it 
gets plugged in as part of her earnings record. It benefitted 
the other person greatly, not so good for my wife.
    That said, how does that happen? And do we have enough 
defense in depth of our automated systems so that we are able 
to discern something that is about to go plugged in on 
somebody's earnings record that should not be there? And is 
there a way that those things can be flagged? Because her 
earnings record was pretty consistent for years and years and 
years and years and years, and then all of a sudden, something 
appears out of the blue. It threw us for a loop.
    And I know there are a lot of people out there that 
probably are caught up particularly with stolen identities and 
what have you. There are a lot of people caught up in this kind 
of a scenario, and it bothers me that they may not know what to 
do.
    Ms. Colvin. This scenario we are very concerned about. We 
know that people are always trying to hack into the systems. We 
certainly take security measures. We right now are reviewing 
our authentication process. As you know, My Social Security has 
not been up that long. We have had tremendous response, but we 
are looking at the authentication process to see if we need to 
make it more vigorous and more robust. So we are always looking 
at that.
    We work with our Office of Inspector General if they 
identify any cases that are the kinds of cases that you are 
talking about to do an analysis to determine what happened, how 
it happened, and how to prevent it from happening again.
    We realize that we have an awful lot of data Personally 
Identifiable Information (PII) and we do everything that we can 
to protect that data. To say we have never had a breach, I do 
not think I could say that. But I will tell you that protecting 
PII has the highest priority in the agency. We have reviews 
that are done by an outside auditor each year. We have inside 
reviews that are done by our own staff, and then we have the 
OIG reviews. But this is an area we focus on.
    Mr. Womack. Thank you very much.
    I yield back.
    Mr. Kingston. The gentleman's time has expired.
    I wanted to, number one, make sure that on this fraud 
thing, that we are taking it very, very seriously--a fraud or 
overpayment. You know, I am outraged about 26 people who I am 
not even sure what Ms. DeLauro meant on the crop insurance. But 
frankly, we should pursue them. The school lunch program has a 
16 percent error rate. The school breakfast program has a 26 
percent error rate. Lord knows the Pentagon procurement system 
is broken and needs lots of attention. I think the military can 
play the game as well as anybody when it comes to moving funds 
around and making things very confusing.
    But we as Democrats and Republicans and Independents are 
charged with the job that I do not think we are taking as 
seriously as we should be. There is a lot more common ground 
than we want to give ourselves credit for. If we cannot agree 
on overpayments and error rates and fraud, then this country 
has no hope, and if this country has no hope, the world has no 
hope. I just feel very strongly about it. When I go home and I 
talk about this, this is just unbelievable that we cannot 
sincerely have a shared outrage about this.
    You know, as a Republican conservative, certainly I 
understand these 14 union employees. None of them would 
probably vote Republican. We understand that this is a 
political deal. And it is a statute. You cannot do anything 
about it and I cannot get anything about it but get frustrated. 
$14,000,000 for union activities on the taxpayer dime. But you 
know, maybe we cannot change that immediately for partisan 
reasons.
    But why can we not really go after the overpayment with a 
great zeal and just a great fervor? I mean, why can we just not 
say--you know the old expression, partisanship ends at the 
water's edge. The President is about to go to Israel. He met 
with us yesterday. I am glad he is going. But why can 
partisanship not end when it comes to over payment and fraud 
and abuse and inefficiencies? And to me, it seems like there 
should be a culture.
    I will ask you this, and I know I am lecturing. I do not 
mean to lecture, but I am getting it off my chest, which I hope 
we all feel some common ground with.
    SSI claims, according to your testimony, have gone up 38 
percent since 2007. Do you really believe in your heart of 
hearts that that many people have become disabled? Or is it, as 
folks tell me on the street, their unemployment ran out and 
that gives them an opportunity for a more permanent income 
stream. And I am not saying they are not desperate. But do we 
really believe--and I will ask you. Do you share any of my 
outrage on that 38 percent increase since 2007 in SSI? Is that 
merely coincidence?
    Ms. Colvin. Well, Mr. Kingston, the SSA actuaries indicate 
that the increase is due to the changing demographics, that it 
is due to the aging of the baby boomers. It is due to the 
people reaching their disability-prone years, and that some of 
it is due to unemployment, but that that is due to the fact 
that individuals who normally would qualify for disability 
under our listings try to stay in the workforce and they do as 
long as they can, and they reach a point where they just are no 
longer able to because of their disability.
    So I am not seeing anything to suggest that--I mean, we 
certainly try to apply the disability law according to the 
standards. We have quality reviews. The accuracy rate in the 
DDSs still remains high.
    Mr. Kingston. I mean, you are not on trial here.
    Ms. Colvin. No, but I am telling you what I understand.
    Mr. Kingston. I mean, you are not on trial and this is not 
your fault.
    Ms. Colvin. I understand.
    Mr. Kingston. But do you really believe this is because of 
changing demographics? I mean, I know you can get an actuary, 
just like a lawyer, to give you a lot of answers, and I am not 
saying you did that at all.
    Ms. Colvin. Well, if you ask me do I believe as an 
individual, I would say yes. I worked with the disability 
population at the local and State level. When I was in 
Maryland, I was responsible for that population, when I was in 
Montgomery County, at the local level. If you look at the 
disabilities under which they come, it is no different than the 
Social Security Disability Insurance (SSDI) population except 
that they come based on income as opposed to the fact that they 
paid into the system. I did not see a difference.
    Mr. Kingston. Well, then you probably have the breakdown of 
that 38 percent, how many, say, are over 50 years old, how many 
are under.
    Ms. Colvin. We would have that.
    Mr. Kingston. And what is that?
    Ms. Colvin. Oh, I do not know it in my head. I will be 
happy to give it to you for the record.
    [The information follows:]

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    Mr. Kingston. But you would know in your head that it is 
consistent because you are saying that it is a demographic 
change. So you had to have something more than a gut instinct.
    Ms. Colvin. No. I am saying that as people get older, they 
become more prone to disabilities. So if you look at the 
population, you can see that.
    Now, for children or younger people who are on the 
disability rolls, some research would suggest that it is due to 
the fact that as you get larger numbers and you see more coming 
on because of mental health issues, et cetera, that can be 
because it is more readily identified. I would be happy to 
share with you the research studies that have been done in that 
area. But I am not seeing anything that----
    Mr. Kingston. Okay. I would like to see it because it is so 
interesting to me.
    Ms. Colvin. We would be happy to do that.
    [The information follows:]

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    Mr. Kingston. You know, I always say to people back home 
you can say what you want about Members of Congress, but we do 
get lots of information and lots of opinions. And certainly, 
you know, when I am back home, this is one of the opinions that 
I have gotten consistently that people have moved towards as a 
pot of money or a stream of money and, again, just because of 
the unemployment situation. So it is interesting to me that 
your conclusion is completely different, and your conclusion is 
presumably backed up by facts. So I would like to see the 
demographic breakdown that this is just the aging of America 
rather than this is the gaming of America, you might say. I 
think it would be very interesting to know. Well, I get a 
different opinion on the street I got to tell you.
    Let me ask you this, though. If I am right, are we in the 
same boat that you would share my outrage if I am right? And if 
I am wrong, I will say, golly, I am wrong and I would tell you.
    Ms. Colvin. As I mentioned before, we take fraud very 
seriously within the agency. In fact, our employees that I 
commend for the work that they do are usually our first line of 
defense. When someone comes in and based on the information 
that they are provided or information that they have obtained, 
that they are attempting to get a benefit that they are not 
entitled to, we are very aggressive in referring that case to 
the Inspector General.
    I will say also that SSA has always been very focused on 
fraud detection and prevention. When I was here in 1998 as the 
Deputy Commissioner for Operations, I instituted the existing 
CDI units, which is a partnership between SSA and OIG because 
we wanted to be very aggressive in going after any individual 
who might be trying to commit fraud. And that was 12 years ago, 
and now it has even been intensified.
    So this is an agency that believes if a person is entitled 
to a benefit, they should get it, but if they are not entitled 
to a benefit, that we should do everything under the law to see 
that they do not get it. And if they got one fraudulently, we 
should aggressively go after them for fraud. So we do that.
    Mr. Kingston. So as founder of this--what did you call it? 
I know my time is way over, Mr. Joyce. I appreciate your 
patience.
    Ms. Colvin. Cooperative Disability Unit, CDI.
    Mr. Kingston. I am reaching out.
    Ms. Colvin. I understand.
    Mr. Kingston. We are on the same page then. We would be on 
the same page on the outrage of somebody who is----
    Ms. Colvin. Yes, absolutely.
    Mr. Kingston. If there is any hope between some of the 
division in this town, I think we should be able to come 
together over somebody who is taking advantage of a benefit 
that should be going to somebody else who, as you pointed out, 
might be getting underpaid.
    Ms. Colvin. Absolutely.
    Mr. Kingston. Or one of your employees who has been in the 
system for 20-25 years and just is frustrated to death right 
now.
    Mr. Joyce.
    Mr. Joyce. Thank you, Chairman.
    I would like to follow up on your questions. One of the 
things that you were talking about with this designation of the 
disability--if someone is under 50, does that continue on for 
the rest of their lifetime--that payment?
    Ms. Colvin. That is a good question. No, sir. That is why 
the CDR is so important. Based on the disability, we diary a 
case and we determine when that case should be reviewed again, 
and that is what triggers our continuing disability review. So 
we would then review that case at an appropriate time to 
determine if there has been any medical improvement that would 
now disqualify that individual. Or if it is an SSI case, and 
they are on the rolls, we would look at the medical piece, but 
we also look at the asset piece to see if they are still 
financially eligible based on income. So we do that on a 
regular basis. And that is why the continuing disability 
reviews and the redeterminations are so important.
    Mr. Joyce. How long into the future do you look then? A 
year, 2 years out after they----
    Ms. Colvin. It depends upon the type of disability if 
medical improvement is expected. We do CDR's every 3, 5, or 7 
years depending upon the type of disability.
    Mr. Joyce. And what, if any, investigation is taken to see 
if they have mislead your agency to the disability?
    Ms. Colvin. Well, that would be where you would be 
verifying the medical information, or you would be verifying 
the asset information. So we would verify that.
    Mr. Joyce. With the ones with the disability that might be 
coming because they have run out of unemployment, can you tell 
whether or not their unemployment ran out and now they are 
applying for the disability?
    Ms. Colvin. I do not know the answer to that question.
    Mr. Joyce. So there is nothing that would indicate or 
trigger for you that perhaps this person was gaming the system?
    Ms. Colvin. You mean because they previously received 
unemployment?
    Mr. Joyce. Right and that expired. Now, all of a sudden, 
they come over----
    Ms. Colvin. We are not looking at whether or not they 
previously got unemployment. We are looking at whether or not 
they meet the standard, the definition of disability. So there 
is a very extensive review process to make that adjudication 
determination.
    Mr. Kingston. Will the gentleman yield?
    Mr. Joyce. Yes.
    Mr. Kingston. A question on that. When 43 percent of them 
do it online, how do you know--do you get a doctor 
verification?
    Ms. Colvin. Oh, that is just the initial application. They 
still have to be physically seen.
    [Clerk's note.--Later corrected to ``They have to get an 
extra medical review by a physician or a consultant.'']
    Mr. Kingston. Okay.
    Ms. Colvin. Yes. We were saying that it happens to save 
time.
    Mr. Kingston. Yes, but it is just the initial.
    Ms. Colvin. Yes.
    Mr. Kingston. Okay. I yield back.
    Ms. Colvin. They still have to be seen. Yes.
    [Clerk's note.--Later corrected to delete ``They still have 
to be seen, yes.'']
    They cannot get a determination just by something that is 
written. They have got to have an entire medical review by a 
physician or a consultant.
    Mr. Joyce. So that would be an independent review by your 
agency after they bring in their documentation from their 
primary care physician.
    Ms. Colvin. Yes. All of that information is given to the 
disability examiner at the DDS level who then has to review 
that. In some instances, they may require an additional medical 
consultant. They may require the individuals to see a physician 
of our choice, but you have all of that. There is a whole 
series of steps that one must go through in order to receive a 
medical determination.
    Mr. Joyce. If you know, what percentage of those are denied 
and what percentage of those who apply are accepted?
    Ms. Colvin. I can get that information for you. I do not 
know the percentage of denials and acceptance.
    I understand that at the initial allowance rate, it is 30 
percent that are allowed.
    Mr. Joyce. And 70 percent denied.
    Ms. Colvin. Yes.
    Mr. Joyce. Thank you.
    I yield back.
    Mr. Kingston. Thank you.
    While you were gone, Ms. DeLauro, I pledged to locate those 
26 farmers. [Laughter.]
    Mr. Kingston. Even if they are all from the great State of 
Georgia or Connecticut.
    Ms. DeLauro. And I hope--and I know you hope as well--that 
they are all farmers.
    Mr. Kingston. They are probably not. They are probably 
doctors. [Laughter.]
    Ms. DeLauro. I am sorry I was not here for the beginning of 
the discussion, but I would like to have you walk us through 
the disability claims process, if you would not mind, to give 
us a better idea of how intense, or labor-intensive it may be.
    Ms. Colvin. I do not think I can do that sitting here. That 
is a very technical process. As I mentioned earlier, it takes 
well over a year for a disability examiner to become 
proficient. Can I give you that for the record?
    Ms. DeLauro. Yes. I would appreciate that. I think it would 
be useful for us to have a better basic understanding of what 
you are faced with.
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    Ms. DeLauro. I will go back to where I left off. What can 
be done with technology and what cannot be done with 
technology?
    Ms. Colvin. In the disability process?
    Mr. Kingston. I promise the majority had nothing to do with 
your microphones.
    Ms. DeLauro. I will give you the benefit of the doubt, 
Jack.
    Because sometimes we over-think the technology side and 
there is a lack of understanding of the person-to-person 
interview, the kind of effort required because this is not 
cookie cutter. This is based on individuals.
    Tell us a little bit about the 1-800 number, what is 
happening with that, what is the backlog, response time. And 
obviously, given the nature of our current budget situation and 
the sequestration, what will happen with that? That has got to 
be one of the most frustrating things, when you put in a call 
and it goes nowhere. It is like a hole. So tell me a little bit 
about what is happening there.
    Ms. Colvin. As I mentioned earlier, we have seen a 
deterioration in all of our metrics. The numbers are going in 
the wrong direction. But just now we are looking at 15 percent 
or 3,300,000 of our calls where when people dial, they get a 
busy signal. That is 15 percent, or 3,300,000 of the calls that 
we get a year. Those individuals get a busy signal.
    Ms. DeLauro. 3,300,000 calls?
    Ms. Colvin. Yes. 15 percent of our calls.
    And then once they get through, we have what we call 
average speed of answer, how quickly we answer once you get 
through. We are now at 7.5 minutes, which means it is doubled 
since fiscal year 2010. So not only do you have trouble getting 
in, once you get in, you still wait another 7.5 minutes before 
you get a live operator. So our metrics are going in the wrong 
direction, and that is because, again, we have not hired since 
2010. More people are calling because of the waiting. They 
would prefer not to stand in line for 2 hours. So they go home 
and they try to call, and they cannot get through.
    Ms. DeLauro. I cannot see the clock, so I do not know if I 
have any time left.
    Mr. Kingston. You are good.
    Ms. DeLauro. You may have answered this, and if that is the 
case, I apologize.
    The reasons disability claims are going up?
    Ms. Colvin. Well, I answered that question. I think Mr. 
Chairman and I sort of had different views, but I indicated 
that our actuary has indicated that those increases are due to 
demographic changes, the result of the baby boomers aging out, 
the individuals reaching the disability-prone years, and some 
of it to unemployment, individuals who meet our listings, tried 
to work but have not been able to sustain work and now with the 
job market have just decided that they are eligible, they 
think, and they apply. Now, in some instances when people are 
unemployed, they apply. So our application rates go up, but 
they are denied. So we still believe that we have a high 
accuracy rate relative to approving people who are, in fact, 
disabled.
    Ms. DeLauro. And then just finally, I would love to see if 
you have the data on gender breakdown, on what is happening to 
women.
    Ms. Colvin. I am glad you brought that up because I missed 
that important variable. The actuary also indicates that 
because more women have entered the labor force, they are on 
parity now, and they also contribute to the incident rate of 
allowances. So that is a variable. Yes. Thank you for 
mentioning that.
    Ms. DeLauro. Thank you, Mr. Chairman.
    Mr. Kingston. Mr. Alexander.
    Mr. Alexander. Thank you, Mr. Chairman.
    Ms. Colvin. Good morning, sir.
    Mr. Alexander. Good morning. I believe in your testimony 
you mentioned closing of some of the field offices, 41. One was 
in Louisiana in my congressional district. Look, I commend you 
for taking the often difficult step of reducing cost, savings, 
but my concern is that there is a lack of a long-term strategic 
plan. So can you outline how field offices are closed and how 
you decide on which ones and tell us how they fit into the 
administration's long-term plan for dealing with----
    Ms. Colvin. Let me answer that in two ways. We are in the 
process of developing a long-term plan. I know this committee 
has been concerned that a plan did not exist. There is a plan 
that is coming in that was developed under the previous 
Commissioner. We are going to let that move forward. But I am 
also going to be starting a planning process during the interim 
period that I am there as Acting Commissioner.
    With the closing of offices, I have asked to look at the 
criteria that we use. A lot of it is based on the viability of 
an office as we lose staff, whether or not there are other 
offices that are in close proximity. So there is a whole host 
of criteria that goes into making a decision about whether or 
not it is going to close. I think it would be better if I 
provided you with something for the record that indicates the 
existing criteria, but I am looking at that again also.
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    [GRAPHIC] [TIFF OMITTED] T6214A.249
    
    Mr. Alexander. Okay. Thank you.
    Mr. Kingston. I wanted to ask. You are in a position to see 
up close what works and what does not work. And you might not 
want to answer this, but just to venture into policy a little 
bit, do you have some suggestions that could be helpful for us 
as we discuss Social Security?
    For example, yesterday the President met with the 
Republican Conference and said that he does support changing 
CPI. And his point to us was that is not necessarily a 
comfortable position for a Democrat. What he was saying to us 
is you have to move from comfortable positions too, and if we 
are going to save these universally popular programs, we have 
to do something.
    He did not say this statistic, but I think this is 
generally accurate. My dad retired at age 65 in 1980, and all 
the money he put in Social Security he received back in 3 
years. He lived 25 years. So it was a great deal for him. Today 
if you retire, I believe it takes 17 years to recoup what you 
put in it. But for our children, they will probably get 70 
cents on the dollar. I think those are roughly correct, don't 
you think?
    And so as we sit here, we know we have to change things. I 
do not know changing CPI does the trick. I do not know that 
means testing does. I do not know that raising the age. And by 
the way, what is the age today? Because I know it is moving up?
    Ms. Colvin. It is around 67.
    Mr. Kingston. It is not quite to 67, though, is it? It is 
66?
    Ms. Colvin. It is between 66 and 67.
    Mr. Kingston. It is going up 3 months a year.
    Ms. Colvin. It is going up depending upon date of birth.
    Mr. Kingston. And you know, when that decision was made in 
1982, I think 40 Members of Congress got an invitation back to 
the private sector showing how difficult it was even then.
    I mean, do you want to say anything about policy? You 
certainly do not need to.
    Ms. Colvin. Well, I think, you know, Mr. Kingston, that the 
Treasury Department is really the agency that deals with the 
solvency debate. Our role at Social Security is to provide 
data, to provide analysis, to indicate what the impacts will be 
of various proposals that go forth. We provide technical 
assistance to the committees here, the congressional 
committees, and we provide technical assistance to the White 
House, to the Office of Management and Budget. My role is to 
implement the law as you have passed it and to run the agency. 
So fortunately or unfortunately, I do not have to----
    Mr. Kingston. I am not trying to debate you in a policy 
discussion. Trust me. I just was wondering.
    Ms. DeLauro.
    Ms. DeLauro. Just in terms of notifying offices on closure, 
how much advance warning do they get?
    Ms. Colvin. 60 days.
    [Clerk's note. Later corrected to ``90 days'']
    Ms. DeLauro. The coordination of workloads between offices. 
You know, what we have heard--the impacts of erosion of funding 
due to inflation, that it is creating a problem to work between 
agencies. Is that accurate?
    Ms. Colvin. Between agencies?
    Ms. DeLauro. Field offices and coordinating workloads. I am 
sorry. Field offices.
    Ms. Colvin. What we do is we have our field offices that 
are stressed, and they are not able to get to the workload. We 
have the ability to transfer work among offices because we have 
virtual offices, and a lot of our work now is electronic. What 
we are trying to do is ensure that you are not disadvantaged 
because you live in a particular geographic area of the country 
and trying to provide the same level of services as we can. So 
we do constantly look at what is happening and see where we can 
share work across offices where it is electronic.
    Ms. DeLauro. And what will be your continued ability to do 
that with further cuts?
    Ms. Colvin. I do not know the answer to that. It depends 
upon my level of funding. As I said, we continue to lose staff. 
So I really do not know the answer to that.
    Ms. DeLauro. I think it is important--and I know Mr. 
Alexander asked about the facility in his district. I really do 
believe it is going to be important for Members to know where 
notices are going out, if that occurs, if we proceed forward 
here with this, and it appears that sequestration is moving 
forward. And I know you said you do advise them and so forth.
    Ms. Colvin. We do.
    Ms. DeLauro. But I think it does not hurt to let people 
know that whether it is your contact station or your field 
offices or even where offices have shortened hours--that always 
generates complaints to our district offices, the lack of 
service. So I just think that Members have to continually be 
aware of what is at stake in these efforts.
    I think it is also interesting that your budget is almost 
entirely staff or support for staff, unlike some of the 
agencies that come before us. At the Social Security 
Administration you do not administer grants or loans or do any 
of that. What is a unique challenge because of the nature of 
your agency with regard to a flat budget or sequestration?
    Ms. Colvin. Well, you know, we have fixed costs that go up, 
rental facilities and other costs that are fixed, and they go 
up each year. So we do not have a lot of flexibility.
    Unlike other agencies, none of our work is discretionary. 
It is all required by statute. And we do not control the number 
of applicants that come in the door. And so if we do not have a 
sufficient budget, which means we do not have sufficient staff 
and we are not able to invest technology, that means we are 
going to continue to see a deterioration of services. And the 
American public has to accept the fact that they are not going 
to get the kind of service that they got in past years.
    We do not have other places to cut. All of our budget 
supports our staff. Training. We are going to see some quality 
issues because if you do not train people, they are not going 
to know how to do the job correctly, and once they learn 
incorrectly, they continue to do it incorrectly. Or if they are 
trying to serve too many people in a span of time, they are 
going to make mistakes. And so every time you have to redo a 
case because it is not correct, the information is older, and 
it is more expensive.
    Ms. DeLauro. That leads me to my last comment, if you will. 
If SSA saves money with program integrity work, those funds are 
simply kept in the trust fund for future years. These are not 
funds----
    Ms. Colvin. It does not help us with our administrative 
needs.
    Ms. DeLauro. With your administrative needs.
    Ms. Colvin. No, it does not.
    Ms. DeLauro. So I would just say once again, as I said 
earlier, that I think that we should not be penny wise and 
pound foolish when it comes to program integrity, that we 
should allow you to deal with those redeterminations and other 
efforts in order to be able to safeguard overall the program 
and the beneficiaries.
    Ms. Colvin. I would really just urge the committee to look 
at giving us adequate, sustained, and predictable funding. I 
think if you look at how we spend the dollars, you can see them 
easily accounted for. Our metrics are very clear. The number of 
benefits we give out, the number of program integrity 
initiatives that we handle are spelled out so there is no lack 
of clarity relative to how we use the money and where it goes. 
But we need sustained funding. We need predictable funding, and 
of course, we need adequate funding. Our funding for the last 2 
years has been $1,000,000,000 less than the President's 
request. It is just not going to allow us to do the work. It is 
not going to allow us to serve the public.
    Ms. DeLauro. Thank you.
    Thank you, Mr. Chairman.
    Mr. Kingston. I just have three closing comments.
    Number one, I want to join--and I want to speak on behalf 
of all the members of this committee. We do feel that your 
field employees, who are a very important part of our field 
offices as well are doing a great job.
    Ms. Colvin. Thank you.
    Mr. Kingston. They are responsive to us. And I believe that 
they have the customer's best interest in mind.
    Ms. Colvin. They do.
    Mr. Kingston. And they are sympathetic and empathetic.
    Number two, I do want to pledge to work with you on this 
SSI issue.
    Ms. Colvin. Thank you.
    Mr. Kingston. If I am wrong, I am going to be the first to 
admit it. If I am right, though, let's join together and find 
out.
    Ms. Colvin. Absolutely.
    Mr. Kingston. And then number three and something very 
important, I wanted to have the pleasure of ending a hearing on 
Social Security with my good friend, Rosa DeLauro, on the far 
right of me. [Laughter.]
    Ms. DeLauro. Touche.
    Mr. Kingston. Thank you very much.
    [The following questions were submitted for the record.] 

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                                         Wednesday, March 20, 2013.

                        CHILDREN'S MENTAL HEALTH

                               WITNESSES

PAMELA HYDE, ADMINISTRATOR, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES 
    ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES
DEB DELISLE, ASSISTANT SECRETARY, OFFICE OF ELEMENTARY AND SECONDARY 
    EDUCATION, DEPARTMENT OF EDUCATION

                             Introductions

    Mr. Alexander. Good morning. The chairman will be here in a 
few minutes, we understand. But he wants to go ahead and get 
started so we won't mess up everybody's day.
    Good morning. Today, we will hear from the Department of 
Education and the Substance Abuse and Mental Health Services 
Administration of the Department of Health and Human Services 
about the state of the mental health system for children in the 
U.S.
    The tragic massacre of 20 children and 6 adults at Sandy 
Hook Elementary School on December the 14th of last year has 
led to a national discussion about whether the mental health 
care system in the U.S. is designed to effectively identify and 
treat youth with mental health diseases and disorders before 
they lead to, in the most extreme cases, tragedies like the one 
I just mentioned.
    The administration is already talking about creating new 
programs. But today, we are going to take a step back and look 
at the current system as it exists today. We will hear about 
what has and hasn't been effective at improving the mental 
health of children and reducing violent and disruptive behavior 
in schools, focusing on the role of Federal programs.
    I am interested in learning how we can better target 
current resources to address this issue. On an issue as 
important as this, we can't afford to waste a single dollar on 
programs that are duplicative or ineffective.
    And I will yield now to Ms. Lee for an opening statement.
    Ms. Lee. Thank you very much.
    First, let me thank both of you for being here today and 
take a moment to just mention that our subcommittee ranking 
member, Congresswoman Rosa DeLauro, was asked to join the 
official House delegation to the inauguration of Pope Francis. 
So she won't be with us today.
    But I am very pleased to take the lead for the Democratic 
side today, as she requested me to do. My background, of 
course, is in clinical social work and mental health, community 
mental health, and I am really pleased to be here today with 
you.
    The recent mass shootings, including those in Connecticut, 
Colorado, and Arizona, have launched a real national discussion 
about mental health issues, especially as they affect our 
youth. This is certainly a discussion we should be having, one 
that really should have started a long time ago. These horrific 
events really serve as a reminder of the possible consequences 
of untreated mental illness.
    But we should also remember that the vast majority of 
people living with mental illness are not violent and also that 
the vast majority of violence is not caused by people with 
mental illness. The fact is that those suffering from a mental 
illness are far more likely to become victims of violence than 
the perpetrators.
    Also, the reality is that for far too long, too many of our 
young people, their experience with violence is not the 
devastating mass shootings, but the everyday violence that is 
all too common in communities like Chicago and my district in 
Oakland and right here in Washington, D.C. So when we fail to 
address mental illness, when people cannot access services and 
there is nowhere for them to go, the outcomes are not positive.
    Children with undiagnosed, untreated mental illness become 
adults who often end up in prison, experience homelessness, and 
are victims of violence and have many health concerns that are 
harder to treat due to their mental state. As a clinical social 
worker, I opened a community mental health center in Berkeley, 
California, that served low-income clients, and I saw firsthand 
the effects of the lack of services on the mental health of 
individuals, on their families, and on their communities.
    There was an overwhelming need then, and that was in the 
'70s. And there is an overwhelming need now. It is the 
resources that, inexcusably, are lacking.
    In recent years, we have seen a dramatic decrease in 
resources for mental health at all levels. SAMHSA mental health 
programs were cut by 5 percent between 2010 and 2012, and 
sequestration has almost doubled that cut. Adjusted for 
inflation and population, 2013 now is about one-fifth lower 
than 2002 level.
    As for the States, the Association of State Mental Health 
Directors estimates that in the last 4 years, States have cut 
$4,350,000,000 in mental health services while, at the same 
time, an additional 1 million people sought help at public 
mental health facilities.
    So I hope that today we can hear more about the 
consequences of these cuts. I hope that we are able to discuss 
what can be done to reach more children with undiagnosed and 
untreated mental health challenges. Since we know that in most 
cases treatment does work, and early treatment and prevention 
is absolutely necessary.
    Finally, I hope to discuss how to make our schools a safer 
learning environment without turning them into armed camps, the 
impact of mental health treatments on the pipeline to prison, 
which is really devastating low-income communities and 
communities of color. So I thank our witnesses for being here 
and look forward to today's discussion.
    Thank you, Mr. Chairman.
    Mr. Kingston [presiding]. Well, thank you very much, Ms. 
Lee and Mr. Alexander.
    Ms. Hyde, we will go ahead and start with you, and then Ms. 
Delisle, you will do the same.

                    Opening Statement of Pamela Hyde

    Ms. Hyde. Thank you, Chairman Kingston and Vice Chairman 
Alexander and Ranking Member DeLauro and Congresswoman Lee, for 
your holding this hearing.
    And I do want to acknowledge Assistant Secretary Deb 
Delisle, whom you are going to hear from in a moment. Our 
agency works very closely with the Department of Education. You 
will see that as we talk through today.
    I think you are aware that SAMHSA's mission is, in fact, to 
reduce the impact of mental illness and substance abuse on 
America's communities, and we do that in a number of ways. We 
do it by being a voice for behavioral health, but also by 
substance abuse and mental health surveillance and data, by 
setting standards and regulating programs, by doing practice 
improvement efforts, by funding States, tribes, territories, 
and communities, and by providing information to the public.
    I wanted to start with just some of that public information 
that we try to get people to be aware of, and that is that 
three-quarters of adult mental health issues start before the 
age of 24, about half before the age of 14. So investing in the 
mental health of our children and youth is critical not only to 
them, but to adults.
    Less than half of adults and less than one in five children 
and adolescents receive treatment for diagnosable mental health 
and substance use disorders. And even less, about 11 percent of 
adults with substance use disorders, receive treatment.
    The reasons for this lack of treatment include cost, not 
knowing whether and where to get help, and not knowing whether 
treatment will work. Generally, people wait much longer to get 
treatment for a mental health or substance abuse disorder than 
for physical symptoms for themselves or their children.
    And science tells us that we can prevent mental and 
behavioral health disorders among young people, and the sooner 
we intervene, the better the outcome. So the longer we can keep 
a young person from drinking or taking drugs such as marijuana 
or abusing prescription drugs, the more likely we can keep that 
young person from developing a serious problem in adulthood.
    Persons with behavioral health problems have higher rates 
of heart disease, hypertension, disease, and smoking than those 
without those conditions. And people with mental and substance 
use disorders are nearly two times as likely as the general 
population to die prematurely. About half the deaths from 
tobacco use in our country are among people with mental and 
substance use disorders.
    Today, suicide is, unfortunately, the third-leading cause 
of death among young people. However, it doesn't have to be 
this way. We know that behavioral health, mental illness, and 
substance abuse prevention, treatment, and recovery is, in 
fact, a public health issue, and it can be tackled and solved 
in that way. Positive emotional, mental, and behavioral health 
increases a young person's chance of social, academic, and 
developmental success, and that benefits us all.
    As you know, in January, the President announced some 
initiatives to ensure that students and young adults receive 
treatment for mental health issues. To ensure adequate coverage 
of mental health and addiction services, the administration 
issued a letter to State health officials about Medicaid plans 
being subject to MHPAEA, or Mental Health Parity and Addiction 
Equity Act. And in addition, the administration will issue 
final regs about MHPAEA this year.
    The President also proposed initiatives to increase mental 
health access for the Nation's young people. And SAMHSA has a 
specific role in three of those.
    The first is Project AWARE, Advancing Wellness and 
Resilience in Education. This project would provide States with 
resources to help schools and communities address mental health 
issues, identify mental illness early, and refer young people 
to treatment. Project AWARE would also provide Mental Health 
First Aid training.
    Second program is Healthy Transitions. It is a proposed new 
grant program for innovative State-based strategies supporting 
young people ages 16 to 25.
    And a third program is a workforce program to be operated 
jointly with HRSA that would train more than 5,000 additional 
mental health professionals to serve students and young adults.
    And finally, HHS and Education, along with the White House, 
will soon launch a national dialogue on mental health.
    So we have come a long way in the prevention, treatment, 
and recovery supports for mental and addictive disorders, but 
we have a long way to go. And we can do better, which is why 
the administration is taking steps to increase awareness of the 
importance of mental health to our Nation's health and increase 
access to mental health services, especially for young people.
    Thank you again for this opportunity to discuss SAMHSA's 
role in this, and I would be pleased to answer any questions 
you may have.
    [The prepared statement of Administrator Pamela Hyde 
follows:] 

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                    Opening Statement of Deb Delisle

    Ms. Delisle. Thank you very much.
    Chairman Kingston, Congresswoman Lee, and members of the 
subcommittee, thank you so much for holding this very important 
hearing on children's mental health.
    I appreciate the opportunity to share the Department's 
efforts, as well as the President's plan for improving mental 
health supports for students. And obviously, I am very pleased 
to be here with my colleague Pam Hyde because we have done a 
lot of work together, and our partnership is deepening every 
single day.
    As you are very well aware and has been expressed earlier, 
our students today face a whole host of challenges to their 
mental, behavioral, and emotional well-being in their schools, 
in their homes, and in their communities. There are many 
complexities of life that impact children's overall well-being 
and, in turn, influence their academic achievement and their 
feelings of inclusiveness and safety in school settings.
    There is a growing awareness among Federal policymakers of 
the linkages between children's exposure to violence and mental 
and emotional wellness. The groundbreaking National Survey of 
Children Exposed to Violence found that 10 percent of children 
in this country have been exposed to multiple forms of 
violence, such as community violence, sexual abuse, and 
domestic violence. And secondly, the risk and severity of 
health and mental disorders increases for children who have 
been victimized multiple times by up to tenfold.
    To ensure that our students can focus on learning, our 
educators must have both school-based resources and effective 
partnerships with community health professionals to identify 
risk factors, recognize students displaying signs of emotional 
and mental distress, and connect students and their families to 
a continuum of supports to help them cope, to recover, and to 
continue successfully in their academic careers as well as in 
life.
    Further, under applicable Federal law, schools have an 
obligation to identify, evaluate, and provide special education 
and related services to students with disabilities, including 
mental health-related disabilities. School-based mental health 
supports are particularly critical to helping educators respond 
effectively to the myriad of incidents affecting students on 
campus and in school buildings, from teen dating violence to 
the emotional distress that students bring to school and to 
tragic events, such as that which occurred in Newtown, 
Connecticut.
    Last December, I testified before the Senate Judiciary 
Committee about our efforts to stem the use of suspensions and 
expulsions, which disproportionately impact students with 
disabilities and students of color. Schools must recognize 
behavioral incidents as opportunities to help students cope 
with trauma and to support, rather than to exclude, students 
with emotional and behavioral difficulties.
    In recent years, the Department has worked to improve 
educator and student access to mental health resources and 
supports through financial support to school districts, 
technical assistance, and interagency partnerships with Federal 
partners, such as SAMHSA. For example, since 1999, the 
Department has partnered with DOJ and SAMHSA to address youth 
violence prevention and support the social, emotional, and 
behavioral needs of students through the Safe Schools/Healthy 
Students initiative.
    Far too often, the resources directly available within a 
school building are limited. For example, while the American 
School Counselors Association recommends a ratio of 250 
students to every counselor, the national student-to-counselor 
ratio is approximately 450 to 1, as of 2010. One counselor to 
attend to the needs of 450 students, is an overwhelming ratio 
for sure.
    Our Office of Safe and Healthy Students administers a grant 
program to establish or expand school counseling in elementary 
and secondary schools. In 2012, we awarded $21,200,000 to 60 
recipients in 24 States to hire and train qualified mental 
health professionals, with the goal of expanding the range, 
availability, quantity, and quality of counseling services.
    The Department's Office of Special Education and 
Rehabilitative Services has invested in behavioral research, 
demonstration, and technical assistance activities for more 
than 20 years, including through the positive behavioral 
interventions and support centers, which provide States, 
schools, and communities with a clear, evidence-based roadmap 
to safer school climates that support students through 
evidence-based behavioral frameworks.
    Further, we are working closely with DOJ and HHS to 
strengthen the use of behavioral frameworks in the 10 cities 
that comprise the National Forum for Youth Violence Prevention, 
which have all pledged to strengthen local capacity to prevent 
youth violence and gang violence.
    On January 16th, as Pam mentioned, the President announced 
a comprehensive plan ``Now is the Time,'' which outlines a 
multifaceted approach to reducing gun violence and is based on 
the recommendations of the Vice President's task force that was 
established in the wake of the school shooting in Newtown, 
Connecticut.
    Mr. Kingston. Your time has expired.
    Ms. Delisle. Okay.
    Mr. Kingston. But Members have looked at your testimony, 
and it is very good, very meaty, and so don't think we 
haven't----
    Ms. Delisle. Thank you. I appreciate that. Thank you for 
the opportunity to be here.
    [The prepared statement of Assistant Secretary Deb Delisle 
follows:]

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    Mr. Kingston [continuing]. Time because I think you will 
find a lot of bipartisan support for the direction we all want 
to move on this committee, and I want to give Members plenty of 
time for questions.
    So, not being rude, but want to move on to the dialogue.
    Ms. Delisle. Thank you.
    Mr. Kingston. Sorry, my mike wasn't on. I hope you heard 
what I said.

          IDENTIFYING CHILDREN WHO NEED MENTAL HEALTH SERVICES

    Ms. Hyde, and I want to say one of just the most 
heartbreaking statistic that I have just heard is that the 
number-three cause of death in teenagers is suicide. I don't 
know that America knows that statistic, but I think all of us, 
as parents and family members, are just heartbroken to ponder 
what that means. And we have all seen it, and so certainly, we 
want to do everything we can.
    A friend of mine, Dr. Chris Tillitski in Macon, Georgia, 
told me that--and he is a child psychologist--said after 
Columbine, there was just a tremendous growth in his industry 
because, he said, any time a child drew a weird picture, the 
mom would bring him in and say, ``Is he the next Dylan 
Klebold?'' the perpetrator of--and he said, you know, for some 
of his colleagues, it was a great opportunity for successions.
    And he said, but there is also, if you know what you are 
doing, you could say, ``No, this is a kid being a kid.'' It is 
so difficult to identify when there is a mental illness, and 
one of the things that your testimony has said is that schools 
would identify. But I don't think schools or school counselors, 
whether it is 1 to 5 or 1 to 500 have that ability to truly 
identify the kids.
    So can you comment on that? Because you sure don't want to 
misdiagnose it and plant some seed that, well, you drew a weird 
picture. Therefore, you have got a problem.
    Ms. Hyde. Thank you, Mr. Chairman.
    That is true. We don't want to identify children that don't 
need help. What we know, though, is that there are a number of 
children who do need help who don't get identified.
    And I think part of what these proposals would do is help 
people have more information--school officials, families, 
community intervention folks, other sort of folks who are 
interfacing with young people--know what the signs and symptoms 
are, what they should be looking for, what is appropriate to 
look for. And then the referral process is to refer to an 
individual who is capable of doing the appropriate assessments 
to determine what is going on.
    So we know that sometimes behaviors are part of young 
people's growing up. But we also know that sometimes those 
behaviors do identify young people with needs that are not 
getting attended to.
    Mr. Kingston. Well, who would have the power--you know, 
coming at it for a minute from a Libertarian standpoint, how 
would the State be given that power that you don't like a 
child. The child is belligerent or whatever. And so, you say 
you need testing and counseling.
    Because I know that teachers aren't perfect, and teachers 
often may have their own ax to grind on a child. And it would 
appear to me to have some concerns about the State having the 
power to be able to send somebody off.
    Ms. Hyde. I don't think the State would take that power. I 
think Assistant Secretary Delisle may want to comment about how 
the schools would do this. We're not asking anyone who is not--
or not suggesting that anyone who is not trained, licensed, and 
able to make those assessments do that.
    What we are trying to do is raise awareness. For example, 
suicidality and other kinds of things that may indicate a need 
for professional help rather than trying to get teachers to be 
diagnosticians. That is not what we are trying to accomplish.
    Mr. Kingston. But the teacher would be closest to the 
child, observe the behavior, refer the child to somebody, and 
that could lead to mandatory assessment. And that is empowering 
the State. Is that not the case?
    Ms. Hyde. I don't know----
    Mr. Kingston. I am just saying there is a real fine line 
there.
    Ms. Hyde. I don't think we are looking at mandatory 
assessments. Parents and others are involved in these 
decisions. It is not the State that makes those decisions. It 
is rather a teacher or a parent who is identifying behavior----
    Mr. Kingston. Well, the teacher is the State, though. I 
mean, the teacher is a State employee. So if the teacher is 
empowered to do it. I am just saying a little concern on that.
    Let me ask you this, in terms of the exposure to violence, 
and you had mentioned exposure to violence very close to being 
a victim of violence. But what about the cultural exposure to 
violence, whether it is from violent lyrics in a song or 
Hollywood movies or whatever? Do you feel like there is any 
influence on behavior because of the barrage that children are 
exposed to?
    Ms. Hyde. We have done a lot of work about child exposure 
to violence. CDC has also done a significant amount of work. 
But frankly, we don't have good evidence about what those 
impacts are. We do know that witnessing violent behavior or 
witnessing violence in the community can have a traumatic 
impact on a child.
    For some children, they have the resilience and capacity to 
take that in and deal with it and bounce back. For others, it 
has a profound and lasting impact on their health and mental 
health.
    So it depends, and we don't have the complete data that we 
need to make those decisions at this point.
    Mr. Kingston. Is that something that we should study?
    Ms. Hyde. I would commend you to the CDC to talk about 
those issues. They and others are looking at whether or not 
those issues can be studied.
    Mr. Kingston. You look very, very young. However, I would 
have to ask you this. Do you think children are exposed to more 
violence today than they were when, say, you were 10 years old?
    Ms. Hyde. Mr. Chairman, I am not as young as you seem to 
think I am. I wish I were. [Laughter.]
    Ms. Hyde. I don't know that I can answer that. My children 
are in their 30s. I know what they did and what they saw when 
they were young people. I don't have grandchildren. So I don't 
know what children so much are exposed to today.
    There is no question that there is a culture in our 
communities about violent behavior, and the issue is how do we 
make sure, from SAMHSA's point of view, that anything that is a 
traumatic event, what is the impact on that child's behavioral 
health. And again, we have a number of years, about 10 years' 
worth of work in child trauma issues and identifying what kinds 
of things will have an impact on a child's behavioral health.
    Mr. Kingston. I am just wondering if gratuitous violence 
and blood splattering in Hollywood is more than it used to be, 
which I think it would be, and if that has any influence? And 
would you think that would be something we should examine, or 
should that not be examined?
    Ms. Hyde. Mr. Chairman, again, this is not my area. So we 
could probably try to get back to you with some information 
about that.
    Mr. Kingston. Okay. Ms. Lee.
    Ms. Lee. Thank you very much, Mr. Chairman.
    Before you arrived, I mentioned that I am a trained 
clinical social worker by profession. My background is mental 
health. And I wanted to follow up with regard to your question 
in terms of the signs and symptoms and just say a couple of 
things, why it is important, I think, to follow up with that.
    Because you are absolutely correct. There is a fine line. 
But trained mental health professionals really know how to make 
those diagnoses, and they know what the signs and symptoms are. 
And that is why it is so important to--and you mentioned the 
ratio of 1 to 450.
    In my own State of California, when I was in the California 
legislature, we had one mental health counselor to about 1,200 
students. And of course, I have legislation that would really 
authorize a full mental health school counselor national 
program. But I think it is extremely important that we know 
that we have to have trained mental health counselors, whether 
it is psychiatrists, psychologists, clinical social workers, on 
campuses to really begin to address that in a big way.
    I don't know what the ratio is now in some States, but I 
know California is even more than 1 to 1,200 counselors. And on 
the other hand, when you look at what is happening with 
students of color, young African-American and Latino boys, they 
are being suspended and kicked out of school for a variety of 
reasons. Where a mental health counselor could identify what 
some of the behavioral issues are and really help reduce the 
drop-out rate tremendously if we had a larger number of mental 
health counselors on campus.
    So let me just ask you, in terms of the violence that the 
chairman referred to, because I think there is--since I was a 
teenager, there is an increase in violence throughout the 
country. I am concerned about the impact of this trauma on a 
child's mental health, whether they are a direct victim of 
violence or witnessing or living in areas.
    Because in my community, some of these young people I would 
diagnose as having post traumatic stress syndrome. They live in 
war zones, and that is how they function, as if they are living 
in a war zone because of the trauma around the violence.
    Could you comment on that and how you see, how this 
administration sees the results of violence in terms of the 
trauma to the mental health of young people throughout the 
country?
    Ms. Delisle. If I could comment----
    Mr. Kingston. If the gentlewoman would yield a second? You 
know one thing that I don't know if you can touch on it now, 
but among the young men of color that you referred to, they 
have not been the perpetrators of these slayings. Is that 
correct?
    Ms. Lee. That is correct. You look at the statistic----
    Mr. Kingston. And that is interesting. You know, I don't 
know if----
    Ms. Lee. But what you would see, though, with young men of 
color, this becomes a pipeline from the cradle to the prison 
because majority of them never come back to school, and they 
end up in behavior that sends them into juvenile hall and then 
into prison.
    Mr. Kingston. Yes, and there are other losses.
    Ms. Lee. That is right.
    Mr. Kingston. Yes, thanks.
    Ms. Hyde. Mr. Chairman and Congresswoman Lee, the issue 
about young men of color, if I could just touch on that? I 
think that we tend to galvanize and get our interest up when a 
mass casualty shooting occurs. But as you said, Congresswoman 
Lee, there are young people who die every day on the streets of 
our cities who are disproportionately, in many cases, people of 
color because of the everyday violence that we experience.
    And I think that is part of what your question is about 
this trauma that we deal with. As I said earlier, we have a 
long history of working in the trauma arena in SAMHSA. We have 
a National Child Traumatic Stress Network and program, and they 
have done significant work in coming up with appropriate 
evidence-based practices to address those issues and to be able 
to identify those young people who have mental health problems 
because of it.
    There is a whole set of issues about risk and resilience 
factors, but there is some point at which resilience is not 
enough if you are exposed to violence constantly. And there is 
pretty good evidence that that exposure to violence, especially 
cumulative, has implications for both health and behavioral 
health issues.
    Ms. Lee. What are the implications, though?
    Ms. Hyde. The implications are more substance use, more 
suicidality, more mental health issues, more depression, 
anxiety, more issues in school in performance, and just the 
developmental growing up process.
    Mr. Kingston. Thank you.

                STUDENT SAFETY TO AND FROM AND AT SCHOOL

    Ms. Delisle. Chairman Kingston and Congresswoman Lee, I 
just want to add one piece to that. That is one of the 
difficulties we have, particularly on the way to school and on 
the way home from school, as you indicated, with neighborhoods. 
So we still know that schools are still one of the safest 
places to be.
    However, having been in education for 38 years, I have seen 
the numbers of students who have passed through my own career 
who have been afraid to come to school. And we know that they 
are walking through gang-infested neighborhoods. They have 
experience--so even as young as 5 years old, student 
absenteeism becomes very high when they are living in 
neighborhoods, when we keep kids out of school for whatever 
reason, through suspensions, expulsions, or when they are self-
selecting out because of walking to and from school in unsafe 
neighborhoods. They are missing school.

        DISPROPORTIONATE IMPACT OF STUDENT DISCIPLINARY ACTIONS

    Your emphasis on the school-to-prison pipeline is very 
real. Obviously, we have a lot of reports out about the range 
of students who--especially students of color and students with 
disabilities--who are disproportionately impacted by 
suspensions and expulsions.
    So, at the Department, we are working really hard to put 
out guidance and to be sure that people are very familiar with 
the data, particularly with some recent data that has been 
released. We have been supportive of schools having a response 
to intervention and restorative justice programs. And we need 
counselors and mental health workers who are able to work with 
students as well as with teachers to ensure that there are 
behavioral supports, that they know what are the strategies to 
use with certain students to be sure that they are focused on 
learning.
    Ms. Lee. Thank you very much.
    Thank you, Mr. Chairman.
    Mr. Kingston. Mr. Alexander.

                        STIGMA OF MENTAL ILLNESS

    Mr. Alexander. I used to be on the Health and Welfare 
Committee in the State legislature, and it was always a puzzle 
to me, as I made visits to sites around the State of Louisiana 
that took care of the mentally ill, it was always a puzzle why 
everyone was reluctant to talk about the problem.
    Parents, every day, today we will hear somebody say, 
``Well, my brother has got cancer,'' or ``My sister has got 
cancer. You all pray for them,'' or whatever. But we never hear 
anybody ask someone to be concerned about a family member that 
has a mental problem.
    Do we find it easier today for individuals to talk about 
the massive problem that we have in mental health? Is it easier 
to talk about it today than 20 years ago?
    Ms. Hyde. Mr. Vice Chairman, it is a great question, and I 
think short answer is, yes, it is easier today than it was 
years ago, but we are a long way from where we need to be. 
There are still a number of negative attitudes about mental 
health. There are misperceptions, misinformation.
    There is an assumption that addiction is just a matter of 
will. There is an assumption that these things are moral issues 
and social issues rather than public health issues.
    There was a time, and I am sure you recall, when cancer was 
not something we wanted to talk about, and we are much more 
willing to do that today. I think one of the positive outcomes 
of things like this hearing and our opportunities to talk about 
it is people are more willing, I think, than ever, as it is 
discussed, to come out, if you will, about being in recovery, 
having a family member who has a mental health or addiction 
issue and being willing to address it.
    So to the extent that those concerns about how people will 
be treated, either in school or for adults their employment or 
other kinds of social relationships, if you look at the public 
attitudes, they do suggest that people have misperceptions 
about not wanting to have such individuals live in their 
community.
    There is a public attitude that doesn't really match 
reality about people thinking people with mental health issues 
are dangerous to each other or to other people in the 
community. So there is a lot of misinformation still out there 
and a lot of concerns about having those disorders. And 
therefore, it makes it difficult for people to be willing to 
talk about it.
    It is part of the reason we are going to announce a 
national dialogue on mental health soon is to try to be able to 
get the volume up on talking about mental health and addiction 
disorders.
    Mr. Alexander [presiding]. Okay. Thank you.
    Ms. Roybal-Allard.
    Ms. Roybal-Allard. Good morning.
    Ms. Hyde. Good morning.
    Ms. Roybal-Allard. Administrator Hyde, I have been very 
concerned about the use of psychotropic drugs to treat children 
with behavioral problems. And I, along with Representative 
DeLauro and Senator Tom Harkin, asked GAO to look into this 
issue. And what GAO found was that children on Medicaid are 
prescribed these medications at twice the rate of privately 
insured children and that an alarming 18 percent of foster 
children were taking psychotropic medications.
    GAO also reported that these drugs represent the single 
largest expenditure in Medicaid. It was over $2,800,000,000 in 
2007. Given your mission to reduce the impact of substance 
abuse, what is your agency doing to address this pervasive and 
costly substance abuse problem? And are you building 
partnerships with Medicaid, the foster care program, medical 
specialty societies, and treatment centers to work on ways to 
better treat these children and avoid turning them into drug-
addicted individuals?
    Ms. Hyde. Thank you, Congresswoman. Thank you for the 
question because we are doing a lot.
    We have a strong relationship with the Administration on 
Children and Families. They have taken this issue on very 
strongly, looking at psychotropic drug use among foster 
children.
    And I am sure you know that foster children are sort of 
disproportionately on Medicaid. So sometimes those numbers 
coincide to make it also look that way for Medicaid-eligible 
children.
    SAMHSA focuses on the right treatment at the right time. We 
are focusing heavily on psychosocial interventions, wraparound 
interventions, where ACF is very much interested in having 
foster parents aware of how they can get those kinds of 
interventions.
    We are trying to monitor with them more the use of 
medications to see what is happening with that and trying to 
make sure that medication is only one part of a treatment plan. 
And frankly, if psychosocial interventions can happen first, 
that is the preference.
    So we also have been sponsoring a child and adolescent 
psychiatric fellow from Johns Hopkins. He comes to SAMHSA once 
a week, and he is currently working on an issue brief regarding 
engaging Asian-American youth in psychiatric treatment and 
trying to look at ways to do this without starting with 
medication.
    So we also have a lot of work with State systems in our 
NCTSI, or National Child Traumatic Stress Initiative. Also 
looks at ways to intervene with young people who have traumatic 
experiences, and frankly, most foster children come to the 
system with some sort of traumatic experience.
    So we are doing a lot, and it is our goal jointly with both 
the private sector professional groups as well as with our 
Federal partners. CMS has also been very heavily involved in 
this effort to try to look at both the trauma aspects, how to 
get more funding into Medicaid for services that are not 
starting with medication for children.
    Ms. Roybal-Allard. Okay. One of the concerns is that there 
is no consistent Federal policy guidance on prescribing these 
drugs to children in the Medicaid and CHIP programs. So as the 
lead mental health agency for our country, what can SAMHSA do 
to encourage that alternative treatment options, such as 
counseling and psychotherapy, find their way into practice for 
these children that are in Medicaid and CHIP?
    Ms. Hyde. Congresswoman, one of the things that we are 
doing with the association for adolescent--child and adolescent 
psychiatry professionals is try to develop guidance on the use 
of psychotropic medications. So it is frequently the 
professional groups that will set this guidance. We are trying 
to provide support in doing that, and we are also supporting a 
youth advisory group working with the AACAP is the acronym.
    That group is providing feedback about Web site resources 
for youth, including the creation of youth videos. So youth by 
youth. Youth listen to other youth, and trying to get them more 
educated about psychotropic medication issues as well.
    Ms. Roybal-Allard. Do I have time for another question, or 
is it----
    Mr. Alexander. I believe you have 36 seconds.
    Ms. Roybal-Allard. Okay. I will just wait.
    Mr. Alexander. I won't be quite as strict as the chairman. 
But thank you.
    And Members will ask questions in the order in which they 
came into the room. So, Mr. Joyce, Dr. Harris beat you over 
here. So, Dr. Harris.
    Mr. Joyce. I am leaving then. [Laughter.]
    Mr. Harris. You chased him out. No, thank you very much.
    And Ms. Hyde, I have a question for you, and I am glad we 
are going to open a dialogue on mental health because it is 
important. But part of my concerns are that as we discuss 
serious mental health issues in youth that could lead to 
problems and then link that to solutions to gun violence 
issues.
    And for instance, in our State, they are attempting to link 
this by requiring that anyone who is involuntarily committed 
loses their right to obtain a firearm for the rest of their 
life. I mean, this is not--and the reason why this is 
significant is because part of your testimony was we have to 
dispel this perception that people with mental health issues 
are dangerous. But in Maryland, they are about to pass a law 
that says someone with a mental health issue is dangerous.
    We are going to add stigma instead of removing stigma. We 
are going to add--I think we add impediments to obtaining help 
rather than removing them.
    Interestingly, one of the Vice President's recommendations 
was is that we address unnecessary barriers, including HIPAA, 
that prevent sharing of data. But HIPAA, the purpose of HIPAA 
is actually to prevent sharing of data, the--some of the most 
private data you have, which is your medical data.
    So the quandary is how do we--and one of the reasons why we 
need a dialogue and haven't it because this is a tough issue. I 
mean, how do we address and how is your administration thinking 
about addressing the issue of identifying people who need help, 
who may be dangerous to themselves and others, but not 
stigmatizing those people? Because I think that is a key to 
getting people into the system in many circumstances.
    So my first question would be how do you--how do you do 
that? And specifically because, again in your testimony, I will 
read word-for-word your testimony. ``For most of these 
conditions,'' you are talking about mental health conditions, 
``prevention works, treatment is effective, and people do 
recover.''
    So how do we avoid a lifelong stigma attached to treatment 
of some of these serious issues?
    Ms. Hyde. Mr. Chairman, Congressman Harris, thank you for 
the question. It is a great question because we share your 
concern.
    And part of the reason we want to launch a national 
dialogue, and we are going to do that with Education, is to try 
to get at these tough issues, as you said. There is already in 
the Brady bill language about prohibition of individuals who 
have experienced involuntary commitment being prohibited from 
getting a gun. It is left to the States to determine whether or 
not there is a way out of that for the individual, and only 
part of the States have passed those laws to allow that.
    Part of what we want to do with the national dialogue is, 
in fact, have fact-based conversations and make sure that we 
don't tie mental illness and dangerousness or violence. There 
is no evidence that people with mental illness who do commit 
acts of violence do it with guns any more than anybody else who 
commit acts of violence.
    So people with mental health problems are not that 
different in that sense. What they have is a public health 
issue and a diagnosable illness that can be treated, in many 
cases prevented, and people do recover.
    So that is the kind of conversation we want to have and 
foster. And then we want to have in each community who takes on 
this kind of a dialogue an opportunity to have facts to support 
that and also to have an opportunity to think about in their 
local community how will they address this issue and how will 
they take that on?
    We want to make sure that local residents who are ordinary 
citizens have that part of that conversation because a lot of 
times, people come to that with media views of what people with 
mental health are, and those are not always accurate. We are 
also working on some media guidelines and trying to help people 
get accurate facts in order to begin the conversation.
    Mr. Harris. Thank you very much.
    I appreciate that because these are--again, these are very 
difficult issues that we are going to have to work our way 
through, always being mindful that individual rights and 
liberties are--that is a cornerstone of America. And I share 
some of the chairman, before he had to leave, some of his 
comments that as we--in our zeal to identify people who need 
treatment, we have to be careful because we are empowering 
people to be agents of I will say agents of the State, really.
    As he suggested, a teacher who refers someone for mental 
health is the government doing it, and we have to be sensitive 
to that, that that kind of perception will--I think in my mind 
will actually impair access at some point. Some people will be 
reticent to have the government involved, and we should be 
thinking of ways to guide some of this more into--more into 
mainstream medical treatment. Because most medical treatment in 
the United States is not delivered by the Government, and that 
is why I think people seek it.
    Ms. Hyde. Congressman, we agree. And one of the reasons 
that we want to do things like Mental Health First Aid is we 
don't want to have someone like me treat cardiac problems, but 
we may want somebody like me to know when a person has the 
signs and symptoms of a heart attack so that we can get the 
right help at the right time.
    So Mental Health First Aid and that whole approach to 
awareness and raising consciousness about this is not at all 
meant to have agents of the State or even the public treat 
people. It is to help them know when to help someone seek help 
and get the help they need.
    Mr. Harris. Great. That is an important distinction.
    Thank you very much, Mr. Chairman.
    Mr. Alexander. Ms. Lee.
    Ms. Lee. Thank you, Mr. Chairman.
    And I think, following up on that question, I think that is 
part of the reason why I am so pleased to see in the 
President's initiative funding to train mental health 
professionals. I mean, that is extremely important. And I hope 
this committee would support that effort because early 
identification of possible mental health issues is extremely 
important.
    And teachers are hired to teach. They are not hired to be 
mental health counselors or psychotherapists. But teachers can 
know the signs and learn the signs. And if we had the mental 
health counselors right there on campus, the early assessment 
could be made, and determinations with the family could be made 
in terms of the course of action.

                          BULLYING PREVENTION

    Let me ask you, Congressman Honda is chair of our bullying 
caucus, and I wanted to ask you about bullying because we know 
that there has been an increased rate of suicide as a result of 
bullying. And how are you--I mean, what is going on now in the 
country?
    Are there strategies and programs to address bullying? 
Because this is a very serious problem that young people are 
faced with in all of our districts.
    Ms. Delisle. Sure. I will start there. Congresswoman Lee, I 
think that this is an issue which is certainly a priority for 
the Department as well as for schools across the country 
because of the issues of bullying, as you mentioned, that 
result in some pretty horrific events for students and for 
children in their lifetime.
    We have a number of initiatives, including through 
proposals in Now is the Time, to increase programs, evidence-
based programs in schools for teachers and for students and for 
families to engage in around the issues of bullying and school 
climate. And I want to emphasize school climate is so critical 
because when many of us have walked into school districts or 
schools, when we have had an opportunity to kind of just walk 
in the school, within 5 minutes you know whether or not you 
want your own child in that school.
    And if the school climate is such that there is an answer 
of no to that question, ``Do I want my own child in this 
school,'' we should not wish it for any other child in any 
other family.
    Part of the culture of that school is creating a safe haven 
for students, is creating a climate in which students and 
teachers feel respected, and they also learn the art, if you 
will, of communicating with one another. And they also provide 
opportunities for students to learn behaviors other than 
bullying, and they respond to that.
    So programs such as Positive Behavior Intervention Support, 
which is included in the proposal in Now is the Time, is one 
such example of increasing funds and technical support to 
schools to do that.
    We also have been working closely with SAMHSA throughout 
the proposals through Now is the Time, in addition, in other 
kinds of ways in making sure that our kids feel safe and secure 
in schools emotionally as well as physically.
    Ms. Hyde. And Congresswoman Lee, I would add to that that 
one of the things that this administration has done, from the 
President and First Lady, is to call on all of us to 
collaborate around the issue of bullying because it is such a 
pervasive issue. We have created a common Web site, 
stopbullying.gov. We had multiple Web sites and multiple places 
for people to get information, schools to get information, kids 
to get information about bullying.
    We have created some cyber-bullying prevention efforts, and 
that common Web site is actually jointly funded and managed 
between HHS and Education. And within HHS, there is three 
operating divisions and offices that are collaborating on the 
editorial board about making sure that we all contribute, and 
then Education is providing a lot of the guidance and 
leadership on that.
    So we are working a lot on that, and CDC and others have 
been doing research around what happens to kids when they are 
bullied and what kinds of impacts that has. You see kids with 
increased behaviors that are like inappropriate sexual 
behaviors, inappropriate eating behaviors, inappropriate 
substance use behaviors, in many cases tied back to bullying 
behavior.
    So we are doing research. We are doing public information. 
We are doing information for teachers and parents and for youth 
themselves, and calling on youth also to get engaged to just 
say this is not okay. It is not an okay behavior that we, as 
youth, want to put up with in our schools.
    Ms. Lee. I will hold my next question until the next go-
around, Mr. Chairman.

                 DUPLICATIVE VS. COLLABORATIVE PROGRAMS

    Mr. Alexander. Thank you.
    I guess I offended Mr. Joyce.
    You both mentioned and the President has mentioned new 
initiatives to deal with mental health. The Government 
Accountability Office tells us that today we have 82 teacher 
training programs, and it is hard for us to believe that within 
the programs that exist today that there is not a program that 
would adequately deal with the problem that lies before us.
    So my question is if these new programs are authorized and 
financed, what current programs would they likely take the 
place of?
    Ms. Hyde. Vice Chairman Alexander, we carefully crafted 
these proposals with the White House, OMB, and each other to 
make sure they were not duplicative and were actually 
collaborative. They, in many cases, build on successes that we 
have done at a pilot level, and we are now proposing to try to 
take some things statewide, to move things into a statewide 
approach.
    In other cases, like Healthy Transitions, for example, it 
is a pilot to try to see if we can specifically address that 
very difficult transition age or what is now being called the 
emerging adults population because they have very specific and 
difficult issues. And some of them are in schools, and some of 
them are not.
    So bringing communities and schools, parents, law 
enforcement, and others together is really critical. So we want 
to support the in-school programs, and we also want to support 
the community-based mental health and first responders and 
parents programs. So we are working very carefully to 
collaborate, rather than to duplicate.
    Ms. Delisle. Yes, I would just add to that, I think the 
strength of the proposals are really deepening our partnership, 
which is already existing and working really hard for schools 
to see that they have an ability to really deepen their 
partnerships in the local community.
    So as I mentioned previously, I have been in education for 
a long time, and it has been more common practice to have 
schools sort of isolate themselves around the community 
services that are available. So part of our partnering and the 
proposals in Now is the Time really lift that up and cause 
communities to think about how do they strategize across the 
support structures that are needed for students in the Pre-K 
through 12 setting.
    And in mentioning the teacher training programs, we also 
have to be very aware that in the teacher training programs, as 
Congresswoman Lee mentioned, teachers are learning to teach our 
youth. They are not learning all the trades and the tools that 
mental health workers have available to them. That is a 
specialty area in and of itself.
    So our proposals are also linking those so that while 
teachers may have access to resources or to become better, I 
guess, identifiers of students who may potentially have issues, 
the real crux here is--in the proposals--is the partnership and 
those community relationships. And some of them are a little 
bit new and deeper.
    So, for example, in Now is the Time, we also are going to 
be providing $25,000,000 to address the post traumatic stress 
disorders that Congresswoman Lee actually mentioned. That is a 
deeper program than has been issued before.
    We are very careful that our programs are not just 
replicating themselves just in quantity, but also in quality.
    Mr. Alexander. Okay. Ms. Roybal-Allard.

               PREVENTING UNDERAGE DRINKING AND VIOLENCE

    Ms. Roybal-Allard. While we have had some success, underage 
drinking remains a serious public health and safety concern. 
Just yesterday, an article in the L.A. Times highlighted the 
severity of the problem, telling the heartbreak story of a 
young woman who was raped while she was intoxicated.
    For years, members of this committee, including Rosa 
DeLauro, Frank Wolf, and myself, have worked to provide SAMHSA 
with resources to prevent underage drinking through the STOP 
Act, and we have watched with disappointment and with a great 
deal of concern as much of the school substance abuse 
prevention money has been reduced or eliminated.
    Administrator Hyde, can you speak more to the relationship 
between youth alcohol abuse and violence, where you have seen 
the most success in preventing youth alcohol abuse and why, and 
what else needs to be done?
    Ms. Hyde. Thank you, Congresswoman Roybal-Allard, and thank 
you for your support of the STOP Act and for these issues.
    As you know, we have reinstituted this year, or last year, 
the ICCPUD. It is sort of the worst acronym in the Federal 
Government. But it is the Interagency Coordinating Committee on 
the Prevention of Underage Drinking. It comes out of the STOP 
Act, and we reinstituted it at the principal level. It had been 
working at the staff level, but really to try to raise these 
issues.
    The connection between youth and students who are drinking 
and causing violent behavior, it is usually one-on-one or 
individual violence, but nevertheless, about 696,000 students 
between the ages of 18 and 24 are assaulted by another student 
who has been drinking each year. These are 2009 data. About 
97,000 students between the ages of 18 and 24 are victims of 
alcohol-related sexual assault or date rape.
    So this is a huge issue. We have seen major gains about the 
reduction of underage drinking in certain age groups. So the 
12- to 17-year-old age group, binge drinking is actually 
quite--is down quite a bit, about 30 percent over the last few 
years. The 18- to 24-year-old age group, not so much. We 
haven't seen those kinds of reductions. We also see continuing 
deaths from alcohol-related injuries by car, by vehicle or by 
accident when a young person is intoxicated.
    So the STOP Act is an important part of our portfolio. Part 
of it is this interagency working effort we have. We have 
launched this year a webinar series that has gotten incredible 
reaction to try to get information out about underage drinking 
and how the data that we put into the congressional report, 
which is funded by the STOP Act, has become a really important 
tool to the field and to communities and to organizations like 
our drug-free communities, prevention programs that are 
focusing on substance abuse among young people, including 
alcohol.
    So the STOP Act itself has funded about 180 communities, 
and last year, we did an additional 81 grants, and we expect 
about 15 new ones this year. You can see that the numbers are 
lower in part because of the reduction in dollars that have 
occurred over the last couple of years. I think Congresswoman 
Lee read those numbers.
    So we provide as much funding and as much support, and the 
webinar series is a way to try to get word and information out 
short of calling people together in conferences and other ways 
that we might have done that in the past, but to try to 
continue to get our efforts around underage drinking dealt 
with.
    We also know, frankly, that young people who don't drink 
until they are older, until they are 21 or older, are much less 
likely to have problem drinking as an adult. So it is a 
critical issue not only for our young people, but for adults as 
well.

               SCHOOL-BASED ALCOHOL PREVENTION STRATEGIES

    Ms. Roybal-Allard. Okay. Assistant Secretary Delisle, can 
you talk about what is being done in the schools to address 
underage drinking with I understand your limited resources as 
well? And what more could be done if you did have adequate 
resources?
    Ms. Delisle. Thank you, Congresswoman, for that question.
    I think one of the issues in schools is always providing 
information to students and to their families. Not just about 
the data around the inappropriateness and the legal 
ramifications of underage drinking, but certainly the health-
related risks as well.
    In my experience in viewing schools across the country, 
they rely heavily on school counselors to help with that 
information gathering, providing support structures for teens. 
We have seen some examples of schools that actually have 
created student support groups and also have created community 
events so that students have a place to go that are non-alcohol 
related.
    So even in the high school years, they may have a prom or 
after prom activities that are totally devoted and are ensuring 
that the students who come there are committed to an alcohol-
free life.
    So the proposals that we put forth to increase counselors 
in the schools would certainly help to provide that 
information, as well as to help bridge the gap with communities 
that are facing the 18 and up group to which Ms. Hyde referred.

              BUDGET REQUEST FOR HEALTHY TRANSITION GRANTS

    Mr. Alexander. Mr. Joyce.
    Mr. Joyce. Thank you.
    Administrator Hyde, I would like to thank you for coming 
today and ask you about when you were speaking about 
individuals 16 to 25 being at high risk for mental illness, 
substance abuse, and suicide, at the same time, these are the 
least likely group to actually go out and seek help.
    I see that the administration arrived at a $25,000,000 
funding level for State-based strategies to support these young 
people. How did you arrive at that number?
    Ms. Hyde. What we were trying to recognize is that this age 
group has special issues--system issues, legal issues, and just 
coming of age issues. We have other programs in about that age 
or about that cost range that will allow us to pilot and do a 
pretty good demonstration to determine what is the best way to 
approach those kinds of issues.
    We have some programs here and there that do transition age 
youth, but it's not been a focus. So what we are trying to do 
is use these dollars to pilot in a few States what would be the 
best approaches. So anytime we start a new program like this, 
we do an extensive evaluation and then try to make sure that we 
have got the best programs and the best practices before we try 
to take it to scale.
    Mr. Joyce. With the other things that you have been doing, 
do you have any idea what your success rate is as far as 
getting kids to attend and be involved in these type of things?
    Ms. Hyde. Our programs, whether it is our Drug-Free 
communities program or whether it is the Safe Schools/Healthy 
Students program or any of them, show incredible success. When 
you engage young people, you can reduce the perceptions of 
violence as well as the actual violent behaviors. You can 
reduce the drug use, and you can reduce the violence associated 
with that drug use or that alcohol use.
    So, on any particular program that we have in place now, we 
do have data, and we can share that with you if you have a 
particular interest in a particular program. Or if you would 
like some information just in general about what we are seeing 
in those programs, we can let you know.
    Mr. Joyce. Thank you.

           IDENTIFYING STUDENTS WHO HAVE MENTAL HEALTH ISSUES

    Assistant Secretary Delisle, thank you also for being here 
today. It is easy for teachers to be able to tell when somebody 
has a fever. What are we doing to assist teachers in trying to 
pick out those who might be having mental issues?
    Ms. Delisle. Congressman Joyce, it is actually nice to 
become reacquainted with you. I actually worked in the West 
Geauga local school districts, and we had some interactions 
with your office. So it is nice to become reacquainted with 
you.
    Mr. Joyce. I recall.
    Ms. Delisle. Yes. [Laughter.]
    I was going to say it wasn't always under the best of 
circumstances. Not on your condition, it was because of some of 
our folks.
    Anyway, I think one of the things we discussed a little bit 
earlier and was provided in my testimony is that it isn't easy 
for a teacher to do because they are not naturally trained in 
that. And as Congresswoman Lee has mentioned, that is not their 
area of expertise.
    So the more that we can provide knowledge and resources to 
teachers, the better. So what are these indicators? And then 
have them be able to connect with a mental health provider who 
can follow up on that and just suggest whether or not that is 
something that we ought to look at a little bit closer, or it 
is developmentally appropriate for that student to be behaving 
in that kind of way.
    What is even more important, though, is not just that 
diagnosis or that recognition of that mental health disorder, 
but also how the strategies that a teacher may use within the 
classroom to more certainly engage that child in a productive 
kind of way. That is what is really necessary.
    So we look to mental health providers to provide that 
information, that knowledge, and resources to students as well 
as to their families because sometimes families don't know how 
to cope with a child who may have a mental health disorder.
    Mr. Joyce. And you know why this is of special interest to 
me after what took place in Chardon?
    Ms. Delisle. Yes.

                   EFFECTS OF VIOLENCE IN VIDEO GAMES

    Mr. Joyce. And that is why I want to know what--also you 
had, Ms. Hyde, you had talked before with the chairman about 
violence in programming. What about has there been any studies 
done on violence in video games and its effect on teenage?
    Ms. Hyde. Congressman Joyce, that was the question the 
Chairman asked me, and it is not my area of expertise. So I 
actually don't have the information here about that. I know 
that there are other parts of the department that are looking 
at those issues. So I would--we can get back to you about who 
might be the right individual to have talk to you about that.
    Mr. Joyce. Do you have any input on that, Ms. Delisle?
    Ms. Delisle. I would say the same. [Laughter.]
    Mr. Joyce. Well, it is of special interest to me, 
obviously, because there is a combination. Obviously, there are 
some mental health issues, and there is also some issues with 
the violence that you will notice that between the video games, 
the fact that--and Hollywood. But in video games, the fact that 
they re-spawn, and all of a sudden, 60 seconds later, 30 
seconds later, I don't know what that is, but then all of a 
sudden, these kids come back.
    And in that case particularly where this young man shot the 
people in the high school, the first thing he asked was ``Why 
did you do it?'' ``I don't know why.'' And wanted to have that 
moment back in time.
    Well, because I really think that it is on top of having 
some mental issues that there is also a play of how much 
violence these kids are getting used to, and it is not right. 
So any help you could give us in that area, I would really 
appreciate it because it is something I am very interested in.
    Thank you.
    Mr. Alexander. Thank you.

        AMOUNT OF FEDERAL FUNDING ON MENTAL HEALTH IN EDUCATION

    What percent or what is the total amount spent by the 
Federal Government on mental health in education? Do we know?
    Ms. Delisle. Congressman, I do not have that number. We 
could certainly get that back to you and combine all of our 
programs out of Ed, but a starting estimate would be $50 
million.
    Mr. Alexander. Thank you.
    Ms. Lee.
    Ms. Lee. Thank you very much.

           MENTAL HEALTH TREATMENT MODALITIES USED IN SCHOOLS

    There are a couple questions I would like to ask, and you 
probably would have to send this to the committee, the answer 
to this one. But I am interested in knowing what the treatment 
modalities now that are being used in schools in terms of 
mental health treatment.
    I mean, I was trained way back in the day in psychoanalytic 
psychotherapy, play therapy, behavioral therapy. Is there any--
and I know it depends on the diagnosis or the kind of plan, the 
treatment plan. But I am curious now to know what the primary 
mode of treatment is for young people.
    Ms. Delisle. Congresswoman Lee, actually, within schools, 
what we see is that the treatment occurs outside of schools 
with mental health professionals in a specific setting. What we 
see happening in schools is sort of what I would view as the 
secondary approach, and that is so everything from play 
therapy, et cetera, that is being used to support what occurs 
with that provider on the outside of the school.
    Ms. Lee. I see.
    Ms. Delisle. So that interaction and that information 
sharing is really critical.
    Ms. Hyde. Congresswoman Lee, there is a program that was 
initially researched by NIMH, the National Institute of Mental 
Health, with very good results, and we have with Education 
implemented it in many school settings. And that is something 
called the ``Good Behavior Game.'' It is a program that is a 
preventive program. It trains teachers how to deal with 
behaviors in the classroom.
    And there are incredible results for both the teachers and 
the young people. That is more of a preventive intervention, 
but it is--and it is child specific. So that is an example of 
something----
    Ms. Lee. I would like to learn more about this.
    Ms. Hyde. Okay.

                   IMPACT OF FUNDING CUTS ON PROGRAMS

    Ms. Lee. Let me ask you about going to the funding. I 
mentioned in my opening statement funds have been cut between 
2010 to 2012 for SAMHSA, what, 5 percent? Now, on top of that, 
we have got sequestration. Funding now is about a fifth lower 
than 2002.
    Tell me what is going on with regard to funding, and how 
you are going to--what the impact of sequestration is on 
children's mental health programs and services? Knowing that we 
are nowhere near where we need to be, does this mean we go 
backwards again, or what do we do at this point?
    Ms. Hyde. Congresswoman Lee, obviously, all of our programs 
are programs that are showing good results in what they do. And 
if they don't show good results, we don't continue them. So any 
program that sees a reduction means it is less that we can do 
for the communities in America.
    In some cases, sequester will result in fewer new grants. I 
gave you an example of that with the STOP Act grants that we 
anticipate this year. In other cases, it is literally fewer 
people who will be able to get substance abuse treatment or 
other kinds of services that support people getting those 
treatments.
    For the last 3 years, we have taken the responsibility to 
consolidate, make sure that programs that are able to be more 
efficient and more effective can be done in a different way. So 
we have done everything we can to reduce expenditures without 
reducing impact on programs.
    We are at the point where that is no longer possible. So 
additional reductions are going to mean reductions in grants 
and programs and our public efforts, our public education 
efforts, and our efforts at outreach and our efforts at data 
collection, et cetera.
    Ms. Delisle. So, Congresswoman Lee, I would add to that 
that in the President's 2013 budget, it actually included 
$196,000,000 for a Successful, Safe, and Healthy Students 
program that was part of the ESEA reauthorization proposal. And 
much of that was really focused in on supporting students in 
schools both with mental health issues as well as creating 
these positive support structures that I place.
    So, like SAMHSA, we are very concerned with sequestration 
about the possibilities of grants being reduced and funding 
available to schools. So, for example, in our Project SERV 
program, we actually provide dollars to the local school 
district. So when there is an incident that occurs, a shooting 
such as in Chardon, Ohio, when learning is interrupted, we 
provide dollars for mental health workers to support the 
students and the educators.
    But the other concern that I have is almost a secondary 
one, which is, for example, in Title I, which serves our 
poorest children, particularly in the areas of reading and 
mathematics, while that is focused on an academic venue, what 
my concern is that with that lowered, lessened services to 
students in the academic field may, in fact, yield more 
behavioral incidents in schools when students become frustrated 
because they can't read or they can't catch up with their 
academics.
    So there is also a secondary component that is really 
critical.
    Ms. Lee. Thank you very much.
    Mr. Alexander. Dr. Harris.
    Mr. Harris. Thank you very much.

               ALARMING TREND IN YOUTH SUICIDE STATISTICS

    Ms. Hyde, let me just talk about another topic that people 
don't like to talk about. We need to talk about it because a 
lot of people are concerned, and that is teenage suicide.
    It is of concern to me that the CDC report last year 
indicated that if you look at children who either attempt or 
complete suicide, that the incidence over the past few years 
from they looked at data from 2009 to 2011, actually increased 
about 20 percent, where just under 8 percent of teenagers say 
they either considered or attempted suicide.
    And interestingly enough, the highest incidence are 
Hispanic girls, which is interesting, and I am not sure what 
the explanation is. But it actually gets to the point, two 
points and two questions.
    One is whatever we are doing, it is not working because the 
incidence is going up. As we continue to spend billions of 
dollars, I mean, the incidence is going up. And I guess the 
questions are related. In your opinion, what is the cause of 
the increased incidence, and why haven't our strategies worked 
for that particular topic, teenage suicide?
    Ms. Hyde. Congressman Harris, thanks again for that 
question.
    You may be aware that over the last couple of years, there 
has been a public-private partnership called the National 
Action Alliance for Suicide Prevention that was kicked off a 
couple of years ago by Secretary Sebelius and Secretary Gates 
because we are also concerned about this issue, obviously, 
among military personnel and veterans and their families.
    That effort has spent 2 years with the Surgeon General 
updating something the Surgeon General just released last fall 
called the ``National Strategy for Suicide Prevention.'' And in 
that strategy, we looked at young people. We looked 
specifically at Native Americans. We looked specifically at 
military personnel, and we looked a number of other groups.
    We also brought together the different players in the 
Federal Government who do the data about this. So CDC tends to 
do the mortality data, and SAMHSA, frankly, does a lot of the 
data around thoughts, plans, and acts to commit suicide, but 
may not result in actual death.
    So we have been able now to combine those data to get a 
better picture of young people who have higher rates of 
attempts and thoughts of suicide. Frankly, older people, older 
men have attempts that result in death.
    So we are sort of looking at the whole range. There is a 
different approach when you are looking at the distress of 
young people that results in the kinds of attempts and acts and 
thoughts versus the actual result in death.
    We also have done an increasing amount of work, at least in 
SAMHSA, to address the Latina, young women of Hispanic 
background. About 25 percent of our Garrett Lee Smith grantees 
are specifically focused on this community. So I think there is 
looking at the data, that is a community that has a higher 
incidence of those kinds of thoughts and actions, and we are 
trying to look at it from young people before college, but also 
on college campuses and that age group that is specifically 
addressed appropriate there.
    Why has it not worked? I think that is part of what we have 
learned through the interagency and public-private partnership 
from the Strategy and the Alliance. And I think what we know is 
intervening early. I think we know that there are a lot of 
individuals who don't know the signs and symptoms. So right in 
front of you can be a young person who is exhibiting signs and 
symptoms, but either a parent or teacher or a faith leader 
doesn't know what kind of outreach to do.
    There are youth who don't know how to reach to other youth, 
and they are some of our best early interveners to get help for 
young people. And then, frankly, young people as well as older 
people who attempt and enter hospitals or enter emergency rooms 
after an attempt are at high, high risk of repeat attempts and 
death from suicide.
    So we are also looking at hospital emergency rooms, 
readmission rates, connections, and care coordination once they 
leave there. Those are the kinds of issues we are also trying 
to look at.
    The National Action Alliance set a goal of a reduction in 
over 5 years of a specific set of numbers, which is not in my 
head at the moment. But so we are really trying to look at the 
metric and trying to get those numbers down.
    Mr. Harris. And what--are there any proposals--has this 
alliance actually come forth with their proposals yet? I mean, 
because this trend is not a new trend. My understanding is this 
trend started around the middle of the last decade, and after 
gradually dropping off, it started to increase.
    And you know, the CDC data is not just mortality. CDC data 
is attempt or complete. So this is not new data. I mean, how 
long is it going to take for us to actually be able to do 
something?
    We spend a lot of money on this. We spend millions and 
millions of dollars on some of the grants you suggest. Is there 
a realistic possibility that we can actually reverse this 
trend?
    Ms. Hyde. Congressman Harris, again, we collaborate with 
CDC and use each other's data. So they do use some of our data 
on the acts and completions--I mean the acts and the thoughts. 
And what we are trying to look at there is what is the trend 
compared to what is going on in the environment?
    So, frankly, as the economic issues have been more dire, we 
have seen some of the rates go up. We are also trying to look 
at what that data, the mortality data comes a little later than 
the data about thoughts and actions. So, yes, the Action 
Alliance has actually put out some recommendations and the 
strategy has very explicit things.
    It just came out last fall, and we are now in the process 
of implementing. And as I said, there is a commitment at the 
public-private level as a metric to reduce those numbers in a 
certain period of time. We can get you that metric. I just 
can't pull it out of my head.
    Mr. Harris. I would appreciate that. Again, and the report, 
any reports you have from the alliance. I would appreciate 
that.
    Ms. Hyde. Okay.
    Mr. Harris. Thank you very much, Mr. Chairman.
    Mr. Alexander. Fiscal year 2012, $117,000,000 was devoted 
to mental health. The fiscal year 2013 request from the 
President was $88,000,000. That is quite a bit less, and the 
President now is proposing after a response or in response to 
the Sandy Hook tragedy to train an additional 5,000 mental 
health providers.
    And another aspect of the President's proposal includes 
devoting $25,000,000 to State-based strategies on young people 
between the ages of 18 and 25. So the question is for those 17 
or 18 to 25 that are no longer in school, how do we propose 
reaching them?
    Ms. Hyde. Congressman Alexander, there are actually two 
parts to your question. The first part, I think, refers to our 
program, which is called the Children's Mental Health 
Initiative. It is a program that has been in existence for a 
number of years. We have done a lot of evaluation, and it is a 
great program. We have developed models that help us know now 
that we need to push those out across the country.
    So in the same President's budget, there was actually a 
proposed increase in the Mental Health Block Grant, and what we 
were trying to do was say, okay, we have proved the process and 
let us begin to move it to scale by moving it throughout all 
the States, not just in the communities that we could fund. So 
there was a rationale to the way that set of proposals was 
proposed.
    You asked a second question, and I have just lost it. Was 
the second part of your question was?
    Mr. Alexander. How do we reach those that are no longer in 
school?
    Ms. Hyde. Ah, okay. The Healthy Transitions project then is 
proposed as what we call our ``theory of change,'' actually. It 
is once we prove a program works for a specific set of kids, 
and the Children's Mental Health Initiative was for young 
people with serious emotional disturbances. We now see a set of 
young people who are moving from the child-serving system to 
the adult-serving system, moving out of school, sometimes into 
community colleges or colleges, but not always, and have a very 
different set of structures to deal with.
    So what we want to do now is do some pilot work to see what 
is the best approach for serving those young people and do the 
evaluation that we have done on some of the other programs that 
have been in place for a while.
    Mr. Alexander. Ms. Lee.
    Ms. Lee. Let me ask you, going back to the funding and the 
impacts, your response in terms of the sequester really is very 
scary because we are talking about what we need to do in the 
future. So I don't know what is going to happen to these kids. 
I just don't know.
    So I want to hear from you what you think could happen and 
what we need to be prepared for in all of our communities. And 
then, secondly, the President's plan that he is putting 
forward, it has, of course, funding requirements. Is this going 
to be in his budget? I mean, he is going to request it in his 
budget, right, and this will come before this committee?
    I mean, well, we are going to have to appropriate some 
funding for the President's plan, right? Okay. Now can you make 
the case for that?
    Ms. Hyde. Congresswoman Lee, I can speak to the proposals 
on the mental health side, and Assistant Secretary Delisle can 
speak to the education programs.
    The case for it I think we have been talking about in this 
hearing, and you have offered us an opportunity to do that, 
which is to try to take a program called Safe Schools and 
Healthy Students that we did a lot of good work on together 
over the last several years. We are taking that program, along 
with a new concept, the Mental Health First Aid, and packaging 
those together to try to take to scale in a few States a 
program called Project AWARE.
    And what that will do is bring what we learned from the 
Safe Schools/Healthy Students program and put it together with 
Mental Health First Aid to get awareness up, to get communities 
and schools working together across a State, and to take it to 
scale in the State. See if we can do that. See if we can go 
from the projects to the scale.
    The second project we just got through talking about is the 
Healthy Transitions Program, which is really trying to address 
that transition age youth. If you look at a number of the mass 
incidents or mass casualty incidents, it is this age group that 
is involved. Not always, but some of them are.
    We are not suggesting that we are trying to prevent those 
issues, but we do know that that age group has particular 
issues. It is when some of the first psychosis tends to happen. 
It is when, we have already talked about, there is more 
incidence of issues and less help seeking.
    We know that parents are less involved as kids become 
adults. They are less able to influence children's behavior 
sometimes. So we are trying to look at all those issues and see 
what that can mean.
    And then the third program is the workforce program, and we 
just produced a report that was requested by Congress, gave it 
to Congress last week, that sort of delineates the need for a 
health workforce of all sorts everywhere. It is not just in one 
place, but it is really a workforce that needs to be produced 
more.
    Ms. Lee. Okay. So what happens, though, to the damage done 
by sequester? You know, I mean, I want to support and make sure 
all of the President's initiatives are fully funded.
    But now we have a problem with the lack of funding for 
those who have been just sort of left outside of the service 
realm because the cuts have taken place. So what happens to 
them?
    I mean, do you double down on the new programs? Do you 
increase it by 50 percent? Do we look at how to make up for 
lost time and lost services and lost children? I mean, how do 
we deal with it?
    Ms. Hyde. Congresswoman Lee, we do the best we can with the 
dollars that Congress appropriates to us. And to the extent 
that the sequester has reduced programs, we are going to see 
fewer people treated. We are going to see fewer professionals 
trained. We are going to see fewer individuals informed about 
their ability to make a difference in this.
    We are going to see less ability to train teachers. All of 
those things are going to happen across the board for the 
programs under the sequester reductions.
    Ms. Lee. Yes, so it seems to me that the dollar amount that 
the President is requesting is not enough, quite frankly.

       COLLABORATION BETWEEN SCHOOLS AND MENTAL HEALTH PROVIDERS

    Mr. Alexander. Mr. Joyce.
    Mr. Joyce. Thank you, Mr. Chairman.
    Again, Assistant Secretary Delisle, if you would, could you 
explain what has been taking place, what outreach has been made 
in trying to encourage collaboration between school systems and 
local mental health facilities? And you may have answered that, 
and I may have been missing. And I apologize.
    Ms. Delisle. Thank you, Congressman Joyce.
    I think we have had a lot of impact in modeling, first of 
all, at the Federal level about our own initiatives across not 
just with SAMHSA, but also with the Department of Justice. We 
have cosponsored some learning sessions. We have cosponsored 
some webinars. We have cosponsored some summits.
    For example, we had a bullying summit last summer, which 
was highly effective in getting people to really discuss a very 
critical issue. So, first of all, we are modeling that at the 
Federal level.
    At the local level, many of our grant programs actually 
have a requirement in them that communities and schools partner 
over a variety of issues, such as mental health issues, such as 
counseling, such as family support structure, such as family 
engagement.
    So we have made that a priority in the Ddepartment for 
schools to actually reach out into the community to support the 
programs and to support the learning needs of all students.
    Mr. Joyce. That is fantastic. Is there any way to measure 
the outcomes of whether or not we are actually getting 
something accomplished?
    Ms. Delisle. Well, to the extent possible, Congressman, 
that we could measure the numbers of meetings and interactions, 
we will be looking at that. So even through our ESEA 
flexibility waiver packages, the States even had to arrive at 
ways in which they would reach out to schools, et cetera, and 
engage community members in those plans.
    So we will be looking at that. I don't know if we will be 
able to actually collect data on the effectiveness of them 
because it is a pretty hard variable to isolate. But certainly, 
the numbers of interactions would be one that we could measure.
    Mr. Joyce. Great. Thank you.
    I would yield back, Mr. Chairman.

           HIGHER RATES OF ATTEMPTED SUICIDE BY LATINA YOUTH

    Mr. Alexander. Ms. Roybal-Allard.
    Ms. Roybal-Allard. I want to go back to the previous issue 
that was raised by Dr. Harris with regards to adolescent 
suicides and add to the previous discussion with regards to 
Latina youth suicide. Because for the past 20 years, adolescent 
Latinas have had significantly higher rates of attempted 
suicide, and in 1995, it was reported that 1 in 5 reported a 
suicide attempt.
    And recently, rates among adolescent girls have decreased. 
However, the Latina population has continued to have higher 
rates even than their African-American or white counterparts. 
More staggering is that for every 1 suicide death, there are 
reports of 8 to 15 attempts. And some of these cases are being 
seen in girls as young as 12 years of age.
    So I just wanted to make the point that there is a real 
need for specific programming and extensive research focused on 
why Latinas are at a higher risk for attempted suicide. I 
really don't have--I have a question, but I just wanted to get 
that on the record.
    Also, Administrator Hyde, for all of these issues that we 
have been discussing today, it is critical that we have a 
culturally and linguistically competent mental health 
workforce. In its Gun Violence Task Force recommendations, the 
administration has proposed $50,000,000 to train more than 
5,000 additional mental health professionals to serve students 
and adults.
    And the proposal seems specifically designed to train more 
social workers, counselors, and psychologists. Can you give me 
a sense of how these resources will be allocated? For example, 
will money be going to the National Health Service Corps? Is 
the administration proposing any new funding at all for the 
SAMHSA Minority Fellowship Program?
    How is all this money going to be distributed and where?
    Ms. Hyde. Congresswoman Roybal-Allard, yes. We are--a 
portion of the workforce proposal is specifically to double the 
Minority Fellowship Program that we do. It is currently a very 
small program, about $5,000,000, but it gives us a lot of 
special efforts at increasing those professionals that are from 
those populations that are least well served.
    We want to double it and focus the Minority Fellowship 
Program on a youth-serving population, not always under 18, but 
that young adult population. We want to try to get at that and 
encourage that. So that is another--that is a $10,000,000 
program.
    Then $35,000,000 of the program will be collaboration with 
HRSA, which is using its authority, it has a mental and 
behavioral health authority, to put specific grants out to 
develop new professionals in the groups that you said. We are 
focusing with them on those professionals that will be 
clinically trained. We can produce Ph.D.s as well, but 
sometimes the Ph.D.s are teachers or trainers.
    And while we need those as well, this particular project is 
trying to focus on master's level individuals who will be 
clinically trained and work directly with young people and 
their families.
    Then there is another part of the project that is for 
peers. So paraprofessionals and peers we know have a great 
capacity to engage, to do recovery supports, and to do some of 
the other really critical services that, frankly, especially 
for young people, a peer can do much better in many ways than 
the licensed professional, clinically trained folks.
    So it is a combination, and we packaged this program with 
HRSA carefully to try to produce as many as we could with the 
dollars we had available in a 2-year period. So it is all of 
those things.
    Ms. Roybal-Allard. Okay. I have just a few seconds left. So 
I didn't know if you wanted to comment on my previous comment 
on the Latina issue?
    Ms. Hyde. On the Latina issue? Oh, yes, we have a very 
strong program that we call the National Network to Eliminate 
Disparities, and a couple of years ago, we also created an 
Office of Behavioral Health Equity. And the National Network to 
Eliminate Disparities in Behavioral Health, which we call NNED, 
has worked with the Human Interaction Research Institute and 
the Valley Nonprofit Resources to offer 20 of our NNED 
organizations, there are about 500 in the network. It is a 
learning community.
    And we have specifically worked on coaching Latina multi-
family group therapy and taken an organization or a program 
called a multi-family group program. It is based on a well-
validated program and really tried to push it out. So we are 
trying to identify programs that work and then trying to help 
minority providers be able to push that out as well.
    So we are trying to create more minority providers. We are 
trying to support them, train them, and then trying to take 
evidence-based practices and get it out as well.
    Ms. Roybal-Allard. Okay. Thank you.
    Mr. Alexander. No more questions. We want to thank you all 
for being here today, and I would like to thank the committee 
members for engaging in a very productive committee hearing.
    And I would remind the committee members that we have 
another meeting scheduled April the 10th. What time is it? At 
10:00 a.m., April the 10th.
    Okay. The committee stands adjourned.
    Thank you.
    [The following questions were submitted for the record.]

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                                          Thursday, April 25, 2013.

        BUDGET HEARING--DEPARTMENT OF HEALTH AND HUMAN SERVICES

                                WITNESS

HON. KATHLEEN SEBELIUS, SECRETARY, DEPARTMENT OF HEALTH AND HUMAN 
    SERVICES
    Mr. Kingston. The committee will come to order, and I 
welcome everyone for the final hearing of the year, for Labor 
Health and Human Services Education and related agency 
subcommittee. We have had a number of hearings. I think we 
would all like to spend more time and getting more questions 
with every agency, but we don't get to, but we are ending on a 
strong note with Secretary Sebelius today, and I know that 
everyone on all sides at all angles and all accounts have lots 
of different questions.
    I think one of the questions that we will want to talk 
about it, and I think we have given some heads up on it, is the 
request for--about the reprogramming and transfer request, and 
we will discuss that in more detail, but let me yield the floor 
to Rosa DeLauro.
    Ms. DeLauro. Thank you very much, Mr. Chairman, and 
welcome, Madam Secretary, delighted to have you here with us 
this morning.
    As we discuss the President's budget, I believe it is 
important that we keep in mind a very key point. This budget 
assumes that the sequestration scheduled for 2014 is replaced 
with a more sensible and balanced deficit reduction package 
such as the one being proposed by the President. I very much 
hope we will succeed in doing that, but I have my doubts. And 
if we are not successful, the budget for HHS will look very 
different. Sequestration will reduce the 2014 cap on non-
defense discretionary appropriations by roughly 
$37,000,000,000, and the Labor HHS bill accounts for almost a 
third of the non-defense discretionary total. I would like to 
hear, Madam Secretary, what the impact of this will be.
    Moving to the budget before us, one proposed increase I am 
particularly pleased to see is the focus on investment in early 
childhood. This is--there is a tremendous need in America for 
further investment in high quality and readily accessible child 
care and learning opportunities for infants and toddlers, and 
while I have some questions about the proposal, I am glad to 
see this budget moves us in the right direction.
    The President's budget also requests appropriations to 
continue implementation of the health insurance marketplaces 
under the Affordable Care Act. That is exactly the right thing 
to do. The ACA is the law of the land, and our constituents 
deserve to access quality insurance options on its exchanges. 
It is unconscionable that Congress failed to provide the 
funding needed this year, and as a result, HHS has been forced 
to divert resources away from other critical public health 
priorities.
    The ACA has the potential to transform health care in this 
country, increasing preventive services, eliminating pre-
existing conditions, and reinforcing our longstanding 
bipartisan support of community health centers.
    I am encouraged that the administration requests additional 
funding for the National Institutes of Health. Patients across 
the country rely on research supported by the NIH, and other 
health agencies like the health care research and quality 
program in order to find out how we can prevent, diagnose 
earlier and better treat diseases like cancer.
    We also rely on public health agencies like the CDC to 
protect us from new diseases, like the avian flu virus that has 
affected more than 100 individuals in China, and to detect and 
control diseases here at home. Even before sequestration, 
appropriations for the CDC had been reduced by more than 
$725,000,000 in 2010. When you add sequestration, the numbers 
are even worse.
    I am pleased that the administration has requested funding 
to restore cuts made to the Title X family planning program in 
recent years.
    There are a few things in this budget, Madam Secretary, 
that I can't support. One is the proposed $445,000,000 
reduction to the Low Income Home Energy Assistance Program, 
LIHEAP. I am opposed to the proposed halving of the community 
services block grant.
    Yet another is the fact that no additional discretionary 
appropriations will go to combat health care fraud and abuse. 
It now looks like the President will seek mandatory funding for 
this. Now, I also understand that the request has been made now 
3 years in a row, and that we have had no increase from the 
majority side of our committee. So that what we need to do is 
increase this $311,000,000 which allows us to be able to combat 
health care fraud and abuse. The effort returned $7 to the 
Treasury for every $1 it spent.
    There are a number of other important issues I hope we can 
discuss today, including the strengthening of access to mental 
health services, especially in the wake of the tragedy at Sandy 
Hook Elementary School in Newtown.
    As a member of the Connecticut delegation, I can only tell 
you that it doesn't get any easier to speak about, and our kids 
need access to quality services after traumatic events like 
Newtown. We need to do a better job of protecting our children, 
and we need to do a better job in making sure that they have 
access to mental health care.
    I look forward to our discussion this morning and to your 
testimony. Thank you again for joining us today.
    Thank you, Mr. Chairman.
    Mr. Kingston. Mrs. Lowey.
    Mrs. Lowey. Thank you, Chairman Kingston, Ranking Member 
DeLauro. Thank you, Secretary Sebelius for appearing at today's 
hearing.
    I joined this subcommittee 20 years ago. With hard work, 
bipartisanship and a healthy allocation, the subcommittee can 
profoundly improve the lives of our constituents. I have been 
privileged to support efforts, including doubling biomedical 
research at the NIH to investigate the causes and treatments 
for breast cancer, autism, diabetes, Alzheimer's and a number 
of other diseases and disorders, strengthening our public 
health system through CDC investments, and expanding Head Start 
to give more children as many opportunities as possible.
    As the subcommittee readies its fiscal year 2014 bill, we 
must keep in mind that $2,500,000,000,000 in deficit reduction 
has been enacted, the vast majority of which is within the 
jurisdiction of the Appropriations Committee. Even without 
sequestration, discretionary spending is on a path to be at its 
lowest percentage of GDP in the last 45 years. HHS' initiatives 
cannot absorb further cuts.
    While I am supportive of key increases in the budget 
request, particularly for NIH, the proposed increase is less 
than one-third the amount lost to sequestration this year. 
There are a number of examples of investments this subcommittee 
makes that save taxpayer dollars. The 3-year rolling average of 
return on investment for the Health Care Fraud and Abuse 
Control Program is 7.9 to 1. For every public dollar invested 
in family planning care, nearly $4 in Medicaid expenditures are 
averted; and for chronic disease, the more we invest in 
prevention, the less we spend on treatment in future years.
    The fiscal year 2014 budget request includes a number of 
promising new initiatives, including the President's BRAIN 
proposal, $130,000,000 to help educators and parents recognize 
signs of mental illness, and increased resources for Head Start 
and child care.
    However, I am concerned with a number of proposed 
reductions, including to children's hospital graduate medical 
education, LIHEAP and the Community Services Block Grant. Once 
again, I would like to thank the Secretary. I look forward to 
today's discussion. Thank you.
    Mr. Kingston. Do any other members have an opening 
statement?
    If not, Madam Secretary, the floor is yours for 5 minutes, 
and we are going to stick strictly to the five-minute rule as 
we always have, so--some committees are a little bit more 
relaxed about it, but we have a lot of people--we like to take 
several rounds, so thank you.

                           Opening Statement

    Secretary Sebelius. Well, thank you, Chairman Kingston and 
Ranking Member Lowey and DeLauro and members of the 
subcommittee. I am pleased to have the chance to be with you 
today to discuss the President's 2014 budget for the Department 
of Health and Human Services.
    This budget supports the overall goals of the President's 
budget by strengthening our economy and promoting middle class 
job growth. It ensures that the American people will continue 
to benefit from the Affordable Care Act. It provides much-
needed support for mental health services and takes steps to 
address the ongoing tragedy of gun violence; strengthens 
education for our children during their critical early years, 
to help ensure they can succeed in a 21st century economy; 
ensures America's leadership in health innovation so that we 
remain a magnet for jobs of the future; and it helps reduce the 
deficit in a balanced sustainable way.
    I look forward to answering your questions about the 
budget, but first I would like to briefly cover a few of the 
highlights.
    The Affordable Care Act is already benefiting millions of 
Americans, and our budget makes sure we can continue to 
implement the law. By supporting the creation of new health 
insurance marketplaces, the budget will ensure that starting 
next January, Americans in every State will be able to get 
quality health insurance at an affordable price. Our budget 
also addresses another issue that, as Congresswoman DeLauro has 
already said, has been on all of our minds recently, mental 
health services and the ongoing epidemic of gun violence.
    While we know that the vast majority of Americans who 
struggle with mental illness are not violent, recent tragedies 
have reminded us of the staggering toll that untreated mental 
illness can take on our society, and that is why the budget 
proposes a major new investment to help ensure that students 
and young adults get the mental health care they need, 
including the training of 5,000 additional mental health 
professionals to join our behavioral health workforce.
    Our budget also supports the President's call to provide 
every child in America with access high quality early learning 
services. It proposes additional investments in new early Head 
Start child care partnerships, and it provides additional 
support to raise the quality of child care programs and promote 
evidence-based home visiting for new parents.
    Together, these investments will create long-lasting 
positive outcomes for families and provide huge returns for 
children and society at large. And our budget also ensures that 
America remains a world leader in health innovation. We make 
significant new investments in the NIH that will lead to new 
cures and treatments and help create good jobs. It provides 
further support for the development and use of compatible 
health electronic record systems and improved care 
coordination, and it includes funding to ensure that our Nation 
can respond effectively to chemical, biological and nuclear 
threats.
    I want to especially thank committee members for your 
support of our efforts to provide a safe environment for 
unaccompanied children who enter our country. As you know, we 
have seen a growing number of children coming into the country 
without any parents or guardians, and our budget includes 
additional funds to help ensure an estimated 26,000 
unaccompanied children are safe and healthy.
    Even as our budget invests in these critical areas, it also 
helps reduce the long-term deficit by making sure that programs 
like Medicare are put on a stable fiscal trajectory. Medicare 
spending per beneficiary, as Ranking Member Lowey has said, 
grew at just four-tenths of 1 percent in 2012, thanks in part 
to the $800,000,000,000 in savings in the Affordable Care Act.
    But the President's 2014 budget would achieve even more 
savings. For example, this budget will allow low income 
Medicare beneficiaries to get their prescription drugs at lower 
Medicaid rates resulting in savings of more than $120 billion 
over the next 10 years. In total, the budget would generate an 
additional $371,000,000,000 in Medicare savings over the next 
decade on top of the savings in the Affordable Care Act.
    To that same end, our budget also aggressively reduces ways 
across our Department. It includes an increase in mandatory 
funding for our Health Care Fraud and Abuse Control Program, an 
initiative that saved taxpayers nearly $8 for every dollar 
spent on it, and it supports additional efforts to reduce 
improper payments in Medicare, Medicaid and CHIP and to 
strengthen the Office of the Inspector General. This all adds 
up to a budget guided by the administration's north star of a 
thriving middle class, promoting job growth, keeping our 
economy strong in years to come, while helping to reduce the 
long-term deficit.
    I am sure many of you have questions, Mr. Chairman, and I 
am happy to take those now. Thank you.
    Mr. Kingston. Thank you very much, Madam Secretary.

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                   AFFORDABLE CARE ACT IMPLEMENTATION

    Mr. Kingston. I think the first question that we have, or 
that I have is that the projection for implementation of 
Obamacare in 2013 was 1.2 billion, but now it looks like you 
are requesting, and are going to use 1.7 billion, which is 
certainly a big swing, but also, I have concerns where this 
money comes from. Some of it comes out of the CDC prevention 
programs, for example, or biomedical research, NIH and other 
programs like mental health training, suicide prevention, 
Alzheimer's disease and prevention outreach, just for a few 
examples, and so I would like to know, you know, I would like 
you to react to that, and I want to add up the additional 
fiscal year 2013 funds that I understand that are being used.
    CMSS made it Obamacare base of 154,000,000 at CMS; residual 
Obamacare implementation fund, 223,000,000; proposed 1 percent 
transfer for authority, which we will review once the operating 
plans are submitted; and prevention public health funds of 
554,000,000, and non-recurring expense funds of 450,000,000 
that comes to this total of 1.7 million.
    So it looks like you are cobbling together some money, and 
I don't--I guess the question is, at what point do you know if 
you have enough? And if you don't get this, how are you going 
to be able to implement Obamacare?
    Secretary Sebelius. Well, Mr. Chairman, as you know, we did 
not have a 2013 budget, and we made a request in the debate 
over the continuing resolution for additional funding 
particularly for outreach and education. That was not granted 
by the United States Congress. It is our job to implement the 
law, and we have millions of Americans looking forward to the 
opportunity for affordable health care, so we have used the 
authorities that I have as Secretary to reprogram some of the 
prevention funding to use specifically for outreach and 
education, to use our non-recurring expense fund for one-time 
IT expenses, and to take advantage of the secretarial transfer 
authority to add additional resources.
    I think the original bill contained $1,000,000,000 in 
administrative funding, and at that time, the Congressional 
Budget Office estimated that the administrative costs would be 
closer to $10,000,000,000.
    So we are now here in 2013 administering this law. We are 
using every dollar that we have been allocated as carefully as 
possible, but the highest priority for public health in this 
country is to try and make sure that every American has good 
health, and access to preventive services and ongoing health 
care, and so we are continuing to implement the law.
    Mr. Kingston. What is the total cost of implementation, do 
you think? Is that 1.7 going to do it?
    Secretary Sebelius. Well, as you know, the budget before 
you, Mr. Chairman, asked for an additional $1,500,000,000.
    Mr. Kingston. And that would do it in its entirety----
    Secretary Sebelius. Well, we are----
    Mr. Kingston. Or what would you say would do it in its 
entirety?
    Secretary Sebelius. I mean, we are, at this point, asking 
for the resources that we think are appropriate, the basic 
infrastructure to run the Federal marketplaces and the Federal 
hub are built with the resources that we have. We are still 
relying on not only the resources we are able to put together, 
but outside partners to help with outreach and education, which 
is a critical part of the program success. If people don't know 
the choices they can make, if they don't have access to 
enrollment help and information, we will struggle to get people 
enrolled.
    So, the resources we have requested, again, are in 
anticipation of additional funding coming in with user fees 
from the marketplaces once they are set up, but also to use for 
outreach and education.
    Mr. Kingston. Okay. And if you take say the funds from CDC 
to do this, what will the impact be on CDC?
    Secretary Sebelius. Well, what we have done, Mr. Chairman, 
these are not CDC budget dollars. They are the Prevention Fund 
dollars that are part of the Affordable Care Act. Many of those 
programs are administered by the Centers for Disease Control 
and Prevention. We have made some very tough choices continuing 
some of the basic operational issues around tobacco cessation 
and control, around obesity prevention, looking at chronic 
disease programs with the community, transformation grants, 
trying to keep whole the major initiatives, but also 
recognizing that the public health direction around the 
Prevention Fund is outreach and education involving preventive 
services, private insurance and Medicaid linking uninsured and 
underinsured individuals to preventive services on an ongoing 
basis, so we are balancing tough choices. We would prefer that 
our budget actually be fully funded. That is what our request 
was. That didn't happen, so we are trying to make it work.
    Mr. Kingston. Okay. Ms. DeLauro. Thanks.

               IMPLEMENTATION OF THE AFFORDABLE CARE ACT

    Ms. DeLauro. Thank you very much, and thank you, Madam 
Secretary. It is important to point out that the request was 
made for the implementation fund, but it was denied by the 
Congress.

      FIREARMS RESEARCH & NATIONAL VIOLENT DEATH REPORTING SYSTEM

    With that, let me just talk about the budget proposal for 
two increases for the CDC injury prevention center. That is in 
conjunction with what the President has talked about as his 
``Now is the Time'' initiative. This involve violence and 
firearms. One increase is to support additional research in 
this area; the other is to expand to all States the National 
Violent Death Reporting System that collects extensive data 
regarding deaths from all forms of violence.
    What is the purpose of the violent death reporting system, 
what benefits would be obtained from expanding it to cover more 
States, what benefits would you hope to achieve from additional 
public health research into firearms-related violence?
    Secretary Sebelius. Well, as you know, Congresswoman, 
Centers for Disease Control and Prevention is responsible for 
investigating, surveilling and gathering information around 
preventable injuries, around public health crises--and 
certainly firearms and deaths related to firearms are a 
significant issue here in the United States. They cause about 
87 deaths a day in America--suicides, unintentional firearm 
deaths, and intentional firearm deaths. There is over $47 
billion in related health costs, loss of productivity, loss of 
life, medical issues directly related to firearm injuries and 
deaths.
    So, it is a significant public health issue, and making 
sure that the data is collected accurately, that it is reported 
accurately and that people can then assess what is happening 
and look for ways to lessen and reduce the impact of firearm 
violence is part of making America a healthier place and 
restoring some resilience in health community by community.

                                TITLE X

    Ms. DeLauro. Thank you. With regard to Title X family 
planning, I mentioned the increase. The program offers major 
benefits in reducing unintended pregnancies and also a range of 
other services--treatment for STDs, screenings for cancer. What 
do you see as the public health benefits of a Title X program, 
what arguments would you want to make to this subcommittee 
regarding the importance of the proposed increase?
    Secretary Sebelius. Well, I think, as you have already 
said, Congresswoman, Title X, which has been a very important 
public health initiative for decades, is serving about 
5,000,000 clients a year and providing not only important 
family planning services, helping families make choices about 
spacing of pregnancies, but cancer screenings, cervical and 
breast cancer screenings, and primary health care in many 
facilities across this country. They serve a very low income 
population, often uninsured and underinsured, and more and more 
clients are making those their providers of choice, so we see 
this as a critical infrastructure for healthy families, healthy 
pregnancies, and screening for early detection of diseases.
    In breast cancer alone, what we know is early detection, 
the survival rate after 5 years is almost 98 percent. If you 
wait until year 3 or 4, the death rate rises dramatically, so 
early detection really is a life-or-death issue in some of 
these screening cases. And again, Title X programs provide 
those very necessary health services.

                        PRESCRIPTION DRUG ABUSE

    Ms. DeLauro. I know that from experience on ovarian cancer.
    A survey by State directors for alcohol and drug abuse 
found that virtually all State directors consider prescription 
drug abuse and misuse to be a top issue impacting their States. 
I am going to get to the question because my time is going to 
run out.
    Do you agree that we face a prescription drug abuse 
epidemic? I want to applaud CDC for the work that they are 
doing in this area. Are there things in your budget proposal to 
address that epidemic? I would note that overall, the budget 
request for SAMHSA proposes to cut substance abuse programs by 
more than $100,000,000.
    Secretary Sebelius. Well, actually, we have a cross-
department group working actively in this area, collecting 
data, looking at all the information around prescription drug 
abuse. I do share the concern that it is a rising issue and one 
that has actually surpassed illegal drug use in some areas. So 
we are looking at all kinds of ways we can partner with States, 
because States run a lot of the initial screening devices. They 
collect data. FDA just made a very important move, we think, 
recently, which is to take the original form of OxyContin off 
the market and substitute a new formulation for OxyContin that 
is much harder to use in illegal ways, and much harder to make 
into substances that either can be snorted or inserted, which 
is what was found to be happening.
    So I think that move, in and of itself, will help control, 
but we are looking at all the tools that we have and we would 
love to work with this committee in these efforts.
    Mr. Kingston. Mr. Alexander.
    Ms. DeLauro. Thank you.

                PUBLIC HEALTH SERVICE ACT EVALUATION TAP

    Mr. Alexander. Thank you, Mr. Chairman, comment and then a 
question. We have talked--we have heard you say something about 
outreach and education a couple of different times already this 
morning, and I find it interesting how that the National 
Institutes of Health, a few weeks ago we were talking with Dr. 
Collins about some of the concerns that he has. Two of his 
biggest concerns, he said, are Alzheimer's and obesity. 
Alzheimer's, we can't prevent, can't cure, can't prolong it, we 
die from it or die with it. Over here, obesity, we can cure, we 
can prevent it, we don't have to die from it, and we already 
know, as we are eating a bag of potato chips, that they are not 
good for us, so we have to question just the wisdom of spending 
a gob of money on education when we already know some of things 
that we do are not good for us.
    But anyway, I want to ask a question that expands or 
touches on something that Chairman Kingston was talking about a 
while ago.
    You are authorized to tax, or to tap, as you like to call 
it, authorize programs of up to 1 percent. Their 
appropriations, in order to conduct program evaluations, the 
administration has asked for an increase. In fact, in 2014 the 
request is to increase the tap to 3 percent or effectively move 
around $1,300,000,000 of resources through this nontransparent 
budget trick.
    Last year, the subcommittee held that tap to 1 percent. I 
am not sure why we continue using this mechanism. For example, 
while the request supposedly provides the National Institutes 
of Health $31,000,000,000 for medical research, in reality it 
shifts about 1,000,000,000 to other activities within your 
Department. The intent of the authority is to provide support 
for program evaluations, of course, when in reality, again, the 
funds are to support program operations within your office.
    So the question is, the projected $1,300,000,000 in tap 
funds proposed for 2014, how much of those funds will be spent 
on actual program evaluations?
    Secretary Sebelius. Well, Congressman, as you know, the 
Congress sets the amount of the tap and the dollar amount that 
we can use, and we will follow that closely. We have made a 
recommendation to you of what we think would appropriately 
cover everything from research and evaluation efforts going to 
program initiatives, but we will work with the committee, but 
ultimately, it is the decision of Congress what that amount is, 
and as you say, you limited the amount to 1 percent. We will 
follow the directions and work with the committee about the 
appropriate amount.
    Mr. Alexander. Do you still think this is the way it should 
be done instead of just appropriating the amount for each 
program that we need to do so?
    Secretary Sebelius. I think it is an effective tool to 
allow us to actually look at initiatives that may have more 
bearing 1 year than the next year, and rather than locking 
money into one place, it allows us to acknowledge that a lot of 
the programs in our Department impact all of the agencies, and 
all of the agencies contribute. I think AHRQ is a good example 
where they do unique efforts to work directly with providers, 
and the work they do with providers actually impacts a lot of 
the different agencies. It impacts NIH. It impacts CDC. So 
having an opportunity for those larger agencies to contribute 
to those important research and outreach efforts and change 
protocol and inform providers, I think, has a mutual benefit.
    Mr. Alexander. Thank you.
    Mr. Kingston. Ms. Lowey.

                               HEAD START

    Mrs. Lowey. Thank you. Madam Secretary, after more than 
four decades of providing the support that children and 
families need to succeed, Head Start still reaches only about 
two-fifths of eligible preschool-age children. Early Head 
Start, which has been in place since the mid 1990s, reaches a 
mere 4 percent of eligible infants and toddlers. Clearly, there 
is a tremendous amount of work that still needs to be done to 
reach these families.
    As you explain in your testimony, the President's budget is 
requesting $1,400,000,000 in resources for a new Early Head 
Start competitive program with a goal of reaching more than 
100,000 additional children under the age of three who do not 
currently have access to high quality early care. In the 
Recovery Act, Congress provided funding for a targeted 
expansion of Early Head Start, in particular.
    Can you tell us if that has been successful? Am I correct 
that the research is clear that this period of time in a 
child's life is of critical importance and that the Early Head 
Start approach is especially effective?
    Secretary Sebelius. Congresswoman, the proposal that the 
President has made in the 2014 budget and outlined a bit in the 
State of the Union is one of the most exciting second-term 
initiatives, and it really is a birth through five initiative, 
recognizing that the single best investment we can possibly 
make is getting all of the children in this country ready to be 
productive citizens and live up to his or her full potential.
    So our portion of this is infants, toddlers, and home 
visiting; and as you say, the resources requested would 
increase the number of children in Early Head Start and 
actually add some cost-of-living increases and continue our 
quality initiatives for Head Start, which has been proven to be 
quite successful, not just in terms of getting children school-
ready, but in terms of long-term impact on their lives--fewer 
dropouts from high school, fewer drug abusers, fewer end up in 
any kind of correctional facility, more long-term success at 
jobs. Any studies that have followed high quality child care 
have proven that for high quality early education. So we think 
this initiative, home visiting plus Early Head Start and child 
care, raising the quality of child care, and there is also a 
piece of this that deals with child care, and then working with 
the States around expanded pre-K and kindergarten are probably 
the best ways we can get America ready for the 21st century.
    Mrs. Lowey. Thank you very much, and I hope that the bill 
will reflect the statistics because as a mother of three and a 
grandmother of eight and someone who visits schools all the 
time, you really see the impact of early education, so I thank 
you.

                              PREPAREDNESS

    On hospital preparedness grants. Last week's terrorist 
attack in Boston serves as a reminder of how vital it is for 
hospitals to maintain a high level of readiness to deal with 
disasters and mass casualty incidents. That means having 
adequate stocks of the necessary supplies and equipment, but it 
also requires planning, coordination and enough drills and 
exercises to stay proficient.
    Like New York, Boston happens to have a number of 
outstanding hospitals and trauma specialists who played a 
significant role in the impressive response to the bombings; 
however, I am concerned that HHS grants to maintain and improve 
hospital preparedness are being steadily reduced. Funding has 
been cut from $420,000,000 in 2010 to $375,000,000 in 2012. Now 
the President's budget request for 2014 proposes yet another 
cut to $255,000,000. Why was that recommended? Can we be 
confident that it won't have a detrimental effect on hospital 
readiness?
    Secretary Sebelius. Well, I think that the budget reflects 
an ongoing interest in, as you say, training, preparedness, and 
working with hospitals. Some of the cuts have been due to the 
fact that some of the early dollars bought one-time equipment. 
It doesn't need to be replaced because it is there. I think 
that there is no question either watching the recent New York 
example. When newborns were evacuated from NYU, and they knew 
exactly where they were going and vulnerable patients were 
evacuated from nursing homes, the hospital had search capacity, 
the ambulance contracts work was successful due to the fact 
that that had been planned for, and that had been talked about 
and had been practiced.
    We saw it again in Boston where injured people were able to 
be quickly transported and taken care of, so we take these very 
seriously. It happens in communities around the country and 
that will be an ongoing effort for us to work on.
    Mrs. Lowey. Thank you, Mr. Chairman.
    Mr. Kingston. Mr. Womack.

                           MEDICAID EXPANSION

    Mr. Womack. Thank you, Mr. Chairman, and thank you, Madam 
Secretary.
    As you know, this week, my home State of Arkansas signed 
into law, pursuant to the recent session of the general 
assembly, something rather innovative as it concerns insuring 
people between 100 and 133 percent of Federal poverty level, 
and providing you approve the proposal, our State is depending 
on you to be a stable funding partner.
    I also recognize that the Arkansas legislation that was 
signed has an off ramp, a circuit breaker in the event that 
promises made today perhaps aren't kept, but I have this 
concern. The Supreme Court, in its ruling, said that Federal 
Government can't condition the first dollar of Medicaid on the 
expansion pursuant to the ACA; however, I am a little unclear 
as to whether that means that if Arkansas opts, as they have, 
into expansion and then decides later for whatever purpose, 
whatever reason, that they have to employ this circuit breaker, 
as it were, that we will be--we will be okay. I know you can't 
speak for the U.S. Supreme Court, but what assurances can you 
give our State that our circuit breaker is legit, is okay?
    Secretary Sebelius. Well, Mr. Womack, I think it is an 
important question, and when the Supreme Court ruled last 
summer, they basically, if you will, divided Medicaid into the 
traditional program, and then this sort of new Medicaid 
program, which would allow States to take advantage of a 
funding partnership outlined in the Affordable Care Act.
    We have said from the outset in our guidance to States that 
you can come in when you want into the new program and come out 
when you want. What Arkansas did in their legislation was sort 
of codify that. There is a lot of fear voiced with governors, 
not just Governor Beebe, but I talk to governors virtually 
every day and they say, well, what if Congress changes the 
deal, what if, you know, we look at this funding and it 
switches next year or the following year, which is why I think 
it was important that the President and Gene Sperling, his head 
of the Council of Economic Advisors made very clear that this 
President, at least, is committed to the funding formula, but 
beyond that, the guidance from HHS has been pretty clear from 
the outset. If this is a financial detriment, you come out of 
the new program and there is no impact on the traditional 
Medicaid, and that is really what the Supreme Court said, is 
that you can't use a threat of losing all of your Medicaid 
dollars as a lever to convince States to come into the new 
Medicaid program, so we really have two kind of separate groups 
of people.
    Mr. Womack. Are you personally concerned that a few years 
from now that we may be having to trigger that circuit breaker?
    Secretary Sebelius. Well, I am hopeful that won't be the 
case. I think that, again, there is some incredibly impressive 
work going on with governors and with the flexibility that we 
have given governors around the Medicaid program. And Arkansas, 
I have to tell you, is one of the States at the front of the 
line, looking not only at this particular new legislation, but 
looking at au pair systems, trying to figure out ways that they 
can be delivering better care at a more cost-effective price. 
We are really working closely with them.
    As a former governor, I take these efforts very seriously. 
We have new dual eligible efforts underway, and for the first 
time last year, between 2011 and 2012, the spending on Medicaid 
per capita around the country went down 2 percent. It is a 
decrease, the first time really in the history of the program, 
so we think there is some very encouraging projects underway. I 
don't know what will happen 5 and 10 years from now, but 
certainly that protection is there for States.
    Mr. Womack. I recognize my time, Mr. Chairman. I have got 
about 25 seconds left, so I know you are going to add that to 
my next round questions, provided I am here. I yield back.
    Mr. Kingston. I think we all want to learn more about 
Arkansas.
    Ms. DeLauro. Worth checking it twice.
    Mr. Kingston. Yes. Ms. Roybal-Allard.

               ADVISORY COMMITTEE ON HERITABLE DISORDERS

    Ms. Roybal-Allard. Madam Secretary, I would like to begin, 
first of all, by thanking you for using your authority to 
continue the Advisory Committee on Heritable Disorders while 
Mr. Simpson and I are working to get the reauthorization of the 
Newborn Screening Saves Lives Act. We truly do appreciate that.

            RACIAL AND ETHNIC APPROACHES TO COMMUNITY HEALTH

    Two years ago, HHS released an unprecedented action plan to 
address racial and ethnic disparities, and that plan cited 
racial and ethnic approaches to community health known as REACH 
as an exemplary program. GAO also praised REACH, and there were 
more than 150 journal articles documenting the achievements of 
the REACH program in reducing health disparities.
    Your fiscal year 2014 budget eliminates REACH and instead, 
points to the community transformation grants as the next stage 
of CDC community-based programs. What evidence can you provide 
to demonstrate that the CTG program will at least be comparable 
to REACH in reducing racial and ethnic health disparities?
    Secretary Sebelius. Well, Congresswoman, as you say, for 
the first time, we do have an action plan based on health 
disparities, and I think there is no doubt that REACH was an 
initial test case for funding, and REACH, I think, funded about 
eight organizations aimed at specific efforts to reduce health 
disparities and deal with a lot of the chronic disease issues 
that affect particularly disparate communities.
    The community transformation grants actually fund 107 
organizations, half of which are also REACH organizations. So a 
lot of what REACH was doing is being taken over and amplified 
by community transformation. We have taken what we have learned 
from REACH and tried to actually expand it dramatically into 
communities across the country, and it will be, I think, a much 
larger lever to use in terms of reducing health disparities.
    Ms. Roybal-Allard. I think the concern that has been 
expressed is that, that those who are either current or former 
REACH grantees have actually been unable to compete against the 
much larger agencies and non-profits winning the CTG grants, 
and so the result is that the organizations with REACH grants 
that have had the greatest success of measurable change in the 
health and wellbeing of racial and ethnic minorities with the 
greatest burden of disease are not going to be participating in 
the CTG, and the concern and what I am concerned about is that 
their inability to successfully compete in the CTG grants will 
impact their successful reductions in health disparities in 
these most vulnerable minority communities.
    And so there just seems to be a gap there that I think that 
we need to look at so that we don't backslide in those areas.
    Secretary Sebelius. Well, I would agree wholeheartedly that 
we don't want to backslide, and my information is that half of 
the REACH organizations actually also are community 
transformation grant organizations, but we would be happy to 
work with you and your staff to look at the details of the 
organizations you are concerned about.
    Ms. Roybal-Allard. And how do you plan to meet the goals of 
the action plan itself? And do you have certain benchmarks that 
have to be met?
    Secretary Sebelius. We do. We are measuring them carefully. 
And I think while there are a number of initiatives that have 
proven successful, we think one of the single biggest 
initiatives that we can make is fully implementing the 
Affordable Care Act, so closing the gap with access to health 
insurance, access to preventive benefits, having a healthy home 
for families who right now struggle with that may make the 
largest difference we could possibly make in health disparities 
in this country.
    Ms. Roybal-Allard. Okay. I can see that my time is almost 
up, so I will reserve for the second round.
    Mr. Kingston. Was it Dr. Harris or Mr. Fleischmann.

                   AFFORDABLE CARE ACT IMPLEMENTATION

    Mr. Fleischmann. I think Doctor--oh, okay. Thank you.
    Thank you, Mr. Chairman. Good morning, Madam Secretary. I 
am Chuck Fleischmann. I represent the Third District of 
Tennessee, and to follow up on some of my colleagues' 
questions, we have heard numerous mentions of the Department's 
intentions to transfer funds from various accounts to implement 
the Affordable Care Act.
    I am particularly concerned about your proposals to use 
$500,000,000 more for ACA implementation than you previously 
predicted you would need, especially given your Inspector 
General's concerns about exchange implementation. You have 
demonstrated a willingness to redirect funds for your purposes. 
I have two questions.
    What changes have you made to support States that are 
looking at buying the expansion population into the exchange? 
And my second question is will you be pushing back the exchange 
implementation to adjust for unforeseen problems that have 
arisen and that have led you to seek additional funds for 
implementation?
    Secretary Sebelius. Well, Congressman, first of all, I 
think we have sought funds in the budget process. We sought 
funds in the CR process. Having failed in both of those efforts 
through the work of the United States Congress, we are then 
using the resources available within the Department to make 
sure we implement the law of the land.
    I am not quite sure I understand your question about the 
States who want the expansion population in the exchange, but 
as you heard Mr. Womack say, Arkansas, which has a plan to use 
their Medicaid dollars to purchase coverage for individuals 
from a company offering coverage in the exchange and then 
provide wrap-around coverage, we are working very closely with. 
We have not yet had a specific proposal from Governor Beebe 
around what their 1115 waiver would look like, but we are eager 
to get it now that the legislation has passed.
    I have had many conversations with Governor Haslam about 
his interest in that possibility. He is watching, I would say, 
the Arkansas situation closely. We have expressed an eagerness 
to work with him outlining what the law allows us to do and 
what it doesn't allow us to do, but we are working with a 
number of governors around the expansion population and what 
the flexibility for the States may look like.
    Mr. Fleischmann. Well, okay, but let me ask you a follow 
up. Will you be pushing back the exchange implementation, 
though? Are you going to push it back, or what are your plans?
    Secretary Sebelius. No, sir.

                                MEDICARE

    Mr. Fleischmann. Okay. Let me ask you a question, if I may, 
in the time I have got left about hospitals and the bad debt 
situation. My question regards the administration's proposal to 
cut Medicare, bad debt payments by $25.5 billion while asking 
for rather sizable funding increases in other parts of the 
budget. This cut to providers, in and of itself, seems to be 
particularly misguided at a time when Medicare already 
underpays hospitals, according to MEDPAC, and when seniors in 
my district are struggling to make ends meet, but what I find 
most curious is the administration's rationale for the cut, and 
I quote, ``this proposal would more closely align Medicare 
policy with private payers.''
    I am sure you are aware that the fixed price system under 
Medicare is completely disconnected from the private pay area 
where hospitals have the flexibility to negotiate. There is no 
negotiation today under Medicare's fee for service system. 
Government sets the price as well as the beneficiary cost share 
amount, period.
    May I respectfully remind the Secretary that the 
administration has stood in the way of repeated efforts to 
modernize Medicare and really allowing policy with private 
payers instead of paying lip service to it when you want to cut 
the hospitals but not grant them the same tools to negotiate 
what they now have in the private system.
    How can you reconcile this inconsistency?
    Secretary Sebelius. Well, Congressman, I think that what 
has happened with Medicare over the past several years is we 
have been working very closely with private payers around the 
country, and they are extremely enthusiastic about the 
framework given to us, thanks to the Affordable Care Act--to 
begin to shift Medicare to a value-based payer as opposed to a 
volume payer. We are starting to implement a number of those 
changes. We are pleased with the 250 or more accountable care 
organizations, many of which include hospitals which have now 
come together voluntarily to look at different ways to deliver 
care and actually share in the savings.
    We have hospitals really engaged in efforts around reducing 
hospital-acquired infections and other issues which drive up 
cost and lower patient care. So I think the framework around 
Medicare dealing with hospitals is very different than it 
looked 4 years ago, and, in fact, is, I think, moving in a very 
positive direction for patients and for providers.
    Mr. Kingston. Ms. Lee.
    Ms. Lee. Thank you very much. Good to see you, Madam 
Secretary, and thank you for being here.

                               RYAN WHITE

    I am pleased to see that the budget included the needed 
increase for the minority AIDS Initiatives as well as the Ryan 
White program, so continued support of Ryan White is very 
critical while we assess the impact on--as it relates to HIV 
and AIDS, as it relates to the Affordable Care Act and how this 
transition is going to happen.

            RACIAL AND ETHNIC APPROACHES TO COMMUNITY HEALTH

    Let me follow up with Congresswoman Roybal-Allard's 
question as it relates to ethnic and health disparities. You 
know, I was disappointed to learn that half of the available 
$949,000,000 in the preventive--it is what, Prevention and 
Public Health Fund, would be used for the Affordable Care Act, 
that half of that has been cut. Secondly, of course, the cut to 
the REACH program, which Congresswoman Roybal-Allard laid out. 
Then what we are looking at also is the fact that now the 
exchange health plans, they really don't include community 
physicians who have traditionally provided care to low income 
and minority communities. Many of the minority providers that I 
have spoken with who practice independently are already 
experiencing competition with community health centers and 
other federally qualified health centers, specifically African 
American physicians are really going to be impacted by this.
    And so what I see now is sort of a, you know, a compilation 
of cuts and provisions of the Affordable Care Act and budget 
and sequestration that really will impact minority communities 
in terms of our efforts to close these disparities. It seems 
like we are getting attacked over and over and over again, and 
so I am wondering how we are going to pick up the pieces now 
because we have made so much progress, but I just see this 
going backwards and people are very concerned.
    Secretary Sebelius. Well, I share your concerns that the 
worst of all worlds is to retreat from what has been 
implemented, an aggressive approach to closing health gaps. 
What I would tell you, Congresswoman, is we would have much 
preferred to have had the resources given directly for the 
Affordable Care Act so we could fully implement the law and 
have the full funding of the Prevention Fund go to a variety of 
programs.
    That was not the case when Congress finished with our CR, 
so we made some decisions, and the dollars that are being 
redirected for this year from the Prevention Fund will be for 
outreach efforts, education efforts and enrollment efforts 
connecting people who are uninsured and underinsured with the 
new benefits available to them in the Affordable Care Act.
    So, many of the communities of color, many of the 
communities who have huge health gaps will, for the first time, 
be looking at the opportunity to have fully covered health 
benefits, but unless they are enrolled, unless they know what 
is coming, unless they have people helping with the application 
process, it won't happen.
    So I think that while on one hand there are some specific 
program cuts or flattening of budgets, on the other hand, there 
will be a huge outreach and enrollment effort that will involve 
many of those same individuals and connecting them with health.
    Ms. Lee. But the trend, though, is going the opposite 
direction. I understand what you are saying, but you have cut 
actually 15 million say from the Office of Minority Health 
Services. That cut----
    Secretary Sebelius. Well, the overall spending on minority 
health issues has actually increased in our department-wide 
efforts. It is not necessarily in that office.
    Ms. Lee. I understand that, but that office was the 
centralized office. It was going to try to make sure that this 
works. And now what I am worried about is it is so dissipated 
that it may not work, that we are going to have to pick up the 
pieces in a few more years to get back to where we are now.
    Secretary Sebelius. Well, again, we would be happy to give 
you and Congresswoman Roybal-Allard a report on what the plan 
says, where we are, what the metrics say, where we see 
ourselves going at the end of 2013. We will do a detailed 
update on the issues of concern.
    Ms. Lee. Okay. And are we going to have a second round, Mr. 
Chairman, because I want to get back to the traditional 
community providers?
    Mr. Kingston. Yes.
    Ms. Lee. Okay. Thank you very much. Thank you, Madam 
Secretary.
    Mr. Kingston. Dr. Harris.

                   INDEPENDENT PAYMENT ADVISORY BOARD

    Mr. Harris. Thank you very much and thank you for coming 
before the committee.
    As a physician, I have got to ask you a couple of questions 
from what I hear some of the concerns in the physician 
community. First and foremost is the Independent Payment 
Advisory Board. My understanding is that the members were 
supposed to have been recommended by last September. It is now 
April. Is there a timeline for appointment of these members?
    Well, there is a timeline. We already know the President 
has already missed it. Is there a new timeline or revised 
timeline? Are these appointments ever going to be made or are 
you going to ultimately have to make those decisions?
    Secretary Sebelius. Congressman, the law provides for the 
President to make appointments to the Independent Payment 
Advisory Board. In consultation with Congress, he has actually 
written to the leaders in both the House and the Senate, the 
minority and majority, in asking for suggestions for Members to 
be appointed. Ultimately he would nominate and the appointees 
would then go to the United States Senate for confirmation.
    Secretary Sebelius. According to the independent actuary 
and the Congressional Budget Office, given the trend lines of 
Medicare, it is not anticipated that any IPAB recommendation 
would even be targeted until 2019.
    Mr. Harris. Sure, and I understand that, Madam Secretary.
    Secretary Sebelius. The consultation is underway.
    Mr. Harris. Okay, in the absence of the Independent Payment 
Advisory Board being appointed, though, all I am saying is, you 
would have to make the decisions. Is that right?
    Secretary Sebelius. No, sir, that is all under the 
construct of the Independent Payment Advisory Board.
    Mr. Harris. So if they are never appointed, what happens?
    Secretary Sebelius. It doesn't exist.

                   RECOVERY AUDIT CONTRACTORS AUDITS

    Mr. Harris. Okay. The second one is the RACs audits. We are 
hearing, you know, from the hospital association, especially, 
they say when they survey their hospitals, about 70 percent of 
those, when they are appealed, they are overturned. You can 
just get back to me off-line about that. I mean, that is of 
great concern to me because both hospitals and physicians spend 
a great inordinate amount of time dealing with these RACs 
audits, and it never shows up, you know, when we claim that 
Medicare is so efficient, you know, we don't take into account 
the back office costs of dealing with these RACs audits.
    Secretary Sebelius. Well, sir, if I could just respond for 
one moment. I think that while there are a number of claims 
overturned, less than 3 percent of the claims are ever 
appealed. So about 97 percent of the RAC recommendations 
actually are implemented, and then of the ones that are 
appealed, a portion are overturned.
    Mr. Harris. That is on part B, Madam Secretary. I am not 
sure the same is true on the hospital side. On part B that is 
true.

                              RATE REVIEW

    In your opening statement you said, and I will quote you, 
``Every American will get quality insurance at an affordable 
price.'' And I think you used the word ``every.'' Now, here is 
the problem I have got. Yesterday, our nonprofit insurer, 
CareFirst BlueCross BlueShield of Maryland insures 70 percent 
of the individual market in Maryland, announced it will have to 
raise its rates on the exchange an average of 25 percent, with 
a range of a slight decrease to 150 percent increase for the 
youngest, healthiest, who apply for insurance.
    So I have got to tell you, that certainly, that person who 
is going to get that 150 percent increase is not going to feel 
that they are getting quality insurance at an affordable price, 
because Madam Secretary, I will tell you that, you know, you 
have been quoted saying, well, they get a better benefits 
package. Well, in fact, in their filing, they said that only 2 
percent of that average increase was due to an increase in 
benefits because Maryland, as you know, already has the second 
best benefits in the country because of our mandated package. 
So, in fact, they said in their filing that the taxes actually 
account for a larger part of that increase than the increase in 
benefits.
    How am I going to explain to those individuals that their 
increase is--these are individuals. These are the ones, and 
again, Maryland has a high-risk pool, so we have already 
factored into account that had affordable care not worked, 
everybody with a preexisting condition could have gotten 
insurance in the high-risk pool.
    How am I going to tell them that this was actually good for 
that 25-year old healthy person who now has to make the choice 
between paying that small penalty or paying a whole lot more 
for the insurance under the exchange.
    Secretary Sebelius. Well, I think there are several things, 
Congressman. I have not gotten any independent information 
about Maryland other than The Washington Post article, so I am 
taking my data from that. First of all----
    Mr. Harris. I would be more than happy to share with you 
their filing.
    Secretary Sebelius. Well, the company has submitted a 
filing and there is a rigorous review process now. So this is 
the starting place and I can tell you as a former insurance 
commissioner, that is unlikely to be the end of the discussion.
    The second piece of news is that it appears Maryland will 
have more competition thanks to the Affordable Care Act than 
they do right now. Two new companies are coming in the market, 
and several other companies filed rates at the same time that 
First Care filed rates that are significantly lower, and don't 
have the kind of whopping increase that First Care has 
requested. Thirdly, for a lot of the young and healthy, the 
under 30-year-olds, they will have a choice of a catastrophic 
policy, or the full benefit policy, which is likely not only to 
be significantly less, but also have some subsidies to help pay 
those premiums.
    So I think there are a variety of factors, but it looks 
like the Maryland market will be significantly more competitive 
than it is now, and for the first time, consumers will be able 
to see the rates side by side and make some choices.
    Mr. Kingston. Mr. Joyce.

                AFFORDABLE CARE ACT IMPLEMENTATION PLAN

    Mr. Joyce. Thank you, Mr. Chairman. Good morning, Madam 
Secretary.
    Secretary Sebelius. Good morning.
    Mr. Joyce. There have been many concerns raised about the 
Affordable Care Act. Is there any written plan of 
implementation that you have been considering?
    Secretary Sebelius. I don't know what you are referring to. 
There is no one written plan. I mean, there are timelines. 
There are build plans. There are contracts.
    Mr. Joyce. Right, is there something we can review now on a 
quarterly basis to know how it is being implemented?
    Secretary Sebelius. Absolutely.
    Mr. Joyce. Can you make that available to us?
    Secretary Sebelius. We would be happy to share what we can, 
certainly.
    Mr. Joyce. Okay, because the other problem I have is 
exchanges, at least in Ohio, it views the same way, that the 
prices are going to continue to go up. Do you have anything to 
contradict that?
    Secretary Sebelius. Well, again, sir, rates are just 
beginning to be filed. There will be a negotiation process in 
every State in the country between now and the fall when the 
final rates will be published. I have no current information 
from the State of Ohio.

                   INDIRECT MEDICAL EDUCATION FUNDING

    Mr. Joyce. Okay. There is a--the other problem that we have 
in the Cleveland area, we have the UH, and the Cleveland 
Clinic, and obviously, they are facing a 91,000 physician 
shortage, and at 130,000 physicians that should grow to by 
2025. And while I appreciate the administration's emphasis on 
primary care, surely, it is split evenly between specialists 
and primary care physicians. The budget proposes a 10 percent 
decrease in Medicare indirect medical education funding. 
Teaching hospitals receive this funding to compensate them for 
higher costs associated with sicker, more complex patients that 
they care for, and they provide unique services that are not 
available at other hospitals, such trauma centers, burn units 
and standby capacity.
    A 10 percent cut will not help finance them in the training 
of next-generation physicians when we know there is already a 
looming shortage and will do nothing to expand the need for 
primary care. In some areas there is a shortage in subspecialty 
areas. In teaching hospitals maintaining a top level of trauma 
center, standby services are expensive. Has the administration 
considered the impact of this cut on teaching hospitals and 
their ability to maintain these critical services?
    Secretary Sebelius. Yes, sir, we have, and again, in a more 
robust budget time, we would make different decisions. We are 
looking carefully at MedPAC's, the advisory body that looks at 
Medicare costs and expenditures, recommendations in this area 
and they have suggested that the cut would be not only fully 
compensate hospitals for the training program, but could come 
out of the overhead. So we are trying to make sure that we have 
the same number of training slots, but reduce some of the 
overhead that wasn't directly related to the residency slots in 
hospitals as we go forward. But this recommendation came 
directly from MedPAC.
    Mr. Joyce. Thank you, I yield back my time.

                               HEAD START

    Mr. Kingston. Thank you. Madam Secretary, I wanted to get 
back to your comments to Ms. Lowey on Head Start, and I have 
not been a critic of Head Start, but I have read the study, or 
scanned the study. I don't want to say I have read the whole 
thing, but this was a study that HHS did, and it certainly 
contradicts the statements that were made, and I will just read 
directly from it.
    It says: ``In summary, there were initial positive impacts 
from having access to Head Start, but by the end of third 
grade, there were very few impacts found for either cohort, or 
any other four domains of cognitive, social, emotional health, 
and parenting practices. The few impacts that were found did 
not show a clear path of favorable or unfavorable impacts on 
children.''
    And you know, as we try to figure out, you know, in Head 
Start, I don't think you can find a more noble concept, but the 
results aren't there. I visited many, many Head Start 
classrooms, and I am always impressed with what I see going on, 
but the statistics don't bear out because I go there and I get 
emotional about it, and it looks good, and it feels good and 
all that, but the science, if you will, doesn't bear that out.
    Where did you get your statistics on the proven reduction 
in dropout rates and better grades, and the numbers you just 
studied, because it is not on here.
    Secretary Sebelius. That is correct, Mr. Chairman. You are 
citing the impact study which looked at kids who were in Head 
Start in 2003, about 10 years ago. The Impact Study tracted 
them.
    Mr. Kingston. I think it started in 2008, didn't it?
    Secretary Sebelius. No, I think the report was out in 2008. 
The kids were in the program 10 years ago, and then they 
tracked them, and there is no question that what they found is 
a leveling out of what had been significant improvements. As 
children leave the Head Start program, they may not continue 
that.
    What has been found in studies that actually longitudinally 
follow children for a longer period of time, is that the 
positive----
    Mr. Kingston. Well, can you tell me what studies those are 
specifically?
    Secretary Sebelius. Yes, I would be happy to get them for 
you, these are longitudinal studies that follow kids for 20 
years, and they look at----
    Mr. Kingston. Well, the reason I said that, is Head Start, 
unfortunately, has moved into a more political kind of arena 
that I think any of us would want it to, meaning that, you 
know, if you are for Head Start, you love children, if you are 
against it, you obviously hate children. You hate teachers. You 
hate education. I mean, it is one of those things where in 
Washington, things spin out of control rapidly in the rhetoric 
debate. And so we have got a lot of studies out there and you 
know, the New Jersey study is pro, and the California study is 
against it. But this was your study.
    Secretary Sebelius. I understand, sir, and we are taking 
those findings seriously. We have done a lot to implement some 
of the changes that we felt were important, improving teacher 
quality, looking at more curriculum. I would say that there is 
a much stronger partnership right now with the Department of 
Education which is part of this Early Education Initiative, as 
well as the fact that with the President's insistence, the 
lower-performing Head Start programs are now recompeting for 
grants for the first time ever in the program. We are not just 
assuming that if you have been a Head Start operator, you can 
continue to be a Head Start operator.
    So the 25 percent lowest performing programs are 
recompeting across this country as we speak, and that has never 
been done before. We would like to make sure that if children 
are enrolled in early education, they are in the highest 
quality programs possible.
    Mr. Kingston. But you have studies to show that there is a 
lower dropout rate, and higher grades?
    Secretary Sebelius. Yes, there is a study that indicates 
that with early education, just 1 year of early education, that 
children have a much different lifetime performance. The long-
term payoff to Society means less school dropouts, drug use, 
engagement in criminal activity--The study showed a reduction 
in those instances, and I would be happy to provide that for 
you.
    Mr. Kingston. Yes, and also, if you would tell me where 
this longitudinal study was wrong? Where, you know, you are 
saying the impact----
    Secretary Sebelius. No, I am saying they are looking at 
children in the third grade. You wouldn't have children 
dropping out in the third grade one way or the other. So some 
of the factors that we are looking at that----
    Mr. Kingston. But, I mean, the premise of the study, this 
was what they were asked to study, and this is how we are going 
to make our investment decision, and the study came back with 
a----
    Secretary Sebelius. Well, what it said, there was a 
definite impact on these children as they entered school.
    Mr. Kingston. And then what?
    Secretary Sebelius. They definitely were caught up with 
their peers as they enter school. Those positive impacts begin 
to fade as they get closer to the third grade. Whether that is 
what is happening to them in the elementary school, the lack of 
the Head Start wraparound, I mean, I think there are a number 
of factors. But the fact that they are school ready when they 
hit school is part of what Head Start was all about.
    Mr. Kingston. Yeah, and well, I think what I would be 
interested in is, you know, a blind, let's look at this as if 
it was a new program. Is this where you would put----
    Secretary Sebelius. Sure.
    Mr. Kingston [continuing]. Money or not. And so I think 
that is what we would like to see, and I yield to Rosa.
    Ms. DeLauro. Just a quick point on that. The study's number 
one finding was that Head Start children enter kindergarten 
performing above their peers in all measurable categories. The 
study you reference looked at children who entered 10 years 
ago. The significance of that is that since then, a number of 
changes have been made to the Head Start program because of 
some of the findings here, and that includes improvement in the 
quality and credentialing of teachers. You have got 92 percent 
of Head Start teachers have an AA, a BA and an advanced degree 
in the field related to early childhood education.
    That is well over the 50 percent threshold that was set in 
the 2007 reauthorization for that year, so there have been a 
number of changes. And maybe, Mr. Chairman, you and the 
Secretary can talk about this, about the changes that have been 
made, I don't want to go into all of them.
    Secretary Sebelius. Sure.
    Ms. DeLauro. And for instance, there is a 2010 report of 
Maryland Montgomery County Public Schools showing that students 
who went to full-day Head Start pre-K needed only half of the 
special education services as their fellow kindergartners. So I 
think there needs to be that fulsome conversation about that, 
because there were some issues. They have been dealt with, and 
I think we need to then look at where the changes are. It is 
one of the most important of programs that we have ever 
embarked on in terms of making our children ready to learn as 
they enter school.

               AFFORDABLE CARE ACT PROGRESS AND SUCCESSES

    Madam Secretary, there is agreement that one of the keys to 
improving the long-term budget picture is finding ways to 
reduce the growth of health care costs while improving quality 
and access. The Department has taken a number of initiatives 
and demonstration projects aimed at the goal, mostly under the 
auspices of the Affordable Care Act.
    I would like you to tell us about some of those efforts, 
how they are progressing. I am going to throw in this last 
question as well. This there are provisions in the ACA designed 
to reduce the rate of increase in health insurance premiums. 
Medical-loss ratio as an example, rebates to customers when too 
much of what an insurance company collects in premiums is used 
for other things.
    In this context, what results have you observed from the 
new rules so far? What are some of your efforts to cut the 
costs? What have medical-loss ratio or other things of that 
nature already in place done?
    Secretary Sebelius. Well, Congresswoman, as you know, there 
are sort of two pieces of this puzzle. One is the insurance 
market, and there has been a lot of attention and focus on the 
insurance market, the new marketplaces, which frankly, will 
affect a number of Americans, but certainly not all Americans.
    Most people with employer-based coverage will see very 
little change with the new marketplace. A lot of folks who are 
in self-insured plans or large government plans, won't see much 
change.
    So on the new market side, you are absolutely right. There 
has been a lot of attention on new rules for insurance 
companies, and one of them is that $0.80 of every premium 
dollar collected has to be spent on health costs, not overhead 
costs, the so-called 80/20 rule. So last year about 
$2,000,000,000 was sent back to customers across the country.
    Ms. DeLauro. $2,000,000,000?
    Secretary Sebelius. $2,000,000,000.
    Ms. DeLauro. Thank you.
    Secretary Sebelius. So people got checks from their 
insurance companies, and we have seen companies actually file 
the lowest level of rate increases over the last 3 years than 
has been the trend line for over a decade because there is now 
much more rigorous review at the State level. And I think that 
is all good news for consumers.
    On the delivery side, which I think is frankly the more 
significant piece of the Affordable Care Act because it really 
affects everybody insured and uninsured. What kind of care do 
you get? What sort of population health do we have? How are we 
spending those underlying health care dollars? There is a lot 
of incredible innovation underway; a lot of it driven by the 
private sector using electronic tools to empower consumers, 
using electronic health records to finally measure results and 
figure out what is going on and locate the cost outliers.
    We are driving programs to these accountable care 
organizations; new collaborative efforts between doctors and 
hospitals to figure out ways to improve health and lower care; 
medical home models, trying to keep people out of the hospital 
in the first place; looking at preventable readmissions.
    For the first time in decades, we are seeing an actual 
decrease in the number of Medicare patients who are released 
from the hospital and go right back in because of the care they 
are receiving in that interim period of time, and one new 
study--I know I am on a yellow light, but since we all love 
babies here, you will, I think, find this interesting.
    Mr. Kingston. Why don't you hold that, because we do love 
babies and we will get back to the baby question.
    Secretary Sebelius. All right.
    Mr. Kingston. It sounds like a piece of good news, and we 
look forward to it. Mr. Alexander.

           PREVENTIVE HEALTH AND HEALTH SERVICES BLOCK GRANT

    Mr. Alexander. Madam Secretary, the Preventive Health and 
Health Services Block Grant. Your budget request eliminates 
that again. For more than 30 years, State and local health 
departments have relied upon the flexibility of this block 
grant to meet their unique needs and problems with local 
solutions, ranging from preventative cancer screening to 
emergency medical services. A large percentage of these funds 
are used to address the prevention and control of chronic 
diseases.
    Last year, this subcommittee provided $100,000,000 for the 
block grant an increase of over the fiscal year 2012 budget. 
Your budget justification says that these activities could be 
more effectively and efficiently implemented elsewhere. It is 
not often that people come into our office and say hey, this 
Federal program is working. Let's not change it. Let's not 
improve it. It works from the local to the State level, but yet 
we are trying to change it. We are trying to eliminate it.
    Now, your budget justification assumes that the Affordable 
Care Act prevention and public health funds will be available 
to help meet these needs, but as we have heard today, 
oftentimes these funds are being used to just implement the 
Affordable Care Act.
    So the question is, can you elaborate on the rationale 
behind the elimination of this program, and what impact do you 
think these cuts will have on the States that we all represent.
    Secretary Sebelius. Well, Congressman, first of all, I 
think the effort to refocus our health system on preventive 
health, and try to keep people healthier in the first place is 
probably the single best way that we can reduce health costs. 
So efforts are underway to focus on a number of the key drivers 
of chronic disease and health costs. Smoking is a number one 
target, and we now have a variety of efforts in place that look 
at ways to reduce smoking, and I would say that the funding 
proposal offered by the President for the Early Childhood 
Initiative may be a significant additional piece of that 
puzzle, which is increasing the cigarette tax, because we know 
that young smokers are particularly price sensitive.
    So that effort is funded outside of the block grant. We now 
have the prevention funds available through the Affordable Care 
Act, and will have over $500,000,000 throughout the country 
dedicated to various prevention efforts, including the 
Community Transformation Grants which are in 107 areas, and 
looking at chronic disease prevention and ways to reduce the 
toll of preventive issues.
    And as people engage in the fully insured market, either 
with access to Medicaid or with access to new private health 
insurance, private health plans must include a package of 
preventive health benefits that are offered with no copay and 
no coinsurance; childhood immunizations, and cancer screenings, 
are of particular help to individuals to stay healthy. So we 
think those efforts actually not only focus on preventive care, 
but ramp it up significantly, and it is not necessary to run 
parallel programs any longer.
    Mr. Alexander. I yield back, Mr. Chairman.
    Mr. Kingston. Thank you, Ms. Roybal-Allard.

  HEALTH CAREER OPPORTUNITY PROGRAM AND AREA HEALTH EDUCATION CENTERS 
                                PROGRAMS

    Ms. Roybal-Allard. Madam Secretary, two other goals in the 
HHS action plan to reduce racial and ethnic health disparities 
were to increase racial and health and ethnic diversity in the 
health professions, and to increase the diversity and cultural 
competency of clinicians. To date, the only HHS programs that 
help accomplish these goals are the HRSA Title VII programs. 
Your fiscal year 2014 budget cuts them by 15 percent and 
eliminates both the Health Careers Opportunity Program, and the 
Area Health Education Centers Program.
    As the Nation prepares to implement the largest health care 
coverage expansion in history, I am trying to understand why 
the only two pipeline programs that address the needs of a 
growing minority in this country are being eliminated.
    How do you expect your fiscal year 2014 budget to help 
increase racial and ethnic diversity in today's and in 
tomorrow's workforce, and specifically, what programs are you 
supporting or depending on to ensure the linguistic and 
cultural competency of clinicians and their retention in the 
health professions?
    Secretary Sebelius. Well, yesterday, Congresswoman, we 
published some new guidelines around cultural competency--
language competency for health providers that have been 
underway for some time because we do take very seriously the 
notion that if you have language or cultural barriers, that 
could be as large a barrier as having any access to a health 
provider. So those have been underway with our Office of Civil 
Rights, and have just been promulgated, and I will be happy to 
get a copy to your office knowing of your interest in this.
    We also have some very specific programs aimed at health 
professionals overall, and I would say our office leaders are 
very sensitive to the notion that we have to have additional 
recruitment and retention efforts around minority providers, so 
doubling of the National Health Service Corps which is underway 
is one of those efforts which brings a lot of, not only 
providers from underserved communities to participate, but they 
get to go home and practice medicine and get rid of their debt. 
And that has been enormously successful.
    So we are going to have 7,100 new National Health Service 
Corps slots. We have new programs for physicians assistants and 
nurses, again, with a recruitment effort that is also aiming at 
the minority community as part of that.
    I would say we have more general workforce efforts that are 
trying to increase capacity, and we feel that that may be a 
stronger way to encourage and recruit minority providers than 
separate disparate programs which only have a small funding 
stream. But to make that a part of what the health disparities 
plan calls on, is that every program, every leader, every asset 
that we have should be focused on reducing racial and ethnic 
barriers.
    So rather than running little streams of money that are 
focused on certain things and letting everybody else off the 
hook, we have made it clear to all senior leaders that every 
effort, so all of the programs HRSA is running, have an eye on 
minority recruitment and minority retention.
    NIH is paying special attention to the diversity of 
researchers, which has been a real problem and developed 
everything from mentoring programs to special training programs 
to try and reach out at a much earlier stage and make sure that 
the research community has a more diverse look about it, and so 
we are trying to pay attention to this at every step along the 
way.
    Ms. Roybal-Allard. Okay. I have to share the feeling that 
Congresswoman Lee has that somehow we are going backwards. So I 
think it is going to be important that we do have that sit-down 
meeting to better understand, you know, what it is you are 
trying to accomplish there.
    Secretary Sebelius. Sure. I would be glad to do that.
    Ms. Roybal-Allard. Okay. Thank you.
    Mr. Kingston. Dr. Harris.

                   INDEPENDENT PAYMENT ADVISORY BOARD

    Mr. Harris. Thank you very much. Madam Secretary, you just 
have to get back to me on this, but I had the staff pull the 
code on the Independent Payment Advisory Board and under 
paragraph 5, it clearly says that if the board fails to submit 
a proposal, then actually the Secretary shall develop it. So 
you will just have to get back to me online why you think this 
doesn't apply to you.

                 CHILDREN'S GRADUATE MEDICAL EDUCATION

    In regard to your statement about the importance of mental 
health, you know, I notice that the CHGME program at Children's 
Hospital is cut by about two-thirds, and obviously, those funds 
do fund pediatric psychiatry. Don't you think that we are, in 
fact, going to have a problem training people who are able to 
deal with psychiatric problems in children which could lead to 
gun violence by cutting back this training?
    Secretary Sebelius. Well, again, Congressman, we have tried 
to allocate in this budget the funding for the training slots, 
and not the indirect costs related to pediatric training. We 
have analyzed the costs for residents in the pediatric 
hospitals. That is what this budget reflects, so we will train 
the same number of pediatric residents. We just don't have the 
overhead----
    Mr. Harris. Madam Secretary, you know, this idea that 
somehow we can ensure, you know, 10 or 20 million more people 
and cost less, that we can train the same number of people with 
less money, you know, that just flies in the face of every rule 
of economics, but again, you know, I am concerned about a two-
thirds cut to pediatric training programs because having been 
on a medical faculty, I would just ask you just to make sure 
that, you know, Maryland Medicare Waiver is threatened, and, 
you know, I just ask to make sure that your Department works 
with our departments to make sure that that gets considered, 
our Medicare waiver.

                         CONSCIENCE PROTECTIONS

    I want to spend the rest of the few minutes on an area of 
great concern to me which is the conscience protection under 
the HHS mandate. My first question is, what is the time frame 
for issuing the final rule now that the comment period is over?
    Secretary Sebelius. Congressman, we are in the process of 
analyzing the comments, and the rule will be promulgated in the 
next couple of months.
    Mr. Harris. Okay, next couple of months. Now, let me ask 
you, and I have to get very specific because, you know, I 
looked and you are named in a whole lot of lawsuits on this. A 
lot of people obviously feel very strongly on this topic of the 
HHS mandate because of the religious, I think, the encroachment 
on religious beliefs that it has. And the one I am going to ask 
about specifically is Hobby Lobby because actually have a 
store, a shop--actually, they have a shop in many districts.
    This very specific problem is with, you know, the week-
after pill, which is not really a week-after pill. It is the 5-
day after pill, Ella. I want to ask you first, since you have 
mandated that it be covered, do you believe that it can cause 
an abortion, that it is an abortifacient drug, Ella. Not any 
other drug, Ella, which is ulipristal.
    Secretary Sebelius. I am not a scientist, and don't pretend 
to be one. I know that the FDA scientists do not believe that 
Ella, or Plan B, are abortifacients based on their impact on 
the reproductive cycle. That is how they are classified. They 
are classified as a contraception, not an abortifacient.
    Mr. Harris. Well, I understand that is the way are 
classified, but I am going to disagree. I think the FDA is not 
clear on Ella. And the European Medical Agency says, quote: 
``The ability to delay maturation of the endometrium likely 
results in a prevention of implantation,'' which is basically 
how an abortifacient would work. So I take it your answer is, 
you believe it is not an abortifacient and you are progressing 
based on that.
    Secretary Sebelius. Again, I don't designate. You should be 
very thankful that I don't designate drug classifications.
    Mr. Harris. Well, Madam Secretary, it is not really true 
that you are not classifying them because what you are doing--
--
    Secretary Sebelius. But the scientists do, and they have 
examined this and they have listed the only recommendation----
    Mr. Harris. Madam Secretary, what do you mean, the 
scientists? The European Medical Agency has said it can do it.
    Secretary Sebelius. FDA has scientists who look at drugs 
and compounds, and do clinical trials, and look at medical 
results. The only thing that the IOM recommendation said, which 
we incorporated, is that FDA-approved contraception and 
contraceptive devices should be included as----
    Mr. Harris. So even if they are abortifacients, and even 
if----
    Ms. DeLauro. Would the gentleman yield?
    Mr. Harris. I am not going to yield time on this topic. I 
have reviewed----
    Ms. DeLauro. You said something that was inaccurate.
    Mr. Harris. Madam Secretary, by functioning, by saying that 
abortion is not covered, but these abortifacients are, because 
it is controversial whether they are, you are, in fact, saying 
they are abortifacients. And I will tell you, I can't 
understand why in the world you would not make an exception for 
that that would allow the Hobby Lobby to go, to comply with 
their conscience on that issue?
    Now, there are other issues involved, but for them it is 
specific. And the cost of this is $40. That is it. It is not a 
drug you take every day. It is $40. And that is what this 
argument is about. And you all are dug in. I am disappointed. 
But let me turn to the--well, if with we have a third round, we 
will turn to the other problem which is that your requirement 
on religious institutions make them pass the unethical behavior 
on to a third party which is a real ethical problem. And I 
don't think you and your Department appreciate what an ethical 
problem it is, but I will get to that in-depth if we go a third 
round. Thank you, Mr. Chairman.
    Mr. Kingston. I was going to get some coffee, but I don't 
need it. We appreciate the passion on the panel up here. Ms. 
Lee.

                       OFFICE OF MINORITY HEALTH

    Ms. Lee. There is a lot of passion here, let me tell you. 
Thank you, Mr. Chairman. This is National Minority Health 
Month. The Tri-Caucus Black, Hispanic, Asian Pacific American 
Caucus, we are going to the floor at noon to talk about 
minority health, ethnic disparities, and the benefits of the 
Affordable Care Act to minority communities.
    A couple of things, Madam Secretary, I wanted to say. First 
of all, the diffusion of these efforts, and I understand what 
you are saying in terms of the general workforce effort to 
increase capacity and make sure everyone is focused on 
diversity efforts, but you have to have, I guess, a centralized 
focus so that these efforts will work, and with cutting the 
Office of Minority Health by $15,000,000, I am really worried 
that a lot of these efforts are going to go away.

                    COMMUNITY & SAFETY NET PROVIDERS

    The question I asked earlier about the--let me just quickly 
reiterate it. The traditional providers in our community who 
provide access to care, they have been around for a long time, 
community physicians, they have traditionally cared for many of 
the underserved. They don't have this infrastructure in place 
that the Affordable Care Act requires, and there are no 
requirements in the exchange plans to include Safety Net 
providers including community physicians who have traditionally 
provided care, such as African-American and Latino physicians, 
and they are really feeling the squeeze.
    We are sending you a letter on this, Madam Secretary. I 
want to talk to you about it. But can you kind of give us some 
sense what to do, what they should do at this point because 
they are not included, and they are going to be wiped out for 
the most part?
    Secretary Sebelius. Well, I am a little baffled as to why 
they wouldn't be included in network plans. I assume that many 
of the providers that you are talking about are currently part 
of a network plan.
    Ms. Lee. Not really. A lot of the--a lot of the minority 
physicians are not, and that is the problem because they are 
not--the exchange health plans don't require the Safety Net 
providers to be part of these plans now. And the majority of 
them aren't.
    Secretary Sebelius. I guess I need the letter from you, 
because I am not quite sure. If they are not part of an 
insurance network, I mean, if they are part of any insurance 
network, any company, that would make them automatically part 
of the exchange.
    So if someone can go with their Blue Cross card to a 
minority provider, someone could go with their Humana card to a 
minority provider, then they would be part of the exchange by 
virtue of that plan being offered on the exchange. If you are 
talking about designating individual doctors as essential 
community providers, that is not something that was done in the 
bill, and I am not sure, in fact, how we would ever do that. 
There are categories of providers that are designated as 
essential community providers, but individual doctors are not.
    Ms. Lee. Okay, I understand that and we will send you a 
letter. The National Medical Association is very concerned 
about this and other groups around the country about how this 
will ultimately play out.

                   NURSING SHORTAGE & MINORITY NURSES

    Let me ask you about nurses. Registered nurses, advanced 
practice nurses, they are expert clinicians who provide high-
quality and cost-effective care in every care setting in every 
community. And they are especially in demand in our medically 
underserved areas. Despite, you know, this need, according--and 
this is the American Association of Colleges of Nursing--their 
enrollment and graduation survey, they are saying the nursing 
schools were forced to turn away 79,000 qualified applications 
from entry-level baccalaureate graduate nursing programs in 
2012, citing faculty vacancy as a top reason.
    And so we are trying to figure out in your budget request, 
I think it was level to the 2012 enacted amount of $24,500,000, 
yet this huge need, this huge shortfall is a big issue in terms 
of our health care system's growing reliance on the need for 
nurses. And I have a mother who was 88, a sister with multiple 
sclerosis. I am in hospitals, emergency rooms all the time, and 
I can tell you, the nursing shortage is tremendous. The lack of 
minority nurses is glaring, and travel nurses, you know, do a 
great job, but you know, they shouldn't have to travel. You 
know, we should have nurses in our own communities to provide 
the badly needed services that they provide.
    Secretary Sebelius. Well, I certainly share your belief, in 
all deference to Dr. Harris, that nurses lift more than half 
the sky in most health systems, and most patient contact is 
often with a nurse in providing the patient information. So 
HRSA has spent a lot of time and effort directing new funding 
to nurses, to nurse practitioners, and to advanced nurse 
practitioners. We are trying to work with States around their 
often restrictive scope of practice.
    Mr. Kingston. Madam Secretary.
    Secretary Sebelius. Oh, I am sorry.
    Mr. Kingston. We are going to try to do a third round, so 
Mr. Joyce.
    Mr. Joyce. Thank you, Mr. Chairman. I will yield my time to 
Dr. Harris.

          STATE LICENSING AUTHORITY FOR MEDICAL PROFESSIONALS

    Mr. Harris. Thank you very much. Let me just follow up on 
that the States have restrictive scope of practice but that is 
within the realm of a State's licensing authority, is that 
correct?
    Secretary Sebelius. Yes, sir.
    Mr. Harris. I mean, there is no Federal licensing authority 
in scope of practice?
    Secretary Sebelius. I said, we are trying to work with some 
States, yes.
    Mr. Harris. But you claim that they are restrictive, but 
from their point of view, they are proper. I mean, I 
understand, and believe me, I love nurses. My daughter is a 
nurse. She is going to be a nurse practitioner. I understand, 
but this is the problem that the Federal Government looks at 
the States and says, see, what you are doing, we think is not 
right. You are too restrictive. But it is up to the States to 
make that final decision. I just want to emphasize that. It is 
up to the States.
    Secretary Sebelius. But if a State has a serious 
undershortage of primary care providers and have not allowed 
trained providers to practice----
    Mr. Harris. Well, Madam Secretary----
    Secretary Sebelius. All we do is have a conversation. It is 
totally up to them.
    Mr. Harris. Madam Secretary, in your opinion, they are 
trained to be equivalent, but it is up to the States in the 
end, and I hope the Department doesn't take coercive action on 
those grounds.
    Secretary Sebelius. We have never suggested taking coercive 
action.
    Mr. Harris. Well, again, to claim that they are 
restrictive, when in fact, they are adequate for the State, 
that is a States-right issue, and a strong States-rights issue.

                         CONSCIENCE PROTECTIONS

    But let's get back to what we were talking about a little 
bit before. Because I still want to express a grave concern 
over a company like Hobby Lobby, which is privately owned, it 
is not public, and its owners feel strongly, they hold strong 
religious beliefs that conflict with some of the HHS mandate.
    What is their option going to be when the new rule comes 
out virtually unchanged, they are subject to the mandate, and 
if they continue to insure their employees as they want to, 
they would be violating their conscience. My understanding is 
their choice is, you either violate your conscience or you 
don't provide health insurance. Am I missing something in 
between?
    Secretary Sebelius. Well, I think, Congressman, the law of 
the land will apply to employers across the board with some 
exceptions that we have outlined, and in the case of Hobby 
Lobby or other nonreligious employers, imposing their religious 
views on their employee choice is not really an option.
    Mr. Harris. Madam Secretary, it is not imposing a religious 
view on their employees. They are paying out of their private 
moneys, these are privately-held companies, they are paying for 
this insurance. So their options, in my mind, will be we either 
violate our ethics, which I would suggest they should never do 
because of a Federal Government mandate, or they will just 
choose to pay the penalty and send people into the exchanges, 
violating the President's promise that if you like your plan 
you get to keep it. Because I will bet the vast majority of the 
Hobby Lobby employees, in fact, like their plan.
    And Madam Secretary, they will not get to keep it under the 
current structure of the HHS mandate. But let me talk, because 
I think the Department is missing a very, very significant 
ethical question here, and that is, we will talk about the 
quote ``religious institutions,'' the subject of a lot of these 
lawsuits, because their position is quite clear, and you know, 
students of ethics will understand this, that if by providing 
insurance for their employees, no matter what scheme or shell 
game you play with who is going to pay for the morally 
objectionable coverage, they will be allowing their employees 
to have access to that, no matter who pays for it.
    The analogy is, you know, a Catholic hospital, for 
instance, can't refer for abortion. They can't say, you know 
what, we don't want to do this, but as long as somebody else 
does it, or somebody else pays for it, that is okay. Because 
Madam Secretary, that is just plain unethical. So what is the 
options if they feel that way, their ethical religious 
construct is that, aren't their options exactly the same?
    We either violate our ethical religious construct, and we 
are not talking about Hobby Lobby. We are talking about the 
University of Notre Dame, a Catholic institution, one of the 
plaintiffs, the Archdiocese of New York, the Diocese of Dallas, 
the Archdiocese of Washington. They would have to violate their 
moral ethical construct, or they just have to send all of their 
employees into the exchange. And again, most of their employees 
probably feel they kind of like the insurance product they 
have, but once again, they are not going to be able to keep it 
because of the HHS mandate. Am I missing something? Those 
really are the only two choices. You either comply with what 
the Federal Government mandates, or too bad.
    Secretary Sebelius. A couple of things. First of all, no 
diocese is included in this law at all. They may be in the 
lawsuit. They are not in the law because they have fallen under 
the total exemption that involves churches. Secondly, the 
commitment was to find an appropriate balance between having a 
religious employer not offer, pay for, or refer people to 
coverage that they find objectionable. On the other hand, 
giving employees the right to exercise his or her own religious 
values and choose coverage that they would find to be healthy 
for themselves and their families. And I think that is what our 
commitment is. That is what we intend to do when we promulgate 
the final rule.
    We have actually had a number of very positive comments 
from entities like the Catholic Health Association, who has 
been working with us. Other entities that are looking at this 
with regard to their--you might find that amusing, but they are 
enthusiastic about what the rules would allow them to do and 
feel that it very much is in line with their----
    Mr. Harris. None of these lawsuits were dropped. The 
Catholic Health Association does not represent any of these 
plaintiffs. Mr. Chairman, I yield back the time.

                              MARKETPLACES

    Mr. Kingston. Madam Secretary, we are going to go to 
another round, try to do 3-minute questions, so we will try as 
you can tell, we have a lot of interest.
    What my question is, and in terms of if a State has 
rejected setting up an exchange, then the Federal Government 
steps in and does the exchange. But I understand that there is 
an administrative fee for that, 3.5 percent, true, or is it----
    Secretary Sebelius. The user fee is for the companies who 
will be offering plans in exchange, and they will pay a user 
fee. Yes, sir.
    Mr. Kingston. What is the statutory basis for that, and----
    Secretary Sebelius. The law requires the exchanges 
eventually to be self-sustaining and the user fees are the way 
to get us there.
    Mr. Kingston. Is there any challenge to that 3.5 percent or 
is everybody accepting it?
    Secretary Sebelius. So far as I know, there is no 
litigation, no. And these are new customers, clearly, for the 
insurance companies.
    Mr. Kingston. Yes. And have you put out the process for 
selecting, if the Federal Government comes in and sets up an 
exchange, then are you doing it with Federal employees? Are you 
doing it with contractors, and you are accepting bids for 
proposals?
    Secretary Sebelius. Well, there are a couple of pieces of 
the puzzle. There is a Federal hub, if you will, that all 
marketplaces will use a data center to verify as Social 
Security numbers, and income numbers, and qualifications for 
the tax credit. Then there are individual exchange hubs, 
private plans in each State, in Georgia, which has chosen not 
to operate a State-based exchange, and there will be a Federal 
exchange, but it will be a Georgia-specific plan with Georgia 
companies who offer products to Georgia citizens. The benchmark 
will be based on the small group market in Georgia, so I think 
as far as the consumer's experience goes, I am not sure they 
will have any idea whether or not it is a Georgia plan or run 
by the Federal Government.
    Mr. Kingston. And have you put out the criteria for who 
would run, who would qualify to submit proposals? Is that out 
there yet?
    Secretary Sebelius. Yes, sir. That is what we are talking 
about in terms of rates coming in. Insurance companies are now 
submitting rates to be part of these marketplaces, and they 
will negotiate about whether or not the rates that they submit 
are actually ones that are justifiable based on an actuarial 
analysis, and then those rates will be finalized, and then 
those market plans will then be available to consumers starting 
October 1st.
    Mr. Kingston. Okay. Rosa.

                      ADVANCED MOLECULAR DETECTION

    Ms. DeLauro. Thank you, Mr. Chairman. I just have one 
comment. I think when your boss' ideology determines your 
health care, we are certainly into a whole new world. Let me 
just talk about CDC for a moment, and the advanced molecular 
detection proposal.
    Secretary Sebelius. Tom Frieden will be so pleased.
    Ms. DeLauro. This is one of the places where I am excited 
about additional funding for food safety, for control of health 
care associated infections, and for this new advanced molecular 
detection initiative.
    My understanding is that the basic idea is to modernize the 
CDC's capacity to use the technologies to do a better job, if 
you will, of tracking pathogens, recognizing patterns of 
diseases. And my understanding is also that CDC has fallen 
behind in the adoption of new technology. It used to be the 
gold standard and that has fallen behind, and now there is an 
urgent need to modernize.
    So I don't know if you are an expert in this area. I 
certainly am not, but can you give us your understanding of 
what this initiative is, and what it is meant to do and why it 
is needed?
    Secretary Sebelius. Well, you are absolutely right. 
Congresswoman, the CDC has been the gold standard in 
surveillance, monitoring, and identification, and we are 
seeing, actually, some of that good work bear very important 
fruit with the emergence of this new avian flu in China. CDC, 
actually over the last number of years, has worked very closely 
with China to help build their CDC capacity and in fact, 
provided a lot of technical assistance.
    So we now have a relationship where we are getting daily 
communications from China. We are able to track what is going 
on. One of the important CDC scientists is in China as we speak 
as part of their team monitoring this disease. But CDC needs 
new capacities, and the advanced molecular detection system is 
a multiyear expenditure that would greatly enhance, increase, 
and update their surveillance capacity. There is an increase in 
the budget this year, but we would see this as a several-year 
effort that would actually bring CDC's lab capabilities up to 
the gold standard once again.
    Ms. DeLauro. Okay, tell us about the babies. You have 35 
seconds. If----
    Secretary Sebelius. Well, let's just say in terms of saving 
money in a very, I think, encouraging way, one of the areas 
that was looked at was so-called elective early deliveries. 
Deliveries not because of any kind of health emergencies, but 
babies were being delivered prior to 39 weeks, for the 
convenience of the doctor, the convenience of the patient, and 
a variety of things. There are huge health differences between 
a baby is carried to full term, and a 36- or 37-week baby. 
Focusing on that, providing some best practices, drilling down 
on that experience has helped hospitals in some cases go from 
20 percent early elective deliveries to almost none. Great 
reduction in NICU days, great reduction in lifetime issues 
around the baby, and it is just an example of identifying an 
easy fix and then having hospitals really engage in it.
    Ms. DeLauro. Thank you. Thank you very much.
    Mr. Kingston. Mr. Joyce.
    Mr. Joyce. Thanks. I will yield my time to Dr. Harris.

                     RELIGIOUS EXEMPTION TO MANDATE

    Mr. Harris. Thank you very much. Let me just follow-up a 
little bit about the religious exception here because of 
course, the churches itself, are not the--the churches 
themselves are exempt, but everything else the churches do, the 
archdiocese, the diocese, they, of course, are not exempt. They 
are subject to the rule. And the rule being, again, and I guess 
I have to ask you, I mean, that is the basis of their lawsuits. 
It is not that you didn't exempt them. It is that you didn't 
exempt their related activities, their charities, their 
hospitals, their schools. Is that the basis of their lawsuit 
from what you understand? Obviously, they are exempt, so they--
--
    Secretary Sebelius. Yes.
    Mr. Harris. Okay, so what you are doing is under the 
current structure of the rule, and again, it really is an 
accounting gimmick. What you are doing is saying, you can offer 
the insurance, but by offering the insurance, so I am just 
going to get it straight, the construct that you are creating, 
by them offering insurance to their employees, their objection 
is that that creates the ability, in fact the necessity, of 
their employees getting coverage for something they find 
morally objectionable. Because under the exception, their 
employees have to get it. There is no choice. They have to get 
it. A third party will do it, or the TPO will contract with 
someone or the insurer will attempt to bury the costs somewhere 
else.
    Secretary Sebelius. If the employee chooses that coverage, 
they would use it, yes.
    Mr. Harris. That is right, so the option is----
    Secretary Sebelius. They would have the option to choose 
the coverage.
    Mr. Harris [continuing]. To be not covered, or to be 
subject to this which would violate the ethical construct of 
the organization that, because I am not talking about the 
employee now. I am talking about from the employer's point of 
view. Their point is, they would either have to offer this 
product to everyone, or they offer it to no one.
    Secretary Sebelius. Again, the employer would not pay for, 
would not refer, and would not provide the coverage.
    Mr. Harris. Madam Secretary, how is that not referring? If 
automatically upon offering an insurance product, that person 
automatically gets the other product. How is that not 
referring?
    Secretary Sebelius. Well, it isn't automatic, Doctor, and 
what we have done is outline a variety of possibilities. In one 
case, the insurance company would directly offer an alternate 
policy directly to employees, not referred to by their 
employer, but directly to employees. And in fact, insurance 
company data indicates that providing contraceptive coverage is 
actually a reduction in the plan, so the benefit would go to 
the employer. If there is a third-party administrator, the 
third-party administrator would offer the coverage and then 
there is some alternate possibilities. And we are evaluating 
comments and we will promulgate a final rule.
    Mr. Harris. Ethically, how is that different from the 
church organization offering the coverage themselves? How is 
that ethically different? You have somehow separated it 
ethically, but it is exactly the same.
    Secretary Sebelius. They do not refer, they do not pay for, 
and they do not recommend the coverage. I don't know how it 
could be clearer. They are not involved.
    Mr. Harris. Thank you.
    Mr. Kingston. Mr. Joyce.

              AFFORDABLE CARE ACT IMPLEMENTATION TIMELINE

    Mr. Joyce. Thank you, Secretary. And I want to follow up on 
what I first asked you because maybe I wasn't very clear, but 
since I am new. You are obviously a very intelligent lady, and 
somewhere you probably have some documents in which you lay out 
for yourself or can sort of show the implementation of the 
Affordable Care Act as it is moving along. I was wondering if 
there is somewhere I could make those same things available for 
myself so I could explain it to the people at home, and if 
there is something that is going to be updated on a quarterly 
basis, because I would like to stay up to speed, because there 
are so many questions being asked, and I don't seem to have the 
answers and I haven't heard all of the answers here today.
    Secretary Sebelius. Well, we would be happy, Congressman, 
to provide you with documents that give you a timeline, and 
what is coming, and where we are, and what we anticipate coming 
in the next quarter and the quarter beyond that, yes, sir.
    Mr. Joyce. And whether or not the exchanges will be coming 
on time.
    Secretary Sebelius. Yes, sir.
    Mr. Joyce. Okay. Great, thank you very much. I have no 
further questions.
    Secretary Sebelius. Sure.

                    COMMUNITY TRANSFORMATION GRANTS

    Mr. Kingston. Madam Secretary, I wanted to ask a little bit 
about Community Transition Grants, and I have raised the issue 
with Tom Frieden on that, and I am certainly a CDC fan, but I 
do feel that Community Transition Grants is kind of junk 
science. I mean, you go out and get the health departments and 
you get them all ginned up about superficial stuff, and they 
come back and say let's reduce sugary beverages, like, oh, I 
haven't thought about that one.
    And as you may know, the stimulus bill actually had 
$266,000,000 in Community Transition Grants just for the CDC. 
And I think it was in 2010 or 2011, but to me, gosh, 
$266,000,000, put it to a lab and a chemist in the back room. 
Let them do, as you had mentioned earlier, what FDA just came 
back with on the OxyContin, something society needed, something 
everybody wanted. But here is an example of a grant 
solicitation, and I am reading directly, it says: ``To limit 
the density of fast-food outlets,'' and it is featuring high 
calorie, high sodium, low nutritional foods, and encouraged 
retail venues to provide access for healthier foods; zoning to 
regulate the number of fast-food restaurants in a given area.
    I mean, it just seems so silly, first, to be doing it on a 
Federal level, you know. If, for example, I like to ride my 
bike and I think in Irving, California, 14 percent of the 
people ride bikes. And that is really to me a good thing, and 
you know, you can find out about that. But that didn't take a 
Federal grant to come up with that. And then here is one, a 
Philadelphia grantee, in their report, came back, campaigned 
for a $0.02 tax on sugary beverages, and it came up one short 
vote in city council. Now, nothing makes our constituents more 
livid than paying tax dollars to lobby for a policy, whatever 
it is, whether you agree about it or not, but you know, again, 
you know, why not put the money in the lab with the scientists 
who can really figure out how to cure cancer?
    Secretary Sebelius. Well, I would like to do both, and I 
think if you look at chronic disease, a lot of it is not going 
to be solved by a pill or a cure. It really is going to be 
solved by, helping to make the healthier choice, the easier 
choice.
    Mr. Kingston. I guess the part of my--and I hate to 
interrupt you, but part of my concern is, none of this is 
original thinking. You know, and for $256,000,000, we want to 
have original thinking, and I understand the local community 
group wants to solicit for higher taxes on something and lower 
zone in a fast food, but it is to me, you know, they are not 
really adding anything to the table. And you know, it is----
    Secretary Sebelius. I would say, chairman, we have had a 
health system that spends 92 cents on every dollar treating 
sick people, and about 8 cents of every dollar trying to get 
people healthy in the first place and keep them healthy. So 
there were some Recovery Act dollars spent really pushing money 
to communities, and it was called Communities Putting 
Prevention to Work, so we engaged with mayors and city councils 
and community activist groups who did everything from bike 
paths and walking trails, looking at food deserts and trying to 
give incentives to people to bring fresh fruit and vegetables 
into areas where there weren't enough, working with local 
schools to update and upgrade what the kids were eating and----
    Mr. Kingston. And my time has expired. Here is what I told 
my friends in the, you know, the agencies that kind of make it 
easier on us. You know, in this budget constraint----
    Secretary Sebelius. I hear you.
    Mr. Kingston. We can't have this, but you know, let's see, 
you know, if you come up--look, for example, and you know the--
the 1 percent reduction in cancer each year and the reduction 
of polio, now the three countries and all that, that is 
something everybody can get behind and, you know, the taxpayers 
feel better about it, our constituents do, and so let me yield.

                          AFFORDABLE CARE ACT

    Ms. DeLauro. Thank you, Jack. I would just say this to you, 
that the fact of sugar in obesity has been determined by 
scientists, so it is based on science and there is something 
there.
    Let me just make a final comment, and I know the Secretary 
has to leave. I just would say this. The House voted for the 
Affordable Care Act, the Senate voted for it, the President 
signed it, the Supreme Court upheld it. We had an election in 
which it was vilified, and in fact, it was overwhelmingly the 
President was elected.
    We now have the Affordable Care Act. Our job is to 
implement it and to make sure that it works well, and I just 
want to say to you, Madam Secretary, I want to just say thank 
you.
    Some of the problems that were there about people who are 
uninsured, those who can't afford insurance, lifetime limits, 
premiums, gender rating, the threat of coverage being canceled 
based on technicalities, all of those things are being 
addressed, phasing out of annual and lifetime limits on 
coverage, prohibition on denying coverage for children based on 
pre-existing conditions, ban on rescissions of coverage.
    We are moving forward. Much has been implemented. The fact 
of the matter is let's get on with it, let's make changes where 
there need to be changes, but let's be able to do what the law 
of the land says. We are going to work to provide insurance. In 
fact, at this moment, the Affordable Care Act has helped to 
hold down premium increases, and there are new consumer 
protections. The marketplace will increase that effort, and we 
will have more transparency in what we know is in our insurance 
policies.
    I say to those who can't deal with the fact of life that we 
have this law of the land, let's move forward and do the right 
thing and get over it and not try to deny the funding for it 
that it needs in order to survive to say, aha, it didn't work. 
It will work if we work at it collectively.
    Thank you very much, Madam Secretary.
    Mr. Kingston. Dr. Harris.

                                LOBBYING

    Mr. Harris. Yeah, just very, very briefly, Madam Secretary, 
just to follow up with what the chairman's last line of 
questioning was. Those community preventive service task force 
grants and the community anti-drug coalition of America grants 
that, you know, were alleged now to have involved State or 
Federal lobbying, I got to ask you a question. Does the 
Department intend to go after them for recouping that just like 
you left the hospitals and doctors? I mean, are you going to 
recoup those grants from those organizations that violated 
their agreements not to do Federal or State lobbying with the 
monies, or bring action or ask the Attorney General to take 
action against them?
    Secretary Sebelius. That is not underway. We have 
definitely gone back to grantees indicating that there is a 
strict prohibition. We have done retraining of all grantees. We 
are watching very closely. I think there is one instance where 
a community grantee, in addition to a lot of other things that 
they were doing, did lobby a local entity, and that was 
immediately stopped by the CDC.
    Mr. Harris. And do you give the physicians and hospitals 
the same opportunity when your auditors find something to 
actually just perhaps advise them, or do you just go ahead and 
ask for recoupment of the money?
    Secretary Sebelius. I think there is the same kind of 
negotiation to figure out what it is that they have done, 
whether or not they indeed violated, and often there is a 
negotiated settlement, and that is the way it is done.
    Mr. Harris. Thank you very much. Thank you, Mr. Chairman.
    Mr. Kingston. Thank you. And Madam Secretary, I just wanted 
to touch base on one thing that we can talk about later, but, 
you know, with the situation with Boston and here and there, I 
just think we are, you know, in a world now where we can expect 
attacks, and because of that, I do have some worry and I think 
we don't discuss about BioShield enough in our country. The 
BioShield fund has been reduced. I am worried about 
pharmaceuticals being able to develop the things and have the 
market. I mean, that is one area where I think Republicans and 
Democrats can agree. There has to be a subsidy for the research 
and development, and it is reduced in this, and so I--do you 
want to comment on that? I see----
    Secretary Sebelius. I think there is a budget 
recommendation for BioShield. It is a one-year recommendation 
given the fact that again we are now operating under a CR. We 
have not had an increase in BioShield since 2012, so we think 
it is a very important program and we would love to work with 
you on it.
    Mr. Kingston. Well, I think there are things that we can, 
you know, really find great common ground on, and I think we 
are finished here. I mean, there is tons more questions. We can 
just bring her back tomorrow. I would like to have----
    Ms. DeLauro. Talk about sugary drinks.
    Mr. Kingston. The hobby lobby would like to yield some time 
to Rosa now.
    We will adjourn. I do want--there were some things I had 
talked to you about in terms of Georgia.
    Secretary Sebelius. Yes.
    Mr. Kingston. About waivers and seafood, I think that 
Rosa----
    Secretary Sebelius. Maryland has an issue also, and I can 
check up on that.
    Mr. Kingston. If you could----
    Secretary Sebelius. Sure.
    Mr. Kingston [continuing]. Follow up with us, and we 
certainly appreciate your time, and thanks for being with us.
    Secretary Sebelius. Sure.
    [The following questions were submitted for the record.]

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                           W I T N E S S E S

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Clancy, Carolyn M................................................     1
Collins, Francis S...............................................     1
Colvin, Carolyn..................................................   269
Conway, Patrick..................................................     1
Delisle, Deb.....................................................   335
Frieden, Tom.....................................................     1
Hyde, Pamela.....................................................   335
Sebelius, Hon. Kathleen..........................................   413
Wakfield, Mary...................................................     1

                                  
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